Progressive Glaucomatous Optic Neuropathy Research Articles

Ab-Interno Bleb Needling in A Failed Trabeculectomy: A Case Report

Introduction : Trabeculectomy remains a gold standard of glaucoma surgical management despite a steady rate of bleb failure due to conjunctival scarring. In this case, we report a case of a failed trabeculectomy managed with ab-interno bleb needling followed by antimetabolite injection of mitomycin C.
 Case Illustration : A 18-year-old male patient with a history of blurry vision in his right eye and vision loss in his left eye. The patient had previously undergone cataract surgery due to juvenile cataracts and developed persistent high intraocular pressure (IOP) in both of his eyes. A trabeculectomy was performed on his right eye six months prior to the examination; however, the IOP remained at 22 mmHg. Ocular examination revealed a shallow anterior chamber and flat conjunctival bleb. An ab-interno bleb needling technique was performed followed by antimetabolite injection of mitomycin C under local anesthesia in an operating theatre. Follow-up results showed a significant reduction of IOP on the first day (13.3 mmHg) and a week after surgery (18.5 mmHg), maintained by one anti-glaucoma eye drop.
 Discussion : Trabeculectomy filtration surgery has a high failure rate in younger patients due to a high risk of conjunctival scarring. The ab-interno needling approach with mitomycin C injection is a novel technique that can be performed and offers the advantage of increasing aqueous outflow through a direct opening of the trabecular meshwork from within the anterior chamber.
 Conclusion : This technique provides effective management of failed trabeculectomy to achieve intraocular pressure lowering effect and a corresponding decrease in the risk of progressive glaucomatous optic neuropathy.

Clinical profile, management and outcomes of pseudoexfoliation syndrome with glaucoma in a tertiary eye care hospital

To study the clinical profile, management and outcomes of pseudoexfoliation (PXF) syndrome with glaucoma in a tertiary eye care hospital.This is a prospective hospital based interventional study over a period of two years from January 2020 to December 2022. 300 eyes of 150 cases aged between forty to ninety years, visiting OPD and diagnosed with PXF syndrome with glaucoma were enrolled in the current study. Cases with other causes of glaucoma, ocular trauma or surgery, cases who were lost on follow-up were excluded. In our study, 67% eyes with PXF syndrome were non-glaucomatous and 33% (300 eyes) were glaucomatous which was taken as the study population. PXF syndrome cases having glaucoma showed 43 % of PXF glaucoma, 27% primary open angle glaucoma, 18 % primary angle closure glaucoma and 12 % normal tension glaucoma respectively. Bilateral glaucoma was seen in 83% .Mean Intra ocular Pressure (IOP) of the cases was found to be 18.28 ± 3.48 mmHg. Surgical intervention was done in 20% with surgical complications reported among 16.7 % eyes. Mean IOP after 1 month and 12 month of surgery was 16.8 mmHg and 14.6 mmHg respectively.Greater prevalence rate was found with age greater than 60 yrs, mean being 64 yrs and there was no gender predilection.We observed a greater incidence of PXF syndrome with glaucoma in our region and a positive statistical correlation with increasing age, poor mydriasis and progressive glaucomatous optic neuropathy unresponsive to medical management.Rate of surgical complications was very high.Hence, Ophthalmologists must emphasize on screening and meticulous preoperative examination of PXF to avoid intraoperative complications in these cases.

