Value of Structural and Hemodynamic Parameters for the Early Detection of Primary Open-Angle Glaucoma

Eye yoga for glaucoma: recovery of vascular dysregulation and visual field function-a randomized controlled trial

Purpose

Because stress can aggravate vascular dysregulation (VD) in primary open-angle glaucoma (POAG), stress reduction by eye yoga (EY) was studied if this predictive, preventive, and personalized medical (3PM) approach could help normalize intraocular pressure (IOP), retinal vessel dynamics, and visual fields (VF).

Patients and methods

POAG patients were randomized to an EY (n = 15) or control group (n = 12). EY was practiced daily for 1 h for 1 month at home using an iPod-audio guide while control patients read relaxing books daily.

Results

After intervention, EY patients, but not controls, showed a 6.4% IOP reduction (p = 0.027) and had significant VF improvements (p < 0.001). After EY, pattern deviation recovered in VF regions where small microvessels showed reduced vasoconstriction (artery: p = 0.012; vein: p = 0.042) and improved mean artery diameter recovered significantly (p = 0.015). When pooling data of both groups, recovered VF regions, but not non-recovered fields, showed significantly larger arterial diameter gains (2.4 [- 0.3-5.3] MU) with no adverse events.

Conclusions and 3PM recommendations

Because EY reduces vasoconstriction and improves VF function in POAG, we propose the "eye ball retraction theory," whereby ocular muscle tension is induced by mental stress which is a contributing mechanism, or even the key mechanism, of POAG. Reducing stress by relaxation is therefore a remedy for it improves blood flow as the fundamental mechanism of vision recovery and restoration. VD reduction is therefore a valuable therapeutic target for glaucoma care and eye yoga home exercises are a safe and effective complementary 3PM method of POAG care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-024-00389-x.

Correlation of retrobulbar perfusion deficits with glaucomatous visual field defects

PURPOSE

This study is to evaluate the correlation between retrobulbar perfusion deficits and glaucomatous visual field defects.

METHODS

Eighty-four patients with glaucoma and 17 normal subjects serving as controls were selected. Color Doppler imaging (CDI) was used to measure the changes in blood flow parameters in the retrobulbar ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCAs). Visual field testing was performed using a Humphrey perimeter, categorizing the visual field deficits into four stages according to the Advanced Glaucoma Intervention Study (AGIS) scoring method. Subsequently, the correlation of retrobulbar hemodynamic parameter alterations among glaucomatous patients with varying visual field defects was examined.

RESULTS

The higher the visual field stage, the lower the peak systolic velocity (PSV) of the OA, CRA, and SPCAs in glaucomatous patients. The CRA had the highest sensitivity to changes in its PSV. The PSV of the temporal SPCA (TSPCA-PSV) was lower in advanced glaucoma than in early-stage glaucoma. The PSVs of the OA, CRA, and TSPCA, as well as the resistance index of the CRA (CRA-RI), were positively correlated with the visual field index and the mean deviation. Except for that of OA, the PSV of the retrobulbar vessels was negatively correlated with the pattern standard deviation (PSD). The OA-PSV and end-diastolic velocity (EDV) of the CRA and TSPCA were lower in patients with superior visual field defects than in those with inferior visual field defects.

CONCLUSIONS

Greater severity of visual field defects corresponded to poorer retrobulbar blood flow in glaucomatous patients. Patients suffered significant perfusion impairments in the CRA at the early stage, accompanied by SPCA perfusion disorder at the advanced stage. The presence of a bow-shaped defect in the superior or inferior region of the visual field in moderate-stage glaucoma was closely correlated with retrobulbar vascular EDV.

TRIAL REGISTRATION

ChiCTR2200059048 (2022-04-23).

The Role of Color Doppler Imaging in the Diagnosis of Glaucoma: A Review of the Literature

Glaucoma is a progressive optic neuropathy and one of the leading causes of irreversible blindness worldwide. Elevated intraocular pressure (IOP) is the major risk factor for the onset and progression of glaucoma. In addition to elevated IOP, impaired intraocular blood flow is also considered to be involved in the pathogenesis of glaucoma. Various techniques have been used to assess ocular blood flow (OBF), including Color Doppler Imaging (CDI), a technique used in ophthalmology in recent decades. This article reviews the role of CDI in both the diagnosis and effective monitoring of glaucoma progression, presenting the protocol for imaging and its advantages, as well as the limitations of its use. Moreover, it analyzes the pathophysiology of glaucoma, focusing on vascular theory and its role in the onset and progression of the disease.

