Factors associated with long-term progression or stability in primary open-angle glaucoma

Association of Long-Term Intraocular Pressure Variability and Rate of Ganglion Complex Thinning in Patients With Glaucoma

PURPOSE

To evaluate the association of mean intraocular pressure (IOP) and IOP variability (IOP fluctuation [SD of IOP] and the IOP range) with the rate of ganglion cell complex (GCC) layer thinning over time in patients with glaucoma.

DESIGN

Prospective cohort study.

METHODS

Participants with at least 4 visits and 2 years of follow-up of optical coherence tomography tests were included. A linear mixed-effect model was used to investigate the association of IOP parameters with the rates of GCC thinning. Subgroup analyses were conducted for eyes with early (MD ≥ -6 dB), and moderate to advanced stage (MD < -6 dB) at baseline.

RESULTS

The cohort consisted of 369 eyes of 249 glaucoma patients (282 early glaucoma and 87 moderate to advanced glaucoma) with mean (standard deviation [SD]) age of 68.2 (10.7) years over 5.1 years of follow-up. The mean rate of GCC change was -0.59 (95% confidence interval [CI], -0.67 to -0.52) µm per year. In multivariable models, faster annual rate of GCC thinning was associated with a higher IOP fluctuation (-0.17 [95% CI, -0.23 to -0.11] µm per 1-mmHg higher, P < .001) or higher IOP range (-0.07 [95% CI, -0.09 to -0.05] µm per 1-mmHg higher, P < .001) after adjustment for mean IOP and other confounding factors. Similar results were found for early and moderate to advanced stages of glaucoma.

CONCLUSIONS

IOP variability showed an independent association with macular change in patients with glaucoma regardless of severity at baseline, even after adjustment for mean IOP, supporting its potential value as a therapeutic target for clinical decision-making.

Comparison of Patterns of Structural Progression in Primary Open Angle Glaucoma and Pseudoexfoliation Glaucoma

PRCIS

Primary open angle glaucoma and pseudoexfoliation glaucoma showed different progression patterns of the retinal nerve fiber layer and ganglion cell-inner plexiform layer thinning in OCT-guided progression analysis.

PURPOSE

To compare the patterns of progression of retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thinning by guided progression analysis (GPA) of optical coherence tomography (OCT) in primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG).

MATERIALS AND METHODS

The progression of RNFL and GCIPL thinning was assessed by the GPA of Cirrus HD-OCT (Carl Zeiss Meditec, Dublin, CA). By overlaying the acquired images of the RNFL and GCIPL thickness-change maps, the topographic patterns of progressive RNFL and GCIPL thinning were evaluated. The rates of progression of RNFL and GCIPL thinning were analyzed and compared between patients with POAG and those with PXG.

RESULTS

Of the 248 eyes of 248 patients with POAG (175 eyes of 175 patients) or PXG (73 eyes of 73 patients) enrolled, 156 POAG eyes and 48 PXG eyes were included. Progressive RNFL thinning was significantly more common in PXG than in POAG ( P =0.005). According to the RNFL progression-frequency maps, progression appeared mainly in the superotemporal and inferotemporal areas in POAG, whereas it had invaded more into the temporal area in PXG. According to the GCIPL maps, progression was most common in the inferotemporal area in both POAG and PXG. The average progression rate of GCIPL thinning was faster in PXG than in POAG ( P =0.013), and when analyzed in 2 halves (superior/inferior), the progression rate of the inferior half was faster in PXG than in POAG ( P =0.011).

CONCLUSIONS

OCT GPA showed progression patterns of RNFL and GCIPL thinning in POAG and PXG. Understanding the specific patterns of progressive RNFL and GCIPL thinning according to glaucoma type may prove helpful to glaucoma-patient treatment and monitoring.

Comparison between primary Ahmed valve implantation and primary trabeculectomy with mitomycin C in pseudophakic patients with exfoliative glaucoma

PURPOSE

To compare the efficacy and safety of primary Ahmed valve implantation (AVI) and primary trabeculectomy with mitomycin C (MMC) in patients with pseudophakic exfoliative glaucoma (XFG).

METHODS

All enrolled patients were divided into two groups: the TRAB group, comprising patients who underwent trabeculectomy with MMC, and the AVI group, comprising patients who underwent AVI. Intraocular pressure (IOP), mean deviation (MD), endothelial cell density of cornea (ECD), and the number of topical anti-glaucoma agents used during study period were retrospectively analyzed. Surgical success rates were compared between two groups using Kaplan-Meier survival analysis. Three levels of surgical success were defined as follows: (1) IOP ≤ 18 mmHg and an IOP reduction of 20% without medication; (2) IOP ≤ 15 mmHg and an IOP reduction of 25% without medication; and (3) IOP ≤ 18 mmHg and an IOP reduction of 20%, irrespective of medication.

RESULTS

The TRAB and AVI groups comprised 40 and 36 patients, respectively. At 36 months postoperatively, IOP was 15.7 ± 2.8 mmHg in the TRAB group and 16.9 ± 3.3 mmHg in the AVI group (p = 0.140). Surgical success rates in the TRAB group were 47.5, 37.5, and 77.5% and those in the AVI group were 41.6, 33.3, and 75.0% at 36 months for surgical criteria 1, 2, and 3, respectively. There were no statistically significant differences in the success rates between the two groups. However, regarding surgical criteria 2, the success rate of the AVI group at 1 year was significantly better than that of the TRAB group (p = 0.030).

CONCLUSIONS

Primary AVI was not inferior to primary trabeculectomy with MMC in medically uncontrolled patients with XFG.

Advancements in Wearable and Implantable Intraocular Pressure Biosensors for Ophthalmology: A Comprehensive Review

Glaucoma, marked by its intricate association with intraocular pressure (IOP), stands as a predominant cause of non-reversible vision loss. In this review, the physiological relevance of IOP is detailed, alongside its potential pathological consequences. The review further delves into innovative engineering solutions for IOP monitoring, highlighting the latest advancements in wearable and implantable sensors and their potential in enhancing glaucoma management. These technological innovations are interwoven with clinical practice, underscoring their real-world applications, patient-centered strategies, and the prospects for future development in IOP control. By synthesizing theoretical concepts, technological innovations, and practical clinical insights, this review contributes a cohesive and comprehensive perspective on the IOP biosensor's role in glaucoma, serving as a reference for ophthalmological researchers, clinicians, and professionals.

Regulated Cell Death of Retinal Ganglion Cells in Glaucoma: Molecular Insights and Therapeutic Potentials

Glaucoma is a group of diseases characterized by the degeneration of retinal ganglion cells (RGCs) and progressive, irreversible vision loss. High intraocular pressure (IOP) heightens the likelihood of glaucoma and correlates with RGC loss. While the current glaucoma therapy prioritizes lower the IOP; however, RGC, and visual loss may persist even when the IOP is well-controlled. As such, discovering and creating IOP-independent neuroprotective strategies for safeguard RGCs is crucial for glaucoma management. Investigating and clarifying the mechanism behind RGC death to counteract its effects is a promising direction for glaucoma control. Empirical studies of glaucoma reveal the role of multiple regulated cell death (RCD) pathways in RGC death. This review delineates the RCD of RGCs following IOP elevation and optic nerve damage and discusses the substantial benefits of mitigating RCD in RGCs in preserving visual function.

Association Between Optic Disc Perfusion Determined by Swept-Source Optical Coherence Tomography Angiography and Visual Field Progression in Glaucoma

PRCIS

Reduced optic disc vessel density determined by swept-source optical coherence tomography angiography (SS-OCTA) was associated with visual field (VF) deterioration in glaucomatous eyes, which suggested that this parameter can be a potential biomarker that correlates well with functional deterioration.

PURPOSE

The purpose of this study was to identify the association between optic disc perfusion evaluated by SS-OCTA and VF progression in primary open angle glaucoma (POAG) eyes.