Uniocular Primary Open Angle Glaucoma: An Unusual Case Report from Bangladesh

Purpose: To describe the case of a uniocular patient with advanced primary open-angle glaucoma (POAG) and age-related cataract in the right eye and microphthalmic left eye. Methods: A 73-year-old one-eyed man presented with four years of painless, progressive dimness of vision in the right eye. The vision was 6/18 in the right eye, whereas the left eye had no light perception (NLP). In the left eye, severe ptosis and microphthalmos were detected, while the right eye had age-related cataracts, an open anterior chamber angle, intraocular pressure (IOP) of 30 mmHg, and progressive glaucomatous optic neuropathy. The IOP was dropped to 22 mmHg after a topical timolol maleate (0.5%), brimonidine tartrate (0.2%), and brinzolamide (1%). As the patient had mature cataract, advanced glaucomatous optic nerve damage, target IOP was not reached, and adherence issues with antiglaucoma medications (AGM), the decision was made to proceed with cataract extraction combined with augmented trabeculectomy with mitomycin-C (MMC). Results: There were no intraoperative complications. Over one year, the IOP was maintained in the 12–14 mmHg range without AGM. Conclusion: In advanced glaucoma patients, combined phaco-trabeculectomy operations can considerably lower IOP and drug load or compliance concerns with antiglaucoma drugs. This case represented an efficient and safe surgical technique for uniocular advanced POAG, particularly in a developing country like Bangladesh.

Commentary: The impact of yoga practice on glaucoma.

Yoga is the most popular form of complementary therapy being practiced to maintain one’s physical and mental wellbeing. While yoga traditionally comprises advice for ethical lifestyle and spiritual practice, it is most often associated with physical postures (asanas), breathing techniques (pranayama), and meditation (dhyana). While these exercises are routinely safe, there are risks involved for certain patients including those suffering from or at risk of glaucoma. The effects of yoga on intraocular pressure (IOP) have been found to be bidirectional, and the exact mechanisms are not yet fully understood. The authors have reviewed literature to study the effect of yoga on IOP and glaucoma. They have observed a reduction of IOP in patients of glaucoma through Jyoti tratak (candle meditation) and slow yoga breathing exercises and a rapid increase in IOP immediately after head-down posture yoga.[1] Tratak kriya is said to lead to contraction and relaxation of ciliary muscles, which may possibly increase the aqueous humor outflow and subsequently decrease the IOP.[2] Dada et al.[3] have evaluated the effect of yoga and meditation on IOP, quality of life, stress markers, neurotrophins, and gene expression in patients with primary open-angle glaucoma and found an improvement in all parameters. On the other hand, progressive glaucomatous optic neuropathy and field loss in patients who regularly practiced Sirsasana (Headstand) has also been identified.[1,4,5] Four yogasanas [Adho Mukha Savasana (downward-facing dog), Uttanasana (standing forward bend), Halasana (plough pose), and Viparita Karani (legs-up-the-wall)] showed a 20–73.7% increase in IOP in all study subjects.[1] Yoga with head-down positions was associated with a rapid rise in IOP in glaucoma and healthy eyes and with the body vertical, with a doubling of the IOP, remaining elevated as long as the position was maintained.[1] Mani Baskaran et al.[6] observed a twofold increase in IOP during Sirsasana, which was maintained during the posture in all age groups irrespective of their ocular characteristics. Valsalva maneuver is known to affect IOP; so it is expected that breath-holding yogic exercises are likely to cause IOP elevation. Forced unilateral nostril breathing has also been observed to affect IOP significantly.[7] Rakstyte et al.[8] studied an impact on IOP before, during, and after Matsyasana (fish yoga pose) and found an increased IOP in head- down position which returns to the initial value shortly after. A case series by Mehrdad Malihi et al.[9] to study the effect of different body and head positions on IOP shows a lower measurement while sitting with a neutral neck position and a rise in IOP in all other positions. Acute angle-closure glaucoma attacks often precipitated by prone-position yoga exercises suggest that this position probably increases pupillary block in “at risk” eyes by causing the lens to fall onto the iris, which has been the principle of the prone provocative test for decades. Certain questions, however, remain unanswered. It is unclear whether yoga has any sustained effects on the IOP and optic nerve. Further research is needed to fully comprehend the mechanisms by which yoga exerts its effects and determine the types, optimal duration, and frequency of yoga practice for glaucoma patients. Future studies are also warranted to ascertain whether yoga-associated IOP changes are associated with parallel changes in perimetry and nerve fiber thickness and changes in cerebrospinal fluid pressure, blood pressure in lamina cribrosa capillaries, and the ocular blood flow. It is difficult to establish direct causality between different yogic postures and glaucomatous progression, but in patients with pre-existing glaucomatous optic neuropathy, dramatic changes in IOP can definitely be harmful. Inquiring about the practice of yoga in cases of unexplained progression despite an apparently well-controlled IOP can, therefore, be an important consideration. Relaxation and meditative aspects of yoga may help to reduce stress and improve the overall well-being of an individual which can be indirectly beneficial. The key is to “keep the head above the heart at all times.” It is also important to note that yoga should not replace traditional glaucoma treatment but rather be practiced/advised as a complementary therapy and glaucoma patients should consult their healthcare provider before beginning any new exercise or relaxation program, including yoga.

