Glaucoma in United States Veterans: An Overlooked Group? Priyanka Kamath, MS; Zohra Prasla, BBA; Matthew Harrison, BS; Karanjit Kooner, MD Dallas Veterans Affairs Medical Center 4500 South Lancaster Road Dallas, TX Department of Ophthalmology, University of Texas Southwestern Medical Center Dallas, TX MATERIALS AND METHODS Study Design and Participant Selection: From July 2005 to July 2009, The Dallas Glaucoma Registry (DGR) has compiled epidemiological data for over 4,000 glaucoma patients seen at UT Southwestern Medical Center and its affiliated clinics in the North Texas region. Our research population consisted of 1800 United States military veterans, both male and female, who have been followed for glaucoma or a risk of developing glaucoma at the Dallas VAMC. We included the following: Patients who have been seen two or more times by an ophthalmologist at the Dallas VAMC Patients with sufficient necessary information in their medical chart, including gender, race, diagnosis, visual field records, IOP measurements, medications prescribed, etc. Patients who have primary or secondary glaucoma (not tertiary to other disease processes). Data Collection and Analysis: Data was gathered by reviewing medical charts and completing a custom form for each patient. (Figure 1) We recorded information on ocular characteristics such as intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disk ratio (C/D), medications, surgeries, visual fields (VF), and visual acuity (VA) as well as demographic data such as age, gender, and ethnicity. Each patient was enrolled only once in the registry, regardless of the number of clinic visits. We analyzed several risk factors based on four glaucoma subtypes: Primary Open Angle Glaucoma (PAOG), Suspect, Secondary, and Narrow Angle Glaucoma/Angle Closure Glaucoma (NAG/ACG). We used means and standard deviations to characterize quantitative variables and percentages to describe categorical variables. The data was transferred to Microsoft Excel (Microsoft Corporation, Seattle, WA, USA) and risk factors were analyzed using SAS 9.2v (SAS Institute, Cary, NC, USA) and SPSS (SPSS Inc., an IBM Company, Chicago, IL, USA). INTRODUCTION United States veterans are a highly understudied group of individuals and are deserving of our highest level of care. Today, approximately 5 million veterans in the U.S. use the services of a VA medical facility which provides many specialized medical programs and treatment options unique to their needs. These include Blind Rehabilitation Centers, Vision Impairment Services, and social work--needs that other health care facilities are often unable or unwilling to meet. Despite the availability of these services, the VA Health Service has more than 300,000 patients afflicted with glaucoma, the second leading cause of blindness. 2 Also, the incidence of blindness is more than 10 times higher in veterans as compared to the general population. 1 At the Dallas Veterans Affairs Medical Center (VAMC), 30% of 250 blind patients were so due to glaucoma. Unfortunately, there is very little information on glaucoma in veterans. Thus, t he data collected for this study will provide healthcare professionals with invaluable information regarding glaucoma in this patient population thereby improving he quality of veterans’ health outcomes. CONCLUSIONS Glaucoma suspects were the most prevalent group (46.8%) and were treated much less frequently by either medication or surgery than the other groups. Of the 1463 POAG eyes, 465 (31.8%) had severe VF defects, 581 (39.7%) were treated by 3 or more medications and 408 (27.9%) required surgery. Of the 167 eyes diagnosed with secondary glaucoma, 49 (29.3%) were due to surgery and 42 (25.1%) had a history of trauma. REFERENCES 1. Marcussen, BL, Newcomb RD. Mil Med1994 Jan;159(1): Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and Br J Ophthalmol. 