METHODS

A total of 266 POAG eyes of 266 patients (5.4 y of mean follow-up) were included. Optic nerve head SS-OCTA was performed to evaluate the optic disc vessel density (dVD), parapapillary choroidal vessel density (pcVD), choroidal microvascular dropout (cMvD), and optic disc microvascular dropout (dMvD). VF progression was defined using Early Manifest Glaucoma Trial criteria. Factors associated with VF worsening were assessed by Cox proportional hazard analysis.

RESULTS

Eighty (30.1%) out of the 266 POAG eyes showed VF progression. The progression group showed a significantly higher proportion of disc hemorrhage, cMvD, and dMvD but lower dVD and pcVD than the stable group (all P <0.05). Considering the strong association between the parameters [dMvD vs. dVD ( r = -0.757, P =0.010], cMvD vs. pcVD ( r = -0.745, P =0.012), dMvD vs. cMvD ( r = 0.802, P <0.001], dVD vs. pcVD ( r = 0.862, P <0.001), CMvD vs. dVD ( r = -0.698, P =0.031), and dMvD vs. pcVD ( r = -0.688, P =0.034)], 6 models with different combinations of covariates compensating for multicollinearity were developed. Younger age, presence of disc hemorrhage, and lower dVD were consistently associated with progression in all models that included these parameters.

CONCLUSIONS

Optic disc perfusion, represented as dVD, may be a useful biomarker that correlates well with functional deterioration in POAG eyes.

The Association between Vascular Abnormalities and Glaucoma-What Comes First?

Glaucoma is a leading cause of irreversible blindness worldwide. While intraocular pressure (IOP) presents a major risk factor, the underlying pathophysiology still remains largely unclear. The correlation between vascular abnormalities and glaucoma has been deliberated for decades. Evidence for a role played by vascular factors in the pathogenesis of glaucomatous neurodegeneration has already been postulated. In addition, the fact that glaucoma causes both structural and functional changes to retinal blood vessels has been described. This review aims to investigate the published evidence concerning the relationship between vascular abnormalities and glaucoma, and to provide an overview of the "chicken or egg" dilemma in glaucoma. In this study, several biomarkers of glaucoma progression from a vascular perspective, including endothelin-1 (ET-1), nitric oxide, vascular endothelial growth factor (VEGF), and matrix metalloproteinases (MMPs), were identified and subsequently assessed for their potential as pharmacological intervention targets.

Peripheral Microvascular Abnormalities Associated with Open-Angle Glaucoma

PURPOSE

To investigate peripheral microvascular abnormalities associated with patients with open-angle glaucoma (OAG).

DESIGN

This was a cross-sectional study.

PARTICIPANTS

Patients with OAG and controls.

METHODS

All subjects underwent detailed ophthalmic evaluation, including Humphrey visual field (HVF) tests and swept source OCT. To evaluate peripheral microvascular abnormalities, nailfold capillaroscopy (NFC) and laser Doppler imaging (LDI) were performed. The presence of microhemorrhages, tortuous capillaries, dilated capillaries, avascular areas, and the capillary density, among other characteristics, were recorded using NFC; fingertip blood flow (FBF) was measured using LDI at different time points, before and 1, 10, and 20 minutes after exposure to a cold stimulus. In addition, venous blood samples were collected to measure serum endothelin-1 (ET-1) concentrations as well as serum autoantibodies.

MAIN OUTCOME MEASURES

Presence of microhemorrhages, tortuous capillaries, and dilated capillaries; FBF; ET-1; and autoantibodies.

RESULTS

Sixty-eight subjects (43 patients with OAG and 25 controls) were enrolled in the study. Microhemorrhages were found in the nail bed of 65.1% of the patients with OAG compared with 25.0% of the controls (P = 0.003). There was a significant difference in the mean FBF at the baseline in patients with OAG versus controls (293.6 ± 100.2 vs 388.8 ± 52.0 perfusion units, respectively, P < 0.001), together with a significant decrease in the mean FBF 10 and 20 minutes after cold stimulus in patients with OAG in comparison to controls (P < 0.001 for all comparisons). There was a positive correlation between mean baseline FBF and HVF mean deviation (r = 0.27, P = 0.03) and between mean baseline FBF and average retinal nerve fiber layer thickness (r = 0.44, P = 0.001). Neither the analysis of ET-1 concentrations (P= 0.71) nor the autoantibodies measurements (P > 0.05, for all) showed any difference between the 2 groups.

CONCLUSIONS

Significant peripheral microvascular abnormalities were found in patients with OAG compared to controls, suggesting that microvascular changes might play a role in the pathogenesis of the disease. In addition, part of these peripheral microvascular abnormalities seems to be correlated with both functional and structural glaucomatous damage.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Effects of chronic mild hyperoxia on retinal and choroidal blood flow and retinal function in the DBA/2J mouse model of glaucoma

Purpose

To test the hypothesis that mild chronic hyperoxia treatment would improve retinal function despite a progressive decline in ocular blood flow in the DBA/2J mouse model of glaucoma.

Materials and methods

DBA/2J mice were treated with chronic mild hyperoxia (30% O₂) beginning at 4.5 months of age or were untreated by giving normal room air. Retinal and choroidal blood flow (RBF and ChBF, respectively) were measured at 4, 6, and 9 months of age by MRI. Blood flow was additionally measured under hypercapnia challenge (5% CO₂ inhalation) to assess vascular reactivity. Intraocular pressure (IOP) was measured using a rebound tonometer at the same time points. Scotopic flash electroretinograms (ERGs) were recorded at 9 months of age.

Results

Both ChBF and RBF were reduced and significantly affected by age (p < 0.01), but neither were significantly affected by O₂-treatment (p > 0.05). ChBF significantly increased in response to hypercapnia (p < 0.01), which was also unaffected by O₂-treatment. Significant effects of age (p < 0.001) and of the interaction of age with treatment (p = 0.028) were found on IOP. IOP significantly decreased in O₂-treated mice at 6 months compared to 4 months of age (p < 0.001), while IOP trended to increase with age in untreated mice. The amplitude of the b-wave from ERG was significantly increased in O₂-treated DBA/2J compared to the untreated mice (p = 0.012), while the a-wave and oscillatory potentials were not significantly affected (p > 0.05).

Conclusion

This study investigated the effects of chronic mild hyperoxia on retinal function and on retinal and choroidal blood flow in a mouse model of glaucoma. Retinal function was improved in the O₂-treated mice at late stage, despite a progressive decline of RBF and ChBF with age that was comparable to untreated mice.

Primary glaucomas in adults: Epidemiology and public health-A review

Glaucoma is a mixed group of optic neuropathies that lead to irreversible visual field loss and blindness if left untreated. It is estimated that 3.5% of the global population aged 40 to 80 years have any glaucoma, being the primary open-angle and the primary angle-closure glaucoma the most prevalent forms. Although the age-standardised prevalence of blindness caused by glaucoma has decreased substantially over the last decades, population growth and ageing impose many challenges in preventing glaucoma-related morbidities on a global level. In addition, difficulties in diagnoses and treatment, along with its chronic and irreversible nature, urge the development and implementation of innovative approaches in confronting the disease. This manuscript reviews recent literature related to the epidemiology of primary glaucomas in adults, the risk factors attributed to the development of the disease, and discuss challenges and potential solutions from a public health perspective.

Efficacy and safety of newly developed preservative-free latanoprost 0.005% eye drops versus preserved latanoprost 0.005% in open angle glaucoma and ocular hypertension: 12-week results of a randomized, multicenter, controlled phase III trial

AIM

To evaluate the therapeutic efficacy, safety and tolerability of newly developed preservative-free (PF) latanoprost generic [TJO-002] and compare it with benzalkonium chloride (BAK)-preserved latanoprost [Xalatan^®] in patients with primary open angle glaucoma (POAG) and ocular hypertension (OHT).

