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

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

Correlation of visual field progression between eyes in patients with open-angle glaucoma

PURPOSE: To investigate the correlation of visual field progression between eyes in patients with chronic forms of open-angle glaucoma (OAG) and to determine risk factors for progression. DESIGN: Retrospective observational case series. PARTICIPANTS: One hundred fifty-two patients seen between April and November 2000 undergoing bilateral treatment for at least 2 years for OAG and who were followed with standard automated perimetry at the University of Washington Medical Center Eye Clinic. METHODS: Visual field progression was defined using criteria modified from Anderson and Advanced Glaucoma Intervention Study (AGIS) scoring. Progression from a normal to an abnormal visual field required abnormality of two of three criteria (glaucoma hemifield test, corrected pattern standard deviation, and total deviation plot abnormality) on at least two consecutive fields. For abnormal visual fields, criteria for progression were modified from Anderson and were based on worsening observed at three adjacent points on the total deviation plot on at least two consecutive fields. Another definition of progression was a change in AGIS score of four or more points. MAIN OUTCOME MEASURES: Visual field progression. RESULTS: The mean follow-up period was 7.5 +/- 3.6 years. Fifty-four patients (35.5%) showed progression of the more severely affected of the two eyes (worse eye), and 37 patients (24.3%) had progression in the less affected fellow (better) eye. Among these patients, 24 (15.8%) had bilateral progression (44% and 65% of worse and better eyes with progression, respectively). The between-eye correlation for progression was statistically significant (chi-square with Yates' continuity correction; chi = 16.7, P = 0.00004; R = 0.348, P = 0.00001). The Kaplan-Meier estimates at 10 years for progression in the worse eye, the better eye, and both eyes was 44%, 33%, and 21%, respectively. CONCLUSIONS: Between-eye correlation of visual field progression in patients with chronic OAG was statistically and clinically significant. Patient-specific factors may play an important role in visual field progression in OAG. Documented progression of visual field loss in one eye may prompt the physician to consider reducing the target intraocular pressure in both eyes.     

Optic disk and visual field correlations in primary open-angle and low-tension glaucoma

If the amount of visual field loss is less than expected from the amount of optic disk cupping in low-tension glaucoma compared with primary open-angle glaucoma, it might imply a difference between the two conditions in the type of optic nerve lesion produced. To test this hypothesis, three observers independently examined, in a masked fashion, optic disk stereoscopic photographs of 127 eyes with primary open-angle glaucoma and 71 eyes with low-tension glaucoma. For each stereoscopic photograph the observer predicted whether the visual field loss would be mild, moderate, or severe. The visual field were then classified, according to the number of sectors defective on the Goldmann perimeter chart, as having mild (1 to 15 sectors), moderate (16 to 30 sectors), or severe (more than 30 sectors) visual field loss. For no observer did the frequency of underpredictions or overpredictions in the two conditions differ significantly. The results of this study, thus, did not support the theory that the optic disk damage in primary open-angle glaucoma differs from that in low-tension glaucoma.     

Progression of visual field loss in untreated glaucoma patients and glaucoma suspects in St. Lucia,West Indies

PURPOSE: A 1986-1987 survey found 8.8% prevalence of open-angle glaucoma in the black population of St. Lucia, West Indies. This follow-up study assessed visual field loss progression in untreated glaucoma patients and glaucoma suspects 10 years later. DESIGN: Cohort study. METHODS: Subjects were 205 glaucoma patients and suspects; 1987 data included age, sex, visual acuity, and visual fields measured by automated threshold perimetry (Humphrey C 30-2 test), and 1997 data included intraocular pressure, visual acuity, and visual fields measured by the same test. Exclusion criteria included field unreliability, field improvement due to vision improvement, nonglaucomatous vision deterioration, glaucoma treatment since 1988, and scoring of a visual field as end stage in 1987. Visual fields were scored by algorithms for the Advanced Glaucoma Intervention Study (AGIS) and Collaborative Initial Glaucoma Treatment Study (CIGTS). RESULTS: By AGIS criteria, 55% of 146 right eyes and 52% of 141 left eyes showed progression of visual field loss. In linear regressions, progression severity was unassociated with sex, intraocular pressure, or baseline visual field score, but was positively associated with age (P <.001, right; P =.002, left). The cumulative probability of reaching end stage in 10 years in at least one eye was approximately 16% by AGIS criteria. By CIGTS criteria, 73% of 146 right eyes and 72% of 141 left eyes progressed. CONCLUSIONS: These data provide a unique opportunity to study progression of untreated glaucoma. The percentage of eyes showing visual field loss progression and the percentage reaching end stage were considerably higher than in studies of visual field progression in treated eyes.     

