Clinical Ophthalmology Dovepress

open access to scientific and medical research

Open Access Full Text Article O r i g i nal Resea r c h

The association between primary open-angle

glaucoma and fall: an observational study

This article was published in the following Dove Press journal:

Clinical Ophthalmology
1 March 2012
Number of times this article has been viewed

Sachiko Tanabe 1,2* Purpose: Falls are among the most serious public health concerns for the elderly. Information
Kenya Yuki 1* conveyed via the visual sense is relevant to postural balance and movement, and proper visual
Naoki Ozeki 1 function is essential to avoid falls. Here we investigated the prevalence of injurious falls among
Daisuke Shiba 1 patients with primary open-angle glaucoma (POAG) who were more than 45years old, compared
Kazuo Tsubota 1 with comparably aged healthy subjects.
Methods: This is a cross-sectional study. Consecutive patients who visited the Tanabe Eye
1
Department of Ophthalmology,
Keio University School of Medicine,
Clinic, Yamanashi, Japan between January 1 and March 30, 2009 were screened for eligibility
Shinanomachi 35, Tokyo, Japan; by ophthalmic examination. A total of 117 control subjects (77 men, 40 women; aged
2
Tanabe Eye Clinic, Kai City, 60.27.5years) who were free of ocular disease and 101 POAG patients (58men, 43 women;
Yamanashi, Japan
aged 62.3 8.7 years) were consecutively enrolled. Participants answered a questionnaire
*These authors contributed equally on injurious fall experience during the previous 10years. The prevalence of injurious fall in
to this work
subjects with POAG versus healthy controls was examined with Fishers exact test. Adjusted
odds ratios and 95% confidence intervals were estimated with logistic regression models for the
subjects with POAG (factors: age, gender, mean deviation in the better eye or worse eye).
Results: The self-reported prevalence of injurious fall was 0.9% (1/117) in the control group
and 6.9% (7/101) in the POAG group. The association between injurious fall and POAG was
statistically significant (P=0.026, Fishers exact test). Within the POAG patients, the group
reporting falls was significantly older and had a lower BMI, worse BCVA, and worse mean
deviation in both the better and worse eye than the group reporting no falls. Worse mean deviation
in the eye with the better visual field (odds ratios 0.75; 95% confidence intervals: 0.57 to 0.99;
P=0.036) was a significant risk factor for injurious falls in subjects with POAG.
Conclusions: POAG was significantly associated with injurious falls.
Keywords: primary open-angle glaucoma, fall, visual field defect, injury

Introduction
Falls are among the most serious public health concerns for the elderly, worldwide.
About 30% of individuals over the age of 75years fall at least once in a year; 10%20%
of the falls lead to injury, and 5%6% result in fractures.1,2 Falls are associated with
restricted activity,3 hospitalization,4 subsequent admission to a nursing home,5 and
Correspondence: Kenya Yuki injury-related death.68
Department of Ophthalmology, Glaucoma is the second leading cause of blindness in the world, affecting
Keio University School of Medicine,
35 Shinanomachi, Shinjuku-ku,
approximately 5million adults globally; it is the leading cause of blindness in Japan.9,10
Tokyo, 160-8582, Japan A previous study reported that glaucoma is not diagnosed in 93.3% of Japanese people
Tel +81 333 531 211, ext 63919
Fax +81 333 598 302
with the disease, even though they have significant visual field defects.10 Furthermore,
Email yukikenya@a6.keio.jp many of those with diagnosed glaucoma have little awareness of the disease, probably

submit your manuscript | www.dovepress.com Clinical Ophthalmology 2012:6 327331 327

Dovepress 2012 Tanabe etal, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
http://dx.doi.org/10.2147/OPTH.S28281 which permits unrestricted noncommercial use, provided the original work is properly cited.
Tanabe etal Dovepress

