Rim Loss Research Articles

Association of blood and ocular perfusion pressure with structural glaucomatous progression by flicker chronoscopy

BackgroundVascular risk factors have been associated with glaucomatous visual field progression.AimWe determined the relationship between vascular risk factors and structural glaucomatous progression using serial flicker chronoscopy images.MethodsTwo glaucoma fellowship-trained ophthalmologists,...

Evaluation of Progressive Neuroretinal Rim Loss as a Surrogate End Point for Development of Visual Field Loss in Glaucoma

To evaluate the validity of using progressive loss of neuroretinal rim area as a surrogate end point for the development of visual field loss in glaucoma. Prospective, observational cohort study. The study group included 492 eyes of 328 patients classified with suspected glaucoma at the baseline visit. These eyes had an average of 7.4±2.8 confocal scanning laser ophthalmoscopy (CSLO) images during a mean follow-up time of 6.6±1.6 years. Rim area measurements were acquired with CSLO during follow-up. The visual field end point was considered the development of 3 consecutive abnormal visual fields on standard automated perimetry. Strong predictive ability and large proportion of treatment effect (PTE) explained are requisites for a suitable surrogate end point. A joint longitudinal survival model was used to evaluate the ability of rates of rim area loss in predicting visual field development, adjusting for confounding variables (baseline age, race, and corneal thickness and follow-up measurements of intraocular pressure [IOP] and pattern standard deviation). The PTE was calculated by comparing the effect of IOP on the risk of development of visual field loss when incorporating rim area loss in the same model with the effect of IOP in the model excluding rim area measurements. Predictive strength was measured by survival-adapted R(2) and PTE. Sixty-two of 492 eyes (13%) developed visual field loss during follow-up. The mean rate of rim area change in eyes that developed visual field loss was-0.011 mm(2)/year versus-0.003 mm(2)/year in eyes that did not (P<0.001). In the multivariable model, each 0.01 mm(2)/year faster rate of rim area loss was associated with a 2.94 higher risk of visual field loss (hazard ratio, 2.94; 95% confidence interval, 1.38-6.23; P= 0.005). R(2) values were 62% and 81% for univariable and multivariable models, respectively. The PTE was 65%. Progressive rim area loss was highly predictive of the development of visual field loss in glaucoma and explained a significant PTE on the clinically relevant outcome. These findings suggest that rim area measurements may be suitable surrogate end points in glaucoma clinical trials.

Comparison of Resource Utilization in the Treatment of Open‐Angle Glaucoma between Two Cities in Finland: Is More Better?

Glaucoma is a progressive optic neuropathy associated with neural rim loss of the optic disc and the retinal nerve fibre layer typically causing visual field (VF) deterioration. Generally, glaucomatous lesions in the eye and in the visual field progress slowly over the years. In population-based cross-sectional studies, the percentage of unilateral or bilateral visual impairment varied between 3-12%. In screening studies, 0.03-2.4% of patients have been found to suffer visual impairment. Glaucoma has previously been associated with substantial healthcare costs and resource consumption attributable to the treatment of the disease. The disease also causes reduction in health-related quality of life (HRQoL) in patients with glaucoma. This study compares patients with diagnosed open-angle glaucoma from two geographically different regions in Finland. A total of 168 patients were examined, 85 subjects from an area with higher per patient treatment costs (Oulu) and 83 patients from a region with lower per patient treatment costs (Turku). All patients had a history of continuous glaucoma medication use for a period of 11 years. For each patient, the total direct costs from glaucoma treatment were calculated and the total amount of resource consumption was determined from registries and patient records. Each patient underwent a clinical examination with visual field assessment and fundus photography. These data were used to determine the current stage of disease for each patient. Health-related quality of life questionnaire (15D) was used in determining each patient's subjective HRQoL score. When applying the current diagnostic criteria for open-angle glaucoma, a total of 40% of patients did not to display any structural or functional damage suggesting glaucoma after 11 years of continuous medical treatment and follow-up. Patients with higher glaucoma stage (worse disease) were found to have statistically higher treatment costs compared with those at lower disease stages. Resource consumption was also greater in the patients in higher glaucoma stage. Patients in the Oulu district consumed more resources, and glaucoma treatment was more expensive than in the Turku area. The total treatment cost in Oulu and Turku was 6010 € and 4452 €, respectively, for the whole 11-year period. There was no statistically significant difference in quality-of-life scores between the two areas. No difference was noted between the higher-spending and lower-spending areas in this respect. However, when the population was analysed as a whole, patients with higher glaucoma stage were found to have lower vision-based 15D scores compared with those at lower disease stages. This observation was made also at both districts independently. Major cost source in open-angle glaucoma treatment is medication, up to 74% of annual costs. In addition, it seems that higher resource consumption and higher treatment costs do not increase the patients' HRQoL as assessed by the 15D instrument.