Regulatory mechanisms of retinal ganglion cell death in normal tension glaucoma and potential therapies.

Normal tension glaucoma (NTG) is a multifactorial optic neuropathy characterized by normal intraocular pressure, progressive retinal ganglion cell (RGC) death, and glaucomatous visual field loss. Recent studies have described the mechanisms underlying the pathogenesis of NTG. In addition to controlling intraocular pressure, neuroprotection and reduction of RGC degeneration may be beneficial therapies for NTG. In this review, we summarized the main regulatory mechanisms of RGC death in NTG, including autophagy, glutamate neurotoxicity, oxidative stress, neuroinflammation, immunity, and vasoconstriction. Autophagy can be induced by retinal hypoxia and axonal damage. In this process, ischemia can cause mutations of optineurin and activate the nuclear factor-kappa B pathway. Glutamate neurotoxicity is induced by the over-stimulation of N-methyl-D-aspartate membrane receptors by glutamate, which occurs in RGCs and induces progressive glaucomatous optic neuropathy. Oxidative stress also participates in NTG-related glaucomatous optic neuropathy. It impairs the mitochondrial and DNA function of RGCs through the apoptosis signal-regulating kinase-JUN N-terminal kinase pathway. Moreover, it increases inflammation and the immune response of RGCs. Endothelin 1 causes endothelial dysfunction and impairment of ocular blood flow, promoting vasospasm and glaucomatous optic neuropathy, as a result of NTG. In conclusion, we discussed research progress on potential options for the protection of RGCs, including TANK binding kinase 1 inhibitors regulating autophagy, N-methyl-D-aspartate receptor antagonists inhibiting glutamate toxicity, ASK1 inhibitors regulating mitochondrial function, and antioxidants inhibiting oxidative stress. In NTG, RGC death is regulated by a network of mechanisms, while various potential targets protect RGCs. Collectively, these findings provide insight into the pathogenesis of NTG and potential therapeutic strategies.

271. Role of Chakshusya Rasayana (neuroprotection) in the management of progressive glaucomatous optic neuropathy – A clinical study

271. Role of Chakshusya Rasayana (neuroprotection) in the management of progressive glaucomatous optic neuropathy – A clinical study

Boston keratoprosthesis type 1: outcomes of the first 38 cases performed at Moorfields Eye Hospital.

To evaluate outcomes of Boston keratoprosthesis type 1 (K-Pro) surgery in a cohort of high-risk patients at Moorfields Eye Hospital. Our patients were referred to us at the end-point of their ocular disease. A retrospective review of all K-Pro surgery performed between March 2011 and July 2015 with a minimum follow-up of 12 months. 39 eyes of 38 patients were included. Mean follow-up was 28.4 months (range: 12-56). The main indication for surgery was bullous keratopathy from multiple failed grafts (56%). 26 cases (72.2%) had known posterior segment disease pre-operatively. Mean BCVA for the entire cohort (n = 39) initially improved from HM vision to 1/60 before returning to CF vision by 6 months and was maintained for the duration of follow-up. By final follow-up (n = 39), 46% had improved vision (1 line improvement in 10%; 2 lines or more in 36%) and 31% maintained pre-operative visual acuity. Anterior segment pathology was not an independent variable in visual outcome. However, absence of posterior segment disease was significant and performed best, improving from HM to 6/15 and maintaining that vision in the longer term. There were 13 (33%) cases of progressive glaucomatous optic neuropathy, 10 (26%) retinal detachments, 8 (21%) retroprosthetic membranes, 3 (8%) infective keratitis and 2 (5%) vitritis of which 1 progressed to endophthalmitis. In all, 3 (8%) had NPL vision and 4 (10%) required removal of the K-Pro. Implantation of the Boston K-Pro can lead to improved vision, with the main limiting factor being posterior segment pathology.

