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1 From the Departments of Epidemiology and Biostatistics and 2 Ophthalmology, Erasmus University Rotterdam, The Netherlands; 3 The Netherlands Ophthalmic Research Institute, Amsterdam, The Netherlands; the 4 Glaucoma Service, Moorfields Eye Hospital, London, United Kingdom; and the 5 Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix AReferences |
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METHODS. Of the 7983 subjects 55 years of age or older participating in the population-based Rotterdam Study, 6756 subjects participated in the ophthalmic part of this study (6281 subjects living independently and 475 in nursing homes). The criteria for the diagnosis of OAG were based on ophthalmoscopic and semiautomated Imagenet estimations of the optic disc such as vertical cup-to-disc ratio (VCDR), minimal width of neural rim, or asymmetry in VCDR between both eyes, and visual field testing with kinetic Goldmann perimetry. All criteria for the diagnosis of OAG were assessed in a masked way independently of each other.
RESULTS. Mean VCDR on ophthalmoscopy was 0.3 and with Imagenet 0.49, and the 97.5th percentile for both was 0.7. The prevalence of glaucomatous visual field defects was 1.5%. Overall prevalence of definite OAG in the independently living subjects was 0.8% (95% confidence interval [CI] 0.6, 1.0; 50 cases). Prevalence of OAG in men was double that in women (odds ratio 2.1; 95% CI 1.2, 3.6). Different commonly used criteria for diagnosis of OAG resulted in prevalence figures ranging from 0.1% to 1.2%.
CONCLUSIONS. The overall prevalence of OAG in the present study was comparable to most population-based studies. However, prevalence figures differed by a factor of 12 when their criteria for OAG were applied to this population. A definition for definite OAG is proposed: a glaucomatous optic neuropathy in eyes with open angles in the absence of history or signs of secondary glaucoma characterized by glaucomatous changes based on the 97.5 percentile for this population together with glaucomatous visual field loss. In the absence of the latter or of a visual field test, it is proposed to speak of probable OAG based on the 99.5th or possible OAG based on the 97.5th percentiles of glaucomatous disc changes for a population under study.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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The aim of the present study was to quantify in a masked way the prevalence of determinants of open-angle glaucoma (OAG) in a white population, to propose diagnostic criteria for OAG, and to study the influence of various diagnostic criteria for OAG on the prevalence of OAG. Because we did not specifically exclude pseudoexfoliation at baseline, we will further write about OAG instead of POAG.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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Ophthalmologic Examination
The ophthalmologic examination (Table 2
18
19
) was performed by three ophthalmologic
residents and two technicians. After perimetry, mydriatic drops were
administered in both eyes, irrespective of the anterior chamber angle
depth or history of glaucoma,20
for lens and fundus
examination, and photography. At the end of the first phase a miotic
(Table 2)
was administered in both eyes to counteract the mydriasis.
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Proposed Definitions for Probable and Possible Glaucomatous Optic
Neuropathies
Because cupping of the optic nerve head is the hallmark for
glaucomatous optic neuropathy (GON), we chose to use this term.
However, it does not imply that a person with GON definitely has
glaucoma.
Probable GON was defined as the presence of at least one of the following characteristics: a VCDR, or asymmetry in VCDR between both eyes, or minimum width of the neural rim equal to or surpassing the 99.5th percentile of the population concerned. Possible GON was defined as the above and greater than or equal to the 97.5th but less than the 99.5th percentile of the population.
Visual Field Screening and Determination
The visual field (VF) screening during the first phase (Table 2) reduced examination time and the chance of rim artifacts. Three or more
contiguously missed points on the screening test (
4 when blind spot
was included) were taken as evidence for a VF defect. In the case of a
defective or unreliable VF test, VFs were retested with the same
screening test in the second phase, about 2 weeks later. Subjects with
a VF defect or unreliable test in the second phase of the study
underwent kinetic Goldmann perimetry on both eyes, performed by a
skilled perimetrist in the third phase, some weeks later. Also, in
cases with a Goldmann VF defect gonioscopy was performed to exclude
cases with narrow angles. All subjects with glaucomatous VF defects had
normal open anterior chamber angles. VF testing was unreliable or
impossible in the institutionalized subjects, mainly due to physical
and mental disabilities.