[Modern capabilities of ophthalmic tonometry in pathologically altered corneas]

Changes in intraocular pressure have great influence on the course of various processes in ocular tissues. Presently, the scientific discussion has returned to the theoretical issues of tonometry and the creation of models that would allow assessing the influence of various ocular parameters on IOP values. Some of the modern tonometers (Icare, Tono-Pen) are convenient and effective when measuring IOP in eyes with damaged, uneven or edematous cornea. It is necessary to analyze the results of ophthalmic tonometry by modern methods in accordance with the data of direct intracameral manometry in pathological conditions of the cornea and after keratoplasty.

Ophthalmic Artery and Superior Ophthalmic Vein Blood Flow Dynamics in Glaucoma Investigated by Phase Contrast Magnetic Resonance Imaging

PRECIS

Ophthalmic artery (OA) and superior ophthalmic vein (SOV) blood flow were quantified by phase contrast magnetic resonance imaging (PC MRI) and seemed lower in glaucoma. Venous flow dynamics was different in glaucoma patients with a significantly decreased pulsatility.

INTRODUCTION

Studies using color Doppler imaging and optical coherence tomography flowmetry strongly suggested that vascular changes are involved in the pathophysiology of glaucoma, but the venous outflow has been little studied beyond the episcleral veins. This study measured the OA and the SOV flow by PC MRI in glaucoma patients compared with controls.

METHODS

Eleven primary open-angle glaucoma patients, with a mean±SD visual field deficit of -2.3±2.7 dB and retinal nerve fiber layer thickness of 92±13 µ, and 10 controls of similar age, were examined by PC MRI. The mean, maximal and minimal flow over cardiac cycle were measured. The variation of flow (ΔQ) was calculated.

RESULTS

The OA mean±SD mean flow was 13.21±6.79 in patients and 15.09±7.62 mL/min in controls (P=0.35) and the OA maximal flow was 25.70±12.08 mL/min in patients, and 28.45±10.64 mL/min in controls (P=0.22). In the SOV the mean±SD mean flow was 6.46±5.50 mL/min in patients and 7.21±6.04 mL/min in controls (P=0.81) and the maximal flow was 9.06±6.67 in patients versus 11.96±9.29 mL/min in controls (P=0.47). The ΔQ in the SOV was significantly lower in patients (5.45±2.54 mL/min) than in controls (9.09±5.74 mL/min) (P=0.04).

DISCUSSION

Although no significant difference was found, the mean and maximal flow in the OA and SOV seemed lower in glaucoma patients than in controls. The SOV flow waveform might be affected in glaucoma, corroborating the hypothesis of an impairment of venous outflow in those patients.

Aspects of Tertiary Prevention in Patients with Primary Open Angle Glaucoma

The purpose of the study is to assess the health of patients in the activity of tertiary prevention dedicated to preventing blindness caused by POAG (primary glaucoma with open angle and high tension) and NTG (primary glaucoma with open-angle and statistically normal tension-particular form of glaucoma with open angle) and preservation of the remaining visual function. The design of the study is epidemiological, observational, descriptive and retrospective, and uses only the data recorded in the existing records in the archives of the Ophthalmology office within the Integrated Outpatient Clinic of the Emergency Clinical Hospital of Oradea (IOCECHO) during the years 1999-2019 (anamnestic data; objective examination and paraclinical examination: intraocular pressure-IOP and visual field-VF). The methods of the study included the standardized protocol: anamnesis, physical ophthalmological examination, IOP determination, and computerized perimetry with the "Fast Threshold" strategy performed with the "Opto AP-300" perimeter. The obtained results were statistically processed with a specialized software (S.P.S.S.-I.B.M. Statistics version 22). The study examined the available data of 522 patients of which 140 were men (26.8%) and 382 were women (73.2%). The gender ratio was 0.37. In the period 1999-2019, 150,844 people with ophthalmic pathology were consulted in the Ophthalmology office of IOCECHO out of which 522 patients (0.35%) were diagnosed with primitive open-angle glaucoma, 184 people (35.2%) presented high IOP (POAG), and 338 people (64.8%) had statistically normal IOP (NTG). The annual proportion of cases diagnosed with glaucoma in the total number of patients examined was between 0.1% (2005; 2008; 2010) and 2.4% in 2012, when 101 people were detected. In the studied records, no cases of uni- and/or bilateral blindness were mentioned. The mean age of glaucoma patients at the first consultation was 60.81 ± 12.14 years with high frequencies in the 55-69 age groups and at the last consultation it was 66.10 ± 12.47 years with high frequencies in the age groups between 60-74 years. Monitoring and treatment of glaucoma patients was beneficial; IOP decreased statistically significantly: in patients with POAG by 46.16%, from 30.50 ± 7.98 mmHg to 16.42 ± 3.01 mmHg (p = 0.000) and in those with NTG by 17.44%, at 16.39 ± 3.66 mmHg at 13.53 ± 1.92 mmHG (p = 0.000). The duration of treatment and monitoring was on average 5.1 ± 3.4 years, for 184 patients (35.2%) with POAG and 5.1 ± 3.8 years for 338 patients (64.8%) with NTG. Tertiary prevention of glaucoma, by providing specialized care, ensures effective control of IOP and implicitly of the long-term evolution of the disease. IOP is the only modifiable risk factor in patients with POAG and NTG and its decrease prevents the progression of the disease and emphasizes the importance of early diagnosis and treatment. The management of the glaucoma patient consisted of: complete ophthalmological examination (subjective and objective), paraclinical examination with IOP, and VF measurement (valuable ophthalmological diagnostic tool) for disease detection and effective assessment of disease progression in order to improve the process of therapeutic decision making.

