Smoking identified as significant risk factor for vision-threatening ocular outcomes

A large retrospective cohort study using the TriNetX electronic health records platform found that smoking is associated with an increased risk of multiple vision-threatening ocular conditions over a 10-year period. The analysis, led by first author Marina Gad El Sayed, a medical student at the University of California, Riverside, School of Medicine in Riverside, California, included 12,183,254 patients, with 304,823 identified as smokers and 11,878,431 as non-smokers.

After 1:1 propensity score matching for demographic characteristics and vascular risk factors, 300,867 patients were included in each group. Incidence rates for cataract, glaucoma, age-related macular degeneration (AMD), diabetic retinopathy (DR), retinal vascular occlusion, uveitis, and ischemic optic neuropathy (ION) were compared using risk ratios (RR).

Smokers demonstrated a significantly higher risk for all evaluated outcomes (p < 0.0001). The strongest associations were observed for posterior subcapsular cataract (RR 2.60; 95% CI, 2.41–2.82), uveitis (RR 2.43; 95% CI, 2.25–2.63), and retinal vascular occlusions, including central retinal artery occlusion (CRAO; RR 2.35) and central retinal vein occlusion (CRVO; RR 2.16). Elevated risks were also reported across glaucoma subtypes (RR range, 1.57–2.47), AMD (RR 1.85), and DR (RR 1.21).

Over the 10-year follow-up, 9.5% of smokers developed cataract compared to 5.4% of non-smokers (RR 1.77; 95% CI, 1.73–1.8). The highest cataract risk was observed for the posterior subcapsular subtype. Glaucoma incidence was 4.3% in smokers versus 2.7% in non-smokers (RR 1.57; 95% CI, 1.52–1.61), with the greatest risk seen in primary angle closure glaucoma (RR 2.47). AMD incidence was 3.8% among smokers compared to 2.1% among non-smokers (RR 1.85; 95% CI, 1.79–1.9), while DR incidence was 2.4% versus 1.9%, respectively (RR 1.21; 95% CI, 1.17–1.25).

Smoking was also associated with higher rates of retinal vascular occlusions, including branch retinal artery occlusion (RR 2.45), CRAO (RR 2.35), CRVO (RR 2.16), and branch retinal vein occlusion (RR 1.64), all with p < 0.0001. The incidence of ION was 0.13% in smokers compared to 0.08% in non-smokers (RR 1.69; 95% CI, 1.43–1.99). Uveitis occurred in 0.7% of smokers versus 0.3% of non-smokers (RR 2.43; 95% CI, 2.25–2.63).

“These findings highlight the need for ophthalmologists and public health professionals to incorporate smoking history into risk stratification and screening programs and to emphasize ocular health during smoking cessation counseling,” the study authors stated.

The study utilized de-identified data from more than 200 healthcare organizations and applied propensity score matching to account for age, sex, hypertension, and diabetes. Statistical significance was set at p < 0.001.

The authors note that the retrospective design and reliance on electronic medical records may introduce limitations, including potential underreporting of smoking status and residual confounding factors. Additionally, the study did not differentiate between current and former smokers or account for smoking duration and intensity. As an observational analysis, the findings indicate associations rather than causation.

The results suggest that smoking is associated with an increased risk of several major ocular diseases and may be relevant for risk stratification, screening, and smoking cessation counseling in ophthalmic care.

Reference:

1. Gad El Sayed M, Vu Pham N, Bandaru D, et al. Smoking and risk of vision threatening complications: A global database analysis. Clin Ophthalmol. 2026;20:596936. https://doi.org/10.2147/OPTH.S596936