Is Obstructive Sleep Apnea Associated With Progressive Glaucomatous Optic Neuropathy?

The purpose of this study was to evaluate the relationship between obstructive sleep apnea syndrome (OSAS) and glaucoma progression, and to examine the correlation between OSAS severity and rate of visual field (VF) loss. Patients with concurrent diagnoses of open-angle glaucoma and OSAS between 2010 and 2016 were identified. Enrollment criteria consisted of glaucomatous optic neuropathy and VF loss, ≥5 reliable VFs, ≥2 years of follow-up, and polysomnography (PSG) within 12 months of final VF. PSG parameters including apnea-hypopnea index (AHI) and oxygen saturation (SpO2) were collected. Eyes were classified as "progressors" or "nonprogressors" based upon event analysis using Glaucoma Progression Analysis criteria. Two-tailed t test comparisons were performed, and correlations between rates of VF loss and PSG parameters were assessed. A total of 141 patients with OSAS and glaucoma were identified. Twenty-five patients (age 67.9±7.6 y) with OSAS (8 mild, 8 moderate, 9 severe) were enrolled. Eleven eyes (44%) were classified as progressors, and had more severe baseline VF loss (P=0.03). Progressors and nonprogressors had nonsignificantly different (P>0.05) age (69.9±8.7 vs. 66.4±6.6 y), follow-up (4.4±0.7 vs. 4.3±1.0 y), intraocular pressure (13.1±2.8 vs. 14.9±2.5 mm Hg), mean ocular perfusion pressure (49.7±5.5 vs. 48.8±9.0 mm Hg), AHI (31.3±18.6 vs. 26.4±24.0), body-mass index (27.8±5.5 vs. 28.8±5.6), and SpO2 (94.1±1.6% vs. 94.0±1.6%). AHI was not correlated with slopes of VF mean deviation (r, -0.271; P, 0.190) or pattern standard deviation (r, 0.211; P, 0.312), and no substantial increase in risk of progression was found with increase in AHI. This study does not support a relationship between OSAS and glaucomatous progression. No correlation was observed between OSAS severity and rate of VF loss.

Unsupervised Gaussian Mixture-Model With Expectation Maximization for Detecting Glaucomatous Progression in Standard Automated Perimetry Visual Fields.

PurposeTo validate Gaussian mixture-model with expectation maximization (GEM) and variational Bayesian independent component analysis mixture-models (VIM) for detecting glaucomatous progression along visual field (VF) defect patterns (GEM–progression of patterns (POP) and VIM-POP). To compare GEM-POP and VIM-POP with other methods.MethodsGEM and VIM models separated cross-sectional abnormal VFs from 859 eyes and normal VFs from 1117 eyes into abnormal and normal clusters. Clusters were decomposed into independent axes. The confidence limit (CL) of stability was established for each axis with a set of 84 stable eyes. Sensitivity for detecting progression was assessed in a sample of 83 eyes with known progressive glaucomatous optic neuropathy (PGON). Eyes were classified as progressed if any defect pattern progressed beyond the CL of stability. Performance of GEM-POP and VIM-POP was compared to point-wise linear regression (PLR), permutation analysis of PLR (PoPLR), and linear regression (LR) of mean deviation (MD), and visual field index (VFI).ResultsSensitivity and specificity for detecting glaucomatous VFs were 89.9% and 93.8%, respectively, for GEM and 93.0% and 97.0%, respectively, for VIM. Receiver operating characteristic (ROC) curve areas for classifying progressed eyes were 0.82 for VIM-POP, 0.86 for GEM-POP, 0.81 for PoPLR, 0.69 for LR of MD, and 0.76 for LR of VFI.ConclusionsGEM-POP was significantly more sensitive to PGON than PoPLR and linear regression of MD and VFI in our sample, while providing localized progression information.Translational RelevanceDetection of glaucomatous progression can be improved by assessing longitudinal changes in localized patterns of glaucomatous defect identified by unsupervised machine learning.