Focal Lamina Cribrosa Defects Associated With Glaucomatous Rim Thinning and Acquired Pits

Considering the potential clinical importance of focal lamina cribrosa (LC) defects as a characteristic structural feature in glaucoma and a risk factor for glaucomatous visual field progression, it may be helpful to know the structure of focal LC defects and the spatial relationship between them and glaucomatous optic disc changes such as neuroretinal rim thinning/notching and acquired pits of the optic nerve (APON). To investigate structural and spatial relationships between focal LC defects and glaucomatous neuroretinal rim thinning/notching and APON. In a cross-sectional analysis of data from an ongoing, prospective, longitudinal study, serial enhanced-depth imaging (EDI) optical coherence tomographic (OCT) images of the optic nerve head were obtained from patients with glaucoma and reviewed for focal LC defects (laminar holes or disinsertions). Anterior laminar insertion points and edges of laminar holes or disinsertions were marked in EDI-OCT images, reconstructed 3-dimensionally, and superimposed on optic disc photographs. A glaucoma referral practice. Two hundred thirty-nine eyes (120 patients) were examined. Fifty-four eyes were excluded because of an incomplete horizontal or vertical set of serial EDI-OCT images or poor-quality EDI-OCT images owing to media opacity, irregular tear film, or poor patient cooperation. Among the remaining 185 eyes, 40 (from 31 patients) had laminar holes or disinsertions and were included for analysis. Presence, extent, and location of laminar holes or disinsertions. Among 185 eyes, 11 laminar holes and 36 laminar disinsertions were found in 40 eyes. Superimposed images of the 3-dimensionally reconstructed focal LC defects and disc photographs showed that the outline of the LC defect corresponded almost precisely to that of clinical APON for 6 laminar holes and that the LC defect was much larger than and enclosed APON for 10 laminar disinsertions. The remaining 5 laminar holes and 26 laminar disinsertions corresponded to focal neuroretinal rim loss, with no evidence of APON in disc photographs. Focal LC defects (laminar holes or disinsertions) are associated with neuroretinal rim loss and APON. The extent of LC defects can be visualized more effectively on EDI-OCT images than by clinical examination.

Agreement of Flicker Chronoscopy for Structural Glaucomatous Progression Detection and Factors Associated With Progression

To evaluate agreement of flicker chronoscopy for structural glaucomatous progression detection and factors associated with progression. Retrospective cohort study. Two glaucoma fellowship-trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from 1 eye of a cohort of glaucoma patients for features of structural progression. Agreement between graders was determined, as was accuracy for determining the temporal order of images. After adjudication, simple and multiple logistic models were constructed to determine baseline variables associated with increased odds of progression. Fifty of 103 included eyes/patients (48.5%) had at least 1 sign of structural progression. Temporal sequence was incorrectly determined in 14 of 206 cases (6.4%). Interobserver agreements for identifying baseline photographs (κ= 0.9), global progression (κ= 0.7), parapapillary atrophy (PPA) progression (κ= 0.7), disc hemorrhages (κ= 0.7), neuroretinal rim loss (κ= 0.5), and retinal nerve fiber layer (RNFL) loss (κ= 0.2) were calculated. Age was significantly associated with global (1.8; 1.3-2.6, P < .001) (odds ratio; 95% confidence interval, significance) and PPA progression (1.7; 1.2-2.4, P= .002). Lower corneal hysteresis was associated with global progression (0.78; 0.56-0.99, P= .049) and RNFL loss (0.5; 0.3-0.9, P=.02). Goldmann-correlated intraocular pressure (1.0, 0.7-1.4, P= .9), visual field mean deviation (1.0, 0.9-1.0, P= .2), and central corneal thickness (0.9, 0.8-1.0, P= .1) were not significantly associated withprogression. On multivariable analysis, only age was associated with global progression (1.8; 1.2-2.5, P= .002). Flicker chronoscopy demonstrated acceptable interobserver agreement in structural progression detection. Corneal hysteresis and age were both associated with progression, but age was the only significant factor on multivariable analysis.

