Clinical and Experimental Ophthalmology (2002) 30, 173–175
Clinical and Epidemiology
Clinical and Epidemiology
Relationship between age and intraocular pressure: the Blue
Mountains Eye Study
Elena Rochtchina MApplStat, Paul Mitchell MD PhD and Jie Jin Wang MMed PhD
Department of Ophthalmology (Centre for Vision Research), Westmead Hospital, University of Sydney, Sydney, New South Wales,
Australia
ABSTRACT
This study aimed to assess the influence of age on intraocular
pressure (IOP) in a general population. The Blue Mountains
Eye Study assessed 3654 residents aged 49+ years during
1992–1994. Intraocular pressure was measured using Gold-
mann applanation tonometry. Subjects with glaucoma, those
currently on glaucoma medications and those with a history
of cataract surgery were excluded. The IOP was reliably
measured in 3260 subjects. Mean IOP was 16.0 mmHg with
no significant difference found between men and women
(P < 0.89). In univariate analyses, age was positively associ-
ated with IOP (P < 0.05). Systolic blood pressure (SBP) was
strongly positively associated with IOP (P < 0.001). After
adjusting for SBP, there was a trend for IOP to decrease with
increasing age (P < 0.051). After further adjusting for other
potential confounders (diabetes, glaucoma family history and
myopia), age was no longer significantly associated with
intraocular pressure (P < 0.29). In summary, no evidence was
found of an independent age affect on IOP.
Key words: age, intraocular pressure, systolic blood pressure.
INTRODUCTION
Elevated intraocular pressure (IOP) is the principal modifia-
ble risk factor for the development and progression of open-
angle glaucoma (OAG). Although a substantial proportion
of older people with OAG do not have consistently elevated
IOP, this sign has been found to be strongly related to OAG
prevalence in population-based studies.1
Open-angle glaucoma prevalence is strongly age-
related.1–5 However, the relationship between IOP and
increasing age has varied in different populations. Several
studies have found a statistically significant increase in IOP
with age,6–8 although a number of Japanese studies have
consistently reported a statistically significant decrease of
IOP with increasing age among both women and men.9,10
■ Correspondence: Professor Paul Mitchell, Department of Ophthalmology (Centre for Vision Research), University of Sydney, Westmead Hospital, Hawkesbury
Road, Westmead, NSW 2145, Australia. Email: paulmi@westgate.wh.usyd.edu.au
________________________
Other studies were not able to confirm any association
between age and IOP, after including confounding variables
in regression analyses.11–13
The purpose of this report was to assess the affect of age
on IOP in the general older Australian population attending
the Blue Mountains Eye Study (BMES) and to determine
whether any associations found with IOP were independent
of other age-related systemic conditions, such as elevated
blood pressure.
METHODS
The BMES is a population-based survey of age-related eye
diseases in a representative older largely Caucasian Aust-
ralian urban population comprising two postcode areas in
the Blue Mountains region, west of Sydney. Details of the
population and the survey method have been previously
described.1,14 In brief, 3654 residents aged 49 years or older
(82.4% of eligible residents) were examined during
1992–1994, including 2072 women and 1582 men.
A detailed demographic and past medical history was
taken, including history of eye diseases, general health and
medications use. Past diagnosis of hypertension, diabetes,
glaucoma and cataract surgery were recorded. Participants
had their weight and height measured. Body mass index
(BMI) was calculated as weight/height.2 Blood pressure was
measured while seated prior to instillation of any eye drops
(because of the potential effect of phenylephrine on blood
pressure). Subjects underwent a detailed eye examination,
including standardized refraction, automated perimetry and
stereo optic disc photography. Goldmann applanation IOP
was measured for each eye, before pupil dilation. All partic-
ipants were also asked to return for fasting blood tests,
including blood glucose and lipids; 89% had these tests
performed. Family history of glaucoma was obtained by
asking subjects whether any of their parents, siblings or
children had been diagnosed with glaucoma. Diabetes was
diagnosed from past history or elevated fasting blood
glucose (≥ 7.0 mmol/L). Myopia was defined as a spherical
174 Rochtchina et al.