because the visual field loss in many cases occurs only in the The objective of this study was to investigate the
peripheral areas, and visual acuity is preserved for a relatively prevalence of injurious falls among patients with POAG who
long period. This implies that many patients with glaucoma were more than 45years old, in comparison with comparably
do not realize that they have visual field defects. aged healthy subjects.
Several factors, such as age, gender, postural hypotension,
the use of multiple medications, impairment of cognition, Patients and methods
balance, gait,2 or vision,1115 increase the risk of falling and The procedures used in this study conformed to the tenets
fall-related injuries. Information conveyed via the visual of the Declaration of Helsinki and to national (Japanese)
sense is relevant to postural balance16 and movement,17 and and institutional (Keio University School of Medicine)
proper visual function is essential for avoiding a fall. regulations. This study was approved by the Ethics
In a large-scale prospective cohort study, Coleman etal Committee of the Keio University School of Medicine.
reported that 13% of the subjects with no bilateral visual
field loss reported falling, compared with 16%, 19%, and Study design and subject enrollment
22% of subjects with mild, moderate, and severe bilateral The design of this cross-sectional study and subject enrollment
visual field loss, respectively, and this trend was statistically procedures are summarized in Figure1. Those who visited
significant.14 In the Salisbury Eye Evaluation Project, subjects the Tanabe Eye Clinic, Yamanashi, Japan between January
with bilateral, not unilateral, glaucoma had more trouble 1 and March 30, 2009 were screened for eligibility by means
performing balance tasks and bumped into objects more of an ophthalmic examination that included slit-lamp bio-
frequently.18 However, the association between injurious microscopy, funduscopy, gonioscopy, intraocular pressure
fall and primary open-angle glaucoma (POAG) has not been measurements with Goldmann applanation tonometry, and
fully investigated. visual field examination with a static visual field analyzer,

Consecutive patients screened for

eligibility between January 1 and March 30,
2009 (Tanabe eye clinic, Yamanashi, Japan)

Ophthalmic examination

Patients with any fundus disease apart

from POAG
<45 years old

Informed consent

0 refused to provide consent

143 diagnosed with primary 153 found free of fundus

open-angle glaucoma disease and cataract
(POAG group) (Control group)

42 excluded: 36 excluded:
17; systemic hypertension 16; systemic hypertension
20; diabetes mellitus 20; diabetes mellitus
2; cerebrovascular disease
2; Parkinsons disease
1; rheumatoid arthritis

101 completed the questionnaire 117 completed the questionnaire

Figure 1 Design of the cross-sectional study and subject enrollment procedures.