Long-term efficacy of repeat argon laser trabeculoplasty

The role of repeat argon laser trabeculoplasty (RALT) in the management of open-angle glaucoma is controversial. To determine the long-term efficacy of RALT, the authors reviewed case records of 44 patients (50 eyes) who received RALT for uncontrolled glaucoma at the Wills Eye Hospital before 1986. Success was defined as a 3 mmHg or greater decrease in intraocular pressure (IOP) to less than 22 mmHg, and no further surgical intervention. By life table analysis, RALT was successful in 35% of eyes at 6 months, in 21% at 12 months, in 11% at 24 months, and in 5% at 48 months. Thirty-three percent of eyes in which primary ALT was successful for 1 year were successful 12 months after RALT. Complications included IOP spikes in 12%. In conclusion, RALT was generally not effective for long-term control of open-angle glaucoma, but may be useful as a temporizing measure. However, this use of RALT must be weighed against the risks of complications and the additional progression of disease before more definitive surgical intervention.     

Diffuse visual field loss in chronic open-angle and low-tension glaucoma

We examined 37 eyes of 37 patients with chronic open-angle glaucoma and 24 eyes of 24 patients with low-tension glaucoma. All patients had a scotoma confined to the upper or lower hemifield. Eyes with open-angle glaucoma showed twice as much loss of sensitivity in the spared hemifield as compared to eyes with low-tension glaucoma. These differences were statistically significant.     

Visual field assessment in glaucoma: comparative evaluation of manual kinetic Goldmann perimetry and automated static perimetry

PURPOSE: To compare the detection and assessment of progression of visual field defects in primary open-angle glaucoma with manual suprathreshold perimetry on Goldmann perimeter and automated static threshold perimetry on Humphery visual field (HVF) analyzer. METHODS: 105 eyes of 54 patients of primary open-angle glaucoma were followed up with 3-monthly perimetry on Goldmann perimeter and HVF analyzer, for a period of 9 months. RESULTS: HVF analyzer picked up visual field defects in 48 (46%) eyes whereas Goldmann perimeter picked up visual field defects in 26 (25%) eyes. HVF analyzer demonstrated progression in 14 eyes whereas Goldmann perimeter detected progression in 7 eyes during follow up of 9 months. CONCLUSIONS: HVF analyzer is superior to Goldmann perimeter to document and to demonstrate progression of visual field defects in primary open-angle glaucoma.     

The occurrence of primary open-angle glaucoma in the fellow eye of patients with unilateral angle-cleavage glaucoma

The late onset of glaucoma occurs in approximately 7% of eyes with traumatic angle cleavage. We studied 13 patients who developed glaucoma in the angle-cleavage eye at an average of 34 years following trauma. Ten of the 13 patients had 270 degrees or more of angle cleavage. At the time of the initial diagnosis of angle cleavage glaucoma, there were no optic disc or visual field abnormalities in the fellow eyes. After a mean follow-up of 7.7 years, all 13 patients were reevaluated. In addition to standard examination techniques, all underwent disc photos, goniophotos, and Octopus perimetry. Seven of 13 patients (55%) had either frank glaucomatous or suspicious Octopus visual field abnormalities in the fellow eyes. Patients with angle-cleavage glaucoma appear to have at least a 50% chance of developing open-angle glaucoma in the non-traumatized fellow eyes.     

The prevalence of optic disc pits and their relationship to glaucoma

PURPOSE: To determine prevalence and associations of pits of the optic disc in an older population and assess their relationship to open-angle glaucoma. DESIGN: Population-based cross-sectional study. METHODS: The Blue Mountains Eye Study examined 3654 persons (82.4% of permanent residents) aged over 48 years. Stereo-optic disc photographs were graded in a masked fashion. RESULTS: Nine pits were found in 7 persons, a population prevalence of 0.19%. Three morphologic subtypes were found. Four peripheral pits were found at the inferior pole. Four central pits were located adjacent to the main vessel trunk. One pit was on the temporal disc margin. Pit prevalence increased with age (beta=0.0879, P=0.0099). It was strongly associated with high-pressure open-angle glaucoma [odds ratio (OR) 29, 95% confidence interval (95CI) 7-127], beta-peripapillary atrophy (OR 7.5, 95CI 2-32), and optic disc hemorrhage (OR 42, 95CI 9-183) after adjusting for age and sex. All peripheral pits were associated with paracentral visual field loss. CONCLUSIONS: The classically described temporal optic disc pit was the rarest morphologic subtype found in this older population. Optic disc pits were primarily associated with glaucoma and the related signs of optic disc hemorrhage and beta-peripapillary atrophy. The previously reported optic disc pit association with low-tension glaucoma may represent acquisition bias.     

