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Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis

Deborah S Jacobs, MD
Section Editor
Jonathan Trobe, MD
Deputy Editor
Howard Libman, MD, FACP


Glaucoma is a group of eye diseases traditionally characterized by elevated intraocular pressure (IOP). However, glaucoma is more accurately defined as an optic neuropathy than a disease of high pressure. In open-angle glaucoma, optic nerve damage results in a progressive loss of retinal ganglion cell axons, which is manifested initially as visual field loss and, ultimately, irreversible blindness if left untreated [1].

This topic will discuss the epidemiology, clinical presentation, and diagnosis of open-angle glaucoma in adults. Glaucoma in children, angle-closure glaucoma, and treatment and prevention of open-angle glaucoma are discussed elsewhere. (See "Overview of glaucoma in infants and children" and "Angle-closure glaucoma" and "Open-angle glaucoma: Treatment".)


There are different types of glaucoma, generally categorized by the anterior chamber (iridocorneal) angle (figure 1) and the underlying etiology, if known:

Open-angle glaucoma is an optic neuropathy characterized by progressive peripheral visual field loss followed by central field loss in a typical pattern. It is usually but not always in the presence of elevated intraocular pressure (IOP). Increased aqueous production and/or decreased outflow are possible mechanisms for elevated intraocular pressure (figure 2). The optic nerve or "disc" takes on a hollowed-out appearance on ophthalmoscopic examination, which is described as "cupping." Cupping is associated with the loss of ganglion cell axons.

Angle-closure glaucoma is characterized by narrowing or closure of the anterior chamber angle. The normal anterior chamber angle provides drainage for the aqueous humor (the fluid that fills the eyeball). When this drainage pathway is narrowed or closed, inadequate drainage leads to elevated IOP and damage to the optic nerve (figure 3). Acute angle-closure glaucoma occurs in eyes with a certain anatomical predisposition. It presents as a painful red eye and must be treated within 24 hours to prevent permanent blindness. (See "Angle-closure glaucoma".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 17, 2017.
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  1. Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet 2004; 363:1711.
  2. Kingman S. Glaucoma is second leading cause of blindness globally. Bull World Health Organ 2004; 82:887.
  3. Tham YC, Li X, Wong TY, et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 2014; 121:2081.
  4. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991; 325:1412.
  5. Kapetanakis VV, Chan MP, Foster PJ, et al. Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): a systematic review and meta-analysis. Br J Ophthalmol 2016; 100:86.
  6. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006; 90:262.
  7. Friedman DS, Wolfs RC, O'Colmain BJ, et al. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol 2004; 122:532.
  8. Ang GS, Eke T. Lifetime visual prognosis for patients with primary open-angle glaucoma. Eye (Lond) 2007; 21:604.
  9. Richman J, Lorenzana LL, Lankaranian D, et al. Relationships in glaucoma patients between standard vision tests, quality of life, and ability to perform daily activities. Ophthalmic Epidemiol 2010; 17:144.
  10. Haymes SA, Leblanc RP, Nicolela MT, et al. Risk of falls and motor vehicle collisions in glaucoma. Invest Ophthalmol Vis Sci 2007; 48:1149.
  11. Akbari M, Akbari S, Pasquale LR. The association of primary open-angle glaucoma with mortality: a meta-analysis of observational studies. Arch Ophthalmol 2009; 127:204.
  12. Kwon YH, Fingert JH, Kuehn MH, Alward WL. Primary open-angle glaucoma. N Engl J Med 2009; 360:1113.
  13. Czudowska MA, Ramdas WD, Wolfs RC, et al. Incidence of glaucomatous visual field loss: a ten-year follow-up from the Rotterdam Study. Ophthalmology 2010; 117:1705.
  14. Prum BE Jr, Rosenberg LF, Gedde SJ, et al. Primary Open-Angle Glaucoma Preferred Practice Pattern(®) Guidelines. Ophthalmology 2016; 123:P41.