All Goldmann VF charts were independently graded by six different graders (three senior ophthalmologists, two residents, one perimetrist) according to a special grading protocol. Graders were at first masked to all clinical data and optic disc appearances. Classification of the defects was solely based on the shape and localization of the defect. With regard to glaucomatous VF defects (GVFDs) special attention was put on a nasal step, paracentral defects, arcuate scotomas, central rests, remaining peripheral islands, and temporal nerve fiber bundle defects. For fields with inconsistent classifications (30%) a consensus was reached among the graders. The fundus and optic disc transparencies were examined in a masked way for clues for retinal causes of VF defects and, if present, for the expected location of the VF defect. For exclusion of other nonglaucomatous causes of VF defects all other data available in The Rotterdam Study was used, including questionnaire data on and neurologic examination of all subjects, and (history) data from general practitioners including reports from all medical specialists who had treated the subject in the past.
Definition of Glaucomatous VF Defect
Glaucomatous VF defect (GVFD) was as defined as any Goldmann VF
defect for which no other (neur)ophthalmologic cause could be found
(see previous paragraph), thus excluding, for example, hemianopias and
quadrantanopias.
Definitions for Definite, Probable, and Possible OAGs, Ocular
Hypertension, and Elevated IOP
The following OAG definitions hold for a subject in whom in one or
both eyes an open angle was present in the absence of a history or
signs of angle closure or secondary glaucoma.
Definite OAG is the presence of a GVFD in combination with at least possible GON.
Probable OAG is either the presence of a GVFD in the absence of a GON or the absence of a GVFD with a probable GON.
Possible OAG is the presence of possible GON in the absence of either a GVFD or a VF test.
For logistic reasons subjects underwent a glucose tolerance test (GTT; by the cardiovascular research group) approximately 20 minutes before IOP measurement in the first testing phase. This GTT was carried out by giving an oral glucose load of 75 g in 200 ml of water and was performed on all nondiabetic subjects who had not had a gastrectomy.
The IOP was not used in the definition of OAG, neither was the use of
IOP-lowering medication or the performance of an IOP-lowering (laser)
operation in the absence of our criteria for OAG. Elevated IOP was
defined as an IOP > 21 mm Hg or an IOP 
21 mm Hg with any
form of IOP-lowering treatment. Ocular hypertension was defined as an
IOP > 21 mm Hg (or 21 mm Hg with any IOP-lowering treatment) in
the absence of a GVFD or a GON. IOP values were adjusted for the
IOP-lowering effect of the GTT.
Data Analysis
Although the distribution of IOP and VCDR was not completely
gaussian we thought it sound to assume a normal distribution because of
the large numbers in our study. Their 97.5th and 99.5th percentiles,
also corrected for disc area quartiles and age strata, were
parametrically calculated for each eye separately for the whole cohort,
including the OAG cases. These percentiles were rounded up or down to
the closest one decimal but for the minimum neural rim width (to two
decimals), in an attempt to include all OAG cases. In analyses in which
Imagenet data were combined with ophthalmoscopic data, the latter was
only used when the Imagenet data were missing or unreliable
(n = 84).
Prevalence figures of GVFDs; definite, probable, and possible OAGs; elevated IOP; and ocular hypertension were calculated by 5-year age categories and by gender. Prevalence figures of definite, probable, and possible OAGs were calculated using disc data obtained by ophthalmoscopy, by Imagenet and both. To estimate the influence of age and gender on these prevalence figures, logistic regression analysis was used. The odds ratio (OR) was used in these analyses as an approximation of the relative risk. Sensitivity, specificity, and predictive values of different cutoff points for VCDR for the presence of a GVFD and, thus, OAG were calculated.
All analyses were adjusted for age and gender when appropriate and were performed separately for the independently living subjects and for those living in nursing homes.