Patterns of glaucomatous visual field defects in an older population: the Blue Mountains Eye Study

This report aims to describe the frequency of different patterns of visual field loss in open-angle glaucoma (OAG). The Blue Mountains Eye Study examined 3654 persons (aged 49+) during 1992-1994. Humphrey supra-threshold visual fields were performed in 88.9%. Those classified as glaucoma suspects had 30-2 full-threshold fields (9.2%). Of OAG cases (n = 108) with field tests in both eyes (n = 97), unilateral defects were present in 49 (50.5%) and bilateral in 48 (49.5%). Advanced field loss was found in 16 (15.4%) subjects and in 22 (10.9%) eyes, with bilateral loss present in 6 (6.2%) cases. Of all eyes of OAG cases (n = 201), 49 (24.4%) had no defects, 52 (25.9%) upper, 61 (30.3%) lower, and 17 (8.5%) had combined upper and lower loss. Of the upper and lower cases (n = 113), the types of defects included nasal step (36), arcuate (26), nasal plus arcuate (26), and hemispherical defects (25). Of subjects with fields in at least one eye (n = 104), there was a similar proportion in the worse eye of upper defects (28.8%), lower (31.7%), and combined upper and lower (24.0%). Undiagnosed OAG was more frequent in unilateral (65.3%) than bilateral (34.7%) cases (P = 0.003). This study reports the pattern of typical glaucomatous field loss in an older Australian population.     

Glaucomatous optic neuropathy and field loss in primary empty sella syndrome.

Primary empty sella syndrome is associated with certain visual field defects. Typical glaucomatous field defects, however, have rarely been reported. We reviewed eight cases of primary empty sella syndrome. Seven patients had typical glaucomatous optic disc and visual field changes. Three patients had low-tension glaucoma and four had typical primary open-angle glaucoma. We recommend that in addition to neurologic and endocrinologic assessment, patients with primary empty sella syndrome and visual field loss should have a detailed ophthalmologic examination, particular attention being paid to intraocular pressure and optic disc appearance to rule out glaucoma as a cause of the field loss.     

Comparison of visual field progression in patients with normal pressure glaucoma between eyes with and without visual field loss that threatens fixation

AIM: To compare the frequency and site of visual field progression and changes in visual acuity in patients with normal pressure glaucoma (NPG) with and without pre-existing visual field loss. METHOD: Patients with normal tension glaucoma were selected who had at least 10 visual fields over 5 or more years of follow up and no other condition that might influence the visual field or visual acuity. Alternate left and right eyes were selected from patients in random order. These eyes were then subdivided according to visual field defect threatening fixation, visual field defect not threatening fixation, and no visual field defect (fellow eyes). Eyes were defined as showing a threat to fixation according to the presence of a visual field defect involving one of more of four paracentral visual field locations. Pointwise linear regression analysis was applied to each visual field series using PROGRESSOR software. Progression of visual field loss was defined as the appearance of a regression slope 1 dB per year or more with a significance of p<0.01, which remained consistent with the addition of two of three successive visual fields to the series. The number of patients showing progression and the number where progression occurred in one of the four paracentral visual field locations was noted. The number of eyes losing two or more lines of Snellen visual acuity over the follow up period was also noted. RESULTS: 174 eyes of 174 patients were selected. 106 eyes had visual field loss threatening fixation, 46 eyes had visual field loss that did not threaten fixation, and 22 were fellow eyes with normal visual fields. The median follow up was 7.2 years. Eight eyes (36.4%) in the "normal visual fields" group, 31 eyes (67.4%) in the "visual field loss away from fixation" group, and 87 eyes (82.1%) in the "threat to fixation" group showed progression in any part of the visual field. Two eyes (9.1%) in the "normal visual fields" group, nine eyes (19.6%) in the "visual field loss away from fixation" group, and 45 eyes (42.5%) in the "threat to fixation" group showed progression at "threat to fixation". The Cox proportional hazards regression model showed an increased risk of progression at any part of the visual field for female sex and a decreased risk for eyes with normal visual fields. For progression at threat to fixation this model showed an increased risk with pre-existing threat to fixation. Eyes from older patients and those that went on to have progressive visual field loss at fixation were more likely to lose two lines of Snellen visual acuity over the follow up period. CONCLUSION: Since 20-30% of previously field damaged eyes and over 60% without prior field loss fail to demonstrate progressive visual field damage over a long follow up it is recommended that normal pressure glaucoma patients be monitored for progression and that potentially harmful therapy be withheld until progression is demonstrated. Although the presence of visual field loss that threatens fixation does not constitute an increased risk of visual field progression it does indicate an increased risk of further loss of visual field close to fixation which is in turn associated with loss of central acuity. In the light of this finding, patients with visual field loss that threatens fixation should be managed more aggressively.     

