Carlos Gustavo V. De Moraes

β-Zone Parapapillary Atrophy and the Velocity of Glaucoma Progression

PURPOSEnBeta-Zone parapapillary atrophy (PPA) occurs more commonly in eyes with glaucoma. Rates of glaucomatous visual field (VF) progression in eyes with and without beta-zone PPA at the time of baseline assessment were compared.nnnDESIGNnRetrospective, comparative study.nnnPARTICIPANTSnTwo hundred forty-five patients from the New York Glaucoma Progression Study.nnnMETHODSnSubjects with glaucomatous optic neuropathy and repeatable VF loss were assessed for eligibility. Eyes with a Heidelberg Retina Tomograph II (HRT) examination, at least 5 visual field tests after the HRT in either eye, optic disc photographs, and <6 diopters of myopia were enrolled. beta-Zone PPA was defined as a region of chorioretinal atrophy with visible sclera and choroidal vessels adjacent to the optic disc. Global rates of VF progression were determined by automated pointwise linear regression analysis. Univariate analysis included age, gender, ethnicity, central corneal thickness (CCT), refractive error, baseline mean deviation, baseline intraocular pressure (IOP), mean IOP, IOP fluctuation, disc area, rim area, rim area-to-disc area ratio, beta-zone PPA area, beta-zone PPA area-to-disc area ratio, and presence or absence of beta-zone PPA.nnnMAIN OUTCOME MEASURESnThe relationship between beta-zone PPA and the rate and risk of glaucoma progression.nnnRESULTSnTwo hundred forty-five eyes of 245 patients (mean age, 69.6+/-12.3 years) were enrolled. The mean follow-up was 4.9+/-1.4 years and the mean number of VFs after HRT was 9.3+/-2.7. beta-Zone PPA was present in 146 eyes (65%). Eyes with beta-zone PPA progressed more rapidly (-0.84+/-0.8 dB/year) than eyes without it (-0.51+/-0.6 dB/year; P<0.01). Multivariate regression showed significant influence of mean IOP (hazard ratio [HR], 1.11; P<0.01), IOP fluctuation (HR, 1.17; P = 0.02), and presence of beta-zone PPA (HR, 2.59; P<0.01) on VF progression. Moderate (0.5-1.5 dB/year; P = 0.01) and fast (>1.5 dB/year; P = 0.08) global rates of progression occurred more commonly in eyes with beta-zone PPA than in eyes without it. Thinner CCT (<525 microm) had a weak but significant correlation with presence of beta-zone PPA (kappa = 0.13).nnnCONCLUSIONSnEyes with beta-zone PPA are at increased risk for glaucoma progression and warrant close clinical surveillance.

Posture-induced Intraocular Pressure Changes: Considerations Regarding Body Position in Glaucoma Patients

Although glaucoma is a multifactorial disease, elevated intraocular pressure (IOP) remains the most important known risk factor. Different systemic and local factors are thought to influence an individuals IOP. There can be a clinically significant rise in IOP when going from upright to horizontal or inverted body positions. Although there is a significant interindividual variability, the magnitude of the IOP change is greater in glaucomatous eyes. As patients usually spend a significant portion of their lives in the horizontal position, mainly during sleep, this is highly relevant. In this review we discuss the relationship between postural changes and IOP fluctuation, including changes in both body and head position. The possible mechanisms involved and the main implications for glaucomatous eyes are discussed. Finally, considerations with regard to sleep position in glaucoma patients are made based on evidence in the literature.

Spatially Consistent, Localized Visual Field Loss before and after Disc Hemorrhage

PURPOSEnTo evaluate the rate and location of visual field (VF) progression before and after detection of disc hemorrhage (DH).nnnMETHODSnDisc photographs of consecutive patients with glaucoma with >or=5 SITA-Standard 24-2 VF in either eye were evaluated for the presence and location of DH. Exclusion criteria included disorders other than glaucoma likely to affect the VF and an insufficient number of VF test results to create a slope before or after DH detection. Automated pointwise linear regression was used to calculate global and localized rates of progression before and after DH.nnnRESULTSnOne hundred sixty-eight DHs were identified in 122 patients (mean age, 68.9 +/- 11.2 years). The mean number of VF tests was 9.0 +/- 4.4, spanning a mean of 6.7 +/- 3.8 years. Mean global progression rates before and after DH were -0.6 +/- 0.8 and -1.0 +/- 1.2 dB/y, respectively (P = 0.01). The mean rate of progression points corresponding to the DH sector before and after detection were -2.02 +/- 1.0 and -3.7 +/- 3.6 dB/y, respectively (P < 0.01). All rates were significantly faster than in fellow, non-DH eyes (P < 0.05). The VF sector with the fastest progression rate predicted the location of the future DH in 85% of cases. After the detection of DH, the same VF sector maintained the fastest progression rate in almost all eyes (92%).nnnCONCLUSIONSnSpatially consistent, localized VF change occurred in regions of subsequent DH and continued to progress in the same regions at a faster rate. This finding suggests that rapid, localized disease progression predisposes to DH and that progressive VF loss continues because of the ongoing damage at or adjacent to this location.