METHODS

Included patients were aged ≥19y with POAG/OHT. After a washout period, patients with IOP 21-35 mm Hg at 9 a.m. were enrolled. After a full ophthalmic and glaucoma examination, 144 patients with POAG and OHT participated in this study. Subjects were randomly assigned either PF latanoprost (74 eyes) or BAK-preserved latanoprost (70 eyes). All subjects were examined at 4, 8, and 12wk after first administration. At each follow-up visit, IOP was measured at 9 a.m. and 5 p.m. and compliance was assessed. Throughout the study, all adverse events were recorded and monitored by the masked investigators who measured IOP.

RESULTS

Both groups showed a statistically significant decrease of average diurnal IOP at 12wk compared to baseline (-7.21±3.10 mm Hg in the PF latanoprost group and -7.02±3.17 mm Hg in the BAK latanoprost group, both P<0.0001). There was no statistically significant diurnal IOP variation between the groups. In terms of tolerability, pruritus, burning/stinging, and sticky eye sensation, severity was significantly lower in the PF latanoprost group than in the BAK latanoprost group (P<0.05).

CONCLUSION

PF latanoprost has at least similar efficacy in terms of IOP reduction and better tolerability compared with BAK latanoprost.

The Association Between Intraocular Pressure and Visual Field Worsening in Treated Glaucoma Patients

PRECIS

In treated eyes with mild/suspect glaucoma, intraocular pressure (IOP) increments are associated with worsening mean deviation (MD) once IOP reaches the 20s. In moderate/advanced eyes, IOP increments are associated with worse visual field (VF) performance across the entire IOP range.

PURPOSE

The purpose of this study was to describe the relationship between mean treated IOP and VF worsening and understand how this relationship is affected by glaucoma severity and IOP range.

METHODS

A total of 1446 eyes of 869 treated glaucoma patients with at least 5 longitudinal reliable VF tests and IOP measures were included. Mixed-effects linear models were employed to understand the effect of eye-specific mean treated IOP on MD slope. Models included interaction terms to assess the differing relationships between MD slope and mean IOP by glaucoma severity (suspect/mild vs. moderate/advanced) and splines to account for the differing effects of mean IOP on MD slope at different IOP ranges (above or below 21 mm Hg).

RESULTS

In suspect/mild glaucoma, when treated IOP values were <21 mm Hg, a 1 mm Hg increment in IOP was not associated with an increase in the rate of VF worsening (P>0.05) but when treated IOP values rose >21 mm Hg, a 1 mm Hg increment in IOP was associated with faster VF worsening (-0.09 dB/y per 1 mm Hg increment, P<0.05). In moderate/advanced disease, a 1 mm Hg increment in treated IOP was associated with faster VF worsening both below and above 21 mm Hg, but the effect was much more pronounced in the higher range (-0.02 dB/y per mm Hg increment <21 mm Hg vs. -0.74 dB/y per mm Hg increment >21 mm Hg, P<0.05 for both).

CONCLUSION

IOP remained associated with VF worsening in eyes with more advanced glaucoma throughout the IOP range but was only associated with VF worsening in eyes with less severe glaucoma at higher IOP.

Predicting eyes at risk for rapid glaucoma progression based on an initial visual field test using machine learning

OBJECTIVE

To assess whether machine learning algorithms (MLA) can predict eyes that will undergo rapid glaucoma progression based on an initial visual field (VF) test.

DESIGN

Retrospective analysis of longitudinal data.

SUBJECTS

175,786 VFs (22,925 initial VFs) from 14,217 patients who completed ≥5 reliable VFs at academic glaucoma centers were included.

METHODS

Summary measures and reliability metrics from the initial VF and age were used to train MLA designed to predict the likelihood of rapid progression. Additionally, the neural network model was trained with point-wise threshold data in addition to summary measures, reliability metrics and age. 80% of eyes were used for a training set and 20% were used as a test set. MLA test set performance was assessed using the area under the receiver operating curve (AUC). Performance of models trained on initial VF data alone was compared to performance of models trained on data from the first two VFs.

MAIN OUTCOME MEASURES

Accuracy in predicting future rapid progression defined as MD worsening more than 1 dB/year.

RESULTS

1,968 eyes (8.6%) underwent rapid progression. The support vector machine model (AUC 0.72 [95% CI 0.70-0.75]) most accurately predicted rapid progression when trained on initial VF data. Artificial neural network, random forest, logistic regression and naïve Bayes classifiers produced AUC of 0.72, 0.70, 0.69, 0.68 respectively. Models trained on data from the first two VFs performed no better than top models trained on the initial VF alone. Based on the odds ratio (OR) from logistic regression and variable importance plots from the random forest model, older age (OR: 1.41 per 10 year increment [95% CI: 1.34 to 1.08]) and higher pattern standard deviation (OR: 1.31 per 5-dB increment [95% CI: 1.18 to 1.46]) were the variables in the initial VF most strongly associated with rapid progression.

CONCLUSIONS

MLA can be used to predict eyes at risk for rapid progression with modest accuracy based on an initial VF test. Incorporating additional clinical data to the current model may offer opportunities to predict patients most likely to rapidly progress with even greater accuracy.

Evaluation of a Primary Open-Angle Glaucoma Prediction Model Using Long-term Intraocular Pressure Variability Data: A Secondary Analysis of 2 Randomized Clinical Trials

Importance

The contribution of long-term intraocular pressure (IOP) variability to the development of primary open-angle glaucoma is still controversial.

Objective

To assess whether long-term IOP variability data improve a prediction model for the development of primary open-angle glaucoma (POAG) in individuals with untreated ocular hypertension.

Design, Setting, and Participants

This post hoc secondary analysis of 2 randomized clinical trials included data from 709 of 819 participants in the observation group of the Ocular Hypertension Treatment Study (OHTS) followed up from February 28, 1994, to June 1, 2002, and 397 of 500 participants in the placebo group of the European Glaucoma Prevention Study (EGPS) followed up from January 1, 1997, to September 30, 2003. Data analyses were completed between January 1, 2019, and March 15, 2020.

Exposures

The original prediction model for the development of POAG included the following baseline factors: age, IOP, central corneal thickness, vertical cup-disc ratio, and pattern SD. This analysis tested whether substitution of baseline IOP with mean follow-up IOP, SD of IOP, maximum IOP, range of IOP, or coefficient of variation IOP would improve predictive accuracy.

Main Outcomes and Measures

The C statistic was used to compare the predictive accuracy of multivariable landmark Cox proportional hazards regression models for the development of POAG.

Results

Data from the OHTS consisted of 97 POAG end points from 709 of 819 participants (416 [58.7%] women; 177 [25.0%] African American and 490 [69.1%] white; mean [SD] age, 55.7 [9.59] years; median [range] follow-up, 6.9 [0.96-8.15] years). Data from the EGPS consisted of 44 POAG end points from 397 of 500 participants in the placebo group (201 [50.1%] women; 397 [100%] white; mean [SD] age, 57.8 [9.76] years; median [range] follow-up, 4.9 [1.45-5.76] years). The C statistic for the original prediction model was 0.741. When a measure of follow-up IOP was substituted for baseline IOP in this prediction model, the C statistics were as follows: mean follow-up IOP, 0.784; maximum IOP, 0.781; SD of IOP, 0.745; range of IOP, 0.741; and coefficient of variation IOP, 0.729. The C statistics in the EGPS were similarly ordered. No measure of IOP variability, when added to the prediction model that included mean follow-up IOP, age, central corneal thickness, vertical cup-disc ratio, and pattern SD, increased the C statistic by more than 0.007 in either cohort.

Conclusions and Relevance

Evidence from the OHTS and the EGPS suggests that long-term variability does not add substantial explanatory power to the prediction model as to which individuals with untreated ocular hypertension will develop POAG.

Retrospective Chart Review on Real-World Use of Latanoprostene Bunod 0.024% in Treatment-Naïve Patients with Open-Angle Glaucoma

Introduction

The objective of this study was to evaluate real-world effectiveness of latanoprostene bunod (LBN) ophthalmic solution 0.024% in treatment-naïve patients newly diagnosed with open-angle glaucoma (OAG) or ocular hypertension.