Glaucomalike disks without increased intraocular pressure or visual field loss

We studied 48 patients who had glaucomalike disks with increased cupping and pallor, superior or inferior extension of cupping and pallor and asymmetry of cupping and pallor between eyes without increased intraocular pressure or visual field loss, and open angles. We compared these patients with a randomly selected group of 48 patients with primary open-angle glaucoma. The mean age of the patients with glaucomalike disks (45.1 +/- 16.1 years) was significantly younger than the group with open-angle glaucoma (63.8 +/- 11.3 years). Of the patients with glaucomalike disks, 11 (23%) had a family history of glaucoma, 75% of 22 eyes with optic disk fluorescein angiograms had abnormal readings, and 59% of 43 eyes with retinal nerve fiber layer defects had abnormal readings. Photogrammetric measurements of the left disk cups were compared in 22 of the patients with glaucomalike disks to 16 matched patients with primary open-angle glaucoma. The only statistically significant difference was that the patients in the glaucoma group showed a larger cup area (surface opening) of the inferior quadrant. Our findings suggest that some glaucomalike disks may be one variant of primary open-angle glaucoma.     

Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma

PURPOSE: To study the risk associated with diurnal intraocular pressure (IOP) variations in patients with open-angle glaucoma. PATIENTS AND METHODS: Sixty-four patients (105 eyes) from the practices of two glaucoma specialists successfully performed home tonometry with a self-tonometer five times a day for 5 days. All patients had open-angle glaucoma and documented IOP below 25 mm Hg over a mean follow-up period of 5 years. Baseline status and time to progression of visual field loss were identified from the clinical charts. The level and variability of diurnal IOP obtained using home tonometry were characterized. Risk of progression was analyzed using a nonparametric time-to-event model, incorporating methods for correlated outcomes. RESULTS: Although mean home IOP and baseline office IOP were similar (16.4 +/- 3.6 mm Hg and 17.6 +/- 3.2 mm Hg, respectively), the average IOP range over the 5 days of home tonometry was 10.0 +/- 2.9 mm Hg. Baseline office IOP had no predictive value (relative hazard, 0.98). The diurnal IOP range and the IOP range over multiple days were significant risk factors for progression, even after adjusting for office IOP, age, race, gender, and visual field damage at baseline (relative hazards [95% confidence intervals], 5.69 [1.86, 17.35] and 5.76 [2.21, 14.98]). Eighty-eight percent of patients in the upper twenty-fifth percentile of IOP and 57% of patients in the lower twenty-fifth percentile progressed within 8 years. CONCLUSIONS: In patients with glaucoma with office IOP in the normal range, large fluctuations in diurnal IOP are a significant risk factor, independent of parameters obtained in the office. Fluctuations in IOP may be important in managing patients with glaucoma. Development of methods to control fluctuations in IOP may be warranted.     

Site and depth of glaucomatous visual field defects in relation to the size of the neuroretinal edge zone of the optic disk in glaucoma without hypertension, simple glaucoma, pigmentary glaucoma. A clinical study with the Octopus perimeter 201 and the optic nerve head analyzer

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.     

