Research ArticleClinical Studies
Open Access

The Correlation Between Aortic Stenosis and the Subsequent Incidence of Optic Neuropathy: A Population-based Cohort Study

CHIA-YI LEE, SHUN-FA YANG, ELSA LIN-CHIN MAI, JING-YANG HUANG, CHAO-BIN YEH and CHAO-KAI CHANG
In Vivo July 2025, 39 (4) 2133-2143; DOI: https://doi.org/10.21873/invivo.14009

Abstract

Background/Aim: To survey the potential correlation between aortic stenosis (AS) and subsequent optic neuropathies of glaucoma and ischemic optic neuropathy.

Patients and Methods: A retrospective cohort study was conducted with the use of the TriNetX database, a project by the US Collaborative Network which enrolled 68 healthcare institutions. PSM There were 426,980 and 426,980 people divided into the AS and non-AS groups after exclusion. The primary outcomes were the development of glaucoma and ischemic optic neuropathy. Cox proportional hazard regression was used to produce the adjusted hazard ratio (aHR) and 95% confidence interval (CI) of the optic neuropathies between groups.

Results: There were 11,717 and 8,676 glaucoma episodes found in the AS and no-AS groups, and there were 566 and 391 ischemic optic neuropathy episodes found in the AS and no-AS groups. The AS group had a significantly higher risk of glaucoma (aHR=1.277, 95% CI=1.242-1.312, p<0.001) and ischemic optic neuropathy (aHR=1.362, 95% CI=1.197-1.549, p<0.001) compared to the non-AS population. The cumulative probability of glaucoma and ischemic optic neuropathy were significantly higher in the AS group than the non-AS group (both p<0.001). In the multivariate analysis, the incidence of ischemic optic neuropathy was significantly higher in the AS group compared to that of the non-AS group with different characteristics except in those with Asian race, aged 20-44 years old, and aged 65-80 years old (all 95% CIs included 1).

Conclusion: The existence of AS correlates to higher risk of developing glaucoma and ischemic optic neuropathy.

Keywords:

Introduction

Aortic stenosis (AS) is a cardiovascular disease in which aortic valve fibrosis, aortic valve calcification, and aortic valve structure thickening develop (1, 2). In European regions, the prevalence of AS is higher than 5% in both the male and female populations aged older than 65 years (3). Medical approaches can be taken in individuals with mild AS but surgery such as aortic valve replacement should be undertaken in individuals with severe AS (4, 5). The overall survival time after the aortic valve replacement surgery is satisfactory (6, 7), however, the postoperative complications of AS can be fatal (3).

The correlation between AS and diseases occurring in other sites has been found [reviewed in (2)]. In an earlier publication, the incidence of diabetes mellitus was significantly higher in the group diagnosed with AS than the non-AS group (8). Moreover, hypertension is correlated with AS and the presence of hypertension in AS populations can exacerbate clinical symptoms and degree of AS (9). Regarding serum lipids, hypercholesterolemia can insult cardiovascular structures and the chance of AS occurrence and prognosis of AS can be worsened by the presence of hyperlipidaemia (10). As well as metabolic syndromes, increasing systemic inflammatory status and associated biomarkers were observed in those with AS (11).

Optic neuropathy refers to the damage of the optic nerve due to various aetiologies (12). Among them, glaucoma is the most frequent type and results in ocular vasculature defects, progressive visual field defects and reduced visual acuity in the advanced stage (13, 14). In addition, ischemic optic neuropathy, with ischemia in different parts of the optic nerve, can also cause severe visual impairment (15). Because both AS and optic neuropathies present vascular damage (12, 14, 16), a potential correlation between them may be possible. Nevertheless, to our knowledge, there has been no study to evaluate the relationship between AS and optic neuropathies.

As a consequence, the objective of our study was to investigate the possible correlation between AS and subsequent optic neuropathies, including glaucoma and ischemic optic neuropathy. The risks of optic neuropathy development in participants with different characteristics were also analysed.

