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PURPOSE OF REVIEW: The detection of optic disc and retinal nerve fiber layer damage and change is the cornerstone of glaucoma management. Assessment of the retinal nerve fiber layer for localized and diffuse damage has been traditionally based on clinical examination, with documentation of change primarily qualitative. With the latest improvements in optical imaging instruments, objective and quantitative measurements of the retinal nerve fiber layer are now possible. This review summarizes the results from recent cross-sectional studies evaluating the discriminating ability of automated retinal nerve fiber layer measurements to detect glaucoma, and from longitudinal studies assessing the ability to predict and monitor glaucomatous changes. RECENT FINDINGS: Numerous cross-sectional studies have documented good diagnostic accuracy of a scanning laser polarimeter (GDx VCC), the optical coherence tomograph (Stratus), and the Heidelberg Retina Tomograph retinal nerve fiber layer measurements for differentiating between healthy and glaucoma eyes. There are only limited data available on the ability of these retinal nerve fiber layer measurements to document change over time. SUMMARY: It is essential that the clinician understand the specific strengths and weaknesses of each technique so that only good quality retinal nerve fiber layer information will be used in conjunction with careful clinical examination and visual function testing for glaucoma management decisions. Longitudinal studies are needed to evaluate the ability of these instruments to document retinal nerve fiber layer change over time.
PURPOSE: To determine differences between the two treatment groups of the Glaucoma Laser Trial with respect to intraocular pressure, visual fields, optic disk cupping, and therapy for primary open-angle glaucoma. METHODS: The Glaucoma Laser Trial was a multicenter, randomized clinical trial designed to assess the efficacy and safety of starting treatment for primary open-angle glaucoma with argon laser trabeculoplasty vs starting with topical medication. The Glaucoma Laser Trial Follow-up Study was a follow-up study of 203 of the 271 patients who enrolled in the Glaucoma Laser Trial. By the close of the Glaucoma Laser Trial Follow-up Study, median duration of follow-up since diagnosis of primary open-angle glaucoma was seven years (maximum, nine years). RESULTS: Over the course of the Glaucoma Laser Trial and Glaucoma Laser Trial Follow-up Study, the eyes treated initially with argon laser trabeculoplasty had lower intraocular pressure and better visual field and optic disk status than their fellow eyes treated initially with topical medication. As compared to eyes initially treated with medication, eyes initially treated with laser trabeculoplasty had 1.2 mm Hg greater reduction in intraocular pressure (P < .001) and 0.6 dB greater improvement in the visual field (P < .001) from entry into the Glaucoma Laser Trial. The overall difference between eyes with regard to change in ratio of optic cup area to optic disk area from entry into the Glaucoma Laser Trial was -0.01 (P = .005), which indicated slightly more deterioration for eyes initially treated with medication. CONCLUSIONS: Initial treatment with argon laser trabeculoplasty was at least as efficacious as initial treatment with topical medication.
BACKGROUND/AIMS: Recent studies have revealed patients with ocular hypertension to have thicker than normal central corneas and those with normal tension glaucoma to have thinner than normal ones, as determined by ultrasonic pachymetry. Since corneal thickness measurements and applanation tonometric estimates of intraocular pressure (IOP) correlate positively, monitoring of the former parameter have served as the basis for adjusting readings pertaining to the latter, with the consequence that many patients have had to be reclassified. With a view to validating these pachymetric studies, the central corneal thickness was determined in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension, as well as that of normal subjects, using optical low coherence reflectometry, which is a new and more precise method than ultrasonic pachymetry. METHODS: 34 patients with normal tension glaucoma, 20 with primary open angle glaucoma, 13 with pseudoexfoliation glaucoma, and 12 with ocular hypertension, together with 21 control subjects, were included in this observational, concurrent case-control study. One eye per individual was randomly selected for investigation. IOP was measured by Goldmann applanation tonometry and central corneal thickness by optical low coherence reflectometry. RESULTS: Central corneal thickness was significantly higher (p < or =0.001) in patients with ocular hypertension than in normal individuals or in subjects with either normal tension glaucoma, primary open angle glaucoma, or pseudoexfoliation glaucoma, there being no significant differences between the latter four groups. Patients with ocular hypertension were also significantly younger (p < or =0.003) than those within any of the three glaucomatous groups. CONCLUSION: This study confirms that a significant number of patients with ocular hypertension have normal IOPs after the appropriate adjustments have been made for deviations from normal in their central corneal thickness. The accurate measurement of this latter parameter is important not only for individual patient care, in permitting more precise estimations of IOP, but also for clinical studies, in assuring a more reliable classification of subjects.
