Incidence of disc hemorrhages in open-angle glaucoma before and after trabeculectomy

PURPOSE: To investigate the effects of reduction of intraocular pressure (IOP) by surgical intervention on the frequency of disc hemorrhages in eyes with primary open-angle glaucoma (POAG) and normal-tension glaucoma (NTG). DESIGN: Retrospective study. METHODS: We studied 99 eyes of 99 patients with POAG and 50 eyes of 50 patients with NTG, who underwent trabeculectomy with adjunctive mitomycin C (MMC) and were followed regularly at 1 to 3-month intervals at the Glaucoma Service of Gifu University Hospital. We applied Kaplan-Meier life-table analysis for the detection of disc hemorrhages before and after trabeculectomy. RESULTS: Trabeculectomy significantly reduced IOP (in POAG: 19.6 +/- 4.4 down to 11.1 +/- 4.2 mm Hg; in NTG: 15.3 +/- 1.5 down to 11.3 +/- 4.5 mm Hg; mean +/- SD). Life-table analysis revealed that the final cumulative probability of detecting a disc hemorrhage after surgery in POAG was 5.5 +/- 2.2% (calculated probability +/- SE) and was significantly lower than that (33.4 +/- 7.8%) before surgery (P < 0.0001, log-rank test). Likewise, the final probability after surgery in NTG was 23.1 +/- 6.3% and was significantly lower than that (42.1 +/- 8.8%) before surgery (P = 0.0063, log-rank test). CONCLUSIONS: IOP reduction via surgical intervention significantly decreases the frequency of disc hemorrhages in open-angle glaucoma patients.     

Optic disc morphometry in chronic primary open-angle glaucoma

The intrapapillary morphometric data of 290 optic nerve heads of 158 patients with chronic primary open-angle glaucoma and of 253 unselected normal subjects were correlated with the visual field indices of Octopus program 32,34-Delta. Only one eye per patient was considered. Significant correlations (P less than 0.001) were revealed for the neuroretinal rim (NRR) area as a whole and in four defined disc sectors, the ratio of lower temporal to upper temporal rim area, the rim width, the optic cup area and diameters, the horizontal and vertical cup/disc (c/d) ratios, and the quotient of horizontal to vertical c/d ratio. Correlation coefficients ranged between 0.30 and 0.77. They were highest for the rim area of the inferior temporal disc sector, followed by the superior temporal, nasal, and temporal sectors. There were no correlations for the optic disc size and form. The topographic morphometry of the intrapapillary optic disc structures was unremarkable in four glaucomatous eyes with small discs.     

Optic disc morphometry in chronic primary open-angle glaucoma

Four hundred twenty-seven optic discs of 233 unselected patients suffering from chronic primary open-angle glaucoma were morphometrically evaluated and compared with the optic nerve heads of 253 unselected normal subjects. Only one randomly chosen eye per patient was taken into consideration. We found that glaucoma leads to a change in the characteristic configuration of the neuroretinal rim that in normal eyes is significantly (P < 0.001) largest at the lower disc pole, smaller at the upper and nasal disc side, and smallest in the temporal disc region. Based on this information, significant (P < 0.001) morphometric differences between early glaucomatous and normal discs are: (a) the neuroretinal rim area in the lower temporal disc sector is smaller than in the upper temporal disc sector; the smallest rim width is outside the horizontal temporal disc sector (pathognomonic); the quotient of horizontal to vertical c/d ratio is lowered; and (d) the lower temporal, upper temporal, and total rim area are decreased. No significant difference in overall optic disc size and form exists between normal and glaucomatous eyes. Smaller optic nerve heads are not more susceptible to glaucoma.Parts of this study have been presented at the 85th meeting of the German Ophthalmic Society held in Heidelberg, 20–23 September, 1987. This study was supported by Deutsche Forschungsgemeinschaft, grant DFG Jo/155/2-1, Ernst-Muck Foundation, and Meyer-Schwarting-Foundation     

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.     

