Initial Visual Field Loss Research Articles

Peripapillary Versus Macular Thinning to Detect Progression According to Initial Visual Field Loss Location in Normal-Tension Glaucoma

PurposeTo investigate the predictive capabilities of peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thinning to detect visual field (VF) progression in normal-tension glaucoma patients with an initial parafoveal scotoma (IPFS) or nasal step (INS). DesignRetrospective cohort study. Methods185 early-stage glaucoma eyes, followed for 10 years, were retrospectively stratified into IPFS and INS groups. Progressive pRNFL and mGCIPL thinning were assessed using spectral-domain optical coherence tomography and VF progression using both event- or trend-based analysis. Kaplan-Meier survival analysis compared VF survival in each VF phenotype with or without progressive pRNFL and mGCIPL thinning. Cox proportional regression analysis identified VF progression factors. ResultsVF progression was detected in 42 IPFS (n=86) and 47 INS (n=99) eyes. Among VF progressors, pRNFL thinning was significantly faster in INS group compared to IPFS group (P < 0.01), while mGCIPL thinning was similar (P = 0.16). At five years, eyes with progressive mGCIPL thinning showed significantly lower VF survival in both VF phenotypes (all P < 0.05). Progressive pRNFL thinning showed significantly lower VF survival only in INS eyes (P = 0.015). Cox multivariate regression revealed that mGCIPL thinning predicted subsequent VF progression in IPFS eyes, while mGCIPL and pRNFL thinning had significant associations with VF progression in INS eyes. ConclusionsmGCIPL outperforms pRNFL at early follow-up in detecting VF progression in IPFS eyes but not INS eyes. Appropriate selection of structural parameters (mGCIPL vs pRNFL) maximizes early VF progression detection according to initial VF defect location.

Normal Visual Recovery after Optic Neuritis Despite Significant Loss of Retinal Ganglion Cells in Patients with Multiple Sclerosis.

Optic neuritis (ON) is a frequent manifestation of demyelinating attack in multiple sclerosis (MS). Initial visual loss can vary from minimal to complete. Visual improvement occurs in about 95% of patients, some of them recovering to normal [visual acuity (VA), color vision, visual field (VF)]. We analyzed retinal ganglion cell layer (RGCL) thickness in MS patients who recovered their normal vision after ON to determine whether a relative preservation of RGCL existed in these patients. We conducted a retrospective study of all patients with MS and ON examined by one of us (F. X. B.) between 2013 and 2018. Inclusion criteria were strictly unilateral ON, full recovery of vision, computerized visual field, and OCT examinations. Full recovery of vision was defined as VA ≥ 10/10, Ishihara ≥ 11/13, and VF mean defect (MD) ≤ 2.6 dB. Evaluation of RGCL was obtained with spectral domain optical coherence tomography (SD-OCT). The normal fellow eye of all patients served as the control group. Relative thinning of RGCL, expressed as percentage, was calculated by comparing results from the affected eye to the fellow eye of the same patient. Twenty-one patients (21 affected eyes - Group 1, 21 normal fellow eyes - Group 2) satisfying the inclusion criteria were retrieved from our database. All patients exhibited the relapsing-remitting form of MS. There were 16 women and 5men. Mean age was 39.3 years old. There were no statistically significant differences between Group 1 and Group 2 for either VA (p = 0.3934) or Ishihara (p = 0.140), but a significant difference was found for VF MD (p = 0.0405). A markedly significant difference for RGCL thickness (p = 0.0001) was found, without any correlation with the degree of visual recovery. A subgroup of patients (n = 14) was examined at the time of initial visual loss. We correlated their results of visual function to the final RGCL thickness, and a correlation was found between either the initial VA loss or the initial VF loss and the final loss of RGCL (R2 = 0.4075 and R2 = 0.00739, respectively). In our study, all patients with ON lost a significant amount of RGCL despite a full recovery of vision, as defined by our criteria. The percentage of RGCL loss varied from 5 - 27% and could not be correlated with any final visual indices. However, a correlation was found with the degree of initial visual loss. Despite sometimes marked RGCL loss after ON, patients with MS can recover normal visual function, according to standard clinical tests.