Patients and Methods

Data source. All the approaches in our study followed the declaration of Helsinki in 1964 and its subsequent amendments. Moreover, our study was approved by the Institute Review Board of Chung Shan Medical University (project code: CS2-23180). The TriNetX database is a global federated health study network delivering connection to numerous electronic medical records (procedures, diagnoses, medications, laboratory values, and genomic information) throughout the distinguished healthcare organizations; this was the source of our data. This project was produced by the US Collaborative Network, which enrolled 68 healthcare institutions. The TriNetX database is a platform that de-identifies and maintains the electronic health documents from different healthcare institutions, most of which are major academic medical centres with both Inpatient and Outpatient Departments at several states of the United States. The TriNetX Analytics provides Internet-based and secure connection to all electronic health records of patients from various hospitals, primary care and specialty intervention providers. Thus, the TriNetX database covers multiple geographical regions, age intervals, ethnic populations, income levels and insurance types. The insurances in TriNetX database include worker compensation insurance, commercial insurances, self-pay as well as uninsured, governmental insurance (Medicare and Medicaid), and finally military as well as Veterans Affairs insurances. The medical data found in the TriNetX database comprise the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, occupation, sex, place of residence, age, educational level, socioeconomic level, laboratory analysis codes, length of hospitalization if presented, surgical codes, image analysis codes, the management codes, and the Anatomical Therapeutic Chemical codes for prescriptions.

Individual selection. A retrospective cohort study was performed, and individuals were chosen as the AS group according to the following criteria: (i) AS diagnosis was made based on the ICD-10 CM codes; (ii) electrocardiogram, echocardiogram, chest X-ray, cardiac catheterization, or cardiac computerized tomography were completed before AS diagnosis; and (iii) the AS diagnosis was confirmed by a cardiologist. The index date in our study was 6 months after the date of AS diagnosis. In addition, the following exclusion criteria were employed to augment the homogeneity of our patient cohort: (i) age younger than 20 years or older than 80 years; (ii) ocular surgery before the index date; and (iii) primary outcome (exhibited in the successive part) was recorded before our index date. After exclusion, each case with AS was matched to a case without AS by propensity score-matching (PSM). The PSM manipulation consolidates systemic disorders, demography, and medications/prescriptions into the specific score system and matches different patients based on that score. After PSM manipulation, a total of 42,6980 people were assigned to the AS group and 42,6980 to the non-AS groups. The flowchart of case selection is represented in Figure 1.

Figure 1.
Figure 1.

The flowchart of subject selection. AS: Aortic stenosis; N: number; PSM: propensity score-matching.

Primary outcome. The primary outcomes of our study were the development of glaucoma and ischemic optic neuropathy. The development of glaucoma was regarded as: (i) Glaucoma diagnosis in agreement with the ICD-10 CM codes; (ii) fundoscopy, optical coherence tomography or visual field examination in agreement with the procedure code; and (iii) glaucoma diagnosis was confirmed by an ophthalmologist. The development of ischemic optic neuropathy was regarded as: (i) Diagnosis of ischemic optic neuropathy in agreement with the ICD-10 CM codes; (ii) undergoing at least one of fundoscopy or optical coherence tomography in agreement with the procedure code; and (iii) ischemic optic neuropathy diagnosis was confirmed by an ophthalmologist. Additionally, only optic neuropathies confirmed after the index date were considered as the primary outcomes in our study. All patients were followed up until optic neuropathy development, study population withdrawal from the healthcare administrations of TriNetX program, or the deadline of TriNetX database: December, 31, 2023.

Confounding components. To better interrogate the correlation between AS and subsequent optic neuropathies, the powers of ensuing confounding factors were balanced in our analysis: age, race, sex, hyperlipidaemia, hypertension, cerebrovascular diseases, diabetes mellitus, ischemic heart diseases, peripheral vascular diseases, high-density lipoprotein (HDL), chronic kidney disease, sleep disorders, estimated glomerular filtration rate, troponin I, low-density lipoprotein (LDL), nicotine dependence and alcohol-related disorders. The presence of these confounding factors was determined in agreement with the related demographic codes, ICD-10 CM codes and laboratory examination codes. To ensure the systemic disease periods were long enough to alter the risk of optic neuropathy, only the systemic disorders lasting for more than 2 years were counted.