2006;90:262–267 SUPPORT This research is supported in part by an unrestricted grant from the Society to Prevent Blindness New York, NY. RESULTS AND DISCUSSION In this study of 1800 patients (3600 eyes), glaucoma suspect was the most prevalent diagnosis (46.8%). These patients were on average the youngest of all four groups and had the smallest average C/D ratio (0.55). Interestingly, however, suspicious optic disk (SOD) was the most common risk factor for these patients followed by elevated IOP. The second most prevalent group was POAG (40.6%). The mean C/D ratio for POAG was 0.71, which was higher than secondary, suspect, and NAG/ACG (0.62, 0.55, and 0.29, respectively). In addition, the average number of medications taken was 2.21 for POAG, 1.68 for secondary, 1.55 for NAG/ACG, and 0.56 for suspect. 465 (31.8%) POAG eyes had visual field (VF) defects that were described as “severe,” or in other words, had a mean defect greater than -12. (Figure 2) Eyes diagnosed with secondary glaucoma were the third most prevalent (4.6%). Of these, 49 (29.3%) had glaucoma secondary to surgery and 42 (25.1%) had glaucoma secondary to trauma. (Figure 3) The NAG/ACG group was least prevalent (4.3%). However, they had the highest number of surgeries (76.6 %) compared to POAG (26.7%), secondary (26.1%), and suspects (1.8%). a history of trauma. Figure 2 Figure 3 DALLAS GLAUCOMA REGISTRY (1)Name:_____ (2) Hospital No.: ___________ (3) Date first seen in Dallas _________ (1)Date of last exam (5) DOB _ __ (6) Sex: 1 | 2 1= M, 2 = F (7) Hosp.: 1 | 2 | 3 | 4 1 = Aston, 2 = PMH, 3 = VA, 4 = JPS (8) Race: 1 | 2 | 3 | 4 | 5 | 6 1 = White, 2 = Black, 3 = Hispanic, 4 = Asian, 5 = East Indian, 6 = N/A, 7 = other (9) Glaucoma status 1 | 2 | 3 1 = stable, 2 = undetermined, 3 = unstable; (10) Glaucoma Diagnosis (A) OD: 0│1 | 2 | 3 | 4 | 5 │6│7_| (B) OS: 0 │ 1 | 2 | 3 | 4 | 5 │6│7 | 0= normal; 1 = POAG; 2 = LTG/NTG; 3 = glaucoma suspect; 4 = secondary; 5 = ACG/NAG, 6= childhood; a) primary; b) secondary; c) juvenile; 7=other__________________ VF defects (A) OD 0 | 1 | 2 | 3 (B) OS 0 | 1 | 2 | 3 0 = normal, 1 = mild, 2 = moderate, 3 = severe Initially diagnosed in Dallas? 1 | 2 | 1 = yes, 2 = no (13) C/D ratio (A) OD ________ (B) OS ________ (14) Glaucoma surgery: (A) OD 1 | 2 | 3 | 4 | 5 | 6 | 7 (B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7 1 = ALT/SLT, 2 = LPI, 3 = trabeculectomy, 4 = glaucoma shunt, 5 = cyclodestruction, 6 = no surgery, 7 = other __________________ Glaucoma medications: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 1 = prostaglandin analogues (Xalatan, Travatan, Lumigan, Rescula), 2 = beta blockers (Timoptic, Betimol, Betoptic, Betagan, Carteolol, Istalol), 3 = alpha agonist (Iopidine, Alphagan 0.2%, 0.15%, 0.1%), 4 = topical CAI (Trusopt 2%, Azopt 1%), 5 = system CAI (Neptazane 25 mg, /50 mg, Diamox 250/500mg), 6 = sympathomimetic (Propine), 7 = miotics (Pilocarpine 2%, 4%, 6%, Carbochol.75%, 1.5%, 3%), 8 = no meds, 9 = other ____________________ Number of medications: ______________ Glaucoma suspect: 1 | 2 | 3 | 4 | 5 1 = increased IOP, 2 = suspicious disc(s), 3 = strong family history, 4 = suspicious VF or NFL, 5 = other ___________ Secondary glaucoma: 1 | 2 | 3 | 4 | 5 1 = rubeotic, 2 = traumatic, 3 = inflammatory, 4 = post-surgical, 5 = other _______ ACG/NAG: 1 | 2 | 3 | 4 1 = primary acute angle closure, 2 = plateau iris, 3 = chronic angle closure, 4 = CMG, 5 = others _________________________ (20) Vision Best Corrected (A) OD: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | (B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 1= 20/20, 2= 20/40, 3=20/60, 4= 20/80, 5=20/100, 6= 20/200, 7= CF, 8= HM, 9=LP, 10=NLP, 11=Prosthesis (21) IOP (mmHg) (A) OD _____________ (B) OS _____________ (22) CCT (µ): (A) OD____________ (B) OS______________ Figure 1: Form Used To Collect Data From Patient Charts Type (%) Age (±SD) IOP (±SD) C/D (±SD) CCT (±SD) POAG (40.6) (10.60)15.98 (4.85)0.71 (0.21) (69.35) Suspects (46.8) (11.68)17.17 (4.28) 0.55 (0.19) (43.57) Secondary (4.6) (11.28)18.77 (9.57)0.62 (0.26) (66.67) NAG/ACG (4.3) (10.41)17.23 (5.48)0.59 (0.29) (50.89) Table 1: Risk Factors Based on Types of Glaucoma