Factors Affecting Rates of Visual Field Progression in Glaucoma Patients with Optic Disc Hemorrhage

PURPOSEnOptic disc hemorrhage (DH) is an important risk factor for glaucoma progression. We sought to investigate factors affecting the rate of visual field (VF) progression after DH in glaucomatous eyes.nnnDESIGNnRetrospective cohort study.nnnPARTICIPANTSnConsecutive glaucoma patients from our Glaucoma Progression Study with > or =5 Swedish interactive threshold algorithm standard 24-2 VFs from 1999 through 2008.nnnMETHODSnDisc photographs of all patients were evaluated for the presence of DH. Exclusion criteria were conditions other than glaucoma likely to affect the VF and insufficient number of VFs to create a slope after DH detection. Automated pointwise linear regression was used to determine the rate of VF loss after DH detection. Fast progression was defined as a global VF loss of > or =1.5 dB/year. Factors associated with a fast rate of VF loss after the detection of the DH were evaluated.nnnMAIN OUTCOME MEASURESnAssessed variables included baseline (age, gender, intraocular pressure [IOP], central corneal thickness, VF mean deviation [MD], presence of migraine, Raynauds phenomenon, low blood pressure, and exfoliation syndrome) and intercurrent data (DH recurrence, fellow eye involvement, glaucoma surgery, and IOP reduction). Odds ratios (ORs) and 95% confidence intervals (CIs) were determined for each variable.nnnRESULTSnSeventy-six eyes (76 patients; mean age, 68.3+/-10.9 years) were enrolled. Mean IOP and VF MD at the time of the DH detection were 16.6+/-3.8 mmHg and -5.6+/-5.7 dB, respectively. The mean global progression rate after DH was -1.1+/-1.3 dB/year (mean follow-up, 3.8+/-2.8 years). A rate of progression of > or =1.5 dB/year was found in 20 (26%) eyes. Multivariate logistic regression analysis revealed larger baseline MD (OR, 1.11; 95% CI, 1.01-1.20; P = 0.03) and older age (OR, 1.06; 95% CI, 1.01-1.13; P = 0.04) to be significant risk factors for fast progression after DH. Eyes with a baseline MD worse than -4.0 dB had a 270% increased risk of fast progression compared with those with an MD better than -4.0 dB.nnnCONCLUSIONSnThe presence of a DH in older subjects with a worse VF predicted further VF global MD deterioration by more than 5 dB within 4 years. These eyes should undergo careful and frequent disease surveillance and consideration should be given to more aggressive treatment.

Association of exfoliation syndrome and central retinal vein occlusion: an ultrastructural analysis

Purpose:u2002 To evaluate prospectively the frequency with which exfoliation syndrome (XFS) occurs in patients with central retinal vein occlusion (CRVO) by clinical examination and ultrastructural examination of conjunctival biopsy specimens.

A Comparison of Functional and Structural Measures for Identifying Progression of Glaucoma

PURPOSEnTo compare glaucoma progression by functional and structural tests.nnnMETHODSnThe authors prospectively studied 33 glaucoma patients (55 eyes); 20 eyes (15 patients) had disc hemorrhage, and 35 eyes (18 patients) had exfoliation glaucoma. The following tests were performed at two baseline and three follow-up examinations: frequency doubling perimetry (FDT), 24-2 Humphrey visual fields (HVF), multifocal visual evoked potentials (mfVEP), and optical coherence tomography (OCT). To identify progression, the baseline measurements were averaged and compared to those obtained at the final examination. Stereophotographs of the optic disc were obtained at baseline and compared with those at the final examination.nnnRESULTSnPatients were followed up for 21.1±1.8 months. For HVF there were significant changes in mean deviation (MD) in eight (14.5%) eyes but in pattern standard deviation (P/SD) in only two (3.6%) eyes. For FDT, there were significant changes in MD in 13 (23.6%) eyes. Five eyes showed changes in MD for HVF and FDT. For mfVEP, there was an increase in abnormal points in nine (16.4%) eyes. Six of these eyes did not show significant HVF or FDT changes. For OCT, RNFL average thickness values were significantly decreased in nine (16.4%) eyes. Nine (16.4%) eyes showed progression on stereophotography; four of these eyes did not show significant changes on OCT and functional tests.nnnCONCLUSIONSnEach test showed evidence of progression in some eyes. However, agreement among tests and stereophotography regarding which eyes showed progression was poor, illustrating the importance of following up patients with a combination of functional and structural tests.