Focal Loss Analysis of Nerve Fiber Layer Reflectance for Glaucoma Diagnosis

Purpose

To evaluate nerve fiber layer (NFL) reflectance for glaucoma diagnosis.

Methods

Participants were imaged with 4.5 × 4.5 mm volumetric disc scans using spectral-domain optical coherence tomography. The normalized NFL reflectance map was processed by an azimuthal filter to reduce directional reflectance bias caused by variation of beam incidence angle. The peripapillary area of the map was divided into 160 superpixels. Average reflectance was the mean of superpixel reflectance. Low-reflectance superpixels were identified as those with NFL reflectance below the fifth percentile normative cutoff. Focal reflectance loss was measured by summing loss in low-reflectance superpixels.

Results

Thirty-five normal, 30 preperimetric, and 35 perimetric glaucoma participants were enrolled. Azimuthal filtering improved the repeatability of the normalized NFL reflectance, as measured by the pooled superpixel standard deviation (SD), from 0.73 to 0.57 dB (P < 0.001, paired t-test) and reduced the population SD from 2.14 to 1.78 dB (P < 0.001, t-test). Most glaucomatous reflectance maps showed characteristic patterns of contiguous wedge or diffuse defects. Focal NFL reflectance loss had significantly higher diagnostic sensitivity than the best NFL thickness parameter (from map or profile): 77% versus 55% (P < 0.001) in glaucoma eyes with the specificity fixed at 99%.

Conclusions

Azimuthal filtering reduces the variability of NFL reflectance measurements. Focal NFL reflectance loss has excellent glaucoma diagnostic accuracy compared to the standard NFL thickness parameters. The reflectance map may be useful for localizing NFL defects.

Translational Relevance

The high diagnostic accuracy of NFL reflectance may make population-based screening feasible.

Longitudinal Structural and Microvascular Observation in RCS Rat Eyes Using Optical Coherence Tomography Angiography

Purpose

To evaluate the change of retinal thickness and ocular microvasculature in a rat model of retinitis pigmentosa using swept source optical coherence tomography angiography (SS-OCTA)

Methods

Three-weeks-old Royal College of Surgeons (RCS) rats (n = 8) and age-matched control rats (n = 14) were imaged by a prototype SS-OCTA system. Follow-up measurements occurred every three weeks on six RCS rats until week 18, and cross-sectional measurements were conducted on control rats. Thicknesses of different retinal layers and the total retina were measured. The enface angiograms from superficial vascular plexiform (SVP) and deep capillary plexiform (DCP) were analyzed, and the image sharpness was also extracted from the choroidal angiograms. Immunohistochemical analysis was done in the RCS rats after week 18, as well as in three-week-old RCS rats and age-matched controls.

Results

In RCS rats, the thicknesses of the ganglion cell complex, the nuclear layer, the debris/photoreceptor layer and the total retina decreased over the weeks (P < 0.001). The SVP metrics remained unchanged whereas the DCP metrics decreased significantly over the weeks (P < 0.001). The immunohistochemical analysis confirmed our OCTA findings of capillary dropout in the DCP. The choroidal plexus appeared indistinct initially due to scattering of light at the intact retinal pigment epithelium (RPE) and became more visible after week nine probably due to RPE degeneration. Loss of choriocapillaris was visualized at week 18. In control rats, no vascular change was detected, but nuclear layers, photoreceptor layers and total retina showed slight thinning with age (P < 0.001).

