Tiago S. Prata

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.

Visual field progression differences between normal-tension and exfoliative high-tension glaucoma.

PURPOSEnTo compare the pattern, location, and rate of visual field (VF) change in normal-tension (NTG) and exfoliative high-tension glaucoma (XHTG).nnnMETHODSnRecords of all patients with glaucoma in the New York Glaucoma Progression Study with five or more VF tests were reviewed. Patients were divided into NTG (all known IOP < 21 mm Hg) and XHTG (untreated IOP >or= 21 mm Hg) groups. Automated pointwise linear regression analysis determined global and localized rates of change.nnnRESULTSnThere were 139 NTG and 154 XHTG eyes. Patients with XHTG were significantly older than those with NTG (mean +/- SD: 72.6 +/- 9.4 years vs. 62.7 +/- 12.8 years, P < 0.01), had higher mean IOPs (16.5 +/- 3.2 mm Hg vs. 13.3 +/- 2.0 mm Hg, P < 0.01) and greater central corneal thickness (CCT, 544.0 +/- 35.7 microm vs. 533.9 +/- 35.9 microm; P = 0.01). During a similar period, XHTG progressed globally almost twice as rapidly as did NTG (-0.64 +/- 0.7 dB/y vs. -0.35 +/- 0.3 dB/y, P < 0.01), which became nonsignificant after adjustment for differences in age, mean IOP, and CCT. In a multivariate model, variables significantly associated with progression were higher mean IOP (odds ratio [OR]: 1.09, P = 0.03) and decreased CCT (OR/40 mum thinner: 1.37, P = 0.03). Progression within the paracentral VF was more common in the NTG group (75% vs. 57.3%, P = 0.04). The most important factor associated with paracentral progression among eyes that reached a progression outcome was the diagnosis of NTG.nnnCONCLUSIONSnXHTG and NTG eyes progress at a similar global rate after adjustment for differences in IOP, CCT, and age. However, NTG eyes progress more often in the central VF, independent of other factors. Glaucoma surveillance in eyes with open-angle glaucoma and statistically normal IOP should include periodic assessment of the central field.

The Region of Largest β-Zone Parapapillary Atrophy Area Predicts the Location of Most Rapid Visual Field Progression

PURPOSEnTo determine if visual field (VF) progression occurs most rapidly in the region of largest β-zone parapapillary atrophy (PPA).nnnDESIGNnRetrospective cohort.nnnPARTICIPANTSnOne hundred twenty-five patients from the New York Glaucoma Progression Study with both β-zone PPA and VF progression.nnnMETHODSnTreated open-angle glaucoma patients with 8 or more Swedish Interactive Threshold Algorithm Standard 24-2 VFs (Humphrey Field Analyzer II; Carl Zeiss Meditec, Inc., Dublin, CA) in either eye were identified. Eyes with optic disc photographs, β-zone PPA, less than 6 diopters myopia, and VF progression were studied. Visual field progression was defined using trend analysis as the presence of at least 2 adjacent progressing points in the same hemifield using standard pointwise linear regression (PLR) criteria.nnnMAIN OUTCOME MEASURESnThe correlation between β-zone PPA and location of most rapid future VF progression.nnnRESULTSnOne hundred twenty-five eyes (125 patients; mean age, 71.9 ± 12.3 years; 58% women; 75% European descent) with β-zone PPA and VF progression were enrolled. The mean follow-up was 6.8 ± 1.7 years and the mean number of VFs was 12.5 ± 3.6. Ninety-three patients (74%) had more β-zone PPA inferiorly and 32 patients (26%) had more β-zone PPA superiorly. The fastest VF progression occurred in the superior hemifield in 77 patients (62%) and in the inferior hemifield in 48 (38%) patients. Patients with superior VF progression had a superior localized mean rate of progression of -1.57 ± 1.7 dB/year, and patients with inferior VF progression had an inferior localized mean rate of -0.94 ± 1.4 dB/year (P = 0.012). The mean number of points reaching the predefined PLR end points was 5.6±7.5 for the superior VF hemifield and 3.0±4.9 for the inferior hemifield (P = 0.006). The hemifield with more points reaching PLR progression end points, with fastest average velocity of progression, or both was spatially consistent with the location of largest β-zone PPA in 89 (71%) patients (P = 0.0001, Fisher exact test; κ = 0.35; 95% confidence interval, 0.17-0.53).nnnCONCLUSIONSnIn treated glaucoma patients with β-zone PPA and VF progression, the location of largest β-zone PPA typically correlates spatially with the region of the most rapid future VF progression.nnnFINANCIAL DISCLOSURE(S)nThe author(s) have no proprietary or commercial interest in any materials discussed in this article.