Editorial: Update on Glaucoma Diagnosis and Management.

Glaucoma is one of the most dreadful ocular conditions that affects millions of people worldwide and is one of the major causes of irreversible blindness. Although glaucoma is a complex and poorly understood disorder, the primary goal of therapy is lowering Intraocular Pressure (IOP), which is not only one of the most significant risk factors in development of the disease, but also the only modifiable one. Therefore, a precise measurement of IOP is essential for accurate diagnosis and effective monitoring of glaucoma. Goldmann applanation tonometry is the gold standard method for IOP measurement. It has been known that IOP measurement by this method is affected by corneal properties; typically, thick corneas overestimate and thin corneas underestimate the IOP. Therefore, several methods had been introduced to correct IOP based on the central corneal thickness. However, those methods had oversimplified the problem, and ignored important factors such as corneal viscosity and elasticity. New generation of devices such as Ocular Response Analyzer (Reicherts®) and CorVis ST (Oculus Inc.®) have been devised that can account for corneal biomechanical properties when measuring IOP. It is claimed that these methods are particularly useful for eyes with inherently abnormal and surgically altered corneal biomechanics such as those who have undergone laser vision correction or keratoplasty [1]. Around two-thirds of patients with glaucoma may have their highest IOP readings beyond regular clinic hours, especially during the night. Actually, these undetected IOP spikes have been suggested to play a role in progressive glaucomatous optic neuropathy in a subset of glaucoma patients with apparent normal office-based IOP readings. Therefore, determining the role of IOP fluctuation in glaucoma warrants more extensive research. Accordingly, a 24 hour continuous (or frequent) IOP monitoring would be a commendable goal, especially for those with unexplained progression [2]. In addition to IOP fluctuation, the potential role of corneal characteristics, pathologies, and prior operations on IOP measurement should be considered when interpreting patients’ IOP. While there is no single method which provides an easy, quick and accurate result in all cases, the practitioner should adopt a patient-oriented strategy to select the most appropriate method, based on established strengths and limitations of each device [1]. Antiglaucoma eye drops comprise the mainstay of treatment in most cases of glaucoma. However, some patients still need laser and surgical procedures to prevent glaucoma progression. Nowadays, similar to other aspects of ophthalmology, utilization of laser plays a tremendous role in glaucoma treatment. Typical laser surgeries for glaucoma include laser peripheral iridotomy, laser iridoplasty, laser trabeculoplasty, and laser cyclophotocoagulation. There are also emerging methods of glaucoma laser therapy using advantages of novel inventions such as micropulse laser and pattern delivery [3]. Several surgical procedures have been introduced to help in achieving normal IOP where topical medications are inappropriate or inadequate. For several decades, filtering surgeries (trabeculectomy and shunt) have been used successfully to control IOP in a variety of cases with glaucoma. Although the primary concept has not been changed since then, recent growing knowledge about wound healing allows using modified techniques and novel adjuvants to achieve more efficient filtering blebs with less associated complications [4]. In contrast to open angle glaucoma, small incision cataract surgery with or without goniosynechialysis may be a good alternative for medications or even filtering surgeries in selected cases with angle-closure glaucoma. It can efficiently widen the iridocorneal angle, evades anatomical predisposition to angle closure, and significantly improves IOP control without long-term complications of trabeculectomy [5]. The 5 solicited review articles of this issue deals with the most recent advancements in glaucoma diagnosis and treatment and update the readers with useful and practical information in this regard.

Adjuvant effect of Chakshushya Rasayana with beta-blocker eye drops in the management of progressive glaucomatous optic neuropathy: An open-label randomized controlled trial.