Conclusions

Photoreceptor degeneration in RCS rats was associated with the loss of capillaries in DCP, but not in SVP. The OCTA imaging allows for the characterization of structural and angiographic changes in rodent models.

Waveform parameters of retrobulbar vessels in glaucoma patients with different demographics and disease severity

Introduction:

To identify novel velocity waveform parameters of the ophthalmic artery and central retinal artery by computer-aided image processing of Doppler ultrasonography measurements, and to evaluate correlations between the waveform parameters and different demographics and disease severity of open-angle glaucoma patients.

Methods:

Thirty-six images of 36 open-angle glaucoma patients were considered. A semiautomated image processing code was used to detect the digitalized ophthalmic artery and central retinal artery velocity waveforms and to extract the waveform parameters. Concordance correlation coefficient, two-sample t-test, and Pearson’s correlation coefficient were used to test for similarities, differences, and associations among variables.

Results:

Female glaucoma patients showed a statistically higher ophthalmic artery normalized distance between ascending and descending limb (p = 0.004), hypertensive glaucoma patients a statistically higher ophthalmic artery peak systolic velocity time (p = 0.025), glaucoma patients with hyperlipidemia a statistically higher ophthalmic artery resistivity index (p = 0.023) and a statistically higher ophthalmic artery peak systolic velocity acceleration (p = 0.025), glaucoma patients with cardiovascular diseases a statistically lower central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.033) and a statistically higher central retinal artery period (p = 0.028), and patients with different body mass index a statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p = 0.016). Groups with different disease severity, classified following the Brusini glaucoma staging system 2, showed statistically different central retinal artery normalized distance between ascending and descending limb of the wave (p < 0.001) and central retinal artery period (p = 0.016). No statistical differences were found in regard to race, diabetes status, glaucoma family history, and smoking.

Discussion:

Ophthalmic artery and central retinal artery computer-aided analysis of velocity waveforms could identify novel waveform parameters capable of differentiating among different demographics and disease severity of open-angle glaucoma patients.

[The role of retinal microcirculation disorders in the progression of glaucomatous optic neuropathy]

PURPOSE

To assess the progression of primary open-angle glaucoma (POAG) and to study the role of retinal microcirculation in its progression.

MATERIAL AND METHODS

In this 2-year prospective study, the rate of POAG progression was determined using perimetry (ROP1) and spectral domain optical coherence tomography (SD-OCT) by thinning of retinal nerve fiber layer (RNFL) (ROP2) and ganglion cell complex (GCC) (ROP3). The vessel density of parafoveal superficial plexus (VD parafovea) and peripapillary retina (VD ppr) was assessed using OCT angiography, peripheral resistance index (RI), and blood flow velocity in the posterior short ciliary arteries (PSCA) and central retinal artery (CRA) with the use of color Doppler mapping. The predictive properties of each parameter were calculated using the area under receiver operating curve (AUC).

RESULTS

Progression was detected in 9.8% cases by perimetry and in 19.7% cases by OCT. The combination of these two methods increased the detection up to 32.8%. Circulatory parameters - VD parafovea (AUC 0.70±0.07), VD ppr (0.715±0.07), PSCA RI (0.801±0.12), CRA RI (0.798±0.11) - had similar high predictive properties as IOP max (0.79±0.05), corneal hysteresis (0.755±0.07), thickness of inner parafoveal layers (0.728±0.07) and RNFL (0.692±0.06). The study revealed the following correlations: ROP1 with maximum IOP (p=0.01), ROP2 with blood flow velocity in PSCA (p=0.01), VD parafovea with corneal hysteresis (p=0.01), and GCC thickness with ocular perfusion pressure (p=0.01).

CONCLUSION

The obtained data demonstrates the importance of combining perimetry with OCT for detecting the progression of glaucoma and indicates its relationship with reduced ocular hemoperfusion.

[Comparative study of factors associated with the progression of primary open-angle and angle-closure glaucoma]

PURPOSE

To compare the factors associated with the progression of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

MATERIAL AND METHODS

This prospective study analyses clinical data of POAG and PACG patients followed up for 6 years. The progression of glaucomatous optic neuropathy (GON) was determined using perimetry and spectral optical coherence tomography (OCT). The value of each diagnostic indicator (z-value) was calculated using the Wilcoxon-Mann-Whitney test and the area under the ROC-curve (AUC) to identify the parameters reliably associated with the progression in both groups of patients.