  15. Mukesh BN, McCarty CA, Rait JL, Taylor HR. Five-year incidence of open-angle glaucoma: the visual impairment project. Ophthalmology 2002; 109:1047.
  16. Leske MC, Heijl A, Hyman L, et al. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology 2007; 114:1965.
  17. Chauhan BC, Mikelberg FS, Balaszi AG, et al. Canadian Glaucoma Study: 2. risk factors for the progression of open-angle glaucoma. Arch Ophthalmol 2008; 126:1030.
  18. Khachatryan N, Medeiros FA, Sharpsten L, et al. The African Descent and Glaucoma Evaluation Study (ADAGES): predictors of visual field damage in glaucoma suspects. Am J Ophthalmol 2015; 159:777.
  19. Varma R, Wang D, Wu C, et al. Four-year incidence of open-angle glaucoma and ocular hypertension: the Los Angeles Latino Eye Study. Am J Ophthalmol 2012; 154:315.
  20. Vajaranant TS, Wu S, Torres M, Varma R. The changing face of primary open-angle glaucoma in the United States: demographic and geographic changes from 2011 to 2050. Am J Ophthalmol 2012; 154:303.
  21. Tielsch JM, Katz J, Sommer A, et al. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol 1994; 112:69.
  22. Wiggs JL. Genetic etiologies of glaucoma. Arch Ophthalmol 2007; 125:30.
  23. Zegers RH, Reinders EF, de Smet MD. Primary open-angle glaucoma: the importance of family history and role of intraocular pressure. Med J Aust 2008; 188:312.
  24. Ekström C. Risk factors for incident open-angle glaucoma: a population-based 20-year follow-up study. Acta Ophthalmol 2012; 90:316.
  25. Heijl A, Leske MC, Bengtsson B, et al. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol 2002; 120:1268.
  26. Nemesure B, Honkanen R, Hennis A, et al. Incident open-angle glaucoma and intraocular pressure. Ophthalmology 2007; 114:1810.
  27. Miglior S, Zeyen T, Pfeiffer N, et al. Results of the European Glaucoma Prevention Study. Ophthalmology 2005; 112:366.
  28. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration.The AGIS Investigators. Am J Ophthalmol 2000; 130:429.
  29. Martínez-Belló C, Chauhan BC, Nicolela MT, et al. Intraocular pressure and progression of glaucomatous visual field loss. Am J Ophthalmol 2000; 129:302.
  30. Bengtsson B, Leske MC, Hyman L, et al. Fluctuation of intraocular pressure and glaucoma progression in the early manifest glaucoma trial. Ophthalmology 2007; 114:205.
  31. Cedrone C, Mancino R, Cerulli A, et al. Epidemiology of primary glaucoma: prevalence, incidence, and blinding effects. Prog Brain Res 2008; 173:3.
  32. Zhao D, Cho J, Kim MH, Guallar E. The association of blood pressure and primary open-angle glaucoma: a meta-analysis. Am J Ophthalmol 2014; 158:615.
  33. Zhao D, Cho J, Kim MH, et al. Diabetes, fasting glucose, and the risk of glaucoma: a meta-analysis. Ophthalmology 2015; 122:72.
  34. Girkin CA, McGwin G Jr, McNeal SF, et al. Hypothyroidism and the development of open-angle glaucoma in a male population. Ophthalmology 2004; 111:1649.
  35. Miglior S, Torri V, Zeyen T, et al. Intercurrent factors associated with the development of open-angle glaucoma in the European glaucoma prevention study. Am J Ophthalmol 2007; 144:266.
  36. Xu L, Wang H, Wang Y, Jonas JB. Intraocular pressure correlated with arterial blood pressure: the beijing eye study. Am J Ophthalmol 2007; 144:461.
  37. Grødum K, Heijl A, Bengtsson B. Risk of glaucoma in ocular hypertension with and without pseudoexfoliation. Ophthalmology 2005; 112:386.
