Factors Associated with Open-Angle Glaucoma among Iraqi Patients لماوعلاب ةطبترملا نيباصملا نييقارعلا

Back ground: Glaucoma is the leading cause of blindness world wide and 22.5 million people are estimated to suffer from it. Open angle glaucoma is more prevalent form of glaucoma than closed angle glaucoma blindness can be avoided if glaucoma treated early. Objectives: There are many factors associated with open angle glaucoma this study is performed to assess The most important factors that associated with open angle glaucoma among Iraqi patients who had glaucoma attending AL-Yarmook teaching hospital Methods: Across sectional study was conducted at AL-Yarmook hospital in Baghdad from October 2013 till June 2014 one hundred fifty 150 glaucomatus patients age >35 years both sexes were included in this study .open Angle glaucoma was diagnosed by ophthalmologist depending on the American Academy of Ophthalmology 2012 the data were obtained by using an interview questionnaire that was applied to patient with open angle glaucoma. The data include the age, sex. family history and clinical data which include intra ocular pressure ,Myopia, smoking, history of hypertension, diabetes and using systemic drugs as corticosteroid the data was analyzed by SPSS. Results: The study included 150 patients with open angle glaucoma. almost half of the patients were above 65 years, the rate of open angle glaucoma is more in those who have I.O.P.>20 mm Hg(92%) ,myopia 65%family history72%,history of hypertension 63%, history of diabetes 53%,history of taking steroid 59% and smoking 52%. Open angle glaucoma was significantly associated with intra ocular pressure 0.0001, myopia P0.001, family history 0.0005, history of hypertension 0.001, and history of taking steroid 0.01. it show that there is no significant association with history of diabetes and smoking (P 0.1,0.2 )respectively. Conclusion: This study show that old age, intra ocular pressure, Myopia, family history, history of hypertension and history of taking steroid are risk factors for open angle glaucoma. Recommendation: education of the people about risk factor associated with glaucoma and routine checking of I.O.P for old age and patients with hypertension and diabetic


INTRODUCTION
Primary open angle glaucoma (OAG) is progressive chronic optic neuropathy in adults in which intraocular pressure (IOP) and other factors are contributed to the damage optic nerve.It is characterized by late presentation and absence of pain which is a driving force for seeking medical help (1) .Glaucoma is the leading cause of blindness world wide and 22.5 million people are estimated to suffer from it ( 2) .The highest prevalence of primary open angle glaucoma (POAG) occurs in Africans (3) .
More recently, the Nigerian National Blindness and Visual impairment Survey has shown that the cause specific prevalence of blindness due to glaucoma was 0.7% second to cataract with 1.8%, and glaucoma blindness covers all the six geopolitical zones of the country though slightly higher in the south eastern part of the country (4) .
Institution-based studies have also indicated the importance of glaucoma as a cause of blindness.A study in India confirmed glaucoma in 2.7% (5) .Considering the challenge of identification and management of glaucoma on one hand and the deficit in human and material resources on the other hand; there is huge responsibility for caring of those who have glaucoma (5) .
There is good evidence that high intra ocular pressure IOP history are the main risk factors for POAG and various population studies of glaucoma have shown that high intraocular pressure (IOP), has been considered a main remarkable feature of POAG (6,7,8,9,10,12,13,14,15,16) but it is not always observed in POAG patients thus some time patients had normal I.O.P . ( 11)pen-angle glaucoma is a disease that develops later in life; therefore, the result that age was a significant risk factor for having POAG is no surprise at all and is compatible with many results (6-7) Family history, as recent understanding of specific associations between genes and glaucoma increases, family history of glaucoma has been known to be associated with POAG (12,13) .

PATIENT AND METHODS
This cross sectional study was conducted on 150 patients had open angle glaucoma attending AL-Yarmook hospital in Baghdad between October 2013 and June 2014 These patients were diagnosed by an ophthalmologist in the same hospital the diagnosis was based on the American Academy of Ophthalmology 2012 (AAO) ( 17), socio-demographic clinical data were obtained by using an interview questionnaire that was applied to patient with open angle glaucoma .thedata include sociodemographic characters like age, sex and clinical data which include I.O.P(>20 mmHg was considered as acute point according to International Council of Ophthalmology ICO(18) Myopia which were measured by trained optometrists, history of hypertension, diabetes (defining hypertension and diabetes by specialist doctor or the reported taking of medication for them)and using systemic drugs as corticosteroid and smoking were taken by the researcher.
Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS, version 11.5).chisquare for association between two variables P value 0.05 was considered as significant.Table 1 shows that the number of the patients increased with age of the study sample about half of the patients with O.A.G 44% who were >65 years (33female,33 male) followed by the age 46-55 ,35.34%(22female -31 male).13.34%(8 female,12 male) for the age 46-55 and only 7.35% for the age 35-45years.There is significant association between open angle glaucoma O.A.G and age( P 0.002) there is no significant differences between female and male in this study( P 0.2) Table 2 show that the rate of open angle glaucoma is more in those who have I.O.P.>20 mmhg92% ,myopia 65.34% ,family history72%,history of hypertension 63.34%, history of diabetes 53.34%,history of taking steroid 59.34% and smoking 52%.O.A.G was significantly associated with I.O.P 0.0001,myopia P0.001,family history 0.0005,history of hypertension 0.0.001,history of taking steroid 0.01.and it show that there is no significant association with history of diabetes and smoking (P 0.1,0.2 ) respectively.