Statistical analysis. SAS version 9.4 (SAS Institute Inc, Cary, NC, USA) was used in the analyses in our study. Descriptive analysis was used to reveal the baseline statuses of the AS and the non-AS groups, then the standard mean difference (SMD) was calculated to interrogate the difference of each baseline factor between the two groups. An SMD value larger than 0.1 was considered as a significant difference in our study. After that, Cox proportional hazard regression was used to compare the incidences of optic neuropathies between the AS population and non-AS population, and the adjusted hazard ratio (aHR) as well as 95% confidence interval (CI) for the incidences of optic neuropathies were calculated. The demographic data, diabetes mellitus, hypertension, peripheral vascular disease, dyslipidaemia, cerebrovascular disease, and the laboratory values of LDL, estimated glomerular filtration rate, troponin I, and HDL were incorporated into the Cox proportional hazard regression to balance their power in the development of macular diseases. Kaplan–Meier curves were produced, and the cumulative incidence of optic neuropathy events were compared between the AS group and non-AS group via the log-rank test. In the multivariate analysis, patients were placed into different subgroups according to sex, age, race, and LDL and HDL values. In the next step, the Cox proportional hazard regression was used again to examine the likelihood of optic neuropathies in different populations. Statistical significance was specified as p<0.05.

Results

The baseline status of the AS and non-AS population is given in Table I. The mean age was 64.9±11.8 and 65.4±11.4 years in the AS and non-AS groups, respectively. The comparison of the mean age between groups did not reveal a significant difference. Moreover, differences in other demographic data between the AS and non-AS groups were not significant (all SMD<0.1). Regarding systemic diseases, the distributions of all systemic diseases demonstrated insignificant differences between the AS and non-AS groups (all SMD<0.1), as did the frequency of medical prescriptions (all SMD<0.1) (Table I).

View this table:
Table I.

Baseline characteristics among aortic stenosis cohort and control cohort before and after propensity score-matching.

After the whole study interval, there were 11, 717 and 8, 676 glaucoma episodes found in the AS and no-AS groups, respectively. In addition, there were 566 and 391 ischemic optic neuropathy episodes found in the AS and no-AS groups, respectively. After adjusting for all the confounding factors, the AS group revealed a significantly higher risk of glaucoma (aHR=1.277, 95% CI=1.242-1.312, p<0.001) and ischemic optic neuropathy (aHR=1.362, 95% CI=1.197-1.549, p<0.001) compared to the non-AS population (Table II). The cumulative risks of developing glaucoma and ischemic optic neuropathy were significantly higher in the AS group than the non-AS group (both p<0.001) (Figure 2).

View this table:
Table II.

Primary outcomes between the aortic stenosis (AS) and control groups.

Figure 2.
Figure 2.

Kaplan-Meier curves for cumulative incidence of optic neuropathy in patients with and without aortic stenosis (AS). (A) The cumulative incidence of glaucoma in the two groups. (B) The cumulative incidence of ischemic optic neuropathy in the two groups.

In the multivariate analysis, the incidence of glaucoma was significantly higher in the AS group compared to the non-AS group when patients were stratified by all characteristics (all 95% CI>1) (Figure 3). The incidence of ischemic optic neuropathy was significantly higher in the AS group compared to the non-AS group when patients were stratified by all characteristics except in patients of Asian race, aged 20-44 years old, or aged 65-80 years old (all 95% CIs include 1) (Figure 4).

Figure 3.
Figure 3.

Risk of glaucoma in patients with aortic stenosis stratified by age, sex, race, and high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels. CI: Confidence interval; eGFR: estimated glomerular filtration rate; MDRD: Modification of Diet in Renal Disease; N: number.

Figure 4.
Figure 4.

Risk of ischemic optic neuropathy in patients with aortic stenosis stratified by age, sex, race, and high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels. CI: Confidence interval; eGFR: estimated glomerular filtration rate; MDRD: Modification of Diet in Renal Disease; N: number.

Discussion

In our study, the incidence of optic neuropathies including glaucoma and ischemic optic neuropathy were significantly higher in the AS group than the non-AS group. Moreover, the incidence of optic neuropathies in the AS group were significantly elevated with the longer disease interval of AS. In the analysis of the AS population by different characteristics revealed a higher risk of ischemic optic neuropathy development in those with AS than the non-AS population except in those of Asian race and specific age.