Racial differences in the presentation of chronic open-angle glaucoma

Glaucoma is the third leading cause of blindness in the United States. A review of the literature suggests that blacks biologically are at greater risk for higher intraocular pressure, open-angle glaucoma and glaucoma-induced blindness. Although the incidence of blindness from all causes is reported to be about three times higher for nonwhites in comparison to whites, the risk of blindness from glaucoma in blacks is eight times that of whites. As the most prevalent type of glaucoma in the general population, chronic open-angle glaucoma occurs in the black population more often, at an earlier age, with greater severity, and with more damaging results.     

Anisocoria in untreated unilateral open-angle glaucoma

In 20 consecutive cases of untreated, unilateral open-angle glaucoma (7 primary open-angle glaucoma and 13 pseudoexfoliation glaucoma) it was found that the pupil of the glaucomatous eye was always smaller than the pupil of the contralateral clinically seemingly non-glaucomatous eye. The difference in pupil areas ranged between 0.4 and 40.2% of that of the normal eye. The pupil areas were assessed by planimetry, and when the pupils were compared visually from photographs anisocoria was detected in 65% of the cases. There was no correlation between the degree of anisocoria and the magnitude of intraocular pressure elevation, the extent of the visual field defect or the type of glaucoma. No definite explanation for the anisocoria can be offered. The phenomenon might hypothetically be due to degenerative processes of the ciliary nerves similar to the degenerative changes in the optic nerve in glaucoma.     

Different types of optic disc shape in patients with advanced open-angle glaucoma

Purpose  

To study the characteristics of patients with advanced 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.     

Early optic disc changes in open-angle glaucoma

INTRODUCTION: Early diagnosis of chronic open-angle glaucoma is difficult: early changes in the optic disc often precede troubles in the field of vision, which occur gradually with no typical initial aspect. We report here the results of optic disc observations in normal subjects who became glaucomatous. OBSERVATIONS AND METHODS: A study was conducted on 64 eyes of 51 subjects followed on average over 12 years. At the start these eyes were normal or at risk for glaucoma for various reasons. Doubtful, difficult cases (severe myopia, dysversion or with associated pathology) were eliminated. Eventually, all the eyes presented open-angle glaucoma. All patients underwent clinical and paraclinical examinations by the same examiner. The optic discs of 78 dilated eyes were examined with a slit lamp and a 78-dioptre lens and the results systematically tabulated. Of the 78 optic discs, 40% had initial morphological characteristics (including cup/disc ratios) that were difficult to identify precisely. Preference was given to certain criteria that were easy to evaluate and likely to change. RESULTS: The classic aspects of glaucomatous papillary excavation appearance were observed. Forty-four discs showed notable changes (19 typical changes, 25 atypical), which were observed before visual field abnormalities. The size of the disc influences how the disease develops. Also noted were the frequency of changes in the slope of the papillary profile curve (third moment) and the frequency of changes in the quality of the papillary tissue, which takes on a translucent character locally. CONCLUSION: Documented and comparative observation of the optic disc remains a good and simple means for supervising subjects at risk for and in early diagnosis of chronic open-angle glaucoma. The evaluation of changes in the optic disc is greatly aided by the collection and the systematic recording of observations.     

开角型青光眼患者视盘及脉络膜变化分析

目的　通过频域OCT检查探讨开角型青光眼（open-angle glaucoma,OAG）患者视网膜及脉络膜各参数的变化。方法　回顾性病例对照研究。临床检查确诊为OAG的19例（30眼）患者为OAG组,健康人15名（30眼）为对照组。采用频域OCT的EDI模式测量2组视盘周围神经纤维层厚度、视盘周围脉络膜厚度及黄斑中心凹处神经纤维层厚度、黄斑中心凹处脉络膜厚度,并作对比。结果　OAG组受检眼6方位视盘周围神经纤维层厚度均明显低于对照组,差异均有统计学意义（均为P＜0.05）;5方位（颞上方、颞侧、鼻上方、鼻侧及鼻下方）视盘周围脉络膜厚度均明显低于对照组（均为P＜0.05）,尤其以鼻侧及鼻下方变薄更明显。OAG组黄斑处神经纤维层厚度［（11.27±1.93）μm］及黄斑中心凹处脉络膜厚度［（217.37±11.46）μm］与正常对照组［（11.57±1.65）μm、(215.65±12.42)μm］相比,差异均无统计学意义（均为P>0.05）;两组间黄斑部直径3 mm的内环鼻侧、颞侧区域和直径6 mm的外环鼻侧、颞侧区域脉络膜厚度差异均无统计学意义（均为P>0.05）。结论　OAG患者与正常人相比,视盘周围脉络膜厚度减少,且视盘鼻侧及鼻下方脉络膜厚度变薄更为显著,可能与脉络膜血供减少造成的青光眼缺血性损伤相关。OAG患者黄斑部脉络膜厚度并未发生明显变化。     

