BMJ Open · 10 authors, 4 centres
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This retrospective cohort study of 610 glaucoma suspect patients found that alcohol consumption was associated with a 57% increased risk of developing perimetric glaucoma, particularly in men and individuals of African descent. Smoking was associated with a 73% increased risk in older patients (age >61 years) but not in younger patients. These findings highlight modifiable lifestyle risk factors that may inform glaucoma prevention strategies.
**Background:** Glaucoma is a progressive optic neuropathy and a leading cause of irreversible blindness. While elevated intraocular pressure (IOP) is the main risk factor, many patients develop glaucoma despite normal IOP, suggesting other modifiable factors are involved. Smoking and alcohol consumption have been proposed as potential risk factors, but previous studies have yielded equivocal results. This study aimed to investigate the associations of alcohol consumption and smoking with the development of perimetric glaucoma in patients with suspected glaucoma.
**Methods:** This was a retrospective cohort study using data from the Diagnostic Innovations in Glaucoma Study (DIGS) and the African Descent and Glaucoma Evaluation Study (ADAGES), conducted at three tertiary glaucoma centers in the USA. A total of 825 eyes from 610 patients with suspected glaucoma (normal visual fields at baseline) were included. Patients were followed for an average of 9.0 years (95% CI 8.7 to 9.3). Development of glaucoma was defined as the occurrence of three consecutive abnormal visual field (VF) tests during follow-up. Self-reported smoking and alcohol consumption were recorded via questionnaire. Univariable and multivariable Cox proportional hazard regression models with random effects on eyes were used to investigate lifestyle-related factors associated with development of VF loss. Interactions between age and smoking, and between sex/race and alcohol, were also examined.
**Key Results:** During follow-up, 235 eyes (28.5%) of 196 patients developed repeatable VF defects. In the multivariable model, current alcohol consumption was associated with a significantly higher risk of developing glaucoma (HR 1.57, 95% CI 1.03 to 2.38, p=0.037). Smoking history was associated with increased risk in the univariable model (HR 1.43, 95% CI 1.08 to 1.89, p=0.012) but not in the multivariable model (HR 1.15, 95% CI 0.80 to 1.65, p=0.439). However, a significant interaction was found between age and smoking (p=0.048): in older patients (>61 years), smokers had a higher risk of developing glaucoma than never smokers (HR 1.73, 95% CI 1.10 to 2.72, p=0.019). For alcohol, interactions were found with sex (p=0.034) and race (p=0.066). In men, alcohol drinkers had a higher risk than non-drinkers (HR 1.92, 95% CI 1.00 to 3.68, p=0.048). In individuals of African descent, alcohol drinkers had a higher risk than non-drinkers (HR 1.79, 95% CI 1.02 to 3.15, p=0.043).
**Clinical Implications:** This study provides evidence that alcohol consumption is a modifiable risk factor for the development of perimetric glaucoma in patients with suspected glaucoma, particularly in men and individuals of African descent. Smoking appears to increase risk primarily in older patients. These findings suggest that lifestyle modifications—reducing alcohol intake and smoking cessation—may help reduce the risk of glaucoma development, especially in high-risk subgroups. The results support existing public health strategies aimed at reducing tobacco and alcohol exposure. Future research should explore dose-response relationships and potential causal mechanisms.