Quantitative evaluation of the optic nerve head in patients with unilateral visual field loss from primary open-angle glaucoma

Measurable structural alterations of the optic nerve head may precede visual field abnormalities in early open-angle glaucoma. The authors studied the optic nerve heads of 10 patients with unilateral visual field loss from primary open-angle glaucoma, and 12 age- and sex-matched normal subjects. Topographic optic nerve head parameters were measured with a system of computerized image analysis (Rodenstock Analyzer, G. Rodenstock Instrumente GMBH, Munich, W. Germany). In patients with asymmetric primary open-angle glaucoma, eyes with normal visual fields had a slightly larger mean (+/- standard error of the mean) disc rim area (0.90 +/- 0.04 mm2) than eyes with glaucomatous visual field defects (0.78 +/- 0.05 mm2). However, both sets of eyes in the asymmetric primary open-angle glaucoma patients had smaller mean disc rim areas (P less than 0.0007) than did the control group (1.27 +/- 0.09 mm2). These findings support the hypothesis that loss of the optic disc rim can be detected before perimetric abnormalities develop in primary open-angle glaucoma.     

Pattern of visual field defects in normal-tension and high-tension glaucoma

There are probably two major types of causative factors in open-angle glaucoma: pressure-dependent and pressure-independent. If clinical features such as the pattern of visual field defects differ between normal-tension and high-tension glaucoma, the differences may provide an insight for discriminating between the pressure-dependent and the pressure-independent damage in open-angle glaucoma. This article gives a brief review of the most recent studies including reports wherein progression or pattern of visual field defects in normal-tension and high-tension glaucoma or primary open-angle glaucoma are addressed. Further deterioration of the visual field in 5 years is expected in about 50% of eyes with normal-tension glaucoma in which intraocular pressure is one of the contributing factors. This figure may be greater than that seen in eyes with primary open-angle glaucoma where intraocular pressure is controlled with surgery in the middle teens. When eyes with normal-tension glaucoma and high-tension glaucoma or primary open-angle glaucoma were matched for extent of overall visual field loss, many studies noted a difference in the pattern of visual field defects between the two groups. Visual field defects in normal-tension glaucoma are relatively more localized and closer to fixation, especially in the nasal superior quadrant and may be more predominant in the lower hemifield. Results of other psychophysical tests also appear to support the above findings.     

Ten-year outcomes in newly diagnosed glaucoma patients: mortality and visual function

OBJECTIVES: To determine the mortality within ten years of diagnosis of chronic open angle glaucoma and the visual field progression amongst survivors of a group of patients who were followed for 10 years. PATIENTS AND METHODS: Of the 436 patients seen in a glaucoma case-finding clinic between July 1994 and December 1995 a diagnosis of chronic open angle glaucoma was made in 65. Ten years after diagnosis the outcome of the 57 patients who were treated at the Oxford Eye Hospital was determined. The causes of death were obtained from the general practitioner records and from the official death certificates. The probability of death was analysed using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. The visual outcome was analysed at the 10-year follow up visit. FINDINGS: Seventeen patients (29.8%) died during the 10-year period, including nine from cardiovascular disease. The mean (SD) age at presentation of those that died was 76.4 years (9.7) compared with 69.5 years (10.9) for survivors (p = 0.029). Using a nine-stage grading system, 42 eyes (52.5%) did not deteriorate, 30 eyes (37.5%) deteriorated by one stage, seven eyes (8.75%) two stages and one eye (1.25%) three stages over the 10-year period. The average time to first deterioration by one stage was 8.51 years (CI 7.92 to 9.10). The mean (SD) intraocular pressure was 25.6 mmHg (5.8 mmHg) on presentation and 15.7 mmHg (3.0 mmHg) at the end of 10 years. CONCLUSION: Approximately two thirds of patients will still be under care 10 years after presentation. In older, white patients with glaucoma the overall goal of preventing visual handicap is achievable for most patients 10 years after diagnosis.     

Comparison of visual field defects in the low-tension glaucomas with those in the high-tension glaucomas

We compared the visual fields of 79 eyes (48 patients) with low-tension glaucoma (intraocular pressure less than 21 mm Hg) to the visual fields of 106 eyes (74 patients) with high-tension glaucoma (intraocular pressure greater than 30 mm Hg). Both groups had similar amounts of total field loss as determined by computerized threshold perimetry. Scotomas in the low-tension group had a steeper slope (P less than .001), were significantly closer to fixation (P less than .001), and had greater depth (P less than .001) than those in the high-tension group. These findings suggested that more than one causative factor is important in the production of optic nerve damage in glaucoma.     

Blindness in patients with treated open-angle glaucoma

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