Effects of age and disc area on optical coherence tomography measurements and analysis of correlations between optic nerve head and retinal nerve fibre layer

BackgroundThe aim here was to investigate whether optic nerve head (ONH) parameters or retinal nerve fibre layer (RNFL) thickness correlate with age or disc area and whether the neuroretinal rim correlates with RNFL thickness.MethodsThis cross‐sectional study enrolled 133 healthy subjects and analysed one randomly selected eye of each subject. All measurements of ONH parameters (including neuroretinal rim, disc and cup areas and cup‐to‐disc ratios) and RNFL thickness (global and quadrants) were taken by a single experienced operator using optical coherence tomography (OCT).ResultsOf the rim parameters analysed, average nerve width (the height of the nerve fibre bundle) was independent of age or disc area (p > 0.05). Disc area correlated positively with cup area (p < 0.05) but not with cup‐to‐disc ratios (p > 0.05). Of the RNFL thickness measurements analysed, temporal RNFL was independent of both age and disc area (p > 0.05). According to the analysis of the correlation between RNFL thickness and neuroretinal rim, global or non‐temporal RNFL correlated positively with horizontal integrated rim width (p < 0.05, F > 4.000) and temporal RNFL was independent of all rim parameters (p > 0.05, F < 4.000).ConclusionAging effect on neuroretinal rim loss or RNFL thickness change is non‐uniform, and age is not a constant confounder when using OCT. The temporal RNFL is independent of age, disc area and neuroretinal rim.

In Vivo Evaluation of Focal Lamina Cribrosa Defects in Glaucoma

To assess focal lamina cribrosa (LC) defects in glaucoma using enhanced depth imaging optical coherence tomography and to investigate their spatial relationships with neuroretinal rim and visual field loss. Serial horizontal and vertical enhanced depth imaging optical coherence tomographic images of the optic nerve head were obtained from healthy subjects and those with glaucoma. Focal LC defects defined as anterior laminar surface irregularity (diameter, >100 μm;depth, >30 μm) that violates the normal smooth curvilinear contour were investigated regarding their configurations and locations. Spatial consistency was evaluated among focal LC defects, neuroretinal rim thinning/notching, and visual field defects. Forty-six healthy subjects (92 eyes) and 31 subjects with glaucoma (45 eyes) were included. Ninety-eight focal LC defects representing various patterns and severity of laminar tissue loss were found in 34 eyes with glaucoma vs none in the healthy eyes. Seven of 11 eyes with glaucoma with no visible focal LC defect had a deeply excavated optic disc with poor LC visibility. Eleven focal LC defects presented clinically as an acquired pit of the optic nerve, and the others as neuroretinal rim thinning/notching. Focal LC defects preferably occurred in the inferior/inferotemporal far periphery of the LC including its insertion. Eyes with focal LC defects limited to the inferior half of the optic disc had greater sensitivity loss in the superior visual hemifield and vice versa. Mechanisms of LC deformation in glaucoma include focal loss of laminar beams, which may cause an acquired pit of the optic nerve in extreme cases.Focal LC defects occur in tandem with neuroretinal rim and visual field loss.

Patterns of Damage in Chronic Angle-Closure Glaucoma Compared to Primary Open-Angle Glaucoma

To compare patterns of damage in chronic angle-closure glaucoma (CACG) to a control group of patients with primary open-angle glaucoma (POAG). Retrospective cross-sectional study. setting: Academic tertiary-care glaucoma clinic. study population: Thirty-two eyes of 32 patients with CACG and good-quality Heidelberg Retina Tomograph (HRT) images (pixel standard deviation <50 μm) and stereoscopic disc photographs within 1 year of a visual field showing reproducible glaucomatous field loss (mean deviation ≥-15.0 dB) were enrolled. Control eyes with POAG meeting similar criteria and matched for severity of field loss (±1 dB) and race were selected. outcome measures: Presence of focal rim loss (≤1 clock hour), HRT stereometric parameters, and extent and location of field loss. The average mean deviation was -5.1 dB in both groups. Patients with CACG were more hyperopic (0.6 ± 0.4 vs -1.4 ± 0.5 D; P < .001) and had higher IOP at the time of imaging (15.8 ± 0.8 vs 13.9 ± 0.9 mm Hg; P = .015). Focal disc damage was not less frequent in PACG eyes (19% vs 24%; P = .545). Eyes with PACG had smaller cup area, cup volume, and mean cup depth and larger rim/disc area ratio (P < .05 for all), which persisted after adjusting for disc size, age, refractive error, and IOP. The average (±SD) number of abnormal test locations was similar in the 2 groups (P = .709), although CACG eyes were less likely to have paracentral points involved (47% vs 72%; P = .04). Patterns of glaucomatous damage seem to be different in CACG compared with POAG. This difference in patterns of damage may adversely affect detection of early disease or its progression in CACG.