The correlation between AS and various disorders including metabolic and vascular diseases were confirmed in previous research (9, 17-20). Metabolic syndromes which involve hypertension, dyslipidaemia, and glucose intolerance demonstrated a positive correlation with the existence of AS (21). The chance of diabetes mellitus development was significantly higher in a population diagnosed with AS, and the diabetic population with AS had a higher possibility of aortic valve calcification than their non-diabetic counterparts (8). Furthermore, hypertension as well as hyperlipidaemia occurred more frequently in the population diagnosed with AS (9, 10). Regarding morbidities other than metabolic disorders, carcinoma such as prostate cancer was observed more frequently in those suffering from AS (18). In addition to morbidities, inflammation is a crucial component in AS development; lipid accumulation and increasing inflammation are two critical pathophysiologies of the initial stage in AS (22, 23). Moreover, some inflammatory biomarkers such as tumour growth factor beta, interleukin family members, nuclear factor-kappa B, and bone morphogenic protein were proven to increase with the development of AS (22, 24, 25). In addition, AS is also associated with vasculature defects – vascular fibrosis and endothelial dysfunction were frequently found in the people with AS (16). Ischemic injury was also observed in the population suffering from AS (26). Glaucoma is an optic neuropathy that is correlated to both intraocular pressure elevation and ischemic damage (13, 27). Previous studies reported that vasculature damage and related disorders may be the main pathophysiological mechanism for normal-tension glaucoma (28, 29). Ischemic optic neuropathy is also associated with vascular disorders and ischemic heart disease is related to higher risk of ischemic optic neuropathy (15). Because both the AS and optic neuropathies share the same feature of vascular damage (14-16), we believe AS may be correlated to general vascular damage, which may elevate the risk of optic neuropathy. This hypothesis was supported by the findings of our study.

We found AS was correlated to a significantly higher incidence of glaucoma and ischemic optic neuropathy compared to the non-AS population. In a previous study, the existence of AS was related to the co-existence of cerebrovascular disease (30). Furthermore, the presence of peripheral artery disease was commonly observed in individuals diagnosed with AS and can affect the prognosis of AS (31). Nevertheless, studies to evaluate the correlation between AS and ophthalmic vascular disorders are rare. To our knowledge, we are the first to identify significant correlation between AS and subsequent optic neuropathies, including glaucoma and ischemic optic neuropathy. Furthermore, the optic neuropathy episodes before AS diagnosis were excluded from our study, so it was possible to establish the time sequence between AS and the optic neuropathy. Moreover, several risk factors for the development of glaucoma and ischemic optic neuropathy identified in previous studies, including age, sex, hypertension, and diabetes mellitus (14, 15, 27), were considered in the multivariate analysis. As a consequence, AS may be an independent predisposing factor for the subsequent development of glaucoma and ischemic optic neuropathy. Preceding research illustrated the correlation between glaucoma and coronary heart disease (32), and another study showed the association between ischemic optic neuropathy and subsequent cerebrovascular accident (33). Accordingly, it is reasonable that AS, which is also a macrovascular disease, correlated with the subsequent development of optic neuropathy. The cumulative incidences of both glaucoma and ischemic optic neuropathy were significantly higher in the AS group than the non-AS group. These results may indicate that the risk of optic neuropathy increases especially in those with persistent AS, which would necessitate additional caution in such a population.

In the multivariate analysis, AS was associated with a high risk of developing glaucoma and ischemic optic neuropathy in people with various characteristics. These results further demonstrate the general correlation of AS with the subsequent development of glaucoma and ischemic optic neuropathy in different populations. However, AS in populations of Asian race and specific age did not present significant correlation with the later development of ischemic optic neuropathy. There is scant research to elucidate any reason for this. In a previous article, race and young age were not predisposing factors for the development of ischemic optic neuropathy (12). Accordingly, the results of our study may slightly conflict with preceding literature. A possible reason is that the number of outcomes with ischemic optic neuropathy is relatively small. The total number of cases with subsequent ischemic optic neuropathy was 957, which gives an incidence of merely 0.1% for the whole population. In such circumstance, the occurrence of statistical bias is easy. The aHRs for ischemic optic neuropathy in the populations with Asian race and specific age were still above 1, which may indicate that AS did not have a protective effect on ischemic optic neuropathy in the AS populations of Asian race and specific age. Perhaps a subsequent study with a larger population size should be performed to confirm the relationship between ischemic optic neuropathy and AS in populations with Asian race and specific age.

