Association of choroidal blood flow with autonomic dysfunction in patients with normal tension glaucoma.

There is increasing evidence that autonomic dysfunction is an important factor in the progression of glaucoma. Mechanism of the association between autonomic dysfunction and progression of glaucoma is poorly understood. Since blood circulation is basically regulated by the autonomic nervous system, autonomic dysfunction may contribute to unstable or fluctuating blood pressure. Therefore, It is hypothesized that autonomic dysfunction may