Retinal ganglion cell and axonal loss in optic neuritis: risk factors and visual functions.

PurposeThe peripapillary retinal nerve fiber layer (pRNFL) and the macular ganglion cell-inner plexiform layer (GCIPL) are important predictive factors for the prognosis of optic neuritis (ON). We investigated the risk factors for pRNFL and GCIPL thinning in ON and its relationship with visual function.Patients and methodsWe analyzed 33 eyes of 33 patients with a first attack of unilateral ON. Patients were divided into two groups according to pRNFL and GCIPL thinning, using spectral-domain optical coherence tomography. We evaluated patients' age, sex, color vision, visual acuity (VA), optic nerve findings on MRI, elapsed period from onset of visual symptoms to steroid treatment, visual field (VF) mean deviation (MD), average pRNFL thickness, and GCIPL thickness.ResultsThere was no patient with residual VF defect in the groups without pRNFL or GCIPL thinning. Significant correlations were found between pRNFL (some sectors) and GCIPL (all sectors) thickness and BCVA and VF MD (P<0.03 for all). Multivariate logistic regression analysis revealed that only worse initial VF MD was a significant risk factor of pRFNL and GCIPL thinning after ON (OR, 0.841; 95% CI, 0.730-0.970; P=0.017 and OR, 0.871; 95% CI, 0.761-0.998; P=0.046, respectively).ConclusionRetinal ganglion cell and axonal losses occurred in ON cases showing severe initial VF loss. Therefore, it is necessary to pay more attention to the degree of initial VF loss in ON while considering the possibility of residual VF loss accompanying pRNFL and GCIPL thinning.

Vascular and autonomic dysregulation in primary open-angle glaucoma.

The purpose of this review is to discuss whether vascular dysfunction and autonomic dysfunction are related to primary open-angle glaucoma stratified by the intraocular pressure (IOP) level. Patients with primary open angle glaucoma (POAG) across the spectrum of IOP exhibit a variety of ocular and nonocular vascular abnormalities. Interestingly, common genetic variation in nitric oxide synthase 3 (NOS3) and the caveolin 1/caveolin 2 (CAV1/CAV2) genomic regions, which code for proteins involved in setting vascular tone, are associated with POAG. These markers seem to stratify with POAG subtypes stratified by sex or pattern of initial visual field loss and not by IOP level. Overall, it is clear that there is also cardiovascular autonomic dysfunction in high-tension glaucoma and normal-tension glaucoma but it is unclear if this dysfunction is more common in normal-tension glaucoma compared with high-tension glaucoma. Overall, POAG is likely a heterogeneous disease but stratifying cases by IOP level associated with initial optic nerve damage may be less useful than using other endophenotype approaches. Embracing the evidence suggesting systemic endothelial and autonomic dysfunction are operative in POAG will help us move beyond an IOP-centric view of the disease and facilitate 'tearing down the wall' that divides treating physicians and a better understanding of POAG pathogenesis.

Comparison of risk factors for initial central scotoma versus initial peripheral scotoma in normal-tension glaucoma.

PurposeTo investigate the risk factors for initial central scotoma (ICS) compared with initial peripheral scotoma (IPS) in normal-tension glaucoma (NTG).MethodsFifty-six NTG patients (56 eyes) with an ICS and 103 NTG patients (103 eyes) with an IPS were included. Retrospectively, the differences were assessed between the two groups for baseline characteristics, ocular factors, systemic factors, and lifestyle factors. Also, the mean deviation of visual field was compared between the two groups.ResultsPatients from both ICS and IPS groups were of similar age, gender, family history of glaucoma, and follow-up periods. Frequency of disc hemorrhage was significantly higher among patients with ICS than in patients with IPS. Moreover, systemic risk factors such as hypotension, migraine, Raynaud's phenomenon, and snoring were more prevalent in the ICS group than in the IPS group. There were no statistical differences in lifestyle risk factors such as smoking or body mass index. Pattern standard deviation was significantly greater in the ICS group than in the IPS group, but the mean deviation was similar between the two groups.ConclusionsNTG Patients with ICS and IPS have different profiles of risk factors and clinical characteristics. This suggests that the pattern of initial visual field loss may be useful to identify patients at higher risk of central field loss.

