Yoshiaki Kitazawa

Disk Hemorrhage Is a Significantly Negative Prognostic Factor in Normal-Tension Glaucoma

PURPOSE We investigated the relationship between disk hemorrhage in normal-tension glaucoma and the progression of visual field defects and, additionally, whether hemorrhage plays a role in the pathogenic process of the chronic disease. METHODS We retrospectively reviewed the charts of 70 patients with normal-tension glaucoma (mean follow-up, 5.6 years) who were not medicated for glaucoma, and we applied a regression analysis of survival data based on the Cox proportional hazards model. Several clinical factors were investigated to find a possible association with the progression of glaucomatous visual field defined by two different definitions: one by mean deviation change and the other by glaucoma change probability analysis. RESULTS Disk hemorrhage, corrected-pattern standard deviation, age, systolic blood pressure, and pulse rate had a significant influence on the visual field defect. The cumulative probability of progression of visual field loss was significantly greater for patients with disk hemorrhage than for patients without disk hemorrhage by either criterion for progression (P </=.0008, logrank test). All eyes that had at least two occurrences of disk hemorrhage showed progression, whereas only three of nine eyes showed progression in the nonrecurrent disk hemorrhage group by the glaucoma change probability analysis. The difference was statistically significant (P <.0001, Fishers exact probability test). Furthermore, there was a significant relationship between the location of the disk hemorrhage and the area of the progression of visual field loss in 65.4% of progressive patients with disk hemorrhage. CONCLUSIONS Several clinical factors other than intraocular pressure are significantly associated with the progression of visual field loss during the natural course of normal-tension glaucoma. Among these, disk hemorrhage is a significantly negative prognostic factor in patients with normal-tension glaucoma and may be a sign of progressive damage of the retinal nerve fiber layer, leading to functional deterioration of the visual field.

Optic disc hemorrhage in low-tension glaucoma.

The prevalence of optic disc hemorrhage (DH) was determined in groups consisting of 192 primary open-angle glaucoma, 113 primary angle-closure glaucoma, 78 low-tension glaucoma, and 473 normal patients. The DH was mot prevalent (20.5%) among low tension glaucoma patients (chi 2; P less than 0.001). The epidemiological features of DH were studied in 58 low-tension glaucoma patients by examining them every one to four weeks from 6 to 32 months. All the DHs but one took place within a seven-month follow-up and the incidence of DH varies from 0 to 10% during the 32-month follow-up period. The overall incidence of DH was 24.8% during that period of time. Recurrences were seen in 64% of the eyes and 92% of these occurred within 28 weeks following the previous hemorrhages. Ninety-two percent of all DHs were present for at least four weeks. Low-tension glaucoma eyes seem to consist of two different groups; one which develops recurrent DH and one which is very unlikely to bleed through its entire course.

The effect of Ca2+-antagonist on visual field in low-tension glaucoma

A prospective study was conducted to evaluate the effects of Ca2+-antagonist on the visual field in low-tension glaucoma (LTG). Twenty-five consecutive patients (50 eyes) with LTG received nifedipine at 30 mg/day per os for 6 months. Visual field was tested with an Octopus 201 (program G1) prior to and each month during the period of nifedipine administration. In addition to tonometry and the measurements of systemic blood pressure and pulse rate, the reactivity of peripheral vessels was estimated by determining the response of skin temperature of a finger to cold water (4° C). Twelve eyes (six patients) showed a constant improvement of visual field as expressed by an increase in mean sensitivity (MS). Canonical discriminant analysis demonstrated that the visual field is likely to improve with systemic nifedipine in patients who are young, have a higher initial MS and lower intraocular pressure, and have less decrease in diastolic blood pressure with the nifedipine administration and better cold recovery of skin temperature after their hand is soaked in cold water.

Low-dose and High-dose Mitomycin Trabeculectomy as an Initial Surgery in Primary Open-angle Glaucoma

PURPOSE The purpose of the study is to determine the optimum regimen of intraoperative administration of mitomycin as an adjunct to trabeculectomy. METHODS Of 11 patients with primary open-angle glaucoma, 22 eyes that had not undergone any surgical intervention were included. In each patient, one eye was randomly allocated to a mitomycin 0.2-mg group and the fellow eye to a mitomycin 0.02-mg group. Mitomycin was applied for 5 minutes only once during trabeculectomy. The follow-up period was 6 to 17 months. RESULTS Eleven (100%) eyes in the 0.2-mg group and 7 (63.6%) in the 0.02-mg group achieved successful control of intraocular pressure with or without topical antiglaucoma medication. Transient hypotony maculopathy (18%) and cataract progression (18%) were noted in the 0.2-mg group exclusively. The incidence of other complications was similar between the two groups. CONCLUSION These data suggest that the most appropriate dose of mitomycin for primary surgery seems to be in between the two doses tested in the current study.