Methods

This multicenter retrospective chart review included patients aged ≥ 18 years, with no history of medical, laser, or surgical intraocular pressure (IOP)-lowering intervention and at least two follow-up visits (spanning ≥ 2 months) following initiation of LBN treatment. Extracted data included age, sex, race, cup-to-disk ratio, central corneal thickness, IOP, visual acuity (VA), concomitant medications, and adverse events. In patients treated bilaterally, the eye with the higher baseline IOP was the study eye.

Results

Medical charts for 65 patients (mean [SD] age, 59 [14] years; 53.8% female) encompassing 125 eyes treated with LBN were reviewed across nine clinical sites. Mean (SD) IOP at baseline was 21.7 (5.9) mmHg. Mean days to first and second follow-up visit were 43 and 141, respectively. LBN use resulted in a mean (SD) reduction from baseline of 7.1 (4.7) and 7.3 (5.1) mmHg at the first and second follow-up visits, respectively (P < 0.0001 for both). Reductions among patients with IOP > 21 mmHg (n = 30) at baseline were 10.0 (4.5) and 11.1 (4.6) mmHg at the first and second follow-up visits (P < 0.0001 for both). There were no meaningful changes in VA. Adverse events appeared infrequent, with only one report of ocular redness.

Conclusion

In this real-world, retrospective chart review, LBN 0.024% use resulted in robust IOP lowering in newly diagnosed OAG patients new to treatment, and appeared well tolerated.

Comparison between provocative test-based and long-term intraocular pressure parameters in patients with stable open-angle glaucoma

PURPOSE

To compare provocative test-based and long-term intraocular pressure variation parameters in patients with stable open-angle glaucoma.

METHODS

A prospective observational study was carried out in which stable open-angle glaucoma patients (⩾3 years of follow-up without any changes on current medical regimen) were consecutively enrolled. All patients were submitted to a water-drinking test. Long-term intraocular pressure parameters were obtained from isolated intraocular pressure measurements from each visit (⩾5 visits). We investigated the correlation and agreement between the following water-drinking test and long-term intraocular pressure parameters: mean, peak, and fluctuation. In addition, the percentage of eyes with significant intraocular pressure peaks during the water-drinking test (defined as a difference ⩾25% between water-drinking test intraocular pressure peak and mean long-term intraocular pressure) was assessed.

RESULTS

Sixty-three eyes from 63 open-angle glaucoma patients (mean age, 60.7 ± 11.8 years) were included. Mean and water-drinking test intraocular pressure peak correlated significantly with mean (r = 0.67) and maximum long-term intraocular pressure (r = 0.52), respectively (p < 0.01). The correlation between water-drinking test intraocular pressure fluctuation and long-term intraocular pressure fluctuation was not significant (p = 0.45). Limits of agreement from Bland-Altman plots exceeded the maximum allowed difference between methods (3 mm Hg) for all the intraocular pressure parameters analyzed, suggesting poor agreement between water-drinking test-derived and long-term intraocular pressure values. Overall, significant water-drinking test intraocular pressure peaks were observed in 39.7% of these eyes with stable open-angle glaucoma.

CONCLUSION

Although some water-drinking test-based and long-term intraocular pressure parameters correlate significantly, water-drinking test results may not reflect the long-term intraocular pressure profile of stable open-angle glaucoma patients, as their agreement is poor. Many of these patients may experience significant water-drinking test intraocular pressure peaks, despite long-standing stable disease and unchanged medical regimen.

Risk of developing open-angle glaucoma in patients with carotid artery stenosis: A nationwide cohort study

Whether carotid artery stenosis (CAS) is an independent risk factor for open-angle glaucoma remains unclear. In this study, we investigated the association between CAS and the development of open-angle glaucoma in the Taiwanese population-based cohort derived from a longitudinal database containing claims data from the Taiwan National Health Insurance (NHI) program; this study enrolled 2093 patients with CAS and 8372 patients without CAS matched by age and sex from 1999 to 2010. Diagnoses of open-angle glaucoma (OAG) were identified during a follow-up period lasting through December 31, 2013. A Cox proportional hazards model was applied to evaluate the hazard ratio (HR) for OAG in the CAS cohort compared with the matched cohort. We found that the HR for open-angle glaucoma in the CAS cohort compared with the matched cohort. The adjusted HR for OAG in the CAS cohort was 1.50 (95% confidence interval, 1.11-2.02, P = .008). The Kaplan-Meier analysis revealed that the CAS cohort had a higher cumulative incidence of OAG than did the matched cohort during the follow-up period (log-rank test, P < .001). We concluded that CAS is a significantly independent risk factor for the development of OAG. Our finding is clinically important for the aging population, which has an increasing prevalence of CAS.

Simplifying "target" intraocular pressure for different stages of primary open-angle glaucoma and primary angle-closure glaucoma

Lowering of intraocular pressure is currently the only therapeutic measure for Glaucoma management. Many longterm, randomized trials have shown the efficacy of lowering IOP, either by a percentage of baseline, or to a specified level. This has lead to the concept of 'Target" IOP, a range of IOP on therapy, that would stabilize the Glaucoma/prevent further visual field loss, without significantly affecting a patient's quality of life. A clinical staging of Glaucoma by optic nerve head evaluation and perimetric parameters, allows a patient's eye to be categorized as having - mild, moderate or severe Glaucomatous damage. An initial attempt should be made to achieve the following IOP range for both POAG or PACG after an iridotomy. In mild glaucoma the initial target IOP range could be kept as 15-17 mmHg, for moderate glaucoma 12-15 mmHg and in the severe stage of glaucomatous damage 10-12 mmHg. Factoring in baseline IOP, age, vascular perfusion parameters, and change on perimetry or imaging during follow up, this range may be reassessed over 6 months to a year. "Target" IOP requires further lowering when the patient continues to progress or develops a systemic disease such as a TIA. Conversely, in the event of a very elderly or sick patient with stable nerve and visual field over time, the target IOP could be raised and medications reduced. An appropriate use of medications/laser/surgery to achieve such a "Target" IOP range in POAG or PACG can maintain visual fields and quality of life, preventing Glaucoma blindness.

A retrospective analysis of the use of loteprednol etabonate ophthalmic suspension 0.5% following canaloplasty

Background

While loteprednol etabonate (LE) suspension 0.5% is approved for the treatment of postoperative ocular inflammation, there have been no reported studies of its use in glaucoma patients undergoing canaloplasty.

Methods

This was a retrospective medical chart review conducted at a single US center. Data were collected on patients with glaucoma who underwent canaloplasty with or without cataract surgery, and were prescribed LE suspension 0.5% postoperatively. Outcomes evaluated included postsurgical inflammation (anterior chamber [AC] cells and flare), intraocular pressure (IOP), number of IOP-lowering medications, and postsurgical complications.

Results

Data were collected on 204 patients (262 eyes) with a mean (SD) age of 71.6 (11.3) years. The most frequent LE dosing regimens at day 1, week 1, and month 1 postsurgery were QID (92.3%; 241/261), TID (52.6%; 133/253), and QD (65.5%; 78/119), respectively. Inflammation (AC flare and cells), mostly mild, was noted in 33.2% (86/259) of eyes on postoperative day 1 and 8.6% (21/244) of eyes at month 1. Mean IOP and mean number of IOP-lowering medications were significantly reduced from baseline (P<0.001) at all time points postoperatively. Complete (no IOP-lowering medication) or qualified (use of ≤2 IOP-lowering medications) surgical success was achieved in 78.8% and 90.6% of eyes, respectively, at month 6 and 63.4% and 92.7% of eyes at month 36. The most frequently observed postoperative complication was hyphema in 48.7% (126/259) eyes at day 1, which decreased to 0.4% (1/244) of eyes by month 1. IOP ≥30 mmHg was noted in 13 (5.3%) eyes at postoperative week 1 and rarely thereafter, and no patient discontinued therapy because of an IOP increase.

