Research Article National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 15-19

Glaucoma and Diabetes- Is there an association?

Jain ShashiA, Lakhtakia SujataB,Tirkey Eva RaniC, Jain Sheel ChandraD
AProfessor & head Department of Ophthalmology, S. S. Medical College, Rewa
BAssistant Professor Department of Ophthalmology, S. S. Medical College, Rewa
CAssociate Professor Department of Ophthalmology, S. S. Medical College, Rewa
DRetd. Professor Ophthalmology & Senior Consultant, Anupam Nursing Home
Abstract:
Manuscript Reference
Number: Njmdr_2412_14

Background: Glaucoma and diabetes mellitus both diseases have now emerged as
the leading causes of irreversible blindness. Potential association between diabetes
mellitus and primary open angle glaucoma has been a subject of much debate and
results from various studies and publications have both confirmed and denied this
positive correlation. Since the burden of blindness from both these diseases on the
patients and society is expected to increase due to increase in population, longevity
and alarming rise in incidence of DM, it is important to know if a significant association
exists between them.
Aims: Purpose of the study was to find any positive correlation between DM and
POAG.
Design: Prospective cross sectional random analysis
Material And Methods: Present study was done on 500 confirmed diabetics and 300
confirmed POAG patients who were evaluated for presence of POAG and prevalence
of DM respectively and compared with 300 age matched healthy subjects. Blood
sugar estimation, applanation tonometry, automated perimetry and optic nerve
head evaluation were done for assessment of diabetetic status and glaucoma. POAG
was defined on the basis of glaucomatous visual field defects matching disc changes.
Results: Incidence of primary open angle glaucoma was 9.3 % in diabetics compared
to 7% in control group, and 10% of POAG patients had DM against 7.3% in controls.
Number of subjects having ocular hyper tension was higher in diabetes (4%) than
control group (1%).
Conclusion: In our study no significant association could be established between
diabetes mellitus and primary open angle glaucoma.

Date of submission: 20 September 2014

Date of Editorial approval: 22 September 2014
Date of Peer review approval: 26 September 2014

Key Words: Primary open angle glaucoma (POAG), Diabetes mellitus (DM), Disc
changes, IOP.

Date of Publication: 30 September 2014

Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr. Shashi Jain,
Anupam Nursing Home,
Behind PK School, Rewa,486 001, MP, India
Tel. No.- 9425194657
E-mail shashimala5@yahoo.com
Source(s) of support: None

Introduction:
Primary open angle glaucoma (POAG)
is a chronic, bilateral often asymmetric
progressive
optic
neuropathy,
characterized by morphological changes
at optic nerve head (ONH) and retinal
nerve fibre layer with/without raised

15

intraocular pressure (IOP). It accounted

for 60.5million people in the world in
2010 and this was projected to increase
to 79.5 million worldwide by 2020 [1]. In
India, the prevalence of glaucoma has been
reported to range between 2%- 13% [2].
The estimated risk of blindness from POAG
ranges from 14.5% to 27% (unilateral) and

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 15-19

from 7% to 9% (bilateral) [3 5].

- Gonioscopic finding of occludable angle in either eye

- Visual field defects not compatible with OAG

Elevated IOP has been consistently shown to be a risk factor

for POAG. Other factors which have been said to have an
association with POAG are corneal thickness, age, race,
myopia, cardiovascular diseases and pseudoexfoliation,
of which only IOP can be effectively modulated [6, 7].
Another possible factor that can be influenced is Diabetes
Mellitus (DM).
Diabetes is a highly prevalent condition resulting in major
medical problems throughout the world. It causes an array
of long term systemic and ocular complications [8] which
have considerable impact on both patients and society
because it typically affects individuals in their productive
years. Common ocular manifestations are cataract, vascular
complications and degenerative changes. Of these, diabetic
retinopathy (DR), a microvascular complication has now
emerged as a potential cause of blindness. In addition,
many reports point to an increased incidence of POAG in
DM [9, 10].
The influence of blood glucose on IOP and the effect of
increased IOP on appearance and progression of diabetes
have been widely studied. Some studies have found
an association between diabetes and POAG in general
population while others have not. Thus, a question arises
as to whether diabetes is a risk factor for glaucoma or it is
merely a chance occurrence of both in elderly people.
The present work was designed to evaluate the relationship
between primary open angle glaucoma and diabetes
mellitus in a hospital based population.

Patients and Methods:

The current prospective study was performed on 300 patients
with a confirmed diagnosis of POAG and 500 confirmed
diabetics presenting to the Department of Ophthalmology
directly or through referral from Department of Medicine,
between November 2006 and May 2009 with 300 age and
gender matched apparently healthy individuals as controls.