DISCUSSION
The advanced age show a significant association with O.A.G in this study ( P value 0-0002)this agree with many studies (6,7,8) Primary open-angle glaucoma is a disease that develops later in life.Both incidence and prevalence increase more than linearly with age.In assessing this factor, we could think of age as a surrogate that stands for the deterioration of relevant tissues with time, potentiating ganglion cell death.Older age is also a measure of the length of time that the person is exposed to other risk factors before developing disease.In this sense, it is not inherently a cause, but a measure of the amount of other factors.Age may also be a measure of how long the person with OAG has had the disease, so it stands for duration and may be expected to be associated with greater damage when the disease is progressive.Older age may also modify the attitude of the patient toward disease, perhaps inhibiting cooperation with therapy.Finally, older persons are more often on fixed incomes and their lower socioeconomic status may prevent the purchase of eye drops (6,7,8) Gender is not a risk factor in this study (Pvalue0.2) this go with most studies of OAG (,6,7,8) although one study show that men have been found to have greater risk for presence of disease or progression than women (9) this may be due to the sociocultural attitudes that differ between men and women in ways that are not genetically determined and that differ among cultures.For example, men and women in the United States differ in their rates of accessing medical care, in what care is offered or accepted and in financial resources available to them to pay for treatment (7) .Each of these may modify the relationship of sex to OAG.One study indicated that risk was higher in women with menopause (10) .
In this study I.O.P show strong associating with O.A.G .the majority (92%) 138 out of 150 of OAG patients diagnosed in this Study had high IOP rang(.Pvalue 0.0001) thus IOP, is still identified as a significant risk factor for having OAG It is well known that high IOP is a major risk factor not only for developing OAG but also for progression of OAG which means that having an IOP higher than average (20 mmHg) makes the risk for having POAG about twice (6,7,8,9,10,12,13) this is not agree with a Study in China in 2008 show that glaucoma occur in normotensive IOP among Chinese population as myopia is the main risk factor in this population (11) .
Myopia was a significant risk factor for POAG in this study( P value 0.001)There is population-based studies suggesting association of myopia with the risk for POAG . (14).There is also a report that the association of myopia and glaucoma was strong in glaucoma patients with normal or low I.O.P (11)  Family history in this study show a significant association with O.P.A.G(P valu0-0005).thisagree with many studies (6,7,8,12,13) but the information obtained in the interview with participants about the family history of glaucoma was very limited, we cannot draw a conclusions from the present study concerning the association of family history with OAG.
History of hypertension show a significant association with OAG in this study (Pvalue 0-001) The association between hypertension and POAG was mostly likely due to correlation of age and hypertension.This is in agreement with many studies (6,7,8) the relationship is not simple and must be considered in the light of other risk factors that interact with blood pressure (15).
History of Diabetes in this study show no significant association with O.A.G Pvalue(0.1).thisagree with Bonovas S et al study (16) .althoughdiabetes was assumed to be a risk factor for OAG in many studies (6,7,8) .Corticosteroids using history show a significant association with O.A.G(Pvalu 0.01) this agree with many studies (6,7,8) Steroid exposure has been associated with increases in IOP.Topical corticosteroid eye drops and oral intake of large steroid doses has long been known to raise IOP.In this study smoking history show no significant association with O.A.G P value (0.2).Cigarette smoking, although a major risk factor for macular disease and cataract, has not been consistently been associated with OAG (17).

CONCLUSION
This study was exploring the main risk factors of O.A.G.The most important risk factors for OAG are elevated IOP, increasing age, family history, and myopia.For the other risk factors hypertension ,diabetes and corticosteroid using drug they should, always be considered alongside with the clinical examination for signs of OAG, which has traditionally focused on assessment of the optic nerve head, Recent innovations in diagnostic technology such as optical coherence tomography (OCT) and dynamic contour tonometry, bring exciting prospects of improved detection of glaucoma within reach of the community optometrist.Further research into glaucoma risk factors will increase our knowledge of an individual patient's personal risk profile for the disease.

RECOMMENDATION
Education of the people about risk factor associated with glaucoma and routine checking of I.O.P for old age and patients with hypertension and diabetic