Finally, definitions of definite OAG used in other population-based studies (Table 1) were, as far as available and common to those in our study, applied to our data.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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0.7 (as it was in a different substudy on this population
for the Heidelberg Retina Tomograph). The cutoff point for
asymmetry in VCDR between both eyes was 0.2 for both
ophthalmoscopy and Imagenet. The chosen cutoff points for
definitions of GON derived from Table 7 , thus were used for definitions
of OAG in the Rotterdam Study (Table 1)
.
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0.7. This prevalence increased to 38% in subjects
with a VCDR 0.8 and to 60% in subjects with a VCDR
0.9.
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IOP Distribution in this Population
Although IOP was not used for the diagnosis of OAG in this study,
we will present our data on IOP here for comparison with other studies.
Our IOP data were influenced by the GTT. The IOP-lowering effect of the
GTT was studied by comparing the IOPs of subjects who had undergone a
GTT with those of subjects who had not (those who refused and diabetic
subjects). Subjects with a GTT had a significantly lower mean IOP
(-1.13 mm Hg; 95% CI -1.41, -0.84) than subjects without GTT
(similar in diabetic subgroup and refuser subgroup). Unadjusted for the
effect of the GTT the mean IOP (subjects with IOP-lowering treatment
were excluded) was 14.5 mm Hg (95% CI 14.46, 14.61). After correction
for the IOP-lowering effect of the glucose solution, the mean IOP was
15.6 mm Hg (95% CI 15.48, 15.64). The cumulative distribution of IOP
(adjusted for the GTT) is shown in Figure 1
. There were no significant IOP differences between independently living
subjects and subjects in nursing homes (P = 0.185,
adjusted for age and gender), or between men and women, and there was
no clinically significant change in IOP with increasing age.
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On the other hand, of the 242 independently living subjects with
IOP-lowering treatment, only 13 (OR 8.7%; 95% CI 5.1, 12.2) had
definite OAG when using only ophthalmoscopic data, and 23 (9.5%, 95%
CI 5.8, 13.2) subjects had definite OAG using the combined Imagenet and
ophthalmoscopy data. The sensitivity of elevated IOP for detection of
OAG was calculated only in the newly diagnosed OAG cases (because
the IOPs at the time of diagnosis of the known OAG cases were not
available). The sensitivity was 11.1% (3 of 27 cases had an elevated
IOP) and the specificity 98.0% (5827 of 5943 subjects had no definite
OAG). The predictive value of an IOP > 21 mm Hg for the detection
of OAG was only 2.5%; the predictive value of an IOP 21 mm Hg
for its absence was 99.6%.
Figure 2 shows the variation in prevalence of OAG by age in our study, when OAG definitions from other large population-based studies were applied to our data. This resulted in prevalence figures varying between 0.1% and 1.4% in the youngest age-categories to prevalence figures between 0.9% and 5.9% in the oldest ones.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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When looking at Table 1 and reference 15, it seems that we have not made much progress in defining glaucoma since Donders coined the term glaucoma simplex in 1861.23 It, thus, seems like a risky enterprise to start defining criteria for POAG nearly 150 years later. On the other hand, it is clear also from Figure 2 that there is a need for valid comparisons between studies. Current variations in definition allow wide variations in prevalence data, as well as justification for treatment. In this study we define cutoff values for OAG determinants based on statistical grounds. This means that on arbitrary statistical grounds a division is made between normal and abnormal discs. We realize that this might be artificial and that some subjects may falsely be defined as healthy or abnormal. However, because of the large variation in OAG definitions in epidemiologic and/or clinical research, we think it is for the time being a good starting point to use such a definition for better comparison and pooling of study results. In due time further refinement of the definition may become possible when more incidence data become available. Using 97.5th or 99.5th percentiles to define abnormality does not mean that we used these criteria to define someone as being diseased. Only in combination with other signs we propose the term definite OAG. We felt that our database allowed for the definition of OAG on statistical grounds and that such an approach may become a starting point for future diagnostic fine-tuning. This may not be too far away because some large population-based studies are working on incidence data on POAG.