328 submit your manuscript | www.dovepress.com Clinical Ophthalmology 2012:6

Dovepress
Dovepress Primary open-angle glaucoma and falls

using the 30-2 Swedish Interactive Threshold Algorithm past ten years (yes or no). The answers to the questionnaire
Standard Strategy (Carl Zeiss Meditec, Dublin, CA) in the were collected and analyzed in a masked fashion to avoid
glaucoma subjects. Patients with ophthalmologic diseases observer bias.
that could potentially compromise visual acuity or visual
field loss, such as age-related macular degeneration, and Statistical analysis
fundus disease apart from POAG, were excluded. Patients Descriptive statistics were calculated for the demographic,
younger than 45 were also excluded. The study methods were medical, and visual function variables. The homogeneity
explained to every patient who met the inclusion criteria, and of distributions between the POAG and control groups was
all of them agreed to participate. examined with an unpaired t-test or Fishers exact test,
Written informed consent was obtained from all of those depending on the variable. Differences between the group of
enrolled. A single ophthalmologist (ST) subspecializing in POAG subjects who reported falling and those who reported
glaucoma performed all of the examinations. no falls were also examined. The adjusted odds ratios (OR)
on injurious fall and 95% confidence intervals (CIs) were
POAG diagnostic criteria estimated with logistic regression models (factors: age,
POAG was diagnosed in 143 patients according to the gender, (1) mean deviation (MD) in the better visual field
following three findings: (1) glaucomatous optic cupping eye or (2) MD in the worse visual field eye).
represented by notch formation, generalized enlargement of
cupping, senile sclerotic disc or myopic disc, or nerve fiber- Results
layer defects; (2) typical glaucomatous visual field defects A total of 117 control subjects (77men, 40 women; aged
such as Bjerrum scotoma, nasal step, or paracentral scotoma 60.27.5years) and 101 POAG patients (58men, 43 women;
compatible with optic disc appearance; and (3) open angle aged 62.38.7years) were recruited. All the participants
observed on gonioscopy. were ethnic Japanese. The demographic characteristics of the
controls and POAG subjects are summarized in Table1.
Control subject inclusion criteria The self-reported prevalence of injurious fall was 0.9%
The 153 control participants were mostly outpatients who (1/117) in the control group and 6.9% (7/101) in the POAG
visited the clinic for such purposes as annual ophthalmologic group. The association between the occurrence of injury
check-ups, screening and correction of refractive errors, or by fall and POAG was statistically significant (P=0.026,
treatment of external ophthalmopathy. All control participants Fishers exact test, Table2).
were free of fundus disease and cataracts affecting visual Within the POAG subjects, the group reporting falls was
acuity. significantly older and had a lower BMI, worse BCVA, and
worse MD in both the better and worse eye, compared to the
Exclusion criteria group reporting no falls (Table3). Worse MD in the better
Patients were excluded from the study if they had any systemic visual field eye (OR 0.75; 95% CI, 0.57 to 0.99; P=0.04,
disease, including but not limited to diabetes mellitus, systemic adjusted for age and gender) was a significant risk factor for
hypertension, cerebrovascular disease, Parkinsons disease, injurious fall in subjects with POAG, but not better MD in
and rheumatoid arthritis. Those who could not understand the worse visual field eye (OR 0.83; 95% CI, 0.68 to 1.02;
the questionnaire were also excluded. These criteria resulted P=0.07, adjusted for age and gender).
in the exclusion of 42 subjects (hypertension, 17 subjects;
diabetes mellitus, 20; cerebrovascular disease, 2; Parkinsons Discussion
disease, 2; rheumatoid arthritis, 1) from the POAG group and The current study demonstrated that POAG is associated
36subjects (hypertension 16; diabetes mellitus, 20) from the with an increased frequency of injurious falls. These results
control group. were compatible with previous reports.1922
In our study, a total of 218 participants experienced
Questionnaire 8injurious falls over the recall period of 10years (3.9% for
All participants were requested to fill out a questionnaire 10years; average annual rate, 0.4%). This number of falls is
on their demographic characteristics, ie, age, sex, weight, rather small compared to previous reports.23,24 Yasumura etal
height, history of smoking, and consumption of alcohol, reported that the annual rate of injurious fall in subjects older
and were asked if they had been injured in a fall during the than 65 was 5.6% (74/1317) in a rural Japanese community.24

Clinical Ophthalmology 2012:6 submit your manuscript | www.dovepress.com

329
Dovepress
Tanabe etal Dovepress

Table 1 Demographic characteristics Table 3 Demographic characteristics of non-fallers and fallers in