Optic Disc Damage Staging System

To evaluate the optic disc damage staging system (ODDSS); a new clinical method of optic disc (OD) classification based on OD size, neural rim (NR) loss severity and localization. Accuracy, reproducibility, and reliability were studied. Agreement of ODDSS with the Heidelberg-Retina-Tomograph (HRT) results was evaluated. One eye of 68 consecutive open-angle glaucoma (POAG) patients and 40 controls underwent standard automated perimetry (SAP), HRT-II, and OD examination using the ODDSS classification by 3 independent graders in this prospective cross-sectional study. Sensitivity, specificity, and area under the receiver operating characteristic curve (AROC) in discriminating between normal and POAG eyes were determined for ODDSS and HRT parameters. ODDSS intraobserver and interobserver agreement and agreement with HRT-Moorfield-Regression-Analysis (MRA) were assessed. ODDSS sensitivity ranged from 72.0% to 89.7%; specificity ranged from 92.5% to 100%. Differences between AROCs for ODDSS (0.89 to 0.94) and for the best-performing HRT parameter (Vertical Cup/Disc Ratio 0.88) were not statistically significant. ODDSS interobserver agreement ranged from 0.33 to 0.78; intraobserver agreement ranged from 0.53 to 0.89. Agreement with HRT-MRA ranged from 0.50 to 0.87. ODDSS is a new method for assessing, recording, and sharing information about the clinical OD appearance. Our preliminary results show that it provides good sensitivity and specificity in glaucoma detection. The interobserver and intraobserver agreement ranged from fair to good.

Morphologic and functional glaucomatous change after occurrence of single or recurrent optic disc hemorrhages

Dear Editor, With much interest we have read the recent paper from de Beaufort et al. about the impact of optic disc hemorrhages (ODH) on the rate of visual field (VF) progression during a mean follow-up of 4.6 years [1]. The study covers an important topic since ODH is a considerable risk factor for occurrence and progression of glaucomatous VF defects in patients with ocular hypertension and open-angle glaucoma. Nevertheless, it seems surprising that the authors did not find a difference in the rate of VF progression between patients with single and recurrent ODH. We would like to add some of our own findings from structural and functional analysis of long-term follow-up of an ongoing cohort study (www. clinicaltrials.gov: ID: NTC00494923). Sixty patients with single or recurrent ODH were recruited from the Erlangen Glaucoma Registry to evaluate the rate of glaucomatous optic disc change and VF deterioration using an event-based approach. All patients underwent annually a complete, standardized ophthalmologic examination including standard static white-on-white perimetry and acquisition of stereographic optic disc slides, which were used for evaluation of ODH. Morphologic assessment of the optic disc was performed by simultaneous projection of optic disc slides in a masked order to determine whether progressive change of the optic disc morphology in comparison to the first date of examination took place or not. Criteria for progression were marked neuroretinal rim (NRR) loss with extension of the optic disc cup or notching accompanied by kinking of small vessels passing the NRR [2]. Morphologic changes had to be confirmed by two experienced examiners independently from each other. Visual field deterioration was defined as significant increasing cluster defects (p<0.01) evaluated with Octopus Field Analysis (Version 2.63). The first two VF tests from each patient were excluded from analysis to avoid learning effects. Subsequent perimetric results just before ODH were used as baseline values. Kaplan-Meier survival analysis and the log-rank test were used to compare the rate of NNR loss and VF deterioration in both groups. The cumulative probability of progressive glaucomatous optic disc change was significantly higher in the recurrent ODH group (p<0.01, Fig. 1). However, no significant difference was found between both groups regarding the incidence of VF progression (p=0.29, Fig. 2). Average follow-up time after the first ODH was 7.2 years for the single group and 8.1 years for the recurrent group. The duration of hemorrhages to disappear varies over a wide range and may reach from a few weeks up to several months. We defined the first observed ODH as the first hemorrhage in our patient group, even if it is not known if any previous hemorrhages occurred. Patients with single ODH may develop another ODH after the maximum followup or between the annual intervals. Indeed, it is very difficult for monitoring ODH patients with both closer time period and long-term follow-up of up to 13 years after occurring ODH. Since the examination interval was standardized and follow-up time is comparable in both groups, we do not Supported by Deutsche Forschungsgemeinschaft SFB 539 “Glaukome und Pseudoexfoliationssyndrom”

Digitale Planimetrie zur Langzeitverlaufskontrolle bei stabilen und progredienten Glaukomen