Glaucoma in United States Veterans: An Overlooked Group? Priyanka Kamath, MS; Zohra Prasla, BBA; Matthew Harrison, BS; Karanjit Kooner, MD Authors have no financial conflict in this study Dallas Veterans Affairs Medical Center 4500 South Lancaster Road Dallas, TX Department of Ophthalmology University of Texas Southwestern Medical Center Dallas, TX 75390

INTRODUCTION United States veterans are a highly understudied group of individuals Approximately 5 million veterans in the U.S. use the services of a VA medical facility ex: Blind Rehabilitation Centers, Vision Impairment Services, and social work Despite the availability of these services, the VA Health Service has more than 300,000 patients afflicted with glaucoma, the second leading cause of blindness The incidence of blindness is more than 10 times higher in veterans as compared to the general population At the Dallas Veterans Affairs Medical Center (VAMC), 30% of 250 blind patients were so due to glaucoma Due to very little information on glaucoma in veterans, the data collected for this study will provide healthcare professionals with invaluable information regarding glaucoma in this patient population thereby improving he quality of veterans’ health outcomes

MATERIALS AND METHODS Study Design and Participant Selection: From July 2005 to July 2009, The Dallas Glaucoma Registry (DGR) has compiled epidemiological data for over 4,000 glaucoma patients seen at UT Southwestern Medical Center and its affiliated clinics in the North Texas region The research population consisted of 1800 United States military veterans, both male and female, who have been followed for glaucoma or a risk of developing glaucoma at the Dallas VAMC. We included the following:  Patients who have been seen two or more times by an ophthalmologist at the Dallas VAMC  Patients with sufficient necessary information in their medical chart, including gender, race, diagnosis, visual field records, IOP measurements, medications prescribed, etc  Patients who have primary or secondary glaucoma (not tertiary to other disease processes)

MATERIALS AND METHODS Data Collection and Analysis: Data was gathered by reviewing medical charts and completing a custom form for each patient (See Figure 1) Information was recorded on ocular characteristics such as intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disk ratio (C/D), medications, surgeries, visual fields (VF), and visual acuity (VA) as well as demographic data such as age, gender, and ethnicity. Each patient was enrolled only once in the registry, regardless of the number of clinic visits Risk factors were then analyzed based on four glaucoma subtypes: Primary Open Angle Glaucoma (PAOG), Suspect, Secondary, and Narrow Angle Glaucoma/Angle Closure Glaucoma (NAG/ACG) Means and standard deviations were used to characterize quantitative variables and percentages to describe categorical variables. The data was transferred to Microsoft Excel (Microsoft Corporation, Seattle, WA, USA) and risk factors were analyzed using SAS 9.2v (SAS Institute, Cary, NC, USA) and SPSS (SPSS Inc., an IBM Company, Chicago, IL, USA)

Figure 1: Form Used to Collect Data From Patients Charts DALLAS GLAUCOMA REGISTRY (1) Name:_____ (2) Hospital No.: ___________ (3) Date first seen in Dallas _________ Date of last exam (5) DOB _ __ (6) Sex: 1 | 2 1= M, 2 = F (7) Hosp.: 1 | 2 | 3 | 4 1 = Aston, 2 = PMH, 3 = VA, 4 = JPS (8) Race: 1 | 2 | 3 | 4 | 5 | 6 1 = White, 2 = Black, 3 = Hispanic, 4 = Asian, 5 = East Indian, 6 = N/A, 7 = other (9) Glaucoma status 1 | 2 | 3 1 = stable, 2 = undetermined, 3 = unstable; (10) Glaucoma Diagnosis (A) OD: 0│1 | 2 | 3 | 4 | 5 │6│7_| (B) OS: 0 │ 1 | 2 | 3 | 4 | 5 │6│7 | 0= normal; 1 = POAG; 2 = LTG/NTG; 3 = glaucoma suspect; 4 = secondary; 5 = ACG/NAG, 6= childhood; a) primary; b) secondary; c) juvenile; 7=other__________________ VF defects (A) OD 0 | 1 | 2 | 3 (B) OS 0 | 1 | 2 | 3 0 = normal, 1 = mild, 2 = moderate, 3 = severe Initially diagnosed in Dallas? 1 | 2 | 1 = yes, 2 = no (13) C/D ratio (A) OD ________ (B) OS ________ (14) Glaucoma surgery: (A) OD 1 | 2 | 3 | 4 | 5 | 6 | 7 (B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7 1 = ALT/SLT, 2 = LPI, 3 = trabeculectomy, 4 = glaucoma shunt, 5 = cyclodestruction, 6 = no surgery, 7 = other __________________ Glaucoma medications: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9