We did not fully exclude pseudoexfoliation as a cause of OAG during baseline examination and, thus, refer in this article to OAG instead of POAG. As no case of OAG in this cohort had pseudoexfoliation on follow-up clinical examination we feel that in practice we may assume that our data are valid as POAG data as did two studies that included pseudoexfoliation in the diagnosis of POAG.11 13
In this study we present prevalence figures for OAG combining GON
data obtained by Imagenet and ophthalmoscopy. We think the Imagenet
data are the more reliable data, especially for follow-up and
risk-factor analyses. However, because the Imagenet module for the
optic disc is not available any more, and neither is the simultaneous
stereoscopic Topcon TRC-SS2 camera, also essential for this module, we
also present prevalence figures based on only ophthalmoscopic optic
disc data for comparison with other studies. We found in a substudy
that Imagenet and the Heidelberg Retina Tomograph had much higher
correlations for the estimation of the VCDR than ophthalmoscopy,
showing that ophthalmoscopy is less reliable than these semiautomated
apparatuses, even carried out by trained examiners. Still we felt that
in daily practice ophthalmoscopy will be the method of choice during
the coming years. Therefore, in choosing cutoff points for the VCDR and
other disc measures we looked primarily at feasibility and tried to
choose cutoff points that were also ophthalmoscopically assessable.
Thus, to create as simple as possible a definition for OAG, based on
glaucomatous VF loss and GON, we propose as a cutoff point for a
statistically abnormal, and thus arbitrarily pathologic, possible GON a
VCDR 0.7, asymmetry in VCDR between both eyes 0.2 or
neuroretinal rim width < 0.1 for data obtained by ophthalmoscopy.
The latter was not assessed in this study by ophthalmoscopy but would
probably be necessary in other studies to detect discs with local
notching of the rim. From Tables 5 and 6
one may see that for the
largest discs the cutoff for pathologic VCDR might have been chosen
as 0.8, and the same holds for those 75 years of age and older.
All these subdivisions make the definition more and more complicated
and that is why we propose to keep as the cutoff point for a possible
GON a VCDR 0.7. It should be borne in mind that this definition
exists for the cohort studied and that for other cohorts and especially
different races this type of definition might have different values.
Hitherto, some studies did not specify whether one used information on IOP or disc measures to grade VF defects as glaucomatous.2 8 13 Two were masked in this respect9 11 and one was not.14 Similarly, before deciding whether a subject had OAG, all studies mentioned in Table 1 looked at the combined data of a case while we tried to do so by combining strictly defined determinants without subjective overall evaluation at the end. We believed that this would lead to less assessment bias. On the other hand, this resulted in small differences in prevalence of OAG when the Imagenet or ophthalmoscopy data were used.
Our overall prevalence of definite OAG of 0.8% (with combined use of Imagenet and ophthalmoscopic data; 0.7% when only using ophthalmoscopic data) and its rise with age are comparable with prevalence figures of the Framingham Study24 (1.2%), of The Baltimore Eye Survey7 (1.1%), and among the white subjects of the Barbados Eye Study9 (0.8%). The Beaver Dam Eye Study and the Blue Mountains Eye Study, on the other hand, found a higher overall prevalence, 2.1%8 and 3.0%,11 respectively. The prevalence of definite plus probable OAG in the Rotterdam Study was 3.2% and this may explain the gap. Several more reasons for these differences exist. All studies mentioned in Table 1 but the Egna-Neumarkt and the Rotterdam Study used for final assignment to glaucoma diagnosis a review of all data by one or more principal investigators, glaucoma specialists, or ophthalmologists. In this study we combined the VF and optic disc data, and this led straightforward to one of three diagnostic categories (apart from normals) without additional influence on the final results. The discrepancy with the Beaver Dam Study could be explained by their wider criteria for POAG. Other sources for differences between studies include sampling and perimetry techniques, screening methods for glaucoma, subjective interpretation of examination data, diagnostic criteria, age distributions, and real geographic contrasts in prevalence due to differences in lifestyle or genetic drift.