Cup/disc ratio in early open-angle glaucoma

Summary At the earliest stage of clinical detection of open-angle glaucoma with visual field defect namely that of initial diagnosis prior to significant symptoms, one can already demonstrate a significant deviation of the distribution of C/D ratio from that of individuals with similar pressure readings who are free from glaucomatous visual field defect. This difference consists of a markedly reduced frequency of small C/D values in glaucomatous eyes and a great increase in large C/D values.In addition, one can demonstrate at this stage enlargement of the optic cup as evidenced by the increased frequency of a difference between the ratios of the two eyes which is > 0.2. In general, the C/D ratio was greater in the affected eye in monocular involvement and in the eye with greater field defect. It is hypothesized that the C/D ratio is one of the factors involved in determining the vulnerability of the visual field to higher ocular pressure in openangle glaucoma. This relationship results in a great increase in the relative frequency of involvement of the visual field by the glaucomatous process in eyes with large C/D ratios and a reduction of that frequency in eyes with small C/D ratios. It was also hypothesized that different sets of factors operate in the production of field defect in eyes with different C/D ratios.From the clinical standpoint, the findings emphasize the importance of ophthalmoscopic evaluation of the optic nerve in the early suspicion and detection of open-angle glaucoma. This evaluation should include a careful estimation, recording and monitoring in time the characteristics of the optic cup.

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Zusammenfassung Es konnte gezeigt werden, daß schon in den Anfangsstadien eines Weitwinkelglaukoms mit Gesichtsfeldveränderungen das Verhältnis des horizontalen Durchmessers der Exkavation zum horizontalen Durchmesser der Papille (C/D) sich von dem unterscheidet, welches man bei Kranken mit gleichem Augendruck, aber ohne für Glaukom charakteristische perimetrische Störungen findet. Bei den ersteren sind die niedrigen C/D Werte viel seltener und die hohen Werte häufiger.Außerdem läßt sich bereits in diesem Stadium eine Erweiterung der Exkavation dadurch nachweisen, daß an dem einem Auge der C/D Wert öfter um mehr als 0,2 größer ist als an dem anderen. Im allgemeinen entspricht der höhere Wert dem mehr erkrankten Auge.Es scheint, daß der C/D Wert die Empfindlichkeit des Gesichtsfelds pathologischen Druckwerten gegenüber mitbestimmt. Dies würde die relative Häufigkeit von Gesichtsfelddefekten in Glaukomaugen mit hohen C/D Werten, wie auch die Seltenheit bei niedrigen Werten erklären. Man kann aber auch vermuten, daß noch andere Faktoren hierbei im Spiele sind.Jedenfalls ist vom klinischen Standpunkt aus die genaue Aufstellung des C/D Wertes wichtig. Dieser sollte schon bei Glaukomverdacht oder bei der ersten Feststellung eines Weitwinkelglaukoms genau registriert und später regelmäßig beobachtet werden.