Control POAG P-value* subjects with primary open-angle glaucoma
(N = 117) (N = 101) Non-faller Faller P-value*
Age (years) 60.2 7.5 62.3 8.7 0.06 (N = 94) (N = 7)
Gender (male/female) 77/40 58/43 0.21 Age 61.2 7.8 77.0 6.6 ,0.001
BMI 22.6 1.5 22.5 3.0 0.76 Gender (male/female) 56/38 2/5 0.13
Smoking history never 71/46 77/24 0.08 BMI 22.8 2.9 19.6 3.6 0.006
or former/current BCVA (better eye; logMAR) 0.07 0.12 0.54 0.45 ,0.001
Alcohol consumption 29/40/48 27/39/35 0.64 BCVA (worse eye; logMAR) 0.04 0.08 0.30 0.22 ,0.001
(daily/sometimes/none) MD in the better eye -3.2 3.5 -10.7 5.8 ,0.001
BCVA 0.01 0.05 0.05 0.12 ,0.001 MD in the worse eye -6.6 4.5 -15.8 7.1 ,0.001
(better eye; logMAR)
Note: *Unpaired t-test or Fisher exact test was used depending on the variable
BCVA 0.03 0.08 0.11 0.20 0.001
(eg, continuous and categorical variables).
(worse eye; logMAR) Abbreviations: BMI, body mass index; BCVA, best corrected visual acuity; logMAR,
MD value -3.8 4.1 logarithm of the minimum angle of resolution; MD, mean deviation.
(better eye, dB)
MD value -7.3 5.2
(worse eye, dB) subjects only rarely fall. Therefore, we used a long time
Topical eye drop
frame to collect as many events as possible. Consequently,
Prostaglandin 90 (90/101 = 89.1%)
Beta blocker 58 (58/101 = 57.4%) however, recall bias was an important limitation. (2) A rela-
CAI 10 (10/101 = 9.9%) tively small number of participants reported injurious fall,
Note: *Unpaired t-test or chi-square test was used depending on the variable (eg, especially among the control subjects in this study. (3) Recall
continuous and categorical variables).
Abbreviations: POAG, primary open-angle glaucoma; BMI, body mass index;
inaccuracies and a reluctance to provide information might
CAI, carbonic anhydrase inhibitor; BCVA, best corrected visual acuity; logMAR, have affected the self-reported data. Subjects with POAG
logarithm of the minimum angle of resolution; MD, mean deviation.
might remember an injurious fall better than subjects without
POAG, which could increase the number of reported falls in
The low injurious fall rate in our study may partially be POAG subjects. (4) Visual and ophthalmological data were
explained by the following factors, which are all associated obtained only after a fall had occurred, typically several years
with the risk of falling11,25: (1) the relative youth of the later. Therefore, the visual field of the subjects who fell may
subjects enrolled in this study (ie, age is a significant risk have differed at the time of the fall from that measured at
factor for falls), (2) the exclusion of subjects with systemic the time of enrollment. Because we could not evaluate the
disease, (3) the inclusion of fewer subjects with fall proneness patients visual field when the fall occurred, the accuracy of
(ie, multiple falls by the same individual may have been our conclusion might be affected. (5) It is possible that in
included in earlier reports), and (4) the male-skewed gender some cases the glaucoma severity was inaccurate because of
ratio in our study compared to previous studies (ie, being the cross-sectional nature of the data and the progression of
female is a significant risk factor for injurious falls). the disease over the long time frame. (6) We did not define the
The strengths of the present study are that (1) all of the criteria for an injurious fall in this study. Thus, whether the
subjects with POAG and the controls without POAG were outcome was a serious fall (one resulting in hospitalization
examined by a single glaucoma specialist at a single institution, or fracture), or one that caused a milder injury, such as
and (2) clear diagnostic criteria for POAG were applied. soft tissue damage, bruises, or lacerations, was unknown.
The limitations are the following. (1) The long recall period Therefore, the damage caused by the fall may have varied,
might diminish the reporting accuracy. We sought to examine and mild falls may not have been recorded. (7) We asked the
the association between relatively young glaucoma patients patients to answer dichotomously, and did not collect the data
and falls, because the prevalence of glaucoma in Japan is 5% as numbers of injurious falls. This was a limitation because
in 40-year-old people.10 However, it is well known that young the number of falls would have enabled more efficient
analysis techniques, such as negative binomial regression
Table 2 Number of injurious falls models. (8) The exclusion of subjects with hypertension and
diabetes mellitus was an important limitation. In the POAG
Group Control (N = 117) POAG (N = 101) P-value*
group, these exclusion criteria meant that over 25% of the
Injurious fall 1 (1/117 = 0.9%) 7 (7/101 = 6.9%) 0.026
Note: *Fishers exact test.
potential participants were excluded, and these would have
Abbreviation: POAG, primary open-angle glaucoma. likely been older patients. The relatively young age group