Conclusion

These real-world data suggest that canaloplasty with or without cataract surgery managed postoperatively with LE suspension 0.5% is effective and safe in the glaucoma patient.

Measurement of the hypotenuse of the vertical optic nerve head cup with spectral-domain optical coherence tomography for the structural diagnosis of glaucoma

Purpose

To evaluate the hypotenuse of the vertical optic nerve head cup (HVOC), measured using the length and depth of the cup obtained with enhanced depth imaging spectral-domain optic coherence tomography (SD-OCT), as a biomarker for glaucoma diagnosis.

Methods

This was a prospective cross-sectional study of patients with glaucoma and controls. SD-OCT was performed in all participants to assess average circumpapillary retinal nerve fiber layer (RNFL) thickness. A vertical B-scan of the optic nerve head (ONH) was obtained for HVOC measurement. The length and depth of the optic nerve cup formed the sides of a right triangle that were used to calculate the HVOC. Participants also underwent standard automated perimetry.

Results

One hundred and fifty-six eyes were divided into three groups: mean deviation (MD) <−7 dB (60 eyes); MD ≥−7 dB (74 eyes); and healthy subjects (22 eyes). The mean (SD) HVOC in these groups was 1,419.8 (347.2) µm, 1,234.6 (258.8) µm, and 685.79 (315.4) µm (P<0.01), respectively. In the secondary structure–function analysis, only discs with a vertical diameter of 1.51–2.00 mm were included (120 eyes). The HVOCs were divided into four percentile groups, with the following means: 940, 1,128, 1,390, and 1,662 µm. There was a significant difference in MD between percentile groups 1 and 3 (P<0.03), 1 and 4 (P<0.001), 2 and 3 (P<0.02), and 2 and 4 (P<0.001). RNFL thickness differed among all percentile groups (P<0.001).

Conclusion

HVOC may provide an additional morphometric biomarker for the structural evaluation of ONH remodeling in glaucoma.

Long-Term Progression at Individual Mean Intraocular Pressure Levels in Primary Open-Angle and Exfoliative Glaucoma

Purpose

To describe progression and non-progression rates at individual mean intraocular pressure (IOP) levels for patients with primary open-angle and exfoliative glaucoma.

Methods

A meta-analysis of five previously published retrospective studies describing progression and non-progression rates at individual intraocular pressure levels over 5 or more years of follow-up. All patients had primary open-angle (four studies) or exfoliative glaucoma (one study).

Results

This meta-analysis included 822 patients of whom 655 (80%) had primary open-angle glaucoma and 167 (20%) had exfoliative glaucoma. In total, 220 patients progressed (27%), while 602 (73%) remained stable over 5 years. The mean IOP was 20.0 for progressed and 17.1 mmHg for stable patients (p=0.0004). The peak IOP was 29.1 for progressed and 23.6 mmHg for stable patients (p=0.0014). At an IOP level >18 mmHg, 49% of patients remained stable; at 18 mmHg, 78%; between 13 and 17 mmHg, 82%; and <13 mmHg, 96%. Additional factors associated with progression were older age (p=0.0004) and exfoliative glaucoma (p=0.0001). However, multivariant regression analysis identified only mean IOP as a risk factor for progression (p=0.039).

Conclusions

This study suggests that maintaining an IOP well within the normal range over 5 years in patients with primary open-angle or exfoliative glaucoma helps to prevent glaucomatous progression.

Intraocular Pressure Fluctuation: Is It Important?

Elevated intraocular pressure (IOP) is a major risk factor for the development and progression of glaucoma. Previous prospective, randomized, long-term studies have demonstrated the strength of IOP reduction in slowing the progression of disease. It is well known that IOP is not a fixed value but fluctuates considerably over time. Although there have been some studies on IOP fluctuation and the progression of glaucoma, whether IOP fluctuation is an independent risk factor for glaucomatous damage and disease progression remains controversial. In this article, we reviewed the definition of IOP fluctuation, and both the evidence and the speculation for and against the effect of IOP fluctuation on glaucoma progression. Although conclusions seem to vary from study to study, we considered that different studies examined different groups of patients, at different stages of disease, and at different IOP levels. Our conclusion is that these apparently disparate results are not conflicting, but rather can be viewed as complementary. In clinical care, we recommend the consideration of IOP “modulation” rather than just IOP “reduction” when glaucoma patients are treated. Quality-based IOP control may be more effective than quantity-based IOP reduction to prevent or retard disease progression.

Intereye comparison of ocular factors in normal tension glaucoma with asymmetric visual field loss in Korean population

PURPOSE

To identify ocular parameters corresponding to asymmetric visual field (VF) loss in normal tension glaucoma (NTG) through intereye comparisons.

PATIENTS AND METHODS

Medical records of NTG patients with asymmetric and symmetric VF losses were retrospectively reviewed. The criterion for asymmetry in VF was 6 dB difference of mean deviation. Refractive error, intraocular pressure (IOP), central corneal thickness, ovality index, and peripapillary atrophy (PPA)/disc area ratio were obtained from each patient. Intereye comparison was performed for asymmetric group, symmetric group, and myopic and nonmyopic asymmetric subgroups.

RESULTS

We included 155 patients; 110 patients in asymmetric group and 45 patients in symmetric group. In intereye comparison for total asymmetric group, refractive error (P = 0.006), initial IOP (P = 0.001), ovality index (P = 0.008), and PPA (P < 0.001) were significantly asymmetric. For myopic subgroup, refractive error (P = 0.004), ovality index (P = 0.001), and PPA (P = 0.003) were significant factors. For nonmyopic subgroup, initial IOP (P = 0.003) and PPA (P = 0.007) were significant factors. Symmetric group showed no significant difference between the eyes. Multivariate analysis demonstrated that refractive error (P = 0.002) and PPA (P = 0.028) were significant factors in myopic subgroup, and initial IOP (P = 0.022) and PPA (P = 0.002) were significant factors in nonmyopic subgroup.

CONCLUSIONS

In this intereye comparison, the more myopic eye in myopic NTG patient, and the more pressured eye in nonmyopic NTG patient demonstrated more severe VF loss. Myopic and nonmyopic patients may follow different pathophysiologic processes. Discriminative attentions should be paid to NTG patients by subtypes.

Peripapillary Retinal Nerve Fiber Layer Vascular Microcirculation in Eyes With Glaucoma and Single-Hemifield Visual Field Loss

Importance

Understanding the differences in vascular microcirculation of the peripapillary retinal nerve fiber layer (RNFL) between the hemispheres in eyes with glaucoma with single-hemifield visual field (VF) defects may provide insight into the pathophysiology of glaucoma.

Objective

To investigate the changes in the microcirculation of the peripapillary RNFL of eyes with glaucoma by using optical microangiography.

Design, Setting, and Participants

Eyes with glaucoma and single-hemifield VF defect and normal eyes underwent scanning using an optical microangiography system covering a 6.7 × 6.7-mm2 area centered at the optic nerve head. The RNFL microcirculation was measured within an annulus region centered at the optic nerve head divided into superior and inferior hemispheres. Blood flux index (the mean flow signal intensity in the vessels) and vessel area density (the percentage of the detected vessels in the annulus) were measured.

Main Outcomes and Measures

Differences in microcirculation between the hemispheres in eyes with glaucoma and normal eyes and correlations among blood flow metrics, VF thresholds, and clinical optical coherence tomography structural measurements were assessed.