Correlation of Retinal Nerve Fiber Layer Thickness and Visual Fields in Glaucoma: A Broken Stick Model

To determine the retinal nerve fiber layer (RNFL) thickness at which visual field (VF) damage becomes detectable and associated with structural loss. Retrospective cross-sectional study. Eighty-seven healthy and 108 glaucoma subjects (1 eye per subject) were recruited from an academic institution. All patients had VF examinations (Swedish Interactive Threshold Algorithm 24-2 test ofthe Humphrey Visual Field Analyzer 750i) and spectral-domain optical coherence tomography RNFL scans. Comparison of RNFL thickness values with VF threshold values showed a plateau of VF threshold values at high RNFL thickness values and then a sharp decrease at lower RNFL thickness values. A broken stick statistical analysis was used to estimate the tipping point at which RNFL thickness values are associated with VF defects. The slope for the association between structure and function was computed for data above and below the tipping point. The mean RNFL thickness value that was associated with initial VF loss was 89μm. The superior RNFL thickness value that was associated with initial corresponding inferior VF loss was 100μm. The inferior RNFL thickness value that was associated with initial corresponding superior VF loss was 73μm. The differences between all the slopes above and below the aforementioned tipping points were statistically significant (P< .001). In open-angle glaucoma, substantial RNFL thinning or structural loss appears to be necessary before functional visual field defects become detectable.

A retrospective analysis of long-term outcomes following a single episode of transscleral cyclodiode laser treatment in patients with glaucoma

ObjectivesTo investigate the efficacy of a single cyclodiode laser photocoagulation treatment for refractory glaucoma and its effect on visual outcome in patients with good visual potential as well as to...

Nonarteritic Anterior Ischemic Optic Neuropathy and Tobacco Smoking

To evaluate whether tobacco smoking may be a risk factor for development of nonarteritic anterior ischemic optic neuropathy (NA-AION). Cohort study. Six hundred twenty-four consecutive patients with NA-AION who fulfilled our inclusion criteria. All patients provided a detailed ocular, medical, and smoking history, and underwent a comprehensive ophthalmic evaluation. For data analysis, patients were divided into current, former, and never smokers. The prevalence for current smoking in the NA-AION patients was compared to the corresponding race-, gender-, age-, and period-matched subgroup of the U.S. population. Association between NA-AION and tobacco smoking. Of the 624 patients, 369 (59.1%) were men, and mean (+/- standard deviation) age was 61.0+/-12.3 years. Of all the patients, 151 (24.2%) were current smokers, 160 (25.6%) former smokers, and 313 (50.2%) had never smoked. The prevalence of smoking in NA-AION patients was not significantly different from the prevalence in the period-matched U.S. population and the period matched Iowa population. In contrast, the prevalence of diabetes mellitus, ischemic heart disease, arterial hypertension, and cerebrovascular disease in NA-AION patients was significantly higher compared to the prevalence of these chronic conditions in the matched U.S. population (P<0.0001). There was no significant difference in initial visual acuity (P = 0.97) or the amount of initial visual field loss (P = 0.31) among nonsmokers, former smokers, and current smokers. Current smokers had NA-AION in the first eye at a significantly younger age (57.8+/-11.7 years) than former smokers (64.0+/-10.2 years; P<0.0001), and nonsmokers (60.4+/-13.5 years; P = 0.032). Comparison of the distribution of the time to develop NA-AION in the fellow eye showed no significant difference among the 3 groups (log-rank test P = 0.186). Our study showed no association between NA-AION and tobacco smoking.

