Avaliação da relação entre a espessura da camada de fibras nervosas e variação da pressão intraocular em suspeitos de glaucoma e em pacientes com glaucoma primário de ângulo aberto / Evaluation of the relationship between nerve fiber layer thickness and intraocular pressure variation in glaucoma suspects and in patients with primary open-angle glaucoma

Introdução: Glaucoma é uma neuropatia óptica caracterizada pela perda irreversível das células ganglionares retinianas, sendo a pressão intraocular (Po) o principal fator de risco para a doença. Grandes variações da pressão intraocular durante um determinado período de tempo têm atraído a atenção como um potencial fator de risco para o desenvolvimento e progressão do glaucoma. Objetivo: Avaliar a relação entre a flutuação de 24 horas da pressão intraocular (∆Po) e a espessura da camada de fibras nervosas da retina (CFNR) medida por tomografia de coerência óptica de domínio espectral (TCO-DE). Método: O estudo incluiu 125 olhos de 65 pacientes. Sessenta e três olhos (50,4%) tiveram o diagnóstico de glaucoma primário de ângulo aberto (GPAA) e 62 (49,6%) foram considerados suspeitos de glaucoma (SG). Todos os olhos foram submetidos a imagens usando TCO-DE, juntamente com medição da Po de 24 horas e perimetria computadorizada acromática. Apenas pacientes com ∆Po anormal (>6 mmHg) foram incluídos. Correlação e modelos mistos lineares generalizados foram usados para investigar a relação entre ∆Po e a espessura da CFNR ajustando para potenciais fatores de confusão, como idade, diagnóstico de glaucoma, espessura da córnea, Po média durante 24 horas e gravidade da doença. Resultados: A idade média foi semelhante entre os grupos SG e GPAA (62,2 ± 15,6 vs. 64,6 ± 12,0, P = 0,50), enquanto o desvio médio do campo visual apresentou diferença entre SG e GPAA (0,41 ± 1,33 vs. -3,09 ± 3,23, P <0,001). A Po média também foi semelhante entre os grupos SG e GPAA (15,6 ± 3,47 vs. 15,6 ± 2,83 mmHg, P = 0,90), assim como o pico da Po às 6h (21,7 ± 3,85 vs. 21,3 ± 3,80 mmHg, P = 0,68). Correlações negativas estatisticamente significativas foram encontradas no grupo GPAA entre a Po às 6h e a espessura da CFNR global (rs = 0,543; P < 0,001), quadrantes inferior (rs = -0,540; P < 0,001), superior (rs = -0,405; P = 0,009) e nasal (rs = −0,561; P < 0,001). Correlações negativas também foram encontradas entre ∆Po e a espessura da CFNR global (rs = −0,591; P < 0,001), e todos os demais setores (P < 0,05). No SG a Po às 6h correlacionou-se apenas com a espessura da CFNR no quadrante inferior (rs = −0,307; P = 0,047). Cada 1 mmHg maior na ∆Po foi associado à afilamento de -1,44 µm na espessura global da CFNR (IC 95%: -2,77 a -0,11, P = 0,03). Além disso, cada incremento de 10 anos na idade foi associado à afilamento de -3,56 µm na espessura global da CFNR (IC 95%: -6,06 a -1,05, P = 0,006). O GPAA teve uma afilamento média de -10,91 µm na CFNR global em relação aos SG (IC 95%: -20,21 a -1,62, P = 0,02). A Po média não foi associada à espessura global da CFNR (IC 95%: -1,37 a 0,91, P = 0,69). Conclusão: Maior ∆Po foi associado à menor espessura global da CFNR medida pelo TCO-DE, em pacientes com ∆Po >6 mmHg. Esse achado corrobora um papel potencial da flutuação da Po como fator de risco para perda estrutural no glaucoma.