Results

Twenty-one eyes from 21 patients with glaucoma (7 men and 14 women; mean [SD] age, 63.7 [9.9] years) and 20 eyes from 20 healthy control individuals (9 men and 11 women; mean [SD] age, 68.3 [10.7] years) were studied. In eyes with glaucoma, the abnormal hemisphere showed a thinner RNFL (mean [SE] difference, 23.5 [4.5] μm; 95% CI, 15.1-32.0 µm; P < .001), lower RNFL blood flux index (mean [SE] difference, 0.04 [0.01]; 95% CI, 0.02-0.05; P < .001), and less vessel area density (mean [SE] difference, 0.08% [0.02%]; 95% CI, 0.05%-0.10%; P < .001) than did the normal hemisphere. Compared with normal eyes, reduced RNFL microcirculation was found in the normal hemisphere of eyes with glaucoma, measured by mean [SE] differences in blood flux index (0.06 [0.01]; 95% CI, 0.04-0.09; P < .001) and vessel area density (0.04% [0.02%]; 95% CI, 0.02%-0.08%; P = .003) but not in RNFL thickness (3.4 [4.7] μm; 95% CI, -6.2 to 12.9 µm; P = .48). Strong correlations were found between the blood flux index and VF mean deviation (Spearman ρ = 0.44; P = .045) and RNFL thickness (Spearman ρ = 0.65; P = .001) in the normal hemisphere of the eye with glaucoma.

Conclusions and Relevance

Reduced RNFL microcirculation was detected in the normal hemisphere of eyes with glaucoma, with strong correspondence with VF loss and RNFL thinning. Although the results suggest that vascular dysfunction precedes structural changes seen in glaucoma, longitudinal studies would be needed to confirm this finding.

Ocular manifestations of Noonan syndrome in twin siblings: a case report of keratoconus with acute corneal hydrops

Ocular manifestations of Noonan syndrome (NS) in a set of healthy 20-year-old African-American fraternal twins are reported with emphasis on a rare finding of keratoconus with acute corneal hydrops in one twin. Both the twins had learning disabilities and attended a special needs school. Evaluation included visual acuity assessment, tonometry and external eye, slit lamp and dilated fundus examinations, topography with Pentacam and external photographs. The first case was more remarkable as keratoconus with acute corneal hydrops was observed. The patient presented with severe cloudy vision that had worsened over a span of 1 month. It improved significantly on follow-up. The second case included a unique constellation of ocular pathology that highlights the diversity of NS manifestations even amongst twins. Conservative treatment of keratoconus with acute corneal hydrops in a NS patient helped largely resolve the patient's condition. We report the diverse spectrum of ocular manifestations associated with this rare congenital disorder.

Selective Laser Trabeculoplasty Reduces Intraocular Pressure Peak in Response to the Water Drinking Test

PURPOSE

To determine the effect of selective laser trabeculoplasty (SLT) on intraocular pressure (IOP) peak and fluctuation induced by the water drinking test (WDT) in patients with open-angle glaucoma and ocular hypertension.

METHODS

Patients with open-angle glaucoma or ocular hypertension underwent the WDT before and after SLT within a 12-month period. No other changes to therapeutic regimen were permitted. IOP was measured with a Goldmann applanation tonometer at baseline and every 15 minutes for 45 minutes following a fluid challenge of 800 mL over 15 minutes. Baseline, peak, and percentage fluctuation in IOP from baseline were compared using a repeated measures analysis of variance with Bonferroni adjustment.

RESULTS

Twenty eyes from 20 patients were included in this study. The median patient age was 73±15 years (interquartile range) and 70% of patients were female. Ten eyes (50%) had a diagnosis of primary open-angle glaucoma and 10 eyes had ocular hypertension. Following SLT there was a statistically significant reduction in mean baseline IOP from 16.9±2.4 to 14.2±2.3 mm Hg (P<0.001), peak IOP from 21.9±3.7 to 16.9±3.1 mm Hg (P<0.001).

CONCLUSIONS

Patients with open-angle glaucoma and ocular hypertension treated with SLT have significantly reduced peak IOPs and fluctuation in IOP in response to the WDT.

Maladaptive coping strategies and glaucoma progression

The identification of modifiable risk factors for glaucoma progression is needed. Our objective was to determine whether maladaptive coping styles are associated with recent glaucoma progression or worse visual field mean deviation.A hospital-based case-control study was conducted in the Glaucoma Service of Maisonneuve-Rosemont Hospital in Montreal, Canada. Patients with primary open angle glaucoma or normal tension glaucoma with ≥4 years of follow-up and ≥5 Humphrey visual fields were included. Cases had recent visual field progression as defined according to the Early Manifest Glaucoma Trial pattern change probability maps. Controls had stable visual fields. The Brief Cope questionnaire, a 28-item questionnaire about 14 different ways of coping with the stress of a chronic disease, was asked. Questions were also asked about demographic and medical factors, and the medical chart was examined. Outcomes included glaucoma progression (yes, no) and visual field mean deviation. Logistic and linear regressions were used.A total of 180 patients were included (82 progressors and 98 nonprogressors). Although none of the 14 coping scales were associated with glaucoma progression (P > 0.05), higher denial was correlated with worse visual field mean deviation (r = -0.173, P = 0.024). In a linear regression model including age, sex, education, depression, intraocular pressure, and family history of glaucoma, greater levels of denial (β = -1.37, 95% confidence interval [CI] -2.32, -0.41), Haitian ethnicity (β = -7.78, 95% CI -12.52, -3.04), and the number of glaucoma medications (β = -1.20, 95% CI -2.00, -0.38) were statistically significantly associated with visual field mean deviation.The maladaptive coping mechanism of denial was a risk factor for worse visual field mean deviation. Further prospective research will be required to verify the pathways by which denial may exert an effect on glaucomatous visual field loss.

Optic nerve head perfusion in normal eyes and eyes with glaucoma using optical coherence tomography-based microangiography

BACKGROUND

To investigate the differences of perfusion in the optic nerve head (ONH) between normal and glaucomatous eyes using optical microangiography (OMAG) based optical coherence tomography (OCT) angiography technique.

METHODS

One eye from each subject was scanned with a 68 kHz Cirrus 5000 HD-OCT-based OMAG prototype system centered at the ONH (Carl Zeiss Meditec Inc, Dublin, CA, USA). Microvascular images were generated from the OMAG dataset by detecting the differences in OCT signal between consecutive B-scans. The pre-laminar layer (preLC) was isolated by a semi-automatic segmentation program. En face OMAG images for preLC were generated using signals with highest blood flow signal intensity. ONH perfusion was quantified as flux, vessel area density, and normalized flux within the ONH. Standard t-tests were performed to analyze the ONH perfusion differences between normal and glaucomatous eyes. Linear regression models were constructed to analyze the correlation between ONH perfusion and other clinical measurements.

RESULTS

Twenty normal and 21 glaucoma subjects were enrolled. Glaucomatous eyes had significantly lower ONH perfusion in preLC in all three perfusion metrics compared to normal eyes (P≤0.0003). Significant correlations between ONH perfusion and disease severity as well as structural changes were detected in glaucomatous eyes (P≤0.012).

CONCLUSIONS

ONH perfusion detected by OMAG showed significant differences between glaucoma and normal controls and was significantly correlated with disease severity and structural defects in glaucomatous eyes. ONH perfusion measurement using OMAG may provide useful information for detection and monitoring of glaucoma.

Impact of Age and Myopia on the Rate of Visual Field Progression in Glaucoma Patients

Myopia is rapidly increasing in young populations and patients with glaucoma associated with myopia are reported to be young aged in East Asia. These young patients have a longer life expectancy, which increases their risk of end-of-life visual disabilities. There is a need to understand the clinical course of myopic glaucoma patients, which may be important for the care of these myopic populations. In this study, we evaluated the relationship between the age at presentation and the rate of glaucoma progression in the visual field (VF) according to the presence of myopia. The study was conducted as a prospective observational study including 179 patients with open-angle glaucoma who had undergone at least 5 VF examinations with a follow-up of at least 5 years. The progression rate of the mean deviation (MD) and the pattern standard deviation (PSD) are expressed as change in decibels (dB) per year. The slopes of the MD and PSD were calculated by linear regression analyses. Factors related to the slope of VF MD changes were analyzed with correlation and regression analyses. The slope of the linear fit line plotted against age at presentation and the rate of change in the VF MD was -0.026 (P < 0.001) in the myopic group and -0.008 (P = 0.167) in the nonmyopic group; the relationship was more prominent in the myopic group than the nonmyopic group. In the myopic group, age (β = -0.417; 95% confidence intervals (CI), -0.651 to -0.200; P = 0.050) and baseline untreated intraocular pressure (β = -0.179; 95% CI, -0.331 to -0.028; P = 0.022) were significantly related to the rate of change in the MD, which was only the presence of disc hemorrhage (β = -0.335; 95% CI, -0.568 to -0.018; P = 0.022) in the nonmyopic group. Age at presentation was significantly related to the rate of change in the VF in glaucomatous eyes with myopia compared to eyes without myopia. Older age was significantly related to the rate of change in the VF only in myopic glaucomatous eyes.