The purpose of this study was to investigate whether digital planimetry is appropriate for quantification of neuroretinal rim loss in patients with glaucoma, with and without progression. The optic discs of 44 patients, whose illness had been well documented with photographs over a period of at least eight years were divided in a progression group and an unchanged group with regard to glaucoma. After this evaluation we measured each disc by digital planimetry and correlated the results. The researcher conducting the measurements was unaware of the patients' date of examination and the diagnosis. While the neuroretinal rim decreased by only 0.06 A+/- 0.15 mm(2) on average in the group of patients without glaucoma, the average decrease was 0.30 A+/- 0.27 mm(2) in the group with progression. This corresponds to a yearly decrease on average of merely 0.0043 A+/- 0.011 mm(2) (0.25%/a) in the group without progression and one of 0.0228 A+/- 0.025 mm(2) (1.9%/a) in the group with progression. Mean neuroretinal rim loss was 0.25% per year in the group without progression of glaucoma, and 1.9% per year in the group with progression. This annual difference is significant. (p = 0.003). The average observation time in the morphologically better group was on average significantly shorter (12.3 years compared to 14.5 years). Digital planimetry was able to determine if a morphological progression was found in a clinical examination or if a glaucoma showed no signs of worsening. So we can use this method of digital planimetry of optic discs to examine and re-examine older and more recent photographs to always get the best results of a possible progression of glaucoma.

The Spatial Pattern of Neuroretinal Rim Loss in Ocular Hypertension

To assess the spatial pattern of rim area (RA) decline in ocular hypertension (OHT) as measured with the Heidelberg Retina Tomograph (HRT; Heidelberg Engineering, Heidelberg, Germany). One hundred ninety-eight OHT subjects were examined with the HRT from 1993 to 2001. One eye per subject was selected for analysis, with a median of 10 (range, 5-16) mean topographies, analyzed using the Moorfields Reference Plane. Linear regression of RA/time was performed for each sector; temporal (T), superotemporal (ST), inferotemporal (IT), nasal (N), superonasal (SN), and inferonasal (IN). The mean slope of RA loss (expressed as square millimeters per year and the percentage of baseline RA/year) and the frequency of significant negative slopes were compared in each sector. The steepest mean slopes of RA loss were observed in the IT sector (-1.43%/y) followed by ST (-1.05%/y), SN (-0.52%/y), IN (-0.46%/y), N (-0.31%/y), and T (0.33%/y). Significant negative slopes (P < 0.01) were observed most frequently in the ST sector (12%) followed by IN (10%), IT (10%), N (7%), SN (6%), and T (2%). The rate of RA loss (%/y) was greatest in the IT and ST sectors. However, because the nasal sectors contain more blood vessels (included in the HRT RA measurement), the percentage loss of neural tissue is underestimated in these sectors, to an unknown extent. The frequency of significant negative RA loss slopes was greatest in the ST, IN, and IT sectors. The finding suggests that all disc sectors should be evaluated for glaucomatous change in ocular hypertensive eyes.

Follow‐up of glaucomatous eyes with optic disc haemorrhages: the Beijing Eye Study

Editor, Optic disc haemorrhages play an important role in the ophthalmoscopic diagnosis of optic nerve diseases (Airaksinen et al. 1981). Previous hospital-based studies and population-based investigations have shown that disc haemorrhages are highly significantly associated with glaucoma (Airaksinen et al. 1981; Leske et al. 2003; Ramakrishnan et al. 2003; Budenz et al. 2006). The present study set out to assess how often disc haemorrhages are followed by glaucoma progression in a population-based setting. The Beijing Eye Study 2001, a population-based study on subjects aged ≥ 40 years in Greater Beijing, included 4439 of the 5324 subjects invited to participate. Glaucoma was defined by the appearance of the optic nerve head (‘optic disc glaucoma’ [ODG]) or according to the presence of additional visual field defects (‘perimetric glaucoma’ [PG]), as has recently been described in detail (Xu et al. 2007). In 2001, 221 (2.5%) eyes fulfilled the criteria for the diagnosis of ODG and 134 (1.5%) fulfilled the criteria for PG. In the same year, an optic disc haemorrhage was detected on optic disc photographs in 16 (7.2%) of the 221 eyes with ODG and in 11 (8.2%) of the 134 eyes with PG. Of the 16 eyes with ODG and an optic disc haemorrhage diagnosed in 2001, 11 (69%) returned for re-examination in 2006. Examinable photographs were obtained in nine (56%) of these eyes. In seven (78%) of these eyes, glaucoma had progressed as shown by neuroretinal rim loss and enlargement of the beta zone of peripapillary atrophy. In two (22%) eyes, optic disc appearance appeared unchanged at the 5-year follow-up. Of the 11 eyes with PG and an optic disc haemorrhage diagnosed in 2001, eight (73%) eyes returned for re-examination in 2006 and photographs were obtained in six (55%) of them. In four (66%) eyes, a change in the appearance of the optic disc indicated that glaucoma had progressed, and in two (33%) eyes the optic disc appeared to be unchanged. These results suggest that, in a population-based setting, optic disc haemorrhages in glaucomatous eyes in an adult Chinese population may be followed by a progression of glaucomatous optic nerve damage with a probability of about 70–80%. These results contrast with those of the Ocular Hypertension Treatment Study, which found that although ocular hypertensive subjects with optic disc haemorrhages during follow-up were six times more likely to experience a primary open-angle glaucoma end-point, 87% of study participants with an optic disc haemorrhage did not experience a glaucoma end-point by a median follow-up of 96 months (Budenz et al. 2006). The discrepancy in findings between the studies may reflect the facts that the majority of patients in the present study were not under treatment and that the Ocular Hypertension Treatment Study did not primarily include glaucomatous eyes. This research was supported by the National Key Laboratory Fund, Beijing, China.