Introduction: Glaucoma is an optic neuropathy characterized by irreversible loss of retinal ganglion cells, with intraocular pressure (IOP) being the main risk factor for the disease. Large variations in IOP over a period of time have attracted attention as a potential risk factor for the development and progression of glaucoma. Purpose: To evaluate the relationship between 24-hour fluctuation of intraocular pressure (∆IOP) and retinal nerve fiber layer (RNFL) thickness measured by spectraldomain optical coherence tomography (SD-OCT). Material and Methods: The study included 125 eyes of 65 patients. Sixty-three eyes (50.4%) had a diagnosis of primary open angle glaucoma (POAG) and 62 (49.6%) were considered glaucoma suspects (GS). All eyes underwent imaging using SDOCT, along with 24-hour IOP measurement and standard automated perimetry. Only patients with abnormal ∆IOP (>6 mmHg) were included. Correlation and generalized linear mixed models were used to investigate the relationship between ∆IOP and RNFL thickness adjusting for potential confounding factors such as age, glaucoma diagnosis, corneal thickness, mean IOP during 24 hours, and disease severity. Results: Mean age was similar between the SG and POAG groups (62.2 ± 15.6 vs. 64.6 ± 12.0, P = 0.50), while the mean deviation of visual field showed a difference between SG and POAG (0.41 ± 1.33 vs. -3.09 ± 3.23, P < 0.001). The mean Po was also similar between GS and POAG groups (15.6 ± 3.47 vs 15.6 ± 2.83 mmHg, P = 0.90) as was IOP peak at 6 AM (21.7 ± 3.85 vs. 21.3 ± 3.80 mmHg, P = 0.68). Statistically significant negative correlations were found in POAG group between IOP at 6 AM and RNFL thickness in global (rs = −0.543; P < 0.001), inferior (rs = −0.540; P < 0.001), superior (rs = −0.405; P = 0.009), and nasal quadrants (rs = −0.561; P < 0.001). Negative correlations were also found between ∆IOP and RNFL thickness in global (rs = −0.591; P < 0.001), and all other sectors (P < 0.05). In GS IOP at 6 AM correlated only with RNFL thickness in the inferior quadrant (rs = −0.307; P = 0.047). Each 1 mmHg higher in ∆IOP was associated with thinning of -1.44 µm in global RNFL thickness (95% CI: -2.77 to -0.11, P = 0.03). Also, each 10-years increment in age was associated with thinning of -3.56 µm in global RNFL thickness (95% CI: 6.06 to -1.05, P = 0.006). POAG had on average -10.91 µm thinning in global RNFL than glaucoma suspects (95% CI: -20.21 to -1.62, P = 0.02). Mean IOP was not associated with global RNFL thickness (95% CI: -1.37 to 0.91, P = 0.69). Conclusion: Higher ∆IOP was associated with lower global RNFL thickness measured by SD-OCT, in patients with ∆IOP > 6 mmHg. This finding corroborates a potential role for IOP fluctuation as a risk factor for structural loss in glaucoma.

Structure-function correlation of juxtapapillary choroidal thickness with visual field analysis of patients suspected with glaucoma

Purpose@#To conduct an evaluation of juxtapapillary choroidal thickness of patients suspected with glaucoma obtained through spectral domain optical coherence tomography (SD-OCT) and correlate it with perimetry results.@*Methods@#Design: Cross-sectional Study. Population: 175 eyes diagnosed as “glaucoma suspect” had standard automated perimetry (SAP) to document the presence of functional glaucomatous damage using optimal near-point correction using the Humphrey Visual Field Analyzer II, 30-2 or 24-2 SITA-standard program. SD-OCT imaging of the retinal nerve fi ber layer (RNFL) was also done to look for structural glaucomatous damage and in using enhanced depth imaging of the optic nerve and the Cirrus caliper tool, choroidal thickness was measured at fi ve predetermined points temporal and nasal from the optic nerve. The population was classifi ed into two groups: Group 1 are those with structural or functional glaucomatous damage (n=68) and Group 2 were those without (n=107).@*Results@#One-Way Multivariate Analysis of Covariance was used in comparing the mean temporal and nasal choroidal thickness scores of the two groups. There are no statistical differences in terms of the mean temporal choroidal thickness (p=0.856) and mean nasal choroidal thickness (p=0.734) between patients with and without glaucomatous damage. The mean temporal and nasal choroidal thickness scores of the two groups at different juxtapapillary locations: 0 μm, 250 μm, 500 μm, 750 μm and 1000 μm away from the disc were also not statistically different.@*Conclusion@#Results show that from this present cohort of glaucoma suspect patients, juxtapapillary choroidal thickness is not correlated with structural and functional glaucomatous damage.

Depression and Anxiety in Patients with Glaucoma or Glaucoma Suspect

PURPOSE: To investigate depression and anxiety in patients with glaucoma or glaucoma suspect. METHODS: Seventy-two patients with glaucoma, 72 patients with glaucoma suspect and 26 controls comprised the study population. Anxiety and depression was evaluated by hospital anxiety and depression scale (HADS) questionnaire. In this study, scores higher than 10 on the HADS-A and HADS-D were defined as anxiety and depression, respectively. The relationship between HADS and mean deviation (MD) of visual field tests or visual acuity of the better eye was analyzed in glaucoma patients. RESULTS: Three (11.5%) controls, 11 (15.3%) patients with glaucoma suspect, and 15 (20.8%) patients with glaucoma had anxiety. One (3.8%) control, 5 (6.9%) patients with glaucoma suspect, and 15 (20.8%) patients with glaucoma had depression. In glaucoma patients, the number of anxiety patients was higher in patients who had MD of less than -6 dB and the numbers of anxiety and depression patients were higher in patients who had visual acuity of lower than 20/40. CONCLUSIONS: The rate of depression in patients with glaucoma is higher than that of glaucoma suspect and controls. There is no significant difference between the three groups in rate of anxiety. Clinicians are advised to not only offer medical treatment but also should monitor for mood disturbances like anxiety and depression to ensure compliance and quality of life of patients.