Figure 1: Form Cont’d 1 = prostaglandin analogues (Xalatan, Travatan, Lumigan, Rescula), 2 = beta blockers (Timoptic, Betimol, Betoptic, Betagan, Carteolol, Istalol), 3 = alpha agonist (Iopidine, Alphagan 0.2%, 0.15%, 0.1%), 4 = topical CAI (Trusopt 2%, Azopt 1%), 5 = system CAI (Neptazane 25 mg, /50 mg, Diamox 250/500mg), 6 = sympathomimetic (Propine), 7 = miotics (Pilocarpine 2%, 4%, 6%, Carbochol.75%, 1.5%, 3%), 8 = no meds, 9 = other ____________________ Number of medications: ______________ Glaucoma suspect: 1 | 2 | 3 | 4 | 5 1 = increased IOP, 2 = suspicious disc(s), 3 = strong family history, 4 = suspicious VF or NFL, 5 = other ___________ Secondary glaucoma: 1 | 2 | 3 | 4 | 5 1 = rubeotic, 2 = traumatic, 3 = inflammatory, 4 = post- surgical, 5 = other _______ ACG/NAG: 1 | 2 | 3 | 4 1 = primary acute angle closure, 2 = plateau iris, 3 = chronic angle closure, 4 = CMG, 5 = others _________________________ (20) Vision Best Corrected (A) OD: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | (B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 1= 20/20, 2= 20/40, 3=20/60, 4= 20/80, 5=20/100, 6= 20/200, 7= CF, 8= HM, 9=LP, 10=NLP, 11=Prosthesis (21) IOP (mmHg) (A) OD _____________ (B) OS _____________ (22) CCT (µ): (A) OD____________ (B) OS______________

Type (%) Age (±SD) IOP (±SD) C/D (±SD)CCT (±SD) POAG (40.6) (10.60)15.98 (4.85)0.71 (0.21) (69.35) Suspects (46.8) (11.68)17.17 (4.28) 0.55 (0.19) (43.57) Secondary (4.6) (11.28)18.77 (9.57)0.62 (0.26) (66.67) NAG/ACG (4.3) (10.41)17.23 (5.48)0.59 (0.29) (50.89) Table 1: Risk Factors Based on Types of Glaucoma

RESULTS AND DISCUSSION In this study of 1800 patients (3600 eyes), glaucoma suspect was the most prevalent diagnosis (46.8%). These patients were on average the youngest of all four groups and had the smallest average C/D ratio (0.55). Interestingly, however, suspicious optic disk (SOD) was the most common risk factor for these patients followed by elevated IOP The second most prevalent group was POAG (40.6%). The mean C/D ratio for POAG was 0.71, which was higher than secondary, suspect, and NAG/ACG (0.62, 0.55, and 0.29, respectively). In addition, the average number of medications taken was 2.21 for POAG, 1.68 for secondary, 1.55 for NAG/ACG, and 0.56 for suspect. 465 (31.8%) POAG eyes had visual field (VF) defects that were described as “severe,” or in other words, had a mean defect greater than -12. (See Figure 2) Eyes diagnosed with secondary glaucoma were the third most prevalent (4.6%). Of these, 49 (29.3%) had glaucoma secondary to surgery and 42 (25.1%) had glaucoma secondary to trauma. (See Figure 3) The NAG/ACG group was least prevalent (4.3%). However, they had the highest number of surgeries (76.6 %) compared to POAG (26.7%), secondary (26.1%), and suspects (1.8%) a history of trauma.

Figure 2

Figure 3

CONCLUSION Glaucoma suspects were the most prevalent group (46.8%) and were treated much less frequently by either medication or surgery than the other groups Of the 1463 POAG eyes, 465 (31.8%) had severe VF defects, 581 (39.7%) were treated by 3 or more medications and 408 (27.9%) required surgery Of the 167 eyes diagnosed with secondary glaucoma, 49 (29.3%) were due to surgery and 42 (25.1%) had a history of trauma

REFERENCES Marcussen, BL, Newcomb RD. Mil Med1994 Jan;159(1):10-5. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and Br J Ophthalmol. 2006;90:262–267