Why is Research Focused on Black Patients in Glaucoma Essential?

Risantini Murugan

Introduction

Glaucoma is an eye disease that causes damage to the optic nerve, leading to progressive vision loss. This condition disproportionately affects patients of African descent, where it can be seen in much younger patients and with increased severity (1). Despite the increased prevalence in this sub-population, most of the leading research used to inform treatment guidelines predominantly involves Caucasians. It leads us to ask: are Black patients truly being treated with evidence-based medicine, or are we relying on evidence that has been extrapolated from non-Black populations?

Why is focused research needed?

Glaucoma is one of the leading causes of irreversible blindness worldwide, and its incidence and severity are disproportionately higher among people of African descent. This alone validates the necessity for research tailored to this population. Focused research could help identify modifiable risk factors that may contribute to the accelerated disease course seen in these patients. It could also clarify the impact of anatomical differences – such as thinner corneas, larger optic discs and lower corneal hysteresis – between Black and non-Black populations (2,3). Beyond biology, the socioeconomic factors, mainly barriers to care and treatment adherence in this population, warrant a systematic study if we are to deliver equitable, evidence-based care.

What do we know so far?

Evidence comparing the various intraocular pressure-lowering agents in Black patients is limited. In our recent systematic review, we searched four databases – PubMed, Cochrane Library, Semantic Scholar and Europe PMC – and screened 431 studies (4). Of these, only three met the inclusion criteria of randomised controlled trials involving Black patients.

These three trials compared prostaglandin analogues (PGA), non-selective beta-adrenergic receptor antagonists and prostamides. Our review found that PGAs, which are already recommended as first-line therapy by the National Institute of Care and Excellence (NICE) guidelines for primary open-angle glaucoma and ocular hypertension, were also the most effective agents in Black patients (5). In contrast, the non-selective beta-adrenergic antagonists, often recommended as second-line therapy in guidelines, were less effective and carried a higher risk of adverse effects (5,6). This risk is amplified in Black patients, in part due to the underdiagnosis of cardiovascular and respiratory conditions that can be exacerbated by this drug class (6,7).

Clinical and Research Implications

Clinicians should practice caution when treating glaucoma in Black patients, particularly since current guidelines have been designed by studies conducted in non-Black populations. This highlights the necessity for better-designed, focused research in underrepresented groups to ensure treatment recommendations are truly applicable. As clinicians, our responsibility is to deliver care based on representative evidence, rather than applying findings that may not fully reflect the populations we treat.

References

  1. Kyari F, Abdull MM, Bastawrous A, Gilbert CE, Faal H: Epidemiology of glaucoma in Sub‑Saharan Africa: prevalence, incidence and risk factors. Middle East Afr J Ophthalmol. 2013, 20:111-25. 10.4103/0974-9233.110605
  2. Girkin CA, McGwin G, Xie A, Deleon-Ortega J: Differences in optic disc topography between black and white normal subjects. Ophthalmology. 2005 Jan;112(1):33-9. 10.1016/j.ophtha.2004.07.029
  3. Leite MT, Alencar LM, Gore C, Weinreb RN, Sample PA, Zangwill LM, Medeiros FA: Comparison of corneal biomechanical properties between healthy blacks and whites using the Ocular Response Analyzer. Am J Ophthalmol. 2010 Aug;150(2):163-8.e1. 10.1016/j.ajo.2010.02.024.
  4. Murugan R, Murugan V, Agarwal PK: A systematic review: efficacy of different intraocular pressure-lowering agents in Black individuals. Cureus. 2025 Jun 29;17(6):e86945. 10.7759/cureus.86945.
  5. Glaucoma: diagnosis and management. (2022). Accessed: 26 June 2025: https://www.nice.org.uk/guidance/ng81.
  6. Aftab OM, Khan H, Sangani R, Khouri AS: A national analysis of systemic adverse events of beta-blockers used for glaucoma therapy. Cutan Ocul Toxicol. 2024, 43:293-8. 10.1080/15569527.2024.2402408
  7. Ejike CO, Dransfield MT, Hansel NN, Putcha N, Raju S, Martinez CH, Han MK: Chronic obstructive pulmonary disease in America’s Black population. Am J Respir Crit Care Med. 2019, 200:423-30. 10.1164/rccm.201810-1909PP

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