  38. Topouzis F, Harris A, Wilson MR, et al. Increased likelihood of glaucoma at the same screening intraocular pressure in subjects with pseudoexfoliation: the Thessaloniki Eye Study. Am J Ophthalmol 2009; 148:606.
  39. Marcus MW, de Vries MM, Junoy Montolio FG, Jansonius NM. Myopia as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. Ophthalmology 2011; 118:1989.
  40. Júlvez LP, Del Castillo Sánchez JB, Feijoo JG, Rubio-Terrés C. Methodologic quality of studies on prognostic factors for primary open-angle glaucoma progression measured by visual field deterioration. J Glaucoma 2010; 19:587.
  41. Chan TCW, Bala C, Siu A, et al. Risk Factors for Rapid Glaucoma Disease Progression. Am J Ophthalmol 2017; 180:151.
  42. Ernest PJ, Schouten JS, Beckers HJ, et al. An evidence-based review of prognostic factors for glaucomatous visual field progression. Ophthalmology 2013; 120:512.
  43. Susanna R Jr. Unpredictability of glaucoma progression. Curr Med Res Opin 2009; 25:2167.
  44. Kountouras J, Zavos C, Chatzopoulos D. Primary open-angle glaucoma: pathophysiology and treatment. Lancet 2004; 364:1311.
  45. Ray K, Mookherjee S. Molecular complexity of primary open angle glaucoma: current concepts. J Genet 2009; 88:451.
  46. Wierzbowska J, Wierzbowski R, Stankiewicz A, et al. Cardiac autonomic dysfunction in patients with normal tension glaucoma: 24-h heart rate and blood pressure variability analysis. Br J Ophthalmol 2012; 96:624.
  47. Heijl A, Bengtsson B, Hyman L, et al. Natural history of open-angle glaucoma. Ophthalmology 2009; 116:2271.
  48. Peters D, Bengtsson B, Heijl A. Lifetime risk of blindness in open-angle glaucoma. Am J Ophthalmol 2013; 156:724.
  49. Summaries for patients. Screening for glaucoma: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2013; 159:I.
  50. Vass C, Hirn C, Sycha T, et al. Medical interventions for primary open angle glaucoma and ocular hypertension. Cochrane Database Syst Rev 2007; :CD003167.
  51. Maier PC, Funk J, Schwarzer G, et al. Treatment of ocular hypertension and open angle glaucoma: meta-analysis of randomised controlled trials. BMJ 2005; 331:134.
  52. Henderson P, Labbe T, Kass MA. Ocular hypertension. In: Ophthalmology, 3rd ed, Yanoff M, Duker JS (Eds), Mosby Elsevier, 2009.
  53. Tuulonen A. Cost-effectiveness of screening for open angle glaucoma in developed countries. Indian J Ophthalmol 2011; 59 Suppl:S24.
  54. Hernández R, Rabindranath K, Fraser C, et al. Screening for open angle glaucoma: systematic review of cost-effectiveness studies. J Glaucoma 2008; 17:159.
  55. Burr JM, Mowatt G, Hernández R, et al. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assess 2007; 11:iii.
  56. Vaahtoranta-Lehtonen H, Tuulonen A, Aronen P, et al. Cost effectiveness and cost utility of an organized screening programme for glaucoma. Acta Ophthalmol Scand 2007; 85:508.
  57. Hatt S, Wormald R, Burr J. Screening for prevention of optic nerve damage due to chronic open angle glaucoma. Cochrane Database Syst Rev 2006; :CD006129.
  58. Feder RS, Olsen TW, Prum BE Jr, et al. Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern(®) Guidelines. Ophthalmology 2016; 123:P209.
  59. Moyer VA, U.S. Preventive Services Task Force. Screening for glaucoma: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013; 159:484.
  60. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care, Canada Communication Group, Ottawa 1994. p.932.