Introduction:Primary open angle glaucoma is an insidious and chronic vision-threatening eye ailment due to neuro-retino-optic nerve degeneration, which may be due to the raised intraocular pressure (IOP) or due to independent factors. Management of glaucoma is mainly concentrated on lowering IOP that requires lifetime topical medication, different ocular medicaments for lowering of IOP, and surgical interventions, but it has its own limitations to control the progression of glaucomatous optic neuropathy (GON), and this is the reason behind the use of alternative neuroprotective adjuvants.Aim:To evaluate the neuroprotective effect of Ayurvedic line of management of progressive GON.Materials and Methods:Ingredients of trial drug Vara Fort powder (Chakshushya Rasayana) were procured from the Institute Pharmacy, except Swarnamakshika Bhasma, which was purchased from Dhootapapeshwar Pharmaceuticals. The patients fulfilling inclusion criteria, attending outpatient and inpatient departments, irrespective of their sex, race, religion, occupation, etc., were selected and divided into two groups with open-labeled randomization. In Group A, in addition to betaxolol (0.1%) or timolol (0.5%) (non-iobrim), Chakshushya Rasayana 6 g/day orally with Triphala Ghrita and honey along with Koshtha-Shuddhi (body-microchannel clearing treatment) protocol was tried. Nasya (oleation through nasal route) with Jeevantyadi Taila and Tarpana (eye satiation) with Go-Ghrita were also performed. In Group B (control), brimonidine (iobrim) 0.2% eye drop was used for 3 months.Results:Significant improvement was observed in subjective parameters in Group A such as blurred vision, frequent change of presbyopic glasses, and delayed dark adaptation.Conclusion:Chakshushya Rasayana, if administered in a systematic approach along with a modern topical betaxolol or timolol eye drops, has a definite role in improving the lost retinal sensitivity as much as up to 12 dB in 3 months duration.

Centrally acting cholinomimetics in the complex therapy of progressive glaucomatous optic neuropathy

Many factors exist that are associated with higher risk of glaucoma progression. Arterial hypotension, low perfusion pressure, vasospastic syndrome, diabetes mellitus, myopia, etc. increase the need for neuroprotective therapy, which is aimed at stabilizing the pathological process and creating favorable conditions for maintaining visual functions. The aim of this study was to assess the therapeutic efficacy of Gliatilin as part of the complex treatment of progressive glaucomatous optic neuropathy. A total of 240 patients were randomly selected and divided into 2 groups, 120 patients each. Both groups were matched for age, somatic comorbidity, and the gravity of the glaucomatous process. Patient age averaged 71.3±1.6 years. Advanced glaucoma prevailed in both groups: 70.0 and 76.6% correspondingly. Neuroprotective therapy included drugs from different pharmacological classes so that different aspects of pathogenesis were addressed. Apart from that, patients from Group I first received intravenous Gliatilin (1000 mg/4ml, 12--15 doses) and then switched to oral (1 capsule b.i.d. for 4 months). All patients underwent standard ophthalmic examination and static perimetry. No adverse effects were observed over the first two weeks of Gliatilin course, during which the patients stayed in the hospital. IOP level was normal and stable. Although neuroprotective therapy does not directly affect IOP, stability of the latter describes the dynamics of the glaucomatous process. When assessing changes in visual functions, particular attention was paid to the central visual field, foveolar and total light sensitivity, peripheral visual field, and MD and PSD indices. All mean values showed a tendency toward improvement, more pronounced in the Gliatilin group. A complex therapy cannot be limited to a single drug only, and to make better decisions, one should consider not only ocular, but also general condition of the patient. Adjuvant Gliatilin in the complex therapy of progressive glaucoma is appropriate and efficient, especially in case of systemic atherosclerosis and cerebrovascular insufficiency. The frequency of stabilization therapy depends on the efficacy of the latest course and clinical manifestations of the glaucomatous process.

Boston type 1 keratoprosthesis for primary congenital glaucoma

Background/aimsTo evaluate the Boston type 1 keratoprosthesis (KPro-1) in treatment of eyes with primary congenital glaucoma.MethodsA retrospective review was performed of every eye with congenital glaucoma that was treated with...