Exclusion criteria for POAG Group:

Exclusion criteria for DM group:

- History of DM <10 years
- Type 1 DM (IDDM)
- History of laser treatment for diabetic retinopathy
All patients with significant media opacity which obstructed
fundus examination and fields with low test reliability were
also excluded from the study
After written informed consent, a detailed history was
taken with regard to both diabetes and glaucoma. The
best corrected visual acuity was noted. A complete
ophthalmological examination was done. Deposition
of any pseudo exfoliative material, any sign of uveitis,
neovascularisation of iris, hyphema or other signs of trauma
were noted and appearance of angle was assessed by Van
Herricks method. Posterior segment evaluation was done
by direct ophthalmoscope, indirect ophthalmoscopy and
slit lamp biomicroscopy with 90D lens. Examination of
angle of anterior chamber was done by gonioscopy using
Goldmann single mirror contact lens. Intraocular pressure
was measured by applanation tonometry and visual fields
were analyzed by Humphrey Field Analyzer.
Glaucomatous changes of optic nerve head included
cup: disc ratio of 0.5:1 or more, asymmetry of cups >0.2
between both eyes, nasalization of vessels, bayoneting
and baring of circum-linear vessels, thinning of neuro
retinal rim, disturbed ISNT rule and laminar dot sign.
Retinal nerve fibre layer defects (slit, wedge and diffuse
loss) were also taken into consideration when diagnosing
glaucomatous changes. Visual field examination was
done using 30-2 programme and size III stimulus. Fields
fulfilling the criteria for reliability indices and those which
were reproducible on two consecutive occasions were
included in the study. Glaucomatous fields were diagnosed
on the basis of Andersons criteria.
Diabetic status of both subjects and controls was assessed
by blood glucose levels. Individuals presenting with borderline values underwent a glucose tolerance test (GTT) for
further confirmation.

- Secondary open angle glaucoma (uveitis, trauma, pigment

dispersion syndrome, exfoliation syndrome, rubeosis)

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 15-19

Confirmation of glaucoma:
POAG was diagnosed on the basis of glaucomatous visual
field defects, matching disc changes (without any other
abnormality that could have caused the visual field defect)
regardless of IOP with open angle of anterior chamber.
Patients with IOP >22 mm of Hg without evidence of ONH
changes and field changes typical of POAG were labelled
as having Ocular Hypertension.

Diagnosis of diabetes:
DM was confirmed either by a positive history of previously
diagnosed / treated diabetes (on record) or by post prandial
blood glucose level >140 mg%.
Observations:
Table 1: Demographic profile of study population
AGE(in years)

DM

POAG

CONTROL

40 49
50 59
60 69
>70
Total
SEX
Male
Female
Total

52
212
170
66
500

264
236
500

14
56
134
96
300

132
168
300

54
108
90
48
300

135
165
300

DMn=250
26 %(130)

54%(162)

16 22

62 %(310)

38%(114)

>22

12 %(60)

8%(24)

Total

100 %(500)

100%(300)

Table 3: Prevalence of diabetes in glaucoma and

control group
DM ASSESSMENT

POAG .(n=300)

CONTROL (n=300)

PPBS (>140 mg%)

6.6% (20)

6% (18)

GTT (Positive)

2.6% (08)

2% (06)

TOTAL

9.3% (28)

8% (24)

Table 4: Prevalence of Glaucoma in diabetics and

control group
GLAUCOMA
ASSESSMENT

DIABETIC Group
(n=500)

CONTROL Group
(n=300)

Definite Glaucoma

10% (50)

7.6% (23)

Ocular Hypertension

4% (20)

1% (3)

A definite diagnosis of glaucoma was made in 10% of

patients with diabetes and in 7% of healthy subjects.
The incidence of diabetes did not show any significant
difference (p= 0.6), being 9.2% in POAG patients and 8%
in the control group.
Ocular hypertension was seen in 4% of diabetic patients
as against 1% in controls. This difference was statistically
significant (p = 0.03)

Glaucoma is the second leading cause of blindness

worldwide. Being a progressive disease it has a substantial
impact on the daily functioning of people. Among various
risk factors, influence of DM over glaucoma still remains
controversial. Diabetes mellitus has now emerged as a
major public health problem, and an alarming increase in
disease burden is projected by 2025. Number of people
with diabetes in India is currently around 40.9 million and
is expected to rise to 69.9 million by 2025 unless urgent
preventive steps are taken [8]. If a true positive relation
exists between these two entities, it would be important to
know about it now since the burden of both these diseases
on the patient and society is expected to increase due to
increase in population, longevity and rise in incidence of
DM.

CONTROLn=100

<16

The applanation IOP values between 1622 mm Hg were

observed in 62% of diabetics as against 38% of control
group while IOP values >22 mm Hg were seen in 12% of
diabetics and in 8% of the control group. (Table no. 2)

Discussion:

Table 2: Intra Ocular Pressure measurement in DM

and control groups
IOP(mm Hg)

there was no significant sex predilection with male:female

ratio being1.1:1. Among 300 glaucoma patients, the highest
number was in the age group of 60-69 yrs (44.6%) with
female preponderance (60%). (Table no. 1)

Our study included 500 diabetics of which maximum

patients (42.4%) were in the age group of 50-59 years and

In the present study, the prevalence of diabetes was not

significantly different in patients with POAG and in the
control group. Similar observations have also been made
by Mapstone R et al [11] who reported that the proportion
of abnormal response to GTT in OAG was not significantly
different from that in control group (x2=0.02, p>0.5).
Wilson Hertzmark E et al [12] compared 204 patients of
probable and definite glaucoma with 237 control subjects
and found the incidence of diabetes to be 4.9% and 6.7%
respectively, there by suggesting a weak association.