Überschwellige periphere Stimulation bei präperimetrischen Glaukomen

Early glaucomatous visual field defects can occur outside the central 30 degrees , which is usually examined in perimetric tests used for glaucoma diagnosis and screening. This study aimed to evaluate the diagnostic value of peripheral suprathreshold stimulation in open angle glaucoma before the development of reproducible visual field damage in standard 30 degrees automatic white-on-white perimetry. A total of 352 eyes of 352 patients (ages 35-69 years; visual acuity 0.8 or better) from the Erlanger Glaucoma Registry were included in this study. They were divided into two groups: normal eyes and preperimetric glaucoma. All patients underwent a standardized glaucoma examination including Octopus 500EZ static perimetry (G1 program, all three phases); 95 eyes of 95 patients also received a 135-point suprathreshold test pattern of the Humphrey Field Analyzer (model 750i) for detecting peripheral visual field defects. Sensitivity and specificity were calculated for any single test point in phase 3 of the G1 test pattern and the Humphrey 135-point pattern. A score was calculated, and cluster analysis was performed. In 33 of 176 (18.8%) eyes with preperimetric glaucoma, the score was 3 or higher in phase 3 of the G1 program (normal eyes: 19 of 196; 9.7%). For both examination modalities, the highest sensitivity was found in test locations in the superior nasal midperiphery, corresponding to neuroretinal rim loss predominantly in the inferotemporal sector in early glaucomatous optic disc atrophy. Positive test results using suprathreshold stimulation in the midperiphery can be found in patients with preperimetric glaucoma at a significantly higher frequency than in normal subjects. Longitudinal studies will show whether such tests can be useful for predicting perimetric manifestation of the disease.

Morphologic factors associated with progressive glaucomatous optic disc damage in patients with primary open angle glaucoma and low tension glaucoma

Abstract Purpose: To investigate the influence of morphologic characteristics on the rate of progression in patients with open angle glaucoma with and without elevated intraocular pressure. Methods: One hundred eight eyes of 54 patients with low tension glaucoma and 128 eyes of 64 patients with open angle glaucoma were recruited from the Erlangen Glaucoma Registry for this study. All included patients received an annual standardized glaucoma examination. Progressive glaucomatous optic disc atrophy was determined as rate of neuroretinal rim loss by masked comparative analysis of stereographic optic disc slides by two experienced observers independently. Standard parameter from Scanning Laser Tomography (HRT I, Heidelberg Engineering) from baseline examination were compared between stable and progressive patients in both groups. Results: Neuroretinal rim area and volume was already at baseline significantly lower in the progressive group in patients with open angle glaucoma (1.26 +/‐ 0.38 mm² vs. 1.57 +/‐ 0.48 mm²; p&lt;0.001 and 0.28 +/‐ 0.17 mm³ vs. 0.41 +/‐ 0.23 mm³; p&lt;0.001, Mann‐Whitney‐U test) but not in patients with low tension glaucoma (1.07 +/‐ 0.39 mm² vs. 1.16 +/‐ 0.40 mm²; p=0.404, and 0.19 +/‐ 0.12 mm³ vs. 0.23 +/‐ 0.15 mm³; p=0.180, Mann‐Whitney‐U test) if compared with the non‐progressive group. Conclusions: Patients with open angle glaucoma with and without elevated intraocular pressure seem to differ concerning morphologic factors for eventual progression. Low neuroretinal rim area or volume as quantified by Scanning Laser Tomography may be a risk factor for further neuroretinal rim loss in patients with open angle glaucoma.

