Silmänpaine glaukooman vaaratekijänä

Anja Tuulonen

Näytön aste: A

Vaikka väestön poikkileikkaustutkimuksissa puolella glaukoomapotilaista silmänpaine on normaali, riski glaukoomavaurioiden syntymiselle kasvaa sitä suuremmaksi, mitä korkeammaksi silmänpaine nousee (erityisesti yli 30 mmHg).

Systemaattinen katsaus 1

The systematic review «Burr JM, Mowatt G, Hernández R ym. The clinical ef...»1 aimed to identify the magnitude of risk of OAG attributable to age, ethnicity, family history, myopia and diabetes. Population-based cohort and cross-sectional studies, investigating the risk of developing OAG were included, as well as meta-analyses and systematic reviews of observational population-based studies. Studies reporting populations in UK, Europe, North America, Canada or Australia were included. Hospital or clinic-based setting were excluded. The review was restricted to English language publications. The methodological quality of the included studies was assessed.

4 383 reports were identified from the search for studies on epidemiology, risk and disease progression, of which 285 were selected for full assessment for this review. 92 reports describing 27 studies met the inclusion criteria for the review.

The overall quality of each study was summarised as (A) no major flaws or (B) possible important flaws. Studies were included when they rated ‘A’ in all fields. Exceptions were made to include ‘B’ studies when no better evidence was available. In most studies (81 %), participants were sampled adequately and selected from a relevant population. Suboptimal approaches to diagnose OAG (e.g. high IOP, absence of a visual test, baring of the blind spot, case records, unstandardised criteria) were used in five studies (19 %). IOP status was obtained from a secure record (examination or examination records) in most studies.

Crude and adjusted relative risks (or odds ratios depending on study design) of OAG for the risk factors under investigation were abstracted. Where two or more studies contributed data, a random effects meta-analysis was undertaken. If both an unadjusted and adjusted ratio were reported in a study, an age- and gender-adjusted odds ratio was used in the meta-analysis. A relative risk was generated when an adjusted odds ratio was not reported and raw data were available.

High IOP was defined as ≥ 1 measurements with readings ≥ 26 mmHg. Other IOP cut-offs were also investigated. Seven studies described the prevalence of OAG by a range of IOP levels. Across the studies, the proportion of people with OAG who had an IOP above 21 mmHg was consistently higher than those who had an IOP of ≤ 21 mmHg. The proportion of people with high IOP varied widely across studies. However, all but one included cases with previously detected OAG already under glaucoma therapy, and therefore underestimate the true prevalence of OAG in people with high IOP. The risk of having glaucoma for those with IOP measurements ≥ 26 mmHg was estimated to be 13 times higher than that for those with lower IOP [relative risk (RR) 12.58, 95 % CI 5.07 to 31.24].

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

Systemaattinen katsaus 2

Structured Medline (January 1950 – January 2013) search and a hand search of references and citations of retrieved articles yielding 57 articles from 41 studies were included in a systematic review «Hollands H, Johnson D, Hollands S ym. Do findings ...»2.

The summary prevalence of glaucoma in the highest-quality studies was 2.6 % (95 % CI, 2.1 %-3.1 %). At the commonly used cutoff for high IOP (≥ 22 mmHg), the LR for developing glaucoma was 13 (95 % CI, 8.2-17), while lower IOP made glaucoma less likely (LR, 0.65; 95 % CI, 0.55-0.76).

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

Systemaattinen katsaus 3

The objective of the analysis of this systematic review «Health Quality Ontario. Routine eye examinations f...»3 was to determine the strength of association between age, gender, ethnicity, family history of disease and refractive error and the risk of developing glaucoma. The medical advisory secretariat conducted a computerized search of literature in English-language articles, published from January 2000 to March 2006. In addition, a search was conducted for published guidelines, health technology assessments, and policy decisions. Bibliographies of references of relevant papers were searched for additional references.

Studies including participants ≥ 20 years old, population-based prospective cohort studies, population-based cross-sectional studies when prospective cohort studies were unavailable or insufficient and studies determining and reporting the strength of association or risk- specific prevalence or incidence rates were included in the review. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to summarize the overall quality of the body of evidence.

A total of 498 citations for the period January 2000 through February 2006 were retrieved and an additional 313 were identified when the search was expanded to include articles published between 1990 and 1999. An additional 6 articles were obtained from bibliographies of relevant articles. Of these, 36 articles were retrieved for further evaluation. Upon review, 1 meta-analysis and 15 population-based epidemiological studies were accepted for this review.

Six cross-sectional studies and 1 prospective cohort study contributed data on the association between age and PAOG. From the data it can be concluded that the prevalence and 4-year incidence of POAG increases with increasing age. The odds of having POAG are statistically significantly greater for people 50 years of age and older relative to those 40 to 49 years of age. There is an estimated 7 % per year incremental odds of having POAG in persons 40 years of age and older, and 10 % per year in persons 49 years of age and older.

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

Tutkimus 4

Baltimore Eye Surveyssä «Sommer A, Tielsch JM, Katz J ym. Relationship betw...»4 tutkittiin 5 308 yli 40-vuotiasta henkilöä. Näiden joukosta löydettiin 132 (32 valko- ja 100 mustaihoista) primaaria avokulmaa sairastavaa potilasta, joiden mediaani silmänpaine oli 20 mmHg. Glaukoomamuutosten todennäköisyys kasvoi sitä korkeammaksi, mitä korkeampi silmänpaine oli. Vaikutus näkyi erityisesti yli 30 mmHg:n painetasolla, mutta oli havaittavissa myös matalimmilla painetasoilla. Suhteellinen riski oli 40 painetasolla yli 30–35 mmHg ja 13 painetasolla 22–29 mmHg. Jo aiemmin todettujen, hoitoa saavien glaukoomapotilaiden silmänpaine oli keskimäärin 4 mmHg (17 %) matalampi kuin uusien glaukoomapotilaiden hoitamaton silmänpaine ja 2–3 mmHg (13 %) matalampi kuin ei-glaukomatoottisen väestön silmänpaine.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: hyvä


  1. Burr JM, Mowatt G, Hernández R ym. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assess 2007;11:iii-iv, ix-x, 1-190 «PMID: 17927922»PubMed
  2. Hollands H, Johnson D, Hollands S ym. Do findings on routine examination identify patients at risk for primary open-angle glaucoma? The rational clinical examination systematic review. JAMA 2013;309:2035-42 «PMID: 23677315»PubMed
  3. Health Quality Ontario. Routine eye examinations for persons 20-64 years of age: an evidence-based analysis. Ont Health Technol Assess Ser 2006;6:1-81 «PMID: 23074485»PubMed
  4. Sommer A, Tielsch JM, Katz J ym. Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans. The Baltimore Eye Survey. Arch Ophthalmol 1991;109:1090-5 «PMID: 1867550»PubMed