330 submit your manuscript | www.dovepress.com Clinical Ophthalmology 2012:6

Dovepress
Dovepress Primary open-angle glaucoma and falls

examined would explain the small incidence of injurious falls 11. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent
nonsyncopal falls. A prospective study. JAMA. 1989;261(18):
in the cohort and significantly limits the generalizability of 26632668.
the study findings. (9) Recall inaccuracies and a reluctance 12. Klein BE, Klein R, Lee KE, Cruickshanks KJ. Performance-based and
to provide information may have affected the self-reported self-assessed measures of visual function as related to history of falls,
hip fractures, and measured gait time. The Beaver Dam Eye Study.
data. Cummings etal reported that up to 30% of falls are not Ophthalmology. 1998;105(1):160164.
recalled even in a 1-year period;26 thus, there is likely to be 13. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and
falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc.
significant recall bias in this study design. 1998;46(1):5864.
The current study suggests that POAG is significantly 14. Coleman AL, Cummings SR, Yu F, etal. Binocular visual-field loss
associated with an increased risk for injurious fall. increases the risk of future falls in older white women. J Am Geriatr
Soc. 2007;55(3):357364.
15. Lord SR, Dayhew J. Visual risk factors for falls in older people. J Am
Disclosure Geriatr Soc. 2001;49(5):508515.
16. Lord SR, Menz HB. Visual contributions to postural stability in older
The authors report no conflicts of interest in this work. adults. Gerontology. 2000;46(6):306310.
17. Maino JH. Visual deficits and mobility. Evaluation and management.
References Clin Geriatr Med. 1996;12(4):803823.
1. Ryynanen OP, Kivela SL, Honkanen R, Laippala P, Soini P. Incidence 18. Friedman DS, Freeman E, Munoz B, Jampel HD, West SK. Glaucoma
of falling injuries leading to medical treatment in the elderly. Public and mobility performance: the Salisbury Eye Evaluation Project.
Health. 1991;105(5):373386. Ophthalmology. 2007;114(12):22322237.
2. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among 19. Glynn RJ, Seddon JM, Krug JH, Sahagian CR, Chiavelli ME,
elderly persons living in the community. N Engl J Med. 1988;319(26): Campion EW. Falls in elderly patients with glaucoma. Arch Ophthalmol.
17011707. 1991;109(2):205210.
3. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE. 20. Haymes SA, Leblanc RP, Nicolela MT, Chiasson LA, Chauhan BC. Risk
Fear of falling: measurement strategy, prevalence, risk factors and of falls and motor vehicle collisions in glaucoma. Invest Ophthalmol
consequences among older persons. Age Ageing. 2008;37(1):1924. Vis Sci. 2007;48(3):11491155.
4. Kool B, Ameratunga S, Robinson E, Jackson R. Hospitalisations and 21. Guse CE, Porinsky R. Risk factors associated with hospitalization
deaths due to unintentional falls at home among working-aged New for unintentional falls: Wisconsin hospital discharge data for patients
Zealanders. Injury. 2007;38(5):570575. aged 65 and over. WMJ. 2003;102(4):3742.
5. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admis- 22. Lamoureux EL, Chong E, Wang JJ, etal. Visual impairment, causes of
sion to a nursing home. N Engl J Med. 1997;337(18):12791284. vision loss, and falls: the Singapore Malay eye study. Invest Ophthalmol
6. Kent A, Pearce A. Review of morbidity and mortality associated with Vis Sci. 2008;49(2):528533.
falls from heights among patients presenting to a major trauma centre. 23. Kannus P, Parkkari J, Koskinen S, etal. Fall-induced injuries and deaths
Emerg Med Australas. 2006;18(1):2330. among older adults. JAMA. 1999;281(20):18951899.
7. Driscoll TR, Mitchell RJ, Hendrie AL, Healey SH, Mandryk JA, 24. Yasumura S, Haga H, Niino N. Circumstances of injurious falls leading
Hull BP. Unintentional fatal injuries arising from unpaid work at home. to medical care among elderly people living in a rural community. Arch
Inj Prev. 2003;9(1):1519. Gerontol Geriatr. 1996;23(2):95109.
8. Korhonen N, Niemi S, Parkkari J, Palvanen M, Kannus P. Unintentional 25. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E.
injury deaths among adult Finns in 19712008. Injury. 2010;42(9): Risk factors for falls in community-dwelling older people: a systematic
885888. review and meta-analysis. Epidemiology. 2010;21(5):658668.
9. Foster A, Resnikoff S. The impact of Vision 2020 on global blindness. 26. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited
Eye. 2005;19(10):11331135. accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988;36(7):
10. Iwase A, Suzuki Y, Araie M, etal. The prevalence of primary open-angle 613616.
glaucoma in Japanese: the Tajimi Study. Ophthalmology. 2004;111(9):
16411648.

Clinical Ophthalmology Dovepress

Publish your work in this journal
Clinical Ophthalmology is an international, peer-reviewed journal PubMed Central and CAS, and is the official journal of The Society of
covering all subspecialties within ophthalmology. Key topics include: Clinical Ophthalmology (SCO). The manuscript management system
Optometry; Visual science; Pharmacology and drug therapy in eye is completely online and includes a very quick and fair peer-review
diseases; Basic Sciences; Primary and Secondary eye care; Patient system, which is all easy to use. Visit http://www.dovepress.com/
Safety and Quality of Care Improvements. This journal is indexed on testimonials.php to read real quotes from published authors.
Submit your manuscript here: http://www.dovepress.com/clinical-ophthalmology-journal

Clinical Ophthalmology 2012:6 submit your manuscript | www.dovepress.com

331
Dovepress