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Several factors have been found to affect intraocular preventive-therapeutic measures when they are most
pressure (lOP), including venous and arterial blood pres- beneficial. The identification of high-risk groups through
sure, heart rate, diurnal or seasonal variations and cor- studies like this will make the application of this screening
ticosteroid levels in plasma. 1-4 The effects of age and gen- method more efficient.
der are unclear, and conflicting findings were re-
ported. I ,2,4-8 It has been reported that the lOP in various
populations is slightly skewed to the right. 2,6,7,9
This study analyzed a large, presumably healthy pop- MATERIALS AND METHODS
ulation in Israel, composed of a mixture of employed
individuals from many employment sources and of several STUDY POPULATION
ethnic groups. It was aimed at determining some of the Between 1977 and 1980, approximately 13,000 em-
factors associated with increased lOP. A non-contact to- ployed subjects, aged 40-75 years, underwent compre-
nometer (NCT) was used. The ease and the low cost of hensive health examinations in a multiphasic screening
lOP measurement with the NCT IO, permits mass screening center. These examinations included many physical,
for ocular hypertension (OH), early identification of per- physiological, biochemical and anamnestic parameters.
sons with OH or glaucoma and early introduction of Most of the examinees were referred for routine testing
or for periodic health examinations from large industries
and corporations. The screening tests and examinees were
From the MOR Institute for Medical Data, Department of Preventive and previously described in detail. II ,I2
Social Medicine,· the Department of Physiology and Pharmacology, Sackler The age-sex distribution of the study population is
School of Medicine, Tel Aviv University,t and Maurice and Gabriela Gold- shown in Table 1. The relative age distribution within
schleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.t
each sex group is quite similar in both sexes. This relative
Presented at the Eighty-eighth Annual meeting of the American Academy age distribution (except for the somewhat low presentation
of Ophthalmology, Chicago, Illinois, October 3Q-November 3, 1983. in the study sample of people over 65 years of age, and
Reprint requests to Amos D. Korczyn, MD, Dept. of Physiology and excessive representation of males aged 40-44) was pre-
Pharmacology, Sackler School of Medicine, Tel Aviv University, Israel. viously analyzed and compared to that of the general
311
OPHTHALMOLOGY • APRIL 1984 • VOLUME 91 • NUMBER 4
Table 1. Age-sex Composition of the Study Group found (Carel, Rock, and Korczyn, in preparation) and
and the Mean lOP (±SO) the mean lOP commonly serves as a valid representative
value. 1,2,4
Age Group
(Years) Males Females Total
312
CAREL, et al • FACTORS AFFECTING lOP
significantly to the regression equation or multiple cor- Table 3. Multiple Regression of lOP on the Various Relevant
relation coefficient. Age was the fourth contributing factor Parameters for the Whole Population
but it did not change the multiple R value at all (R = 0.20
and P = 0.22). Multiple
25 MALES
FEMALES ---------
20
15 ,,
,
,'/
10 ,,
,I'
5 / "
,I','
,','
2 8 10 12 14
IO P (mmHg)
Fig 1. Distribution of lOP values of the 12.803 examinees, expressed as percentages for males and females. Note the skewness towards higher
values.
313
OPHTHALMOLOGY • APRIL 1984 • VOLUME 91 • NUMBER 4
Several factors could account for the relationship be- coma suspects in a defined population. Br J OphthalmoI1966; 50:570-
tween lOP and HR or SBP. SBP could increase the fil- 86.
3. Kahn HA, Leibowitz HM, Ganley JP, et al. The Framingham Eye
tration pressure in the eye and thus lOP, but this is an
Study. II. Association of ophthalmic pathology with single variables
unlikely explanation since the correlation of lOP was previously measured in the Framingham Heart Study. Am J Epidemiol
stronger with HR than with SBP. A common mechanism 1977; 106:33-41.
could account for the increase of all three, such as sym- 4. Klein BE, Klein R. Intraocular pressure and cardiovascular risk variables.
pathetic tone, serum corticosteroids or sclerotic changes Arch Ophthalmol1981; 99:837-9.
occurring both in arteries and in the outflow channels 5. Kahn HA, Leibowitz HM, Ganley JP, et al. The Framingham Eye
from the eye. Whatever the mechanism, it should be Study. I. Outline and major prevalence findings. Am J EpidemioI1977;
stressed that its contribution-though highly significant 106:17-32.
statistically-is quantitatively small. Therefore other 6. Armaly MF. On the distribution of applanation pressure. I. Statistical
factors (ie, genetic) must be responsible for the skewness features and the effect of age, sex, and family history of glaucoma.
to the right of the lOP value distribution observed in Arch Ophthalmol 1965; 73: 11-8.