The VF screening and grading procedure in our study resulted in a prevalence of 1.5% of GVFDs compatible with OAG. This is comparable with the findings of the Framingham Study (1.4%, screening in a subset only, enlargement of blind spot excluded)25 but lower than that found in Australia (3.1%).11 The Blue Mountains Eye Study used, after screening, Humphrey full threshold perimetry (C30-2), which is more sensitive than kinetic Goldmann perimetry,26 especially in glaucoma where it might detect up to 21% more defects.27 Full threshold automated perimetry is nowadays considered to be the gold standard for VF examination, but at baseline in 1990 we felt that especially in older subjects it may create more false-positive errors compared with Goldmann perimetry. This might be because of poor fixation that accounted for 9% of inadequate Humphrey fields versus 2% at the Goldmann perimeter.27 Between threshold Humphrey perimetry and kinetic Goldmann perimetry there is 88% concordance when both tests appeared reliable.27 Because the Humphrey algorithms also have changed in the meantime and because we now perform both Humphrey 30-2 and Goldmann perimetry in the follow-up study, a more valid comparison between both methods will be possible within a year from now. It also has been shown that supra threshold perimetry identifies about two thirds of all cases identified by full-threshold perimetry.28 Using this latter test our prevalence of definite OAG might have risen to approximately 1.4%. Even then there still would have been a twofold difference in prevalence by comparison with the Blue Mountains Eye Study. Given the variation in techniques and differences between various studies we believe that conclusions on geographic differences are for the time being not justifiable.
Our study differed from other large population-based studies with
regard to the use of Imagenet to assess the optic nerve. Imagenet used
strict criteria for defining the cup margins, based only on topographic
data, thus reducing variation due to different observers. This makes it
also particularly interesting for follow-up studies.21
We
found a higher mean VCDR on Imagenet measurements (0.49) compared with
studies using other methods for examining the optic disc (mean VCDR
0.28,5
0.310
using ophthalmoscopy by several
examiners, 0.368
and 0.4311
by grading of
photographs). As a result, the prevalence of an enlarged VCDR was also
higher in our study than in other studies (VCDR 0.4: 76.7%
compared with 27.1%5
or 37.0%8
). However,
our prevalence of a VCDR 0.7 (5.1%) was only slightly
different from the findings of the Blue Mountains Eye Study
(5.0%), which examined stereo transparencies with a
viewer.11
Also, asymmetry in VCDR between both eyes
was more prevalent in our study, compared with findings of other studies (4.6% asymmetry 0.2,25
0.7%
asymmetry 0.311
).
The relation between OAG and gender is still controversial. In Framingham5 and Barbados9 a higher prevalence of POAG was found in men, which matched our finding. However, in the Blue Mountains Eye Study a (borderline significantly) higher OR of 1.55 for POAG was found for women,11 and in Baltimore7 and Beaver Dam8 no difference was found. It might be that in younger subjects the association between OAG and gender is not yet present. It would seem possible that if the study cohort had a greater proportion of younger subjects the gender risk would disappear.
Our study did not show any correlation between age, gender, or IOP. This is in contrast to previously published results,1 4 29 but is in agreement with others.1 5 8 Our findings do agree with prevalence data on IOP and VCDR in nursing home inhabitants.30 However, the response in the nursing homes was low, especially in the older subjects, increasing the risk of selection bias. This could explain our lower OAG prevalences compared with that study.30 One could adjust the prevalence rates for probable and possible OAGs in the nursing homes by raising them by 25% similar to the lower response rates in these homes than in the independently living subjects.
In conclusion, the overall prevalence of definite OAG in the Rotterdam Study was 0.8%, which is comparable to findings of other population-based studies on whites. The OR for men to have OAG was higher than for women. There was a significant increase in prevalence of OAG with increasing age. The overall prevalence of OAG varied 12-fold with different criteria and screening algorithms. We hope that standardizing diagnostic procedures and our proposed definitions will improve future (epidemiologic) glaucoma research.
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Appendix A |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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Acknowledgements |
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Footnotes |
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Submitted for publication February 11, 2000; revised April 27, 2000; accepted May 24, 2000.