RESULTS

According to OCT, 47.3% of PACG patients and 52.46% of POAG patients had GON progressing, while according to perimetry, these figures were 21.8% and 23%, respectively. The common factors associated with progression of these glaucoma forms were age (AUC 0.7, z -1.9 in PACG and AUC 0.7, z -2.9 in POAG) and maximum IOP (0.7; -2.7 in PACG and 0.79; -5.4 in POAG). The progression of PACG is associated with lens size (0.7; -2.4), subfoveal choroidal thickness (AUC 0.8, z -3.3) and peripapillary choroidal thickness (0.79; -3.2), resistive index in the vortex veins (0.81; -3.3) and their end diastolic blood flow velocity (0.83; 3.2). The progression of POAG is associated with a thin peripapillary (0.75; 2.6) and subfoveal choroid (0.74; 2.5), increased resistive index in the posterior short ciliary arteries (0.8; -2.3), and initial retinal nerve fiber layer (RNFL) thickness: 0.69; 2.9.

CONCLUSION

The progression of POAG and PACG has only two common factors - age and maximum IOP. The progression of PACG is mainly related to the lens size, venous dysfunction and the choroid expansion, while the progression of POAG is related to the initial RNFL thickness, reduced arterial blood flow and choroid thinning.

[Biomechanical properties of the cornea as predictors of the effectiveness of selective laser trabeculoplasty]

PURPOSE

To study the changes in central corneal thickness (CCT) and corneal hysteresis (CH) after selective laser trabeculoplasty (SLT) in primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) after laser peripheral iridotomy (LPI) and to determine their effect on the prognosis of the surgery.

MATERIAL AND METHODS

The prospective study involved 68 eyes with initial PACG after LPI and 74 eyes with initial POAG observed for 6 months. Corneal-compensated IOP (IOPcc), corneal resistance factor (CRF), CH and CCT were studied as the predictors of SLT, which was considered successful when IOPcc decreased by 20% or more from the baseline without additional hypotensive therapy and/or repeated SLT.

RESULTS

In both forms of glaucoma, CCT increased within the first hour after SLT: 567±24.08 µm (p=0.001) in POAG, and 572±21.41 µm (p=0.000) - persisting for over a month - in PACG. CCT correlated with laser energy at all stages of the examination both in POAG and PACG patients. The following predictors of SLT failure were determined: CH (p=0.000 in PACG and p=0.001 in POAG), as well as initial IOP (p=0.010 in PACG and p=0.016 in POAG) and CRF (p=0.003 in PACG and p=0.005 in POAG) and CCT (p=0.023 in PACG and p=0.026 in POAG). The value of anterior chamber angle (ACA) was a predictor only for PACG (p=0.011).

CONCLUSION

SLT leads to an increase in CCT, which lasts longer in PACG after LPI than in POAG and correlates with the level of laser energy. Lower CH and initially higher IOP are the common predictors of SLT failure in the long term for both forms of glaucoma. Smaller ACA have a negative prognostic sign in POAG.

Assessment of the optic nerve head, peripapillary, and macular microcirculation in the newly diagnosed patients with primary open-angle glaucoma treated with topical tafluprost and tafluprost/timolol fixed combination

RELEVANCE:

The ability of antiglaucoma drugs to improve ocular hemoperfusion is an important aspect of their action. Tafluprost is the first preservative-free prostaglandin analog. The efficacy and safety of tafluprost, as well as tafluprost/timolol fixed combination (FC), were demonstrated in randomized multicenter trials. However, there is no literature on the effect of tafluprost and its FC on the peripapillary and macular blood flow.

PURPOSE:

To determine the changes of microcirculation in the optic nerve head (ONH), peripapillary retina, and macula in patients with newly diagnosed primary open-angle glaucoma (POAG) under the topical tafluprost and tafluprost/timolol FC treatment.

MATERIALS AND METHODS:

Optical coherence tomography angiography (OCT-A) was performed in dynamics with an interval of a week in 36 patients (36 eyes) with a newly diagnosed initial stage of POAG: 12 eyes with tafluprost, 12 – tafluprost/timolol FC, and 12 – no topical treatment (the control group). The change in intraocular pressure (IOP), mean ocular perfusion pressure (MOPP) of the eye, and vessel density (VD) inside the ONH (inside disc), as well as in the peripapillary retina and macula, was evaluated by comparing paired repeated observations using the median growth analysis.