Table 1. Distribution of mean intraocular pressure (IOP) and Table 3. Multiple regression model of associations with
systolic blood pressure (SBP) by age intraocular pressure

Age (years) n IOP (Mean ± SD) SBP (Mean ± SD) Standardized

Variables P value
50–59 988 15.85 ± 2.52 138.0 ± 17.8 coefficient
60–69 1217 16.02 ± 2.61 145.0 ± 20.0 Age (years) – 0.02 0.29
70–79 814 16.07 ± 2.70 152.0 ± 21.9 Systolic blood pressure (mmHg) 0.213 0.0001
80+ 241 16.10 ± 2.89 156.0 ± 24.8 Family history of glaucoma* 0.096 0.0001
Diabetes* 0.055 0.001
Myopia* 0.051 0.005

Table 2. Mean intraocular pressure (IOP) level by confounding *Categorical variable: yes/no.
variables: diabetes, family history of glaucoma and myopia

Variable Participants (%) IOP (Mean ± SD) P value

Diabetes
Yes 7.3 16.52 ± 2.67
No 92.7 15.94 ± 2.61 0.005
Family history of glaucoma
Yes 8.0 16.83 ± 2.82
No 92.0 15.91 ± 2.59 0.0001
Myopia
Yes 11.5 16.35 ± 2.67
No 88.5 15.93 ± 2.61 0.001