Evaluation of the effect of aging on the retinal nerve fiber layer thickness using scanning laser polarimetry.

PurposeThe scanning laser polarimeter is a new diagnostic scanning laser instrument that uses the polarizing properties of the retinal nerve fiber layer to measure its thickness in vivo. We first ascertained the measurement reproducibility of this instrument and then evaluated the effects of aging on the retinal nerve fiber layer. MethodsWe performed three consecutive measurements in six glaucomatous and six age-matched normal healthy eyes to evaluate the instrumentation. The mean thickness of the peripapillary retinal nerve fiber layer within the rings 1. 0, 1. 5, and 2. 0 disk diameters from the center of the optic nerve head was calculated. We then evaluated aging effects on the retinal nerve fiber layer thickness in 75 eyes of 75 normal volunteers 20–66 years of age. ResultsThe mean coefficients of variation of the measurements of the 1. 0, 1. 5, and 2. 0 disk diameters were 3. 64, 3. 59, and 4. 10, respectively, for the normal subjects, and 10. 20, 5. 65, 6. 08, respectively, for the patients with glaucoma. We found a significant, inverse linear correlation between age and the retinal nerve fiber layer thickness when measured along the 1. 5 disk diameter ring (R2 = 0. 16, p = 0. 0004). Significant decreases with aging also were observed in the nasal (R2 = 0. 17, p = 0. 0003) and inferior (R2 = 0. 09, p = 0. 0091) retinal nerve fiber layer thickness. ConclusionsOur results indicate that scanning laser polarimetry is sufficiently reliable to assess the retinal nerve fiber layer thickness in vivo. The retinal nerve fiber layer thickness decreases with age in the normal healthy eye.

An Ultrasound Biomicroscopic Study of Filtering Blebs after Mitomycm C Trabeculectomy

PURPOSES To investigate the relation between filtering bleb function and ultrasound biomicroscopic images, and to establish a new classification system for filtering blebs according to these images. METHODS After trabeculectomy with mitomycin C, the filtering blebs of 117 eyes from 117 patients with various types of glaucoma were examined using ultrasound biomicroscopy. Four parameters of the images-intrableb reflectivity, visibility of the route under the scleral flap, formation of a cavernous fluid-filled space, and bleb height-were correlated with the level of intraocular pressure (IOP). RESULTS Reflectivity inside the bleb and visibility of a route under the scleral flap were highly associated with IOP control. Blebs were classified into four categories according to the four measured parameters: type L (low-reflective), type H (high-reflective), type E (encapsulated), and type F (flattened). Eyes with good IOP control had mainly type L blebs. Type E and type F blebs were seen mostly in eyes requiring additional medication. CONCLUSION The structure inside a filtering bleb is visible by ultrasound biomicroscopy, and bleb function is significantly associated with its ultrasound biomicroscopic image in eyes trabeculectomized with adjunctive mitomycin C.

Correlation between peripapillary atrophy and optic nerve damage in normal-tension glaucoma.

PURPOSE To investigate the correlation between peripapillary atrophy and visual field defects as well as optic nerve head configurations in patients with normal-tension glaucoma (NTG). METHODS Topographic measurements for peripapillary atrophy and optic nerve head using confocal scanning laser tomography and automated static threshold perimetry were performed on 102 eyes of 51 patients with NTG. Peripapillary atrophy was divided into (1) a central zone (zone Beta) with visible, large choroidal vessels and sclera, and (2) a peripheral zone (zone Alpha) with irregular hyper- and hypopigmentation. The area, angular extent around the disc, and radial extent of each zone were measured. RESULTS The area and extent of zone Beta increased significantly with increasing visual field defects expressed in terms of mean deviation, corrected pattern standard deviation, central visual field defects within 5 degrees of fixation, and superior hemifield defects (r = 0.3770-0.5291, P < 0.01). The angular extent of zone Beta represented localized field defects better (r = 0.5217, P < 0.001) than diffuse field defects (r = -0.3770, P < 0.01). Zone Beta significantly correlated with optic nerve head topography. Intraindividual right-left-side differences of corrected pattern standard deviation showed the highest correlation with the side differences of zone Beta area (r = 0.6305, P < 0.001). The location of visual field defects correlated significantly with the location of peripapillary atrophy (chi-square = 9.0484, P = 0.011). Zone Alpha was not significantly correlated with visual field defects or optic nerve head configurations (P > 0.05). CONCLUSION Peripapillary atrophy is significantly associated with functional and structural optic nerve damage in NTG.