RESULTS:

In the tafluprost group, there were a decrease in IOP by 19.4% and an increase in MOPP by 8.7% from the reference level. In the tafluprost/timolol group, these figures were 43% and 30.1%, respectively. OCT-A values did not change reliably, except for VD inside disc: the median growth of the tafluprost group was 2.28 (P = 0.02) and of the tafluprost/timolol group was 1.82 (P = 0.03). These changes were obtained in 11 of 12 patients in each group under treatment. In control group, all indicators remained unchanged.

CONCLUSIONS:

A significant increase of MOPP and a decrease of VD in the ONH in patients with initial glaucoma occurred within a week under the topical tafluprost or its FC. This can be explained by the restoration of autoregulation of the ocular blood flow in conditions of pronounced hypotensive effect of the drugs.

[Pattern electroretinogram and macular perfusion in glaucoma]

PURPOSE

To study microcirculatory and functional changes in macula in patients with Primary Open-Angle Glaucoma (POAG).

MATERIAL AND METHODS

The study included 95 POAG patients and 42 healthy control subjects. Whole en face image vessel density (wiVDRetina) was measured both in fovea and in parafovea using OCT-angiography (OCT-A) by means of SD-OCT AngioVue on Avanti RtVue xR (Optovue Inc., U.S.A.). Macular thickness and parameters of macular ganglion cell complex (GCC) were measured on the same day. Blood flow in the retrobulbar vessels was evaluated by means of Color Doppler Imaging (CDI). Pattern electroretinogram (PERG) was also taken from the study eyes. Correlations between PERG, SD-OCT GCC, macular thickness, and the parameters of OCT-A and CDI were studied.

RESULTS

The amplitude of t-PERG P50 decreased from 6.1±1.3 µV in normal eyes to 2.8±1.6 µV (p<0.0001) in early glaucoma and to 2.3±1.5 µV (p=0.93) in advanced stages. Relative vessel density of the capillary bed decreased from 51.3±3.0% in normal eyes to 45.9±5.0% (p<0.001) and to 41.8±5.0% (p=0.023) in early and advanced glaucoma respectively. The parameters of OCT-A and CDI correlated with morphological and functional parameters in normal and early glaucomatous eyes.

CONCLUSION

The study revealed reduction of macular microcirculation and decrease of PERG in early glaucoma. Correlations between the circulatory parameters and functional changes were found in early stages of the disease.

A comparative study of structural, functional and circulatory parameters in glaucoma diagnostics

PURPOSE

To compare the diagnostic accuracy of structural parameters, vessel density (VD) measured by optical coherence tomography angiography (OCTA), and electrophysiological testing in diagnosis of primary open-angle glaucoma (POAG).

METHODS

35 healthy participants and 90 POAG subjects underwent the measurement of whole image en face (wi) VD in the disc/peripapillary region and macula, the retinal nerve fiber layer (RNFL), and the average thickness of ganglion cell complex (GCC), pattern electroretinograms and pattern visual evoked potentials. The area under the receiver operating characteristic curve (AUC) was assessed for each parameter to differentiate early POAG from healthy eyes and between the POAG stages.

RESULTS

To distinguish early POAG from healthy eyes, the parameters with the highest AUC were detected: P50 amplitude of transient pattern electroretinogram, 1° (AUC 0.93, p = 0.002), P1 component of steady-state pattern electroretinogram (AUC 0.92, p = 0.003), P100 amplitude of pattern visual evoked potential, 1° (AUC 0.84, p = 0.013), wiVD macula superficial (AUC 0.80, p = 0.001), wiVD Disc (AUC 0.74, p = 0.016), GCC (AUC 0.74, p = 0.016) and to distinguish early POAG from the moderate to severe POAG: inferotemporal peripapillary VD (AUC 0.94, p < 0.0001) and focal loss volume of GCC (AUC 0.92, p < 0, 001).

CONCLUSIONS

Our results demonstrate the importance of measuring the microcirculation parameters in the macular area along with PERGs and PVEPs for the early detection of glaucoma. VD in the inferotemporal sector of the peripapillary retina and focal loss volume of the GCC are important for monitoring of the disease. The inclusion of OCTA, PERGs and PVEPs in glaucoma diagnostics may improve its early detection and monitoring.