A comparison between microperimetry and standard achromatic perimetry of the central visual field in eyes with glaucomatous paracentral visual-field defects

Background and aims: The aim was to correlate retinal sensitivity as determined by scanning laser ophthalmoscope microperimetry (SLO-MP) in glaucomatous eyes with paracentral visual field (VF) defects detected by standard automated perimetry (SAP). Methods: Twenty eyes with glaucomatous optic neuropathy and an SAP VF defect involving the central 16 test points (at least one point with p<1% in the 24–2 VF) were enrolled. Eyes with diseases other than glaucoma were excluded. All patients underwent SLO-MP and SAP of the central 10°. Results from each eye were divided into four quadrants for analysis. Normal and abnormal quadrants by SAP were compared with the corresponding normal and abnormal quadrants by SLO-MP. Regression analysis was used to correlate the mean threshold values (dB) of SLO-MP and SAP in each quadrant. Macular optical coherence tomography (OCT) was performed when there was a disagreement between functional tests. Results: The mean age and VF mean deviation were 60.8 (13.4) years and −7.3 (6.1) dB, respectively. There was a significant correlation between SLO-MP and SAP results in all quadrants (r2⩾0.68, p<0.001). All abnormal SAP quadrants had a corresponding abnormal SLO-MP quadrant. However, 21% of the normal SAP quadrants had an abnormal corresponding microperimetry result; a corresponding significant reduction in total macular thickness measured by OCT was present in 75% of these quadrants. Conclusions: Macular sensitivity evaluated by SLO-MP correlates significantly with SAP paracentral VF defects. SLO-MP detected retinal sensitivity reduction in areas of OCT structural damage with normal SAP and suggests that subtle paracentral functional deficits may be present in many more eyes with established glaucoma than generally assumed.

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.

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.

Glaucoma With Early Visual Field Loss Affecting Both Hemifields and the Risk of Disease Progression

OBJECTIVEnTo evaluate whether damage to both hemifields in glaucomatous eyes predicts more rapid disease progression than does single-hemifield involvement.nnnMETHODSnWe reviewed the medical records of 43 660 consecutive patients. Eyes with glaucomatous optic neuropathy, 10 or more Swedish Interactive Threshold Algorithm standard 24-2 visual fields in at least 5 years, and mean deviation (MD) smaller than -6.0 dB were included. Pointwise linear regression was used to determine progression. Cox proportional hazards analysis was used to calculate risk of progression based on different baseline covariates.nnnRESULTSnWe enrolled 205 eyes (205 patients; mean [SD] age, 64.2 [11.0] years; follow-up, 6.5 [1.8] years; number of visual fields, 12.3 [2.9]). Patients were divided into 3 groups: initial superior defect (group A; n = 79; MD, -3.4 [1.9] dB), initial inferior defect (group B; n = 61; MD, -3.4 [1.8] dB), and both hemifields affected (group C; n = 65; MD, -4.2 [1.5] dB). Group C progressed faster than did groups A and B (P < .02). Multivariate analysis showed significant effect of higher baseline intraocular pressure, thinner central corneal thickness, and initial damage to both hemifields.nnnCONCLUSIONSnInitial damage to both hemifields increases the risk of glaucoma progression. More aggressive therapy should be considered for these eyes.