Incidence of delayed onset infection after trabeculectomy with adjunctive mitomycin C or 5-fluorouracil treatment

AIMS/BACKGROUND The introduction of the adjunctive use of antiproliferatives to trabeculectomy has greatly improved the success rate of this operation. Trabeculectomy with antiproliferative treatment, however, is usually associated with a cystic and thin walled filtering bleb, which may be more susceptible to infection. The objective of this study was to evaluate the incidence, clinical findings, and risk factors of delayed onset, bleb related infection after trabeculectomy with adjunctive mitomycin C (MMC) or 5-fluorouracil (5-FU) treatment. METHODS The records of 632 glaucoma patients who underwent 966 trabeculectomies, with and without the use of adjunctive MMC or 5-FU treatment, between January 1985 and February 1995 were analysed. The mean follow up period was 3.5 (2.4) years (range 0.1 to 11.2 years). The mean patient age was 54.8 (18.8) years (range 0 to 88 years). RESULTS Bleb related infection occurred in one of 76 trabeculectomies that did not receive antiproliferatives (1.3%), three of 228 treated with 5-FU (1.3%) trabeculectomies, and seven of 662 treated with MMC (1.1%). Five eyes developed blebitis; six eyes developed endophthalmitis. Bleb related infection developed an average of 3.1 (1.6) (range 0.4 to 6.0) years after trabeculectomy. All eyes had avascular or hypovascular blebs that were cystic in shape before infection and all eyes had reduced intraocular pressure. Early wound leaks and chronic, intermittent bleb leaks were identified to be risk factors for the bleb related infection. CONCLUSION The incidence of delayed onset, bleb related infection after trabeculectomy with antiproliferative treatment is similar to that after trabeculectomy without antiproliferatives.

Use of antifibrosis agents and glaucoma drainage devices in the American and Japanese Glaucoma Societies.

PURPOSE To investigate practice patterns among glaucoma subspecialists in the American Glaucoma Society (AGS) and the Japanese Glaucoma Society (JGS), regarding use of antifibrosis agents and glaucoma drainage devices. METHODS An anonymous survey incorporating 10 clinical situations was mailed to all AGS and JGS members in December 1995. RESULTS Half of the AGS (105 of 210), and JGS (25 of 50) members returned surveys. Most respondents (51-87%) preferred trabeculectomy with adjunctive mitomycin for all 10 clinical situations. Mitomycin concentrations varied from 0.1 to 0.8 mg/ml (range of means for 10 situations 0.31-0.39 mg/ml) and intraoperative application times ranged from 5 s to 7 min (range of means for 10 situations 2.5-4.6 min). Preferences for either no antifibrosis agent (up to 39%) or 5-fluorouracil (up to 29%) were highest in primary trabeculectomy. Thirty-seven percent to 64% of AGS members used glaucoma drainage devices, especially after complicated postsurgical glaucomas (after penetrating keratoplasty, scleral buckling, or pars plana vitrectomy) and in neovascular glaucoma, but few JGS members used them. Large differences between university- and private practice-based AGS members were found only in mitomycin use for primary trabeculectomy (33% vs. 52%, respectively; p = 0.07) and for complicated postsurgical glaucomas (46% vs. 70%, respectively; p = 0.03). CONCLUSIONS Trabeculectomy with mitomycin was the preferred surgical procedure among AGS and JGS members in the clinical situations surveyed. Mitomycin concentration and time of application varied widely. Many respondents used 5-fluorouracil or no antimetabolite in primary trabeculectomy. Glaucoma drainage devices were widely used for complicated glaucomas in the United States.

Prevention of visual field defect progression with brovincamine in eyes with normal-tension glaucoma

PURPOSE A prospective investigation of the effect of brovincamine fumarate, a Ca2+-channel blocker, on visual field changes in normal-tension glaucoma (NTG). METHODS A total of 28, age- and field-matched, patients with NTG were allocated randomly to either brovincamine fumarate (20 mg 3 times daily) or placebo (3 times daily). The patients were followed at least every 4 months for a minimum of 2.5 years, and visual field examinations were carried out at least every 6 months. The mean follow-up periods (+/-standard deviation) were 39.1 +/- 8.7 months in the brovincamine-treated group and 37.9 +/- 10.1 months in the placebo group. Stepwise discriminant analyses were performed to separate the patients who showed improvement of their visual fields from those who failed to improve in the brovincamine-treated group, and to identify factors that may determine the visual field prognosis of all patients with NTG enrolled in the study. RESULTS In the brovincamine-treated group, six patients showed visual field improvement, whereas none showed improvement in the placebo group using the Statpac 2 linear regression analysis. Discriminant analyses identified better cold recovery rate and higher initial systolic blood pressure to be significantly contributory to a favorable outcome in the brovincamine-treated group, and the use of brovincamine, better cold recovery rate, and higher initial systolic blood pressure were identified to be significantly contributory to a favorable prognosis in all subjects. CONCLUSION Brovincamine seems to have a favorable effect on visual field in at least some patients with NTG.