7. Leydhecker W. The intraocular pressure: clinical aspects. Ann
Figure 1.
Ophthalmol 1976; 8:389-99.
The effect on lOP of parameters other than age and 8. Armaly MF. Age and sex correction of applanation pressure. Arch
BP was investigated earlier. HR was previously found to Ophthalmol 1967; 78:480-4.
be related to IOP. 3 ,4 The negative correlation ofIOP with 9. Bankes JLK, Perkins ES, Tsolakis S, Wright JE. Bedford glaucoma
height was demonstrated by Kahn and associates. 3 Positive survey. Br Med J 1968; 1:791-6.
(low) correlation of lOP with smoking habits was shown 10. Forbes M, Pico G Jr, Grolman B. A noncontact applanation tonometer;
by Morgan and Drance (13). Others have shown lOP to description and clinical evaluation. Arch Ophthalmol 1974; 91: 134-
be correlated with blood sugar or diabetes. 3,15 The rela- 40.
tionships of these and other predisposing factors to disease 11. Carel RS, Leshem G. Evaluation of the cost-effectiveness of an au-
occurrence or development, is reminiscent of the known tomated multiphasic health testing system. Prev Med 1980; 9:689-
97.
web of causation in cardiovascular diseases. 16 This concept
12. Tartakovsky MB, Carel RS, Luz Y. A comparison of the body height
could be beneficial in investigating epidemiologic, etio- of the Israeli-born and immigrants to Israel. Hum Hered 1983;
logic and intervention problems related to OH and glau- 33:73-8.
coma. 13. Morgan RW, Drance SM. Chronic open-angle glaucoma and ocular
hypertension; an epidemiological study. Br J Ophthalmol 1975;
59:211-5.
14. Kaskel 0, Baumgart W, Metzler U, Fink H. Blood pressure, blood
REFERENCES flow and intraocular pressure. Ophthalmic Res 1974; 6:338-45.
15. Becker B. Diabetes mellitus and primary open-angle glaucoma. Am
1. Bengtsson B. Some factors affecting the distribution of intraocular J Ophthalmol1971; 71:1-16.
pressures in a population. Acta Ophthalmol 1972; 50:33-46. 16. Friedman GO. Primer of Epidemiology, 2nd ed. New York: McGraw-
2. Hollows FC, Graham PA. Intra-ocular pressure, glaucoma, and glau- Hill, 1980; 3-4.
Discussion
by
R. Stamper, MD
The authors have presented an epidemiologic study of intra- height, were small but statistically significant because of the
ocular pressure in a "healthy", working population aged 40- large numbers in the study (12,800). Some other small corre-
75 years. They correlated the intraocular pressures with age, lations were also demonstrated, such as smoking, blood glucose
sex, ethnicity, heart rate, blood pressure, serum glucose, serum and blood hemoglobin. The clinical significance of these findings
cholesterol, serum uric acid, smoking habits, height, and weight. is questionable.
They found that intraocular pressure correlated only weakly While the total numbers are large enough to make a small
with age. In fact, when they used multivariate analysis to factor correlation statistically significant, the relatively small numbers
out the more significant correlations, the weak correlation with in the higher risk groups (i.e., >65) may have contributed to
age could be explained entirely on the basis of the independent their conclusion that lOP does not increase with age. Presumably
association of those factors (i.e. systolic blood pressure and heart excluded were those at the higher end of blood pressure readings
rate) with age. The positive correlations with systolic blood pres- and blood glucose levels, as these persons may have less like-
sure and heart rate, as well as the negative correlation with lihood of working. This may also have biased their results.
314