Iris Morphologic Changes Related to α1-Adrenergic Receptor Antagonists: Implications for Intraoperative Floppy Iris Syndrome

PURPOSEnTo identify iris structural alterations associated with intraoperative floppy iris syndrome (IFIS) in patients using systemic alpha(1)-adrenergic receptor antagonists (alpha-1ARA).nnnDESIGNnCross-sectional study.nnnPARTICIPANTS AND CONTROLSnTwenty-nine patients with current or past treatment with any systemic alpha-1ARA and 22 untreated controls.nnnMETHODSnConsecutive eligible patients underwent slit-lamp-adapted optical coherence tomography in a masked fashion under standardized lighting conditions.nnnMAIN OUTCOME MEASURESnIris thickness at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and at the sphincter muscle region (SMR; 0.75 mm from the pupillary margin), the ratio between the DMR/SMR (to compensate for possible intersubject variability), and pupillary diameter.nnnRESULTSnMost treated patients were on tamsulosin (27/29). Mean age was similar in study and control groups (70.6+/-7.6 vs 67.1+/-9.1 years; P = 0.061). Photopic pupil diameter was reduced in the study group (2.06+/-0.5 vs 2.5+/-0.6 mm; P = 0.001). The SMR was similar between groups (P = 0.53). Significantly lower values were found in treated subjects for the DMR and the DMR/SMR ratio (P<0.001). These differences remained significant after adjusting for pupil diameter (P<0.001). Multiple regression analysis showed that a longer duration of alpha-1ARA treatment correlated to a reduced DMR/SMR ratio (P = 0.001; r = 0.47). Age and eye color were not significant in this model.nnnCONCLUSIONSnPatients using systemic alpha-1ARA have significantly lower values of DMR thickness and DMR/SMR ratio and smaller pupil diameter when compared with age-matched controls. These differences seem to be related to the duration of drug exposure and provide evidence of structural alterations to the iris dilator muscle from this class of agents in IFIS.nnnFINANCIAL DISCLOSURE(S)nProprietary or commercial disclosure may be found after the references.

Association between corneal biomechanical properties and optic nerve head morphology in newly diagnosed glaucoma patients

Background:u2002 To investigate the association between corneal biomechanics and optic nerve head morphology in newly diagnosed primary open‐angle glaucoma patients.

Repeatability of short-duration transient visual evoked potentials in normal subjects

To evaluate the within-session and inter-session repeatability of a new, short-duration transient visual evoked potential (SD-tVEP) device on normal individuals, we tested 30 normal subjects (20/20 visual acuity, normal 24-2 SITA Standard VF) with SD-tVEP. Ten of these subjects had their tests repeated within 1–2xa0months from the initial visit. Synchronized single-channel EEG was recorded using a modified Diopsys Enfant™ System (Diopsys, Inc., Pine Brook, New Jersey, USA). A checkerboard stimulus was modulated at two reversals per second. Two different contrasts of checkerboard reversal patterns were used: 85% Michelson contrast with a mean luminance of 66.25xa0cd/m2 and 10% Michelson contrast with a mean luminance of 112xa0cd/m2. Each test lasted 20xa0s. Both eyes, independently and together, were tested 10 times (5 times at each contrast level). The following information was identified from the filtered N75-P100-N135 complex: N75 amplitude, N75 latency, P100 amplitude, P100 latency, and Delta Amplitude (N75-P100). The median values for each eye’s five SD-tVEP parameters were calculated and grouped into two data sets based on contrast level. Mean age was 27.3xa0±xa05.2xa0years. For OD only, the median (95% confidence intervals) of Delta Amplitude (N75-P100) amplitudes at 10% and 85% contrast were 4.6xa0uV (4.1–5.9) and 7.1xa0uV (5.15–9.31). The median P100 latencies were 115.2xa0ms (112.0–117.7) and 104.0xa0ms (99.9–106.0). There was little within-session variability for any of these parameters. Intraclass correlation coefficients ranged between 0.64 and 0.98, and within subject coefficients of variation were 3–5% (P100 latency) and 15–30% (Delta Amplitude (N75-P100) amplitude). Bland–Altman plots showed good agreement between the first and fifth test sessions (85% contrast Delta Amplitude (N75-P100) delta amplitude, mean difference, 0.48xa0mV, 95% CI, −0.18–1.12; 85% contrast P100 latency delay, −0.82xa0ms, 95% CI, −3.12–1.46; 10% contrast Delta Amplitude (N75-P100) amplitude, 0.58xa0mV, 95% CI, −0.27–1.45; 10% contrast P100 latency delay, −2.05xa0mV, 95% CI, −5.12–1.01). The inter-eye correlation and agreement were significant for both SD-tVEP amplitude and P100 latency measurements. For the subset of eyes in which the inter-session repeatability was tested, the intraclass correlation coefficients ranged between 0.71 and 0.86 with good agreement shown on Bland–Altman plots. Short-duration transient VEP technology showed good within-session, inter-session repeatability, and good inter-eye correlation and agreement.

Slit‐lamp‐adapted optical coherence tomography for assessment of an overhanging filtering bleb

Acta Ophthalmol. 2010: 88: 910–911