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Résumé Dès la découverte d'un glaucome à angle ouvert présentant des anomalies du champ visuel sans autres symptomes significatifs, on peut démontrer que le rapport diamètre horizontal de l'excavation: diamètre horizontal de la papille (C/D) diffère de celui constaté chez des sujets ayant une pression oculaire analogue, mais aucune altération périmétrique, caractéristique du glaucome. Dans les premiers cas les petites valeurs du C/D sont beaucoup plus rares; les valeurs élevées y deviennent plus fréquentes.De plus, on peut dès ce stade mettre en évidence un élargissement de l'excavation, étant donné que le rapport C/D à un oeil dépasse plus souvent celui de l'oeil adelphe de plus de 0,2. C'est en général l'oeil le plus atteint qui présente le rapport le plus élévé.On peut supposer que le rapport C/D joue un rôle dans la vulnérabilité du champ visuel soumis à des pressions intra-oculaires pathologiques. Ainsi s'expliquerait la relative fréquence des anomalies périmétriques dans des globes hypertendus ayant des C/D élevés et leur rareté en présence d'un rapport peu important. Toutefois, d'autres facteurs peuvent également intervenir. Quoiqu'il en soit, du point du clinique, l'évaluation ophtalmologique soigneuse du rapport C/D parait importante dès la suspicion ou la détection d'un glaucome à angle ouvert, comme au cours de son évolution.

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This investigation was supported in part by research grant CD-00017 from the National Center for Health Services Research and Development Health Services and Mental Health and NB-07328 from the National Institute of Neurological Diseases and Blindness, United States Public Health Service, Bethesda, Maryland.     

Optic disc morphology in juvenile primary open-angle glaucoma

Background: The aim of the study was to evaluate whether, in primary open-angle glaucoma (POAG), patients younger than 40 years differ in optic disc morphology from patients older than 40 years. Methods: Out of a total group of 419 patients with POAG, we formed and compared two subgroups, one consisting of 37 patients with an age of less than 40 years, the other composed of 382 patients with an age equal to or more than 40 years. Both subgroups were matched for neuroretinal rim area. We examined the optic disc morphometrically using stereo disc photographs. Results: The younger subgroup, as compared to the older subgroup, showed deeper and steeper optic disc cupping, concentric emaciation of the neuroretinal rim, a significantly smaller area of parapapillary atrophy, and significantly higher maximal and minimal intraocular pressure measurements (P<0.001). The size and shape of the optic disc and the diameter of the retinal vessels at the optic disc border did not vary significantly. Conclusions: In POAG, patients younger than 40 years differ in optic disc morphology from patients older than 40 years. The younger patients with POAG have high minimal and maximal intraocular pressure readings and an optic disc morphology with deep and steep cupping, concentric loss of neuroretinal rim, and an almost unremarkable parapapillary atrophy. POAG in patients under 40 represents chronic high-pressure open-angle glaucoma with mainly diffuse optic nerve damage.Proprietary interest: none     

Optic disc morphology in myopic primary open-angle glaucoma

Objective: To evaluate the morphology of the optic disc in highly myopic eyes with primary open-angle glaucoma. Methods: Color stereo optic disc photographs of 44 patients with primary open-angle glaucoma and a myopic refractive error exceeding –8 diopters were morphometrically examined and compared with disc photographs of 571 patients with primary open-angle glaucoma and a myopic refractive error of less than –8 diopters. Results: In the highly myopic group, compared to the control group, the optic disc was significantly (P<0.0001) larger, the disc shape was significantly (P<0.0005) more elongated, and the optic cup depth was significantly (P<0.0001) more shallow. The loss of neuroretinal rim was more concentric, and localized retinal nerve fiber layer defects were found significantly less frequently in the highly myopic group than in the control group. In the highly myopic group, zone beta of parapapillary atrophy was significantly (P<0.0001) larger. Conclusion: The optic disc morphology in primary open-angle glaucoma differs significantly between highly myopic eyes and eyes with hyperopia or low to moderate myopia. The highly myopic eyes are characterized by secondary macrodiscs with elongated shape, shallow and concentric disc cupping, large parapapillary atrophy, and low frequency of localized retinal nerve fiber layer defects. Glaucomatous optic nerve damage in highly myopic eyes, compared to eyes with a normal refractive error, is more diffuse than localized.     

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.