Optic nerve head perfusion in normal eyes and eyes with glaucoma using optical coherence tomography-based microangiography

BACKGROUND

To investigate the differences of perfusion in the optic nerve head (ONH) between normal and glaucomatous eyes using optical microangiography (OMAG) based optical coherence tomography (OCT) angiography technique.

METHODS

One eye from each subject was scanned with a 68 kHz Cirrus 5000 HD-OCT-based OMAG prototype system centered at the ONH (Carl Zeiss Meditec Inc, Dublin, CA, USA). Microvascular images were generated from the OMAG dataset by detecting the differences in OCT signal between consecutive B-scans. The pre-laminar layer (preLC) was isolated by a semi-automatic segmentation program. En face OMAG images for preLC were generated using signals with highest blood flow signal intensity. ONH perfusion was quantified as flux, vessel area density, and normalized flux within the ONH. Standard t-tests were performed to analyze the ONH perfusion differences between normal and glaucomatous eyes. Linear regression models were constructed to analyze the correlation between ONH perfusion and other clinical measurements.

RESULTS

Twenty normal and 21 glaucoma subjects were enrolled. Glaucomatous eyes had significantly lower ONH perfusion in preLC in all three perfusion metrics compared to normal eyes (P≤0.0003). Significant correlations between ONH perfusion and disease severity as well as structural changes were detected in glaucomatous eyes (P≤0.012).

CONCLUSIONS

ONH perfusion detected by OMAG showed significant differences between glaucoma and normal controls and was significantly correlated with disease severity and structural defects in glaucomatous eyes. ONH perfusion measurement using OMAG may provide useful information for detection and monitoring of glaucoma.

24-h Efficacy of Glaucoma Treatment Options

Current management of glaucoma entails the medical, laser, or surgical reduction of intraocular pressure (IOP) to a predetermined level of target IOP, which is commensurate with either stability or delayed progression of visual loss. In the published literature, the hypothesis is often made that IOP control implies a single IOP measurement over time. Although the follow-up of glaucoma patients with single IOP measurements is quick and convenient, such measurements often do not adequately reflect the untreated IOP characteristics, or indeed the quality of treated IOP control during the 24-h cycle. Since glaucoma is a 24-h disease and the damaging effect of elevated IOP is continuous, it is logical that we should aim to understand the efficacy of all treatment options throughout the 24-h period. This article first reviews the concept and value of diurnal and 24-h IOP monitoring. It then critically evaluates selected available evidence on the 24-h efficacy of medical, laser and surgical therapy options. During the past decade several controlled trials have significantly enhanced our understanding on the 24-h efficacy of all glaucoma therapy options. Nevertheless, more long-term evidence is needed to better evaluate the 24-h efficacy of glaucoma therapy and the precise impact of IOP characteristics on glaucomatous progression and visual prognosis.

Perimetric progression using the Visual Field Index and the Advanced Glaucoma Intervention Study score and its clinical correlations

PURPOSE

To evaluate the association between clinical parameters and the diagnosis of progression using VFI (Visual Field Index) and AGIS (Advanced Glaucoma Intervention Study) score in primary open angle glaucoma.

METHODS

Retrospective study of 517 visual fields of 78 eyes with primary open angle glaucoma analyzed with VFI and AGIS score. Clinical data registered included: age, sphere, pachimetry, basal intraocular pressure (IOP), and IOP during the follow up.

RESULTS

Only the AGIS score diagnosis of progression was associated with the clinical parameters registered. Among the analyzed data, the mean IOP during follow up (p = 0.0005) and IOP at the third month of follow up (p = 0.004) were statistically associated with progression using the AGIS criteria.

CONCLUSION

The diagnosis of perimetric progression using the AGIS score in the current study was closer to the real functional progression than the diagnosis using the VFI, as the former was associated with known risk factors for progression in glaucoma.

Blindness and Glaucoma: A Multicenter Data Review from 7 Academic Eye Clinics

Purpose

To evaluate frequency, conversion rate, and risk factors for blindness in glaucoma patients treated in European Universities.

Methods

This multicenter retrospective study included 2402 consecutive patients with glaucoma in at least one eye. Medical charts were inspected and patients were divided into those blind and the remainder (‘controls’). Blindness was defined as visual acuity≤0.05 and/or visual field loss to less than 10°.

Results

Unilateral and bilateral blindness were respectively 11.0% and 1.6% at the beginning, and 15.5% and 3.6% at the end of the observation period (7.5±5.5 years, range:1–25 years); conversion to blindness (at least unilateral) was 1.1%/year. 134 eyes (97 patients) developed blindness by POAG during the study. At the first access to study centre, they had mean deviation (MD) of -17.1±8.3 dB and treated intraocular pressure (IOP) of 17.1±6.6 mmHg. During follow-up the IOP decreased by 14% in these eyes but MD deteriorated by 1.1±3.5 dB/year, which was 5-fold higher than controls (0.2±1.6 dB/year). In a multivariate model, the best predictors for blindness by glaucoma were initial MD (p<0.001), initial IOP (p<0.001), older age at the beginning of follow-up (p<0.001), whereas final IOP was found to be protective (p<0.05).

Conclusions

In this series of patients, blindness occurred in about 20%. Blindness by glaucoma had 2 characteristics: late diagnosis and/or late referral, and progression of the disease despite in most cases IOP was within the range of normality and target IOP was achieved; it could be predicted by high initial MD, high initial IOP, and old age.

Comparing glaucoma progression on 24-2 and 10-2 visual field examinations

PURPOSE

To compare the rate of mean deviation (MD) change on 24-2 versus 10-2 VFs in treated glaucomatous eyes with 5 or more examinations.

METHODS

In a retrospective study, 24-2 and 10-2 VFs of 131 glaucoma patients (167 eyes) who had undergone at least 5 VFs examinations during their follow-up were analyzed. All these patients had VF defects both on 24-2 and 10-2 VFs. Rates of MD change were calculated using best linear unbiased predictions (BLUP).

RESULTS

Median age, MD on 24-2 VF at baseline, number of VFs performed during follow-up and follow-up duration were 55 years, -16.9 dB, 9 and 9 years respectively. Median rate of MD change was significantly greater (p<0.001) on 10-2 VF (-0.26 dB/year; interquartile range [IQR]: -0.47, -0.11) compared to 24-2 VFs (-0.19 dB/year; IQR: -0.41, -0.03). Comparing the rates of MD change in eyes with different severities of VF loss (early [MD better than -6 dB], moderate [-6 dB to -12 dB], advanced [-12 to -20 dB] and severe [MD worse than -20 dB]) at baseline (based on the MD on 24-2 VF), median rate of MD change was comparable between 10-2 and 24-2 VFs in mild (-0.45 dB/year vs. -0.40 dB/year, P = 0.42) and moderate (-0.32 dB/year vs. -0.40 dB/year, P = 0.26) VF loss categories, while the same were significantly greater on 10-2 VFs in advanced (-0.28 dB/year vs. -0.21 dB/year, P = 0.04) and severe (-0.18 dB/year vs. -0.06 dB/year, P<0.001) VF loss categories.

CONCLUSIONS

In patients with VF defects both on 24-2 and 10-2 VFs, evaluating the rate of MD change on 10-2 VFs may help in better estimation of glaucoma progression, especially so in eyes with advanced glaucoma at baseline.