This paper describes two subgroups of primary open angle glaucoma: senile sclerotic glaucoma in the elderly with relatively low intraocular pressures, normal chamber angles, senile excavation, peripapillary atrophy and choroidal sclerosis; high tension glaucoma in the younger age-group with high intraocular pressures, signs of mesodermal dysgenesis in the chamber angle, deep and steep excavation, little peripapillary atrophy and no choroidal sclerosis. The description of senile sclerotic glaucoma is new as are the differences in the chamber angle and peripapillary atrophy. The size of the visual field defects in the upper and lower half of the visual field is similar in high tension glaucoma. In senile sclerotic glaucoma the larger defect tends to be in the upper half of the visual field. It is suggested that in senile sclerotic glaucoma the primary cause of damage is local vascular disease, and that in high tension glaucoma the intraocular pressure with a secondary role for an insufficient blood supply is the major cause of damage. Primary open angle glaucoma can be characterized by the ratio of pressure risk factors and vascular risk factors.
AIMS: To assess the prevalence and cumulative incidence of open angle glaucoma (OAG) in a cohort group of siblings of OAG probands. METHODS: Between 1994 and 2003, a group of siblings of OAG probands underwent both initial and follow up standardised ophthalmic examinations. Siblings were classified as "definite glaucoma" (primary OAG (POAG) and normal tension glaucoma (NTG)), "glaucoma suspects" (NTG suspects or ocular hypertension (OHT)), and normal. The prevalence and cumulative incidence of OAG over the follow up interval were calculated. RESULTS: At the initial study, 271 siblings (mean age 63.6 years; female to male ratio 1.2) from 156 probands were examined. 32 (11.8%) were classified as definite glaucoma and 15 (5.5%) as suspects. In the follow up study, 157 of the 224 "normal" siblings from the initial study were examined (mean interval from initial study 7.0 (SD 1.0) years). 11 (7%) were classified as definite glaucoma and 30 (19.1%) as suspects. There were significant trends of increasing prevalence and incidence of OAG with age and a lifetime risk estimated at approximately 20% by age 70. CONCLUSION: Siblings of glaucoma patients have an increased risk of developing glaucoma and the risk increases with age. An effective and repeated screening programme should be considered for this high risk group.