Progression of Patterns (POP): A Machine Classifier Algorithm to Identify Glaucoma Progression in Visual Fields

We evaluated Progression of Patterns (POP) for its ability to identify progression of glaucomatous visual field (VF) defects. POP uses variational Bayesian independent component mixture model (VIM), a machine learning classifier (MLC) developed previously. VIM separated Swedish Interactive Thresholding Algorithm (SITA) VFs from a set of 2,085 normal and glaucomatous eyes into nine axes (VF patterns): seven glaucomatous. Stable glaucoma was simulated in a second set of 55 patient eyes with five VFs each, collected within four weeks. A third set of 628 eyes with 4,186 VFs (mean ± SD of 6.7 ± 1.7 VFs over 4.0 ± 1.4 years) was tested for progression. Tested eyes were placed into suspect and glaucoma categories at baseline, based on VFs and disk stereoscopic photographs; a subset of eyes had stereophotographic evidence of progressive glaucomatous optic neuropathy (PGON). Each sequence of fields was projected along seven VIM glaucoma axes. Linear regression (LR) slopes generated from projections onto each axis yielded a degree of confidence (DOC) that there was progression. At 95% specificity, progression cutoffs were established for POP, visual field index (VFI), and mean deviation (MD). Guided progression analysis (GPA) was also compared. POP identified a statistically similar number of eyes (P > 0.05) as progressing compared with VFI, MD, and GPA in suspects (3.8%, 2.7%, 5.6%, and 2.9%, respectively), and more eyes than GPA (P = 0.01) in glaucoma (16.0%, 15.3%, 12.0%, and 7.3%, respectively), and more eyes than GPA (P = 0.05) in PGON eyes (26.3%, 23.7%, 27.6%, and 14.5%, respectively). POP, with its display of DOC of progression and its identification of progressing VF defect pattern, adds to the information available to the clinician for detecting VF progression.

Reversal of Retinal Ganglion Cell Dysfunction after Surgical Reduction of Intraocular Pressure

The pattern electroretinogram optimized for glaucoma screening (PERGLA) is a noninvasive method of objectively measuring retinal ganglion cell (RGC) function. This study was undertaken to quantify the RGC response to intraocular pressure (IOP) reduction after glaucoma surgery. Prospective cohort study. Forty-seven eyes of 47 patients with uncontrolled IOP or progressive glaucomatous optic neuropathy receiving maximal medical therapy requiring trabeculectomy or aqueous drainage device implantation who met eligibility criteria. Eyes with visual acuity less than 20/30, corneal or retinal pathologic features, or unreliable standard automated perimetry (SAP) results were excluded. All patients underwent complete ocular examination, arterial blood pressure, SAP, and PERGLA at 2 sessions before surgery and at 3 months after surgery. Mean ocular perfusion pressure (MOPP) was calculated. Each measure of PERGLA amplitude and phase was an average of 600 artifact-free signal registrations. Intraocular pressure and PERGLA amplitude and phase. Forty-seven eyes of 47 patients (mean age ± standard deviation [SD], 69.9 ± 11.3 years) were enrolled. Thirty-four eyes (72%) underwent trabeculectomy with antifibrosis therapy; 13 eyes (28%) underwent glaucoma drainage implant surgery. Mean ± SD postoperative IOP (10.4 ± 4.6 mmHg) was significantly (P< 0.001) reduced compared with that before surgery (19.7 ± 8.6 mmHg). Mean ± SD postoperative PERGLA amplitude (0.46 ± 0.22 μV) was significantly (P = 0.001) increased compared with preoperative PERGLA amplitude (0.37 ± 0.18 μV). Mean ± SD postoperative PERGLA phase (1.72 ± 0.20 π-radian) was significantly (P = 0.01) reduced compared with preoperative PERGLA phase (1.81 ± 0.22 π-radian). Mean ± SD postoperative MOPP (53.1 ± 6.4 mmHg) was significantly (P < 0.001) increased compared with mean ± SD preoperative MOPP (45.8 ± 10.1 mmHg). No correlation (P > 0.05) was identified between change in PERGLA amplitude and change in IOP or MOPP. Reversal of RGC dysfunction occurs after surgical reduction of IOP and may be quantified using PERGLA.