Figure 1. Relationship between intraocular pressure (IOP) and

equivalent refractive error of –1.00 D or less. Open-angle
glaucoma was diagnosed from the presence of matching
typical glaucomatous visual field loss and optic disc cupping
with rim thinning, after gonioscopy to exclude other types
of glaucoma.1
Subjects with OAG and those currently using glaucoma
medications were excluded. Because cataract surgery can be
associated with lower IOP levels,15,16 all subjects with a
history of cataract surgery on either eye were excluded. The
average IOP level between two eyes was used in the analysis.
Data were analysed using the Statistics Analysis System
version 6.12 (SAS Institute, Cary, NC, USA). Multiple
linear regression models were used to assess the relationship
between IOP and age, after adjusting for confounding
variables.
RESULTS
After exclusions, IOP was reliably measured in 3260 sub-
jects, with a mean age of 65 years, including 1845 women
(56.6%). Mean IOP (taking the average of the two eyes) was
16.0 mmHg with a standard deviation of 2.62 mmHg. No
significant difference for mean IOP was found between men
and women (T = –0.13, P < 0.89).
The distribution of the mean IOP and systolic blood
pressure (SBP) of subjects by age is shown in Table 1. This
suggests a weak positive association between age and IOP,
with a stronger positive association evident between age and
SBP. In univariate regression analyses, a weak positive asso-
ciation between age and mean IOP was found (T = 1.96,
P < 0.05). The association between SBP and mean IOP was
age without and with adjustments for confounding factors. (– – –),
Crude; (…), adjusted for systolic blood pressure (SBP); (——),
adjusted for SBP, diabetes, family history of glaucoma and myopia.
much stronger (T = 13.33, P < 0.0001). After adjusting for
SBP in a multiple regression analysis, IOP levels decreased
with increasing age (T = –1.94, P < 0.051). Adjusted IOP
levels were 16.08 mmHg, 15.99 mmHg, 15.86 mmHg and
15.70 mmHg, respectively, for ages <60, 60–69, 70–79 and
80+ years. Inclusion of diastolic blood pressure in the anal-
ysis instead of SBP did not alter the findings appreciably.
Body mass index was also positively associated with IOP
(T = 1.99, P < 0.05) in the univariate analysis, but this asso-
ciation was not statistically significant, after simultaneous
adjustment for SBP level (T = 0.61, P > 0.54). Thus, BMI
was excluded from our final multivariate model. Other
potential confounders included in the multiple regression
model were diabetes, family history of glaucoma and
myopia, all of which were positively associated with IOP.
Table 2 shows the mean IOP stratified by these variables.
After simultaneous adjustment for all these potential con-
founders, age was no longer significantly associated with
IOP (T = – 1.06, P < 0.29). Overall, the model explained
only 6% of the variation in IOP, of which 4.5% was contrib-
uted by SBP. The multiple regression analysis findings are
shown in Table 3. Figure 1 shows the effect of adjustments
for confounders.
In our population, IOP distribution was slightly skewed
to the right (skewness = 0.49). We therefore reanalysed our
data using the natural log of IOP. The multiple regression
analysis findings remained essentially the same.
Age and intraocular pressure
DISCUSSION
Although all studies have demonstrated a marked age-
related increase in the prevalence of OAG, few studies have
assessed the influence of age on the finding of elevated IOP
without associated glaucomatous optic disc or visual field
changes, termed ‘ocular hypertension’ by clinicians. In the
BMES, no statistically significant age-related increase was
found in the prevalence of ocular hypertension among
persons aged 50 or older.1 The present study has also not
demonstrated any independent effect of age across the usual
range of IOP, after taking into account the confounding
influences from blood pressure and other systemic factors
found associated with IOP.
Other Caucasian studies to examine the relation between
IOP and age include the USA Beaver Dam Eye Study in
4926 persons aged 43–86 years,13 the USA Framingham Eye
Survey in 2631 persons aged 52–85 years,17 the Italian
Egna–Neumarkt Study of 4297 persons aged 40 years or
older6 and The Australian Melbourne Visual Impairment
Project (MVIP) of 4576 persons aged 40 years or older.18 In
Beaver Dam, IOP was found to be positively associated with
age, blood pressure and BMI in univariate analysis; there was
no significant age-related association, after including con-
founding variables, in a multiple regression analysis.13 The
Framingham Eye Study reported a trend for increasing IOP
up to age 74 years, but not at higher ages.17 In Egna–
Nemarkt, a small age-related increase in IOP was observed
(0.4 mmHg), similar to the magnitude found in our study
(0.3 mmHg) and Beaver Dam (0.5 mmHg), but values were
not adjusted for blood pressure or other variables as in these
two studies. In the MVIP, the association between age and
IOP for the groups either with or without glaucoma was not
significant in multivariate models.18
In contrast, the age effects on IOP seem to be stronger in
non-Caucasian populations. In the black Barbados Eye
Study population of 3752 persons aged 40–84 years, a larger
age-related increase (2 mmHg) was observed than in the
Caucasian populations. Intraocular pressure remained posi-
tively associated with age in a multiple regression model
that included blood pressure, BMI, diabetes and family
history of glaucoma.7
Japanese data were described on 200 000 persons attend-
ing for health check-ups covering all adult ages, using
Schiotz or non-contact tonometry. This report demon-
strated a trend for decreasing IOP with increasing age, and
the trend persisted after adjustment for both systolic blood
pressure and BMI.9 However, these data are difficult to
compare with the major population-based reports, given the
study samples were health volunteers and the different
methods used for IOP measurement. More recent data from
a second large Japanese study covering a similar age range,
again with non-contact tonometry, also indicated a slight
decrease in IOP with age, together with significant associa-
tions between IOP and both BMI and blood pressure.19
175
Interestingly, longitudinal data from the same cohort indi-
cated that IOP increased significantly with age.20 In view of
our similar findings on age and IOP (a decrease of IOP with
age), after adjusting for SBP but before further adjustment
for other confounders, it is possible that the Japanese
findings9,20 could reflect differences in the adjustment for
confounders.
Our study has illustrated the importance of adjusting for
confounders when assessing associations between any two
variables. Failure to account for factors influencing IOP
could lead to bias in assessing the IOP relationship with age.
In summary, most reported population-based data have
demonstrated a small age-related increase in IOP in older
adults. The magnitude of this increase appears similar across
a number of studies, but was higher in the black Barbados
population. In only one population (Japanese) was an age-
related decrease in IOP observed. However, methodological
differences in the Japanese studies make direct comparisons
difficult. Nearly all studies indicate significant positive asso-
ciations between IOP and both blood pressure and BMI.
Our study found no independent influence on IOP from
BMI, after controlling for blood pressure. In our final model
that controlled for blood pressure and other confounders
(e.g. diabetes and myopia), no independent association
between age and IOP was evident in this older population.
ACKNOWLEDGEMENTS
This study was supported by the Australian National Health
and Medical Research Council and the Westmead Millen-
nium and Save Sight Institutes, University of Sydney.
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