Depression and Anxiety in Patients with Glaucoma or Glaucoma Suspect

PURPOSE: To investigate depression and anxiety in patients with glaucoma or glaucoma suspect. METHODS: Seventy-two patients with glaucoma, 72 patients with glaucoma suspect and 26 controls comprised the study population. Anxiety and depression was evaluated by hospital anxiety and depression scale (HADS) questionnaire. In this study, scores higher than 10 on the HADS-A and HADS-D were defined as anxiety and depression, respectively. The relationship between HADS and mean deviation (MD) of visual field tests or visual acuity of the better eye was analyzed in glaucoma patients. RESULTS: Three (11.5%) controls, 11 (15.3%) patients with glaucoma suspect, and 15 (20.8%) patients with glaucoma had anxiety. One (3.8%) control, 5 (6.9%) patients with glaucoma suspect, and 15 (20.8%) patients with glaucoma had depression. In glaucoma patients, the number of anxiety patients was higher in patients who had MD of less than -6 dB and the numbers of anxiety and depression patients were higher in patients who had visual acuity of lower than 20/40. CONCLUSIONS: The rate of depression in patients with glaucoma is higher than that of glaucoma suspect and controls. There is no significant difference between the three groups in rate of anxiety. Clinicians are advised to not only offer medical treatment but also should monitor for mood disturbances like anxiety and depression to ensure compliance and quality of life of patients.

Internal Carotid Artery Aneurysm Presenting with Unilateral Nasal Hemianopsia

PURPOSE: To report a case of unilateral nasal hemianopsia caused by a large internal carotid artery aneurysm. CASE SUMMARY: A 56-year-old female presented with large cupping in the left optic nerve head detected incidentally during a routine check-up. She had no underlying systemic disease except hypertension. The best corrected visual acuity was 20/20 in both eyes and a slit-lamp examination showed no abnormal findings. Ophthalmoscopy showed cup/disc ratios of 0.6 in the right eye and 0.75 in the left eye. Relative afferent papillary defect or color vision defect was not observed. A Humphrey visual-field test indicated unilateral nasal hemianopsia in the left eye. Brain CT and angiography revealed a large 2.2-cm aneurysm on the left internal carotid artery. CONCLUSIONS: Internal carotid artery aneurysm should be considered as a possible cause of unilateral nasal hemianopsia in patients without intraocular lesion.

Longitudinal Analysis of Retinal Nerve Fiber Layer Thickness With GDx-VCC in Glaucoma Suspect

PURPOSE: The changes of retinal nerve fiber layer thickness with GDx-VCC were analyzed to assess the use of this instrument for longitudinal follow-up of retinal nerve fiber layers. METHODS: From July 2004 to July 2007, patients suspected of glaucoma were measured with GDx-VCC at baseline and measurements were repeated at a minimum interval of 12 months. The medical records of 150 patients were reviewed and 42 patients that showed glaucomatous visual field progression in 36 months were classified into a "progression group" and 108 patients with no visual field loss were classified into a "nonprogression group". RESULTS: In the nonprogression group, the temporal superior-nasal-inferior-temporal (TSNIT) average and theinferior average showed statistically significant changes for the follow up periods. However, in theprogression group, there were no parameters with significant changes even though glaucomatous visual field loss was found. The visual field progressed at a rate of 0.1dB/year in the progression group but the relationship between MD, PSD and GDx-VCC parameters could not be established. CONCLUSIONS: GDx-VCC may not be sufficient for longitudinal assessment of the RNFL, especially during the early glaucomatous visual field changes. The progression of glaucoma only with GDx-VCC should be cautiously evaluated, and confirmation with the visual field which elucidates early glaucomatous changes is necessary. Further study is needed before GDx-VCC can be recommended as the instrument for longitudinal assessment.

Comparison of RNFL Thickness among Normal, Glaucoma Suspect and Glaucoma in Children