Asymmetric Progressive Glaucomatous Optic Neuropathy in a Patient With a Rare Developmental Variant of the Ophthalmic Artery

To report a case of a developmental anatomic finding of the ophthalmic artery (OA) in a patient with ipsilateral progressive advanced glaucomatous optic neuropathy and visual field loss. A 59-year-old Asian man with normal tension glaucoma had progressive asymmetric visual field loss OD. Magnetic resonance imaging and angiography of the orbit were performed because of continued progression despite medical and surgical intervention. Magnetic resonance angiography revealed an anomalous OA, lateral to the carotid artery and emanating from a branch of the middle meningeal artery. OA anomalies should be added to the differential diagnosis of risk factors for unilateral progressive glaucomatous optic neuropathy, and neuroradiologic imaging should be considered to detect such anatomic variants.

Predicting Progressive Glaucomatous Optic Neuropathy Using Baseline Standard Automated Perimetry Data

To test the hypothesis that specific locations and patterns of threshold findings within the visual field have predictive value for progressive glaucomatous optic neuropathy (pGON). Age-adjusted standard automated perimetry thresholds, along with other clinical variables gathered at the initial examination of 168 individuals with high-risk ocular hypertension or early glaucoma, were used as predictors in a classification tree model. The classification variable was a determination of pGON, based on longitudinally gathered stereo optic nerve head photographs. Only data for the worse eye of each individual were included. Data from 100 normal subjects were used to test the specificity of the models. Classification tree models suggest that patterns of baseline visual field findings are predictive of pGON with sensitivity 65% and specificity 87% on average. Average specificity when data from normal subjects were run on the models was 69%. Classification trees can be used to determine which visual field locations are most predictive of poorer prognosis for pGON. Spatial patterns within the visual field convey useable predictive information, in most cases when thresholds are still well within the classically defined normal range.

Progressive Optic Neuropathy in Congenital Glaucoma Associated with the Sirsasana Yoga Posture

The authors describe a case of progressive optic neuropathy in a patient with congenital glaucoma who had routinely practiced the Sirsasana (headstand) yoga posture for several years. Ophthalmic examination included best-corrected visual acuity, anterior segment examination, indirect ophthalmoscopy, ultrasound pachymetry for central corneal thickness, and intraocular pressure before, during, and after maintaining the Sirsasana posture for 5 minutes. Intraocular pressure increased significantly during the Sirsasana posture. Transient elevation in intraocular pressure during yoga exercises may lead to progressive glaucomatous optic neuropathy, especially in susceptible patients with congenital glaucoma.

Progression of glaucoma associated with the Sirsasana (headstand) yoga posture

This article reports a case of progressive glaucomatous optic neuropathy and visual field loss that occurred in a patient who practiced the Sirsasana (headstand) yoga posture on a daily basis for many years. Visual field analysis was performed through standard automated perimetry. Intraocular pressure (IOP) was measured through pneumotonometry in the sitting position and in the head-down position. Stereo-optic disc photographs were obtained. IOP increased significantly in the head-down position. Optic disc evaluation revealed a new disc hemorrhage in the left eye. Visual field analysis over a period of 2 y showed progression of a superior arcuate defect in the left eye. Transient increases in IOP associated with the yoga headstand posture may lead to progressive glaucomatous optic nerve damage and visual field loss.

Assessment of Retinal Nerve Fiber Layer Using Optical Coherence Tomography and Scanning Laser Polarimetry in Progressive Glaucomatous Optic Neuropathy

To describe a case of progressive glaucomatous optic neuropathy using scanning laser polarimetry with fixed (SLP-FCC) and variable corneal compensation (SLP-VCC) and optical coherence tomography (OCT). Observational case report. A 21-year-old male with juvenile primary open-angle glaucoma developed progression because of noncompliance with therapy. The patient underwent dilated stereoscopic examination and photography of the optic disk, standard automated perimetry (SAP), OCT, and SLP imaging with FCC and VCC at the baseline examination and after four years of follow-up. Optic disk, retinal nerve fiber layer (RNFL) atrophy, and SAP progression was observed. Reduction in mean RNFL thickness (average, superior, inferior) was 18, 18, and 27 microns (OCT); 22, 40, and 17 microns (SLP-FCC); and 6, 12, and 12 microns (SLP-VCC), respectively. This case demonstrates that digital imaging of the peripapillary RNFL is capable of documentation and measurement of progressive glaucomatous RNFL atrophy.