  61. Wood CM, Bosanquet RC. Limitations of direct ophthalmoscopy in screening for glaucoma. Br Med J (Clin Res Ed) 1987; 294:1587.
  62. Zein WM, Bashshur ZF, Jaafar RF, Noureddin BN. The distribution of visual field defects per quadrant in standard automated perimetry as compared to frequency doubling technology perimetry. Int Ophthalmol 2010; 30:683.
  63. Tielsch JM, Katz J, Singh K, et al. A population-based evaluation of glaucoma screening: the Baltimore Eye Survey. Am J Epidemiol 1991; 134:1102.
  64. Johnson CA, Keltner JL, Cello KE, et al. Baseline visual field characteristics in the ocular hypertension treatment study. Ophthalmology 2002; 109:432.
  65. Ocular Hypertension Treatment Study Group and the European Glaucoma Prevention Study Group. The accuracy and clinical application of predictive models for primary open-angle glaucoma in ocular hypertensive individuals. Ophthalmology 2008; 115:2030.
  66. Hollands H, Johnson D, Hollands S, et al. Do findings on routine examination identify patients at risk for primary open-angle glaucoma? The rational clinical examination systematic review. JAMA 2013; 309:2035.
  67. Harper R, Reeves B. The sensitivity and specificity of direct ophthalmoscopic optic disc assessment in screening for glaucoma: a multivariate analysis. Graefes Arch Clin Exp Ophthalmol 2000; 238:949.
  68. Qiu M, Boland MV, Ramulu PY. Cup-to-Disc Ratio Asymmetry in U.S. Adults: Prevalence and Association with Glaucoma in the 2005-2008 National Health and Nutrition Examination Survey. Ophthalmology 2017; 124:1229.
  69. Johnson LN, Baloh FG. The accuracy of confrontation visual field test in comparison with automated perimetry. J Natl Med Assoc 1991; 83:895.
  70. Omoti AE, Okeigbemen VW, Waziri-Erameh JM. Current concepts in the diagnosis of primary open angle glaucoma. West Afr J Med 2009; 28:141.
  71. Leske MC. The epidemiology of open-angle glaucoma: a review. Am J Epidemiol 1983; 118:166.
  72. Armaly MF, Krueger DE, Maunder L, et al. Biostatistical analysis of the collaborative glaucoma study. I. Summary report of the risk factors for glaucomatous visual-field defects. Arch Ophthalmol 1980; 98:2163.
  73. Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal thickness in the Ocular Hypertension Treatment Study (OHTS). Ophthalmology 2001; 108:1779.
  74. Teng C, Gurses-Ozden R, Liebmann JM, et al. Effect of a tight necktie on intraocular pressure. Br J Ophthalmol 2003; 87:946.
  75. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002; 120:701.
  76. European Glaucoma Prevention Study (EGPS) Group, Miglior S, Pfeiffer N, et al. Predictive factors for open-angle glaucoma among patients with ocular hypertension in the European Glaucoma Prevention Study. Ophthalmology 2007; 114:3.
  77. Herndon LW, Weizer JS, Stinnett SS. Central corneal thickness as a risk factor for advanced glaucoma damage. Arch Ophthalmol 2004; 122:17.
  78. Hazin R, Hendrick AM, Kahook MY. Primary open-angle glaucoma: diagnostic approaches and management. J Natl Med Assoc 2009; 101:46.
  79. Li G, Fansi AK, Boivin JF, et al. Screening for glaucoma in high-risk populations using optical coherence tomography. Ophthalmology 2010; 117:453.
  80. Badalà F, Nouri-Mahdavi K, Raoof DA, et al. Optic disk and nerve fiber layer imaging to detect glaucoma. Am J Ophthalmol 2007; 144:724.
  81. Nakanishi M, Wang YT, Jung TP, et al. Detecting Glaucoma With a Portable Brain-Computer Interface for Objective Assessment of Visual Function Loss. JAMA Ophthalmol 2017; 135:550.