Editors Selection IGR 23-1

Prognostic factors: Race and Ethnicity as Prognostic Factors

Kelsey Stuart
Anthony Khawaja

Comment by Kelsey Stuart & Anthony Khawaja on:

100791 Race and ethnicity differences in disease severity and visual field progression among glaucoma patients, Halawa OA; Jin Q; Pasquale LR et al., American Journal of Ophthalmology, 2022; 0:

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From both a clinical and an epidemiological perspective, ethnicity is an important consideration in glaucoma, with well-documented ethnic variation in the prevalence, diagnosis, severity, progression and treatment of the disease.1,2 While these differences may reflect variation in genetic susceptibility to glaucoma across population groups, there is increasing recognition of the non-genetic factors driving these disparities.3 Is glaucoma simply more aggressive in some ethnic groups, or are there addressable socioeconomic and healthcare access issues that explain the observed differences?

In this large retrospective cohort study (1998‐2020) from a single tertiary eyecare center in the United States, Halawa and colleagues aimed to explore ethnic and language preference differences in the presenting severity and subsequent progression rate of glaucoma, by using visual field (VF) test data as a functional measure of the disease.

Overall, they found that Black/African American, Asian, and Hispanic patients presented at a younger age and with more severe disease than their White/Caucasian counterparts. While Asian and Hispanic patients had a higher frequency of VF testing, Black/African American patients, despite their worse severity at presentation, were monitored less frequently and had greater progression of VF loss over time, compared to White/ Caucasian patients. Similarly, non-English-speakers presented at an older age and with worse glaucoma severity than English-speakers. Interestingly, language preference was found to partially explain the observed differences between ethnic groups, particularly among Asian and Hispanic patients.

Language preference may act as a significant barrier to timely access to healthcare

These results are an important contribution to the growing body of literature demonstrating ethnic disparities across various fields of medicine, and suggest that language preference may act as a significant barrier to timely access to healthcare. The role of other potential mediating factors, including socioeconomic status, medical comorbidities, environmental exposures, physician implicit bias, and structural racism, remain unclear. Additionally, the study design may limit generalizability to other geographic regions or specific glaucoma subtypes. Nevertheless, the study should motivate all those involved in glaucoma care to consider how ethnicity may influence both patient- and clinician-related factors relevant to the management of the disease. Halawa and colleagues have demonstrated that differences in glaucoma metrics and outcomes between ethnic groups may not just be pre-destined in the genetic code, but may be due to addressable differences such as English language proficiency. This offers hope that future interventions addressing these differences can reduce social inequalities that exist in glaucoma care.


  1. Tielsch JM, Sommer A, Katz J, et al. Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey. JAMA. 1991;266(3):369-374.
  2. Ostermann J, Sloan FA, Herndon L, Lee PP. Racial differences in glaucoma care: the longitudinal pattern of care. Arch Ophthalmol. 2005;123(12):1693-1698.
  3. Altangerel U, Nallamshetty HS, Uhler T, et al. Knowledge about glaucoma and barriers to follow-up care in a community glaucoma screening program. Can J Ophthalmol. 2009;44(1):66-69.

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