Progression of visual field defects and visual loss in trabeculectomized eyes

To evaluate progression of visual field (VF) defects and development of visual impairment (low vision and blindness) after trabeculectomy. We evaluated retrospectively 138 eyes of 138 consecutive patients over 40 years of age with primary open-angle glaucoma (POAG) or exfoliation glaucoma (EG) operated on by trabeculectomy without antimetabolites. The mean follow-up period was 3.5 years (range 2-5). In 83 eyes, pre- and postoperative VF measured by the same technique were compared to detect progression. Visual acuities (VA) were recorded as Snellen decimal notations. VA of <0.3 to 0.05 was defined as low vision and VA of <0.05 or VF constricted to less than 20 degrees in diameter as blindness. In 34 (41%) of 83 eyes with comparable fields, VF defects progressed because of glaucoma. In logistic regression analysis, severity of preoperative VF loss (P=0.0047) and use of preoperative oral anti-glaucomatous medication (P=0.047) correlated significantly with VF progression. In univariate analysis, also initial intraocular pressure (IOP) reduction after surgery (P=0.023) and IOP reduction from preoperative to last postoperative examination (P=0.036) were significantly smaller in eyes with VF progression. Defect progression did not, however, correlate significantly with the last IOP (P=0.58). Six eyes (4.3%) were blind due to glaucoma preoperatively and 14 eyes (10.1%) at the last follow-up. Visual impairment correlated with the severity of initial VF loss (P=0.008). Progression of VF defects and development of visual impairment due to glaucoma was fairly common despite trabeculectomy. Both were associated with severity of initial VF defect. In this series, no significant correlation appeared between defect progression and the last IOP, but association between stability of VF and the amount of IOP reduction after surgery indicate that a lower target IOP level particularly in eyes with initially severe VF defect would, however, be needed.

Blindness in patients with treated open-angle glaucoma

Purpose To investigate blindness in patients with treated open-angle glaucoma (OAG) and risk factors for blindness. Design Retrospective observational case series. Participants One hundred eighty-six patients seen between April and November 2000 at the University of Washington Medical Center Eye Clinic, diagnosed in 1975 or later, and treated for at least 2 years for OAG. Methods Chart review with evaluation of visual acuity and visual field. Kaplan-Meier survival analysis was used to estimate the risk of blindness in one and both eyes. Variables considered to be possible risk factors for blindness were evaluated using chi-square test, t test, and Cox proportional hazards regression analysis. Main outcome measures Blindness, defined as visual acuity of 20/200 or worse, and/or continuous constriction of the visual field to 20° or less in all four quadrants with a size III4e Goldmann stimulus or the equivalent on automated perimetry, allowing a higher threshold level on one point in one quadrant on automated perimetry. Results The mean duration of disease was 10.2 ± 4.9 years. Twelve patients were blind in at least one eye from OAG at diagnosis. Nineteen other patients became blind in at least one eye from OAG, and three patients became bilaterally blind from OAG. The Kaplan-Meier estimate for blindness at 15 years in one eye was 14.6%, and in both eyes was 6.4%. Noncompliance with the treatment regimen ( P = 0.016) and worse initial visual field loss ( P < 0.0001) were significantly associated with development of blindness. Nonwhite race was associated with blindness ( P = 0.014) when all blindness, including that found at diagnosis, was considered in the analysis. Conclusions Bilateral blindness from chronic OAG was uncommon in this population of treated patients diagnosed in 1975 or later. Of patients with a blind eye, 39% were blind at diagnosis, and worse visual field loss at diagnosis and noncompliance were associated with development of blindness.