Quantification of Neuroretinal Rim Loss Using Digital Planimetry in Long-term Follow-up of Normals and Patients With Ocular Hypertension

The purpose of this study was to investigate if digital planimetry is appropriate for quantification of neuroretinal rim loss in patients with ocular hypertension (OHT) and if there is an age-related neuroretinal rim loss in normals. Fifty-six patients with OHT without optic disc change, 13 patients with OHT and conversion to early glaucoma during follow-up and 42 age-matched controls were recruited from the Erlangen Glaucoma Registry. Annually, all patients underwent complete ophthalmologic examination including detailed diagnostic testing concerning glaucoma. Gold standard for morphologic evaluation of the optic nerve head was the semiquantitative 2-dimensional-method described by Jonas. Optic disc images from baseline and after 5 or 10 years follow-up were used for digital planimetry. Optic disc area and cup area were measured using commercial software: Soft Imaging System analysis. The investigator was masked for diagnosis and time point of examination. Mean neuroretinal rim loss was 0.36% per year in controls, 0.54% per year in patients with OHT without progressive disease, and 0.95% per year in OHT and conversion. Neuroretinal rim loss was highest in the group of OHT with conversion to early glaucoma during follow-up. In the control group we detected a very low mean neuroretinal rim loss during 10-year follow-up. In ocular hypertensive patients without progressive disease mean neuroretinal rim loss was approximately twice compared with normals.

Topography and Fluorescein Angiography of the Optic Nerve Head in Primary Open-Angle and Chronic Primary Angle Closure Glaucoma

The purpose of this study is to correlate optic nerve head topography with fluorescein angiography of the optic nerve head in patients with primary open-angle glaucoma (POAG), chronic primary angle closure glaucoma (CPACG), and normal controls. This was an institution-based, cross-sectional, case-control study of 30 consecutive patients each with POAG or CPACG, which were compared with 30 age- and sex-matched controls. The fluorescein angiograms undertaken in one eye of each of the 90 subjects were then analyzed both qualitatively and quantitatively. The mean age of controls (group 1) was 51.73 +/- 9.6 years, patients with CPACG (group II) was 53.26 +/- 9.5 years, and patients with POAG (group III) was 54.5 +/- 10.4 years. The mean deviation and corrected pattern standard deviation on Humphrey visual field analyzer, respectively, were -1.51 +/- 2.01 dB and 2.09 +/- 1.04 dB the in control group, -9.4 +/- 9.3 dB and 5.32 +/- 4.02 dB in the CPACG group, and -11.27 +/- 7.7 dB and 7.57 +/- 5.34 dB in the POAG group. There was no significant difference in the disc areas between the three groups (analysis of variance [ANOVA], p = 0.157). All circulatory parameters were delayed in both glaucoma groups compared with controls with the disc filling time (ANOVA, p = 0.001) and the choroidal filling time being significantly delayed (ANOVA, p = 0.006). The Moorfield regression analysis showed good correlation with the pattern of disc fluorescence in all quadrants in cases of CPACG and POAG. The optic nerve head and choroidal circulation was delayed in both patients with POAG and those with CPACG, which correlates with loss of neuroretinal rim and retinal nerve fiber layer on the Heidelberg Retina Tomograph II (HRT). Patients with POAG showed diffuse damage with significant rim loss, whereas patients with CPACG showed marked sectorial abnormalities (superotemporal and the inferior-temporal) on fluorescein angiography and HRT. One possible reason for this discrepancy could be sectorial ischemia occurring in cases of CPACG as a result of a sudden rise of intraocular pressure causing disc and visual field damage.