The risk of newly developed visual impairment in treated normal-tension glaucoma: 10-year follow-up

PURPOSE

To investigate the risk and risk factors for newly developed visual impairment in treated patients with normal-tension glaucoma (NTG) followed up on for 10 years.

METHODS

Patients with NTG, who did not have visual impairment at the initial diagnosis and had undergone intraocular pressure (IOP)-lowering treatment for more than 7 years, were included on the basis of a retrospective chart review. Visual impairment was defined as either low vision (0.05 [20/400] ≤ visual acuity (VA) <0.3 [20/60] and/or 10 degrees ≤ central visual field (VF) <20 degrees) or blindness (VA <0.05 [20/400] and/or central VF <10 degrees) by World Health Organization (WHO) criteria. To investigate the risk and risk factors for newly developed visual impairment, Kaplan-Meier survival analysis and generalized linear mixed effects models were utilized.

RESULTS

During the 10.8 years mean follow-up period, 20 eyes of 16 patients were diagnosed as visual impairment (12 eyes as low vision, 8 as blindness) among 623 eyes of 411 patients. The cumulative risk of visual impairment in at least one eye was 2.8% at 10 years and 8.7% at 15 years. The risk factors for visual impairment from treated NTG were worse VF mean deviation (MD) at diagnosis and longer follow-up period.

CONCLUSION

The risk of newly developed visual impairment in the treated patients with NTG was relatively low. Worse VF MD at diagnosis and longer follow-up period were associated with development of visual impairment.

Intraocular pressure reduction with topical medications and progression of normal-tension glaucoma: a 12-year mean follow-up study

PURPOSE

To investigate whether the amount of intraocular pressure (IOP) reduction with topical medications is associated with the progression of normal-tension glaucoma (NTG) and to identify risk factors for NTG progression.

METHODS

The medical records of 121 eyes of 121 NTG patients, who were treated with topical medications for more than 7 years, were reviewed. NTG progression was defined by either structural (optic disc or retinal nerve fibre layer) or functional (visual field) deterioration. Patients were divided into tertile groups according to the percentage IOP reduction from baseline, and the cumulative probability of NTG progression between upper and lower tertile group was compared using Kaplan-Meier survival analysis. Multivariate analysis with Cox's proportional hazard model was performed to identify the hazard ratio (HR) of clinical factors for NTG progression.

RESULTS

The average follow-up period was 12.2 years, and 56 of 121 eyes (46.3%) showed the NTG progression. Kaplan-Meier analysis revealed that upper tertile group (percentage IOP reduction >22.1%) showed a greater cumulative probability of non-progression than lower tertile group (percentage IOP reduction < 13.3%; p = 0.012). Multivariate Cox's proportional hazard model indicated that percentage reduction of IOP (HR = 0.964; p = 0.007) and the occurrence of disc haemorrhage (HR = 2.410; p = 0.008) were significantly associated with NTG progression.

CONCLUSIONS

The amount of IOP reduction using topical medications was related to NTG progression, and lower percentage reduction in IOP was a consistent risk factor for progression.

Contributing factors for progression of visual field loss in normal-tension glaucoma patients with medical treatment

PURPOSE

To investigate the prognostic factors responsible for the progression of visual field defects (VFDs) in patients with normal-tension glaucoma (NTG) treated with topical antiglaucoma medications.

PATIENTS AND METHODS

A total of 92 eyes in 92 NTG patients treated with only topical antiglaucoma medications for ≥ 5 years were retrospectively analyzed. To identify subfield-based prognostic factors, the central 30-degree visual field (Humphrey Field Analyzer) was divided into 6 subfields: upper and lower arcuate, paracentral, and cecocentral subfields. Factors related to subfield-based progression (age, refraction, mean intraocular pressure (IOP), IOP variability, central corneal thickness, and disc hemorrhage) were evaluated using a linear mixed model.

RESULTS

Ninety-two eyes in 92 NTG patients were included in this study. The mean observation period was 7.7 ± 2.7 (5.0 to 15.5) years, and the estimated rate of change in the mean deviation value was -0.16 ± 0.31 dB/y (P<0.001). A subfield-based linear mixed model analysis of the time course of changes in the mean of total deviation identified a greater extent of myopia as a significant positive prognostic factor for VFD progression in the upper paracentral area (P=0.016). The mean IOP, central corneal thickness, disc hemorrhage, age, and IOP variation showed no significant contribution in any of the subfields.

CONCLUSIONS

The extent of myopia was found to be a significant positive prognostic factor for VFD progression in the upper paracentral subfield for non-high-myopic NTG eyes with an average IOP of 14.2 mm Hg under topical antiglaucoma medication.

Five-year forecasts of the Visual Field Index (VFI) with binocular and monocular visual fields

BACKGROUND

In clinical care, visual field (VF) damage is assessed using monocular VF testing, yet patients perceive the world binocularly. This study was conducted to compare 5-year forecasts for the Visual Field Index (VFI) generated from series of binocular and monocular VFs.

METHODS

Series of ten consecutive VFs (Humphrey 24-2 Full-threshold) spanning on average 3.7 (SD: ±0.8) years from 60 eyes of 30 glaucomatous patients were retrospectively examined. The VFs of both eyes were merged to produce the integrated VF and its VFI score (Binocular VFI) was estimated. Forecasts of binocular and monocular VFIs were calculated for each patient by projecting the fitted linear regression 5 years ahead from the last VF following the method on the Humphrey Guided Progression Analysis (GPA) print-out. The precisions of the forecasts were calculated as the width of the 95% prediction limit (PL).

RESULTS

The mean 5 year forecast for binocular VFIs was 92% (SD: 11%), which was significantly higher than forecasts from right and left eyes (79% [SD: 19%] and 82% [SD: 16%] respectively; P < 0.05). The width of the 95% PL for 5-year predictions with monocular VFIs (mean right eye: 29% [SD: 19%] and mean left eye: 27% [SD: 16%]) were significantly larger than that of the binocular VFI (mean: 12% [SD: 7%]; P < 0.05).

CONCLUSIONS

Five year forecasted VFI values using binocular measures return significantly better values, and can be made with greater confidence than those based on monocular measures. In turn, forecasts of a patient's binocular VFI might be more relevant to estimating the patient's future functional VF.

Comparison of the progression rates of the superior, inferior, and both hemifield defects in normal-tension glaucoma patients

PURPOSE

To investigate the progression rates of superior and inferior hemifield defects and each hemifield in bihemifield defects in normal-tension glaucoma patients and to compare the progression rates of each hemifield between groups in eyes with similar baseline hemifield defects.

DESIGN

Retrospective, observational cohort study.

METHODS

Medical records of 142 normal-tension glaucoma patients who performed more than 5 reliable standard visual field tests with superior (group 2; n = 51), inferior (group 1; n = 44), or both hemifield (group 3; n = 47) defects were analyzed retrospectively. The changes in the mean thresholds of the 10 zones of the glaucoma hemifield test and the entire hemifield were inspected. A linear mixed effect model was used with age, gender, initial intraocular pressure, mean deviation, and pattern standard deviation controlled.

RESULTS

There were no significant differences in age and systemic and ocular factors between groups except for female gender, which showed a significant difference among the 3 groups (P = .032). The progression rate in group 2 was significantly faster than in group 1 (-0.713 dB/year vs -0.516 dB/year; P = .019), especially in central and nasal zones or than in the superior hemifield of group 3 (-0.717 dB/year vs -0.470 dB/year; P = .001). There was no significant difference in the progression rates between group 1 and the inferior hemifield in group 3 (-0.508 dB/year vs -0.441 dB/year; P = .312) or between the superior and inferior hemifields in group 3 (-0.468 dB/year vs -0.442 dB/year; P = .662).

CONCLUSIONS

More careful examination and caution is required in the treatment of normal-tension glaucoma patients with superior hemifield defect.