Regarding the epidemiology of the two diseases, AS is an important cardiovascular morbidity in all ethnicities; the incidence of AS was greater than 3% in a North America population older than 75 years and more than 10 million US citizens were reported to suffer from AS (4, 34). In Chinese citizens older than 75 years, the overall rate of AS was estimated at approximately 20% (35). For resolving life-threatening AS, aortic valve replacement procedures were performed for a large number of patients in developed countries and the associated cost was tremendous (36). Regarding aortic valve replacement, the chance of mortality immediately after completion of the procedure was above 1% despite fair overall survival after this surgery (4, 11). Glaucoma is the second most common cause of legally-defined blindness and the most common cause of irreversible blindness throughout the world (13, 37). The global prevalence of glaucoma in the population aged 40 to 80 years was 3.5% (27). In addition, the cost of glaucoma management is also high (38). Ischemic optic neuropathy, although not as common as glaucoma, had a prevalence of 0.2% in a previous study (39). Since both AS and optic neuropathies can contribute to severe impairment and high medical costs, they should be correlated.

There were certain limitations in our study. Firstly, the TriNetX is a claimed database that contains the codes for diagnosis, procedures, examinations, and medications, the details of these items are absent except for laboratory examinations. Accordingly, crucial information for these diseases, including the site of AS, the actual severity of AS, the type of AS, the presentation of AS, the surgical details of aortic valve replacement surgery, the postoperative outcome, recurrence of AS, details of the co-morbidities, the appearance of the fundus in optic neuropathy, the image of optic neuropathy, the visual field result of the glaucoma, the severity of optic neuropathy, treatment details of glaucoma, and the prognosis of optic neuropathy cannot be evaluated. Secondly, myopia is a predisposing factor for the development of glaucoma (27), but we were unable to include this risk factor in the analysis because myopia presence was rarely recorded in the TriNetX database, this could lead to severe underestimation. Besides, AS, glaucoma and ischemic optic neuropathy were diagnosed by different physicians in different regions, thus the diagnostic criteria may not be totally identical. Finally, the exact mechanism of the possible correlation between the AS and optic neuropathy cannot be examined due to the nature of database study, which may reduce the integrity of our findings.

Conclusion

In conclusion, AS was shown to be correlated with higher incidence of subsequent glaucoma and ischemic optic neuropathy after adjusting for multiple confounders. Furthermore, this correlation becomes more significant in those with a longer period of AS. Consequently, patients with persistent AS and known risk factors for optic neuropathy may need to routinely undergo ophthalmic examination to screen for possible optic neuropathy. Further large-scale prospective study to survey whether the presence of AS affects the severity of optic neuropathy is mandatory.

Footnotes

  • Authors’ Contributions

    Conceptualization, C-K.C.; methodology, S-F.Y. and C-K.C.; software, C-K.C.; formal analysis, J-Y.H.; data curation, E. L-C.M., C-B.Y. and C-K.C.; writing–original draft preparation, C-Y.L.; writing–review and editing, C-K.C.; visualization, C-K.C.; validation, C-K.C.; supervision, C-K.C. All Authors have read and agreed to the submitted version of the manuscript.

  • Conflicts of Interest

    The Authors have no proprietary or commercial interest in any materials mentioned in this article.

  • Received March 12, 2025.
  • Revision received April 2, 2025.
  • Accepted April 7, 2025.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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The Correlation Between Aortic Stenosis and the Subsequent Incidence of Optic Neuropathy: A Population-based Cohort Study
CHIA-YI LEE, SHUN-FA YANG, ELSA LIN-CHIN MAI, JING-YANG HUANG, CHAO-BIN YEH, CHAO-KAI CHANG
In Vivo Jul 2025, 39 (4) 2133-2143; DOI: 10.21873/invivo.14009
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