Neurosensory Detachment Arising From a Fractured Inner-Limiting Membrane Secondary to Chronically Elevated Intraocular Pressure

Diffuse optic nerve excavation and focal rim loss mimicking an optic pit have never been reported to predispose patients to serous detachments despite their relative frequency among patients with glaucoma. Recent reports of idiopathic macular schisis detachments occurring in the setting of elevated intraocular pressure without evidence of a contributing comorbidity have caused some to speculate that alternative mechanisms exist with the capacity to engender these retinal complications. Experimental simian research has unveiled the capacity of chronically elevated intraocular pressure to yield conduction portals between the posterior hyaloid face and the subretinal space by inducing microscopic fractures in the inner-limiting membrane. To our knowledge, this is the first case report providing objective evidence of an idiopathic neurosensory detachment resulting from a fractured inner-limiting membrane arising in the setting of chronically elevated intraocular pressures. A 34-year old black man presented with transient eye pain and fluctuating vision in his left eye with his current spectacle prescription. A 2-year history of right eye blindness from glaucoma was uncovered. Funduscopic evaluation revealed a broad neurosensory detachment in the setting of an excavated optic nerve in the patient's right eye. Optical coherence tomography confirmed the hydrodynamic separation of the sensory retina from the retinal pigmented epithelium and permitted visualization of a fractured inner-limiting membrane with a contiguous communication between the posterior hyaloid face and the subretinal space at the nasal limit of the detachment. Fluorescein angiography studies identified the absence of chorioretinal vascular compromise contributing to the minimal expansion of the dye into serous cavity late into the study. No optic pit was discernible using optical coherence tomography imaging or fluorescein angiography. Although glaucomatous damage of the optic nerve has rarely been shown to predispose an individual to serous complications within the macula, recent reports attest to its pathogenic capacity and propose a theory to explain their infrequent clinical coexistence. This case provides additional support for the mounting evidence to support the role of a compromised inner-limiting membrane in inducing a macular detachment in the setting of chronically elevated intraocular pressure without evidence of preexisting optic pits.

A Statistical Approach to the Evaluation of Covariate Effects on the Receiver Operating Characteristic Curves of Diagnostic Tests in Glaucoma

To describe an approach for the evaluation of covariate effects on receiver operating characteristic (ROC) curves and to apply this methodology to the investigation of the effects of disease severity and age on the diagnostic performance of frequency doubling technology (FDT) and standard automated perimetry (SAP) visual function tests for glaucoma detection. The study included 370 eyes of 211 participants, with 174 eyes of 110 patients having glaucomatous optic neuropathy and 196 eyes of 101 subjects being normal. All patients underwent visual function testing with FDT 24-2 Humphrey Matrix and SAP SITA (Carl Zeiss Meditec, Inc., Dublin, CA). Disease severity was evaluated by the amount of neuroretinal rim loss assessed by confocal scanning laser ophthalmoscopy. An ROC regression model was fitted to evaluate the influence of disease severity and age on the diagnostic performance of the pattern SD (PSD) index from FDT 24-2 and SAP SITA. After adjustment for age, the areas under the ROC curves (AUCs) for SAP SITA PSD for 10%, 30%, 50%, and 70% loss of neuroretinal rim area were 0.638, 0.756, 0.852, and 0.920, respectively. Corresponding values for FDT 24-2 PSD were 0.766, 0.857, 0.922, and 0.962. For 10% and 30% rim loss, FDT 24-2 PSD had a significantly larger AUC than did SAP SITA PSD. A regression methodology to evaluate covariate effects on ROC curves can be useful for assessment of diagnostic tests in glaucoma. Using the proposed methodology, a significantly better performance of FDT 24-2 compared to SAP SITA for diagnosis of early glaucoma was demonstrated.

Three essential elements of glaucomatous optic nerve damage and discrimination of optic nerve rim loss

Three essential elements of glaucomatous optic nerve damages are optic nerve rim loss, retinal nerve fiber layer defects (RNFLD) and optic disc linear hemorrhages. It's suggested that if there are two positive signs detected among the three elements, the diagnosis of the glaucomatous optic nerve damages can be established. There is no definitely described how to identify optic nerve rim loss in the previous textbooks, therefore it is important to know about the morphological features of the physical optic nerve rim and influence factors before discrimination of optic nerve rim loss. Most of physical optic nerve rim are in accordance with ISNT rule, physical large optic cups are also accord with ISNT rule. Exceptional cases exist in two patterns, optic nerve rim loss or normal optic nerve rim morphological variances. The latter includes part of small discs, horizontally oval optic discs, the position of the central retinal vessel trunk and the titled optic discs which affect the morphological feature of optic nerve rim as well. In some small discs, the width of inferior rim is narrower than that of superior rim, therefore, the inferior or the superior rim loss can be evaluated by comparison with nasal rim width. Concerning horizontal oval optic discs, the width of inferior rim and superior rim should be compared to evaluate whether there is the optic nerve rim loss. If those patterns of normal optic nerve rim variances can be recognized, it is not difficult to find the presence of the optic nerve rim loss. However, not all of the optic nerve rim loss is due to glaucomatous optic nerve damages, non-glaucomatous optic nerve damage should be distinguished.