PURPOSE: To compare the retinal nerve fiber layer (RNFL) thickness among normal children, glaucoma suspects, and children with glaucoma, using optical coherence tomography (OCT). METHODS: Ninety-four eyes of 47 normal children, 62 eyes of 38 glaucoma suspects and 33 eyes of 21 children with glaucoma, from the ages of 5 to 15 years were examined at the Ophthalmology Center at the Inha University Hospital. The RNFL thickness was measured with OCT. Patient cooperation and signal strength of the OCT scans were assessed. The mean, superior, inferior, nasal, and temporal RNFL thicknesses were measured by OCT in all three groups. RESULTS: After adjustment by refractive error, the RNFL thicknesses of the mean, superior, inferior, nasal, and temporal areas were 110.8+/-10.1 micrometer, 140.1+/-17.5 micrometer, 134.1+/-14.8 micrometer, 79.9+/-14.5 micrometer, and 89.2+/-16.8 micrometer, respectively, in the normal group; 107.9+/-10.8 micrometer, 134.8+/-15.5 micrometer, 130.2+/-18.8 micrometer, 75.4+/-17.1 micrometer, and 91.2+/-18.7 micrometer, respectively, in the glaucoma suspect group; and 102.8+/-18.1 micrometer, 129.5+/-16.5 micrometer, 126.1+/-20.2 micrometer, 70.3+/-19.7 micrometer, and 85.1+/-16.9 micrometer, respectively, in the glaucoma patient group. There was a significant difference among the three groups in all locations except in the temporal area (p=0.003). CONCLUSIONS: RNFL thickness in children measured by OCT may be useful in the diagnosis and follow-up of glaucoma in children.

Differentiating Patients with Glaucoma from Glaucoma Suspects by Retinal Nerve Fiber Layer Assessment Using Nerve Fiber Analyzer

PURPOSE: To evaluate the difference of retinal nerve fiber layer measurements as obtained by Nerve Fiber Analyser according to visual field defects in subjects with large Cup-to-Disc ratio (C/D ratio>or=0.6) and to determine which predictable parameters are useful in glaucoma diagnosis. METHODS: Fifty one normal subjects, 17 patients with glaucoma, 18 glaucoma suspects based on optic disc appearance and visual field defect participated. Nerve fiber layer thickness assessments using scanning laser polarimeter (Nerve Fiber Analyzer II software version 2.1.; Laser Diagnostic Technologies, Inc., San Diego, California, U.S.A.) were measured in normal subjects, patients with glaucoma, and glaucoma suspects. Measured nerve fiber layer thickness parameters were compared each other. RESULTS: Superior to inferior ratio (S/I ratio) was only statistically significant parameter to differentiate glaucoma from glaucoma suspects having glaucomatous optic nerve head. CONCLUSIONS: Superior to inferior ratio (S/I ratio) is useful parameter to predict differentiating patients with glaucoma from glaucoma suspects.

Clinical Ability of Heidelberg Retinal Tomograph Examination to Detect Glaucomatous Visual Field Change

PURPOSE: We assessed whether Heidelberg retinal tomograph(HRT)is helpful in predicting the progression of glaucomatous field defect. METHODS: The periodic HRT and visual field results were obtained from 103 patients with primary open angle glaucoma (POAG) or glaucoma suspect who had been in our hospital from 1998 to 2000. Except 45 patients who had undergone ocular operation or had a follow-up of less than 1 year, 58 patients (48 eyes with POAG and 29 eyes with glaucoma) were selected. RESULTS: For glaucoma patients, the sensitivity and specificity to HRT on progression of glaucomatous field defect showed 35.7% and 33.3%, respectively. Their positive predictive value was 78.9%, and negative predictive value 6.9%. According to the results obtained after adjusting the cutoff value of classification score in HRT to -0.32 through the ROC curve, the sensitivity and specificity of progression in the glaucomatous field for glaucoma patients were changed to 57.1% and to 33.3%. Furthermore, the positive predictive value was 86% and the negative predictive value was 10% after the adjustment above. CONCLUSIONS: Our results showed that there was no significant correlation between HRT and progression of glaucomatous field defect in POAG patients or glaucoma suspect patients.

Correlation between Optic Disc Tomography and Frequency Doubling Technology in Glaucoma Suspect

PURPOSE: To evaluate the relationship between results obtained by Heidelberg Retina Tomography (HRT) and frequency-doubling technology (FDT) in glaucoma suspect. METHODS: A total of 24 patients with glaucoma suspect were included in this study. Each subject underwent 2 visual field tests (Humphrey central 30-2 and FDT N-30), a comprehensive ophthalmic examination, and HRT upon each eye. RESULTS: A comparison of FDT global indices with the parameters of HRT, MD and PSD of FDT showed no correlation with HRT parameters. However, there was a significant correlation between the number of abnormal points in FDT and the following HRT parameters cup-disc area ratio, rim volume, mean nerve fiber layer thickness, retinal nerve fiber layer cross sectional area, and classification (p<0.05). When comparing the group having two or less abnormal points by FDT to the group having three or more abnormal points by FDT, differences were found in the following HRT parameters disc area, cup-disc area ratio, rim volume, cup shape measure, mean nerve fiber layer thickness, nerve fiber layer cross sectional area, and classification (p<0.05). CONCLUSIONS: Significant correlations were found between the number of abnormal points in FDT and HRT parameters. We believe that the correlations between the results of FDT and HRT parameters in preperimetric glaucoma with normal achromatic visual field suggest that FDT may be used for early diagnosis in patients with glaucoma.