Visual field defects of stages I-IV, in 451 eyes of 451 glaucoma patients, were examined with the Octopus 201 perimeter: 83 patients with low-tension glaucoma (LTG), 316 patients with primary open-angle glaucoma (POAG), and 52 patients with pigmentary glaucoma (PG). Program 31 or 33 was used, with an eccentricity range of up to 30 degrees, 73 test points, and a 6 degrees grid. The mean total field loss (TL) as well as the mean loss per test point (TL/TP) in the 30 degrees field, in the field quadrants, and in the eccentricity ranges from 0-10 degrees, 10-20 degrees, and 20-30 degrees were calculated for each patient with Program Delta. In addition, for each visual field the quotient of total loss and of the number of disturbed test points was calculated, providing a measurement of the mean depth of the field defects. For definition and comparison of visual fields in the different glaucomas at identical stages of the disease according to the amount of TL, the 3 patient groups were subdivided into 4 stages of sensitivity loss: Stage 1: TL less than or equal to 100 dB; Stage 2: TL 101-400 dB; Stage 3: TL 401-800 dB; Stage 4: 801-1600 dB. The results of a comparison of eyes with LTG, POAG, and PG at the same stage of disease were as follows: I. Location of scotomas: 1. Defects more frequent in the lower field in LTG as compared to POAG in stage 2. 2. Defects more frequent in the upper than in the lower field in POAG. 3. Almost equal number of defects in the upper and lower halves in PG. 4. In all 3 glaucoma types the defects are more frequently found in the nasal than in the temporal half of the visual field. 5. In LTG and POAG of all stages the defects are most frequently found in the upper nasal and most seldom in the lower temporal quadrant. 6. In all glaucoma types the defects occur on average most frequently between 10 degrees and 20 degrees of eccentricity. 7. With increasing IOP in POAG the scotomas tend to be equally distributed in the upper and lower quadrants. II. Depth of scotomas: 1. Scotomas are deepest in LTG; they are less deep in POAG, and least deep in PG. 2. In PG the mean scotoma depth depends significantly on maximum IOP.(ABSTRACT TRUNCATED AT 400 WORDS)
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PURPOSE OF REVIEW: This paper summarizes the use of antifibrotic agents adjunctive to glaucoma surgery, reviews recently published studies that address current use of these antifibrotics, and reviews new methods of wound modulation. RECENT FINDINGS: The use of antifibrotic agents, namely, 5-fluorouracil and mitomycin C, in conjunction with glaucoma surgery has resulted in lower postoperative intraocular pressures after trabeculectomy or combined cataract and glaucoma surgery. Mixed results have been seen when these agents are used with glaucoma drainage device surgery. The use of antifibrotic agents has also created and increased complications. Therefore, methods of antifibrotic use have become more refined and modified for specific circumstances. Promising new wound modulation agents, such as CAT-152, are currently under study. SUMMARY: Antifibrotics are potent adjuncts to glaucoma surgery, but along with their beneficial use are risks that need to be considered. While we continue to look for more efficacious agents and methods to treat glaucoma, we must continue to modify techniques with the individual patient's best interest in mind.
The size of the neuroretinal rim area of the disk was measured with the Optic Nerve Head Analyzer in 57 eyes of 57 patients with low-tension glaucoma (LTG), glaucoma simplex (POAG), and pigmentary glaucoma. The visual fields were examined with Program 33 or 31 (30 degrees eccentricity, 6 degrees grid) of the Octopus 201 Perimeter. The mean sensitivity loss per test point in the central field, in the field quadrants, and in the ranges from 0 degrees-10 degrees, 10 degrees-20 degrees, and 20 degrees-30 degrees were calculated with the Delta program. In addition, the mean loss per disturbed point, which gives the mean depth of scotomata, was calculated. In LTG a larger vertical cup/disk ratio (CDR) was found than in POAG for the same amount of total loss. The comparison of eyes with neuroretinal rim areas of equal size revealed that in contrast to POAG and pigmentary glaucoma, eyes with LTG had a smaller mean sensitivity loss; deeper, more localized scotomata; more visual field defects in the lower field in the initial stages; more scotomata in the area up to 20 degrees. The differences between glaucoma with and without high intraocular pressure were found to be most pronounced in the initial stages of the disease. These differences appear to be caused by the varying amounts of vascular pathogenesis involved. Therefore, at least two pathomechanisms have to be considered in glaucoma.
BACKGROUND: Glaucoma is one of the leading causes of blindness in the world. Primary open-angle glaucoma (POAG) and primary congenital glaucoma (PCG) are subtypes of glaucoma. Myocillin is the first gene identified to be involved in POAG. Recently, myocillin mutation has been found in PCG. In this context, we reported a special glaucoma pedigree, which was composed of both PCG and POAG patients, and analyzed the mutation of myocillin in this pedigree. METHODS: The family was composed of the parents, a son and a daughter. All members of the family underwent the complete ophthalmologic examinations. All coding exons 1 - 3 and flanking introns of myocilin gene were screened for sequence alterations by polymerase chain reaction and direct DNA sequencing. RESULTS: The son was the proband, who was diagnosed as PCG in both eyes. The father was diagnosed as POAG in the right eye, the left eye was still normal. Both the sister and the mother of the proband had normal intraocular pressure without glaucomatous optic disc changes. The mutations in intron 2 of myocilin gene were detected in the family. While the proband and the father were homozygous, the mother and the sister were heterozygous for the mutation. CONCLUSIONS: Homozygous mutation in intron 2 of myocilin gene is involved in both POAG and PCG. It is suggested that the pathogenesis might be overlapping in POAG and PCG.