Commercial relationships policy: N.
Presented at the annual meeting of the Association for Research in Vision and Ophthalmology, Fort Lauderdale, Florida, May, 1999.
Corresponding author: Paulus T. V. M. de Jong, The Netherlands Ophthalmic Research Institute, Meibergdreef 47, 1105 BA Amsterdam, The Netherlands. p.dejong{at}ioi.knaw.nl
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TopAbstractIntroductionMethodsResultsDiscussionAppendix AReferences |
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L. Vijaya, R. George, P. G. Paul, M. Baskaran, H. Arvind, P. Raju, S. V. Ramesh, G. Kumaramanickavel, and C. McCarty Prevalence of Open-Angle Glaucoma in a Rural South Indian Population Invest. Ophthalmol. Vis. Sci., December 1, 2005; 46(12): 4461 - 4467. [Abstract] [Full Text] [PDF]
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M. J. Hawker, S. A. Vernon, G. Ainsworth, J. G. Hillman, H. K. MacNab, and H. S. Dua Asymmetry in Optic Disc Morphometry as Measured by Heidelberg Retina Tomography in a Normal Elderly Population: The Bridlington Eye Assessment Project Invest. Ophthalmol. Vis. Sci., November 1, 2005; 46(11): 4153 - 4158. [Abstract] [Full Text] [PDF]
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J. C. Charlesworth, T. D. Dyer, J. M. Stankovich, J. Blangero, D. A. Mackey, J. E. Craig, C. M. Green, S. J. Foote, P. N. Baird, and M. M. Sale Linkage to 10q22 for Maximum Intraocular Pressure and 1p32 for Maximum Cup-to-Disc Ratio in an Extended Primary Open-Angle Glaucoma Pedigree Invest. Ophthalmol. Vis. Sci., October 1, 2005; 46(10): 3723 - 3729. [Abstract] [Full Text] [PDF]
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S. A. Vernon, M. J. Hawker, G. Ainsworth, J. G. Hillman, H. K. MacNab, and H. S. Dua Laser Scanning Tomography of the Optic Nerve Head in a Normal Elderly Population: The Bridlington Eye Assessment Project Invest. Ophthalmol. Vis. Sci., August 1, 2005; 46(8): 2823 - 2828. [Abstract] [Full Text] [PDF]
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M. K. Ikram, S. de Voogd, R. C. W. Wolfs, A. Hofman, M. M. B. Breteler, L. D. Hubbard, and P. T. V. M. de Jong Retinal Vessel Diameters and Incident Open-Angle Glaucoma and Optic Disc Changes: The Rotterdam Study Invest. Ophthalmol. Vis. Sci., April 1, 2005; 46(4): 1182 - 1187. [Abstract] [Full Text] [PDF]
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E. Skenduli-Bala, S. de Voogd, R. C. W. Wolfs, R. van Leeuwen, M. K. Ikram, J. B. Jonas, D. Bakker, A. Hofman, and P. T. V. M. de Jong Causes of Incident Visual Field Loss in a General Elderly Population: The Rotterdam Study Arch Ophthalmol, February 1, 2005; 123(2): 233 - 238. [Abstract] [Full Text] [PDF]
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 M. Tatemichi, T. Nakano, K. Tanaka, T. Hayashi, T. Nawa, T. Miyamoto, H. Hiro, and M. Sugita Possible association between heavy computer users and glaucomatous visual field abnormalities: a cross sectional study in Japanese workers J Epidemiol Community Health, December 1, 2004; 58(12): 1021 - 1027. [Abstract] [Full Text] [PDF]
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M M Rahman, N Rahman, P J Foster, Z Haque, A U Zaman, B Dineen, and G J Johnson The prevalence of glaucoma in Bangladesh: a population based survey in Dhaka division Br. J. Ophthalmol., December 1, 2004; 88(12): 1493 - 1497. [Abstract] [Full Text] [PDF]
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M. K. Ikram, F. J. de Jong, J. R. Vingerling, J. C. M. Witteman, A. Hofman, M. M. B. Breteler, and P. T. V. M. de Jong Are Retinal Arteriolar or Venular Diameters Associated with Markers for Cardiovascular Disorders? The Rotterdam Study Invest. Ophthalmol. Vis. Sci., July 1, 2004; 45(7): 2129 - 2134. [Abstract] [Full Text] [PDF]