Target Intraocular Pressure and Risk Factors for Progression of Visual Field Loss in Primary Open-angle Glaucoma

Evaluation of intraocular pressure(IOP) control below the target level stated by Iwata and study of risk factors for progression of visual field loss in primary open-angle glaucoma (POAG) despite successful reduction of IOP. Statistical difference of visual field deterioration between 27 eyes of POAG with IOPs above target levels and 48 eyes of POAG with IOP below target levels was examined for 28.1 +/- 10.2(mean +/- standard deviation) months. The relationship between the progression of visual field loss and factors of initial visual field loss, mean IOP, variance of IOP, peripapillary atrophy (zone beta), records of glaucoma surgery, age, and sex were studied in 48 patients(48 eyes) with IOPs below target levels. Eight of the 48 eyes(16.7%) showed progression of visual field loss with IOPs below their target levels whereas 15 of the 27 eyes(55.6%) had IOPs above their target levels(p = 0.002). The risk factors for the progression of visual field loss in POAG despite good control of IOP were severity of initial visual field loss(p = 0.003), peripapillary atrophy(p = 0.002), and male sex(p = 0.03). The control of IOP below target level is beneficial for patients with POAG. However, the risk factors which represent circulatory damage, such as peripapillary atrophy, may have a bad influence on the continuing deterioration of visual fields in patients with severe visual field damage, independently of good control of IOP.

Visual field progression in patients with initially unilateral visual field loss from chronic open-angle glaucoma

Purpose To investigate visual field progression in patients with initially unilateral glaucomatous visual field loss, and to determine risk factors for progression. Design Retrospective observational case series. Participants Forty-eight consecutive patients with primary open-angle glaucoma, pseudoexfoliative glaucoma, or pigmentary glaucoma, seen over an 18-month period, who initially had unilateral visual field loss as defined by use of modified Anderson criteria. Patients were followed with standard Humphrey perimetry for a minimum of 2 years. Methods Progression was defined by use of modified Anderson criteria, and Advanced Glaucoma Intervention Study (AGIS) and Collaborative Initial Glaucoma Treatment Study scores. Main outcome measure Visual field progression. Results Three patients (6.2%) had fellow eye progression over a mean follow-up of 76 months and duration of disease of 8.7 years. Fellow eye progression correlated with progression of the first-affected eye ( P = 0.044). Ten patients (21%) had progression of the first-affected eye; these eyes had a larger initial cup/disc ratio compared with stable eyes ( P = 0.041). Increasing initial AGIS score was associated with progression ( P = 0.003). Kaplan-Meier survival analysis estimated the risk of progression at 5 years to be 25% in first-affected eyes and 7.2% in fellow eyes. Conclusions In this population, the risk of fellow eye progression in patients with initially unilateral visual field loss from open-angle glaucoma is low. Progression is higher in eyes with visual field loss at initial testing, and the risk of progression increases as the level of initial visual field loss increases.

Prevalence and Significance of Optic Disc Hemorrhage in a Longitudinal Study of Glaucoma

We determined the prevalence of hemorrhage within 1 disc diameter of the optic nerve head by masked examination of stereoscopic color and red-free fundus photographs in a multilayer study of 1123 patients. At the first (baseline) examination, disc hemorrhages were present in none of the normal subjects (0 of 661), 0.44% (6/1377) of "glaucoma suspect" subjects, and 2.44% (3/123) of glaucomatous eyes. Disc hemorrhage prevalence in glaucomatous eyes was significantly higher than in normal or glaucoma suspect eyes. Glaucoma suspect eyes with disc hemorrhage, compared with matched suspect eyes without disc hemorrhage, had a larger mean vertical cup-disc ratio, an increased rate of nerve fiber layer atrophy 1 year following disc hemorrhage, and a higher rate of conversion to initial visual field loss (numerically higher conversion though not statistically significant). While the number of eyes with disc hemorrhages in this study is small, in a patient with glaucoma or ocular hypertension, disc hemorrhage appears to be associated with a greater likelihood of ongoing damage. The low disc hemorrhage prevalence in an unselected population limits its usefulness as a screening tool for glaucoma.