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OBJECTIVE: To compare the characteristics of visual field defects in primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG). METHODS: Subjects with primary glaucoma aged 30 years and older were prospectively considered for inclusion. Automated static white-on-white perimetry was performed. A minimum of 2 reliable tests was required with a mean deviation (MD) within 2 dB on 2 tests. Subjects with previous symptomatic angle-closure, normal-tension glaucoma, visually significant cataract, or previous intraocular surgery were excluded. RESULTS: Of 234 subjects assessed, 129 had POAG, and 105 had PACG. The MDs (POAG group, -13.3 dB; PACG group, -18.0 dB) indicated more severe visual loss in subjects with PACG. In subjects with POAG, the superior hemifield was more severely affected than the inferior. This was less pronounced in subjects with PACG. Following stratification by MD, the difference between hemifields was marked in the mild (-10 dB<or=MD) and moderate (-20 dB<or=MD<-10 dB) subgroups but was not present in the severe (MD<-20 dB) subgroup. We detected differences between POAG and PACG in retinal sensitivity between the superior and inferior hemifields, independent of severity of damage. CONCLUSIONS: The pattern of visual field loss was different in the 2 diseases. This may give insight into the pattern of visual loss in predominantly pressure-dependent glaucomatous optic neuropathy.
This study compares the cardiovascular disease and risks factors, as well as ophthalmic findings of 20 primary open angle glaucoma, 23 low tension glaucoma and 11 ocular hypertensive patients. The low tension glaucoma group presents a high incidence of cardiovascular disease and risk factors, while the primary open angle glaucoma and the ocular hypertensive patients, present respectively, an average and low incidence of cardiovascular disease and risk factors.
In a study of the visual fields of 160 eyes with low-tension glaucoma (LTG) and 154 eyes with chronic open angle glaucoma with the same degree of optic nerve change, no differences in the qualitative or quantitative characteristics were found. The field defects in those eyes with LTG in which a major hemodynamic crisis had occurred were not different from those in which no crisis had been documented.
To discover if there is difference in central visual field damage between low-tension glaucoma (LTG) and primary open angle glaucoma (POAG) eyes, the data obtained with the 10-2 threshold program of the Humphrey visual field analyzer were analysed using logistic discriminant analysis. One hundred and four LTG eyes from 65 case (maximum IOP < or = 21 mmHg) and 48 POAG eyes from 34 cases (maximum IOP > or = 25 mmHg) with early to moderately advanced visual field damage were included. There was no significant difference in mean deviation (MD, STATPAC), refraction, or age between the 2 groups. The analysis demonstrated that an arcuate area in the upper central 5-10 degrees of the visual field was significantly more depressed in LTG than in POAG eyes.
The correlation of intraocular pressure (IOP) to optic nerve damages was studied in 17 patients of primary open angle glaucoma (POAG) and 24 patients of low tension glaucoma (LTG) both with monocular early glaucomatous damages. In the POAG group, the mean IOP was higher in the glaucomatous eye than in the other, while in the LTG group there was no significant IOP difference between the two eyes. Comparing the optic nerve damages in both groups, patients of POAG presented a concentrically enlarged cup with even disc rim and diffuse retinal nerve fiber layer defect (RNFLD), while patients of LTG exhibited a paracentrical cup with uneven disc rim and localized RNFLD. The results suggested that there could be different mechanisms of optic nerve damages in the two groups.