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The Eye Diseases Prevalence Research Group Prevalence of Open-Angle Glaucoma Among Adults in the United States Arch Ophthalmol, April 1, 2004; 122(4): 532 - 538. [Abstract] [Full Text] [PDF]
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J. A. Landers, I. Goldberg, and S. L. Graham Detection of Early Visual Field Loss in Glaucoma Using Frequency-Doubling Perimetry and Short-Wavelength Automated Perimetry Arch Ophthalmol, December 1, 2003; 121(12): 1705 - 1710. [Abstract] [Full Text] [PDF]
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A J Lee, P Mitchell, E Rochtchina, and P R Healey Female reproductive factors and open angle glaucoma: the Blue Mountains Eye Study Br. J. Ophthalmol., November 1, 2003; 87(11): 1324 - 1328. [Abstract] [Full Text] [PDF]
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M Kroese and H Burton Primary open angle glaucoma. The need for a consensus case definition J Epidemiol Community Health, September 1, 2003; 57(9): 752 - 754. [Abstract] [Full Text] [PDF]
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R R A Bourne, P Sukudom, P J Foster, V Tantisevi, S Jitapunkul, P S Lee, G J Johnson, and P Rojanapongpun Prevalence of glaucoma in Thailand: a population based survey in Rom Klao District, Bangkok Br. J. Ophthalmol., September 1, 2003; 87(9): 1069 - 1074. [Abstract] [Full Text] [PDF]
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B. Nemesure, S.-Y. Wu, A. Hennis, and M. C. Leske Factors Related to the 4-Year Risk of High Intraocular Pressure: The Barbados Eye Studies Arch Ophthalmol, June 1, 2003; 121(6): 856 - 862. [Abstract] [Full Text] [PDF]
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C. A. A. Hulsman, J. J. Houwing-Duistermaat, C. M. van Duijn, R. Wolfs, P. H. Borger, A. Hofman, and P. T. V. M. de Jong Family Score as an Indicator of Genetic Risk of Primary Open-Angle Glaucoma Arch Ophthalmol, December 1, 2002; 120(12): 1726 - 1731. [Abstract] [Full Text] [PDF]
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A Wegner A few remarks about glaucoma Br. J. Ophthalmol., August 1, 2002; 86(8): 836 - 837. [Full Text] [PDF]
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A. P. Rotchford and G. J. Johnson Glaucoma in Zulus: A Population-Based Cross-sectional Survey in a Rural District in South Africa Arch Ophthalmol, April 1, 2002; 120(4): 471 - 478. [Abstract] [Full Text] [PDF]
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P. J Foster, R. Buhrmann, H. A Quigley, and G. J Johnson The definition and classification of glaucoma in prevalence surveys Br. J. Ophthalmol., February 1, 2002; 86(2): 238 - 242. [Abstract] [Full Text] [PDF]
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R. S. Ramrattan, R. C. W. Wolfs, S. Panda-Jonas, J. B. Jonas, D. Bakker, H. A. Pols, A. Hofman, and P. T. V. M. de Jong Prevalence and Causes of Visual Field Loss in the Elderly and Associations With Impairment in Daily Functioning: The Rotterdam Study Arch Ophthalmol, December 1, 2001; 119(12): 1788 - 1794. [Abstract] [Full Text] [PDF]
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 C. A. A. Hulsman, I. C. D. Westendorp, R. S. Ramrattan, R. C. W. Wolfs, J. C. M. Witteman, J. R. Vingerling, A. Hofman, and P. T. V. M. de Jong Is Open-Angle Glaucoma Associated with Early Menopause? : The Rotterdam Study Am. J. Epidemiol., July 15, 2001; 154(2): 138 - 144. [Abstract] [Full Text] [PDF]
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