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 15-19

In contrast, The Blue Mountain Study by Mitchell P

et al [7], confirmed a positive association between DM
and POAG. They found glaucoma prevalence of 5.5% in
diabetics as compared to 2.8% in those without diabetes.
The study also reported 13% prevalence of diabetics in
glaucoma patients compared with 6.9% of those without
glaucoma.
When we studied the difference in the prevalence of POAG
in patients with diabetes and control subjects, we found
that the difference was not statistically significant between
diabetics and controls. This is in accordance with results
of the Framingham Eye Study by Kahn HA et al [13], who
screened 2315 subjects and found direct relation with blood
glucose and IOP (15.3% diabetics had IOP>21mmHg
compared with 9.3% for group as whole). However, no
significant relation could be established between diabetes
and glaucoma, with only 2% of the test population having
clinical diagnosis of POAG. Similar observations were
made in The Baltimore Eye Survey by Thielsch JM et al
[10] A total of 5308 subjects were studied, of which 161
were diagnosed as POAG and 717 as diabetics. Diabetes
was associated with higher IOP 18.5mm versus 17.5mm
in subjects without diabetes but difference was not large.
Ellis JD et al [14] evaluated 6631 diabetics and 166144
non diabetics subjects and reported an incidence of
POAG in diabetes of 1.1/1000 patient years compared to
0.7/1000 patient years in non diabetic group, thus denying
any association. The Rotterdam Study by Voogd S et al
[15] examined 3837 participants without glaucoma and
found relative risk of POAG associated with diabetes to be
0.65(0.25-1.64) after a mean follow up time of 6.5 years.
They concluded in this population that DM is not a risk
factor for glaucoma.
However, The Beaver Dam Eye Study by Klien BEK et
al [16] studied a population of 4926 for the presence of both
definite and probable glaucoma and found that frequency
of definitive glaucoma was significantly higher in diabetics
(4.2%) than non diabetics (2%). Similar relation was found
with probable glaucoma (3.5% versus 1.9%). Also, The
Blue Mountain Study by Mitchell Paul et al [7] reported
an increased prevalence of OAG in diabetic patients.
In our study, IOP values between 1622 mm Hg were
observed more (62%) in diabetics as against control
group (38%). Higher IOP in diabetics was also reported
in Framingham Eye Study (1980) by Kahn HA et al [13].
Ida Dielemans et al [17] in their study on 4178 participants

to study the relation of glaucoma and IOP with newly

diagnosed DM, concluded that elevated serum glucose
level was associated with higher mean IOP and high tension
glaucoma. Ocular hypertension was also more common in
people with diabetes (6.7%), compared with those without
diabetes (3.5%; OR 1.86, CI 1.093.20)
Mechanism of the association between hyperglycaemia
and IOP is possibly that the elevated blood glucose level
in DM may induce osmotic gradient and attract fluid in to
intraocular space, resulting in an elevated IOP or reducing
coefficient of out flow with increasing severity of DR.
The possible reason given by authors supporting the
association between diabetes and primary open angle
glaucoma is that hyperglycaemia and premature aging in
diabetics increases the susceptibility of optic nerve head
to pressure induced damage. Another explanation was that
glycosylation of extracellular matrix protein in trabecular
meshwork reduces the outflow facility in diabetic patients
[18].
The disparity in results of those denying a correlation
between DM and POAG and those supporting it could
be due to various reasons. One may be glaucoma case
misclassification among subjects (as development of visual
field loss in diabetics may mimic glaucoma) or different
definitions and varying criteria for diagnosis. Another may
be the variations in diagnostic criteria for diabetes such as
self- reported cases, medication use and fasting/non-fasting
/ post-load blood glucose levels. Besides this, selection bias
in cases could also be a factor as some studies have been
conducted only on females and some others on Caucasians
only.
Additionally people with DM tend to be under more
medical scrutiny than non-diabetics. Diabetics visit their
ophthalmologists more often to check for DR and so may
be more frequently diagnosed with POAG thus pointing to
a chance association between DM and POAG rather than
an actual correlation.

Conclusion:
The prevalence of both diabetes mellitus and primary open
angle glaucoma is increasing and the diagnosed cases
represent the tip of iceberg only. The association between
both these diseases has been recognized for many years but

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 15-19

it remains controversial because of conflicting results in

various studies.
In our study, we could not find a definite relationship
between POAG and DM and it is probably a chance
detection of glaucoma in diabetics because of their
frequent ophthalmic check-ups. Any relationship between
these two diseases is important to consider since diabetes
is fast gaining the status of a potential epidemic in India
with more than 62 million diabetic individuals currently
diagnosed with the disease and glaucoma is a major cause
of irreversible blindness. Also, since further insights
are being gained into the aetiopathogenesis of POAG
in diabetes, further research with larger study groups is
needed to conclusively define the presence of a positive
and significant correlation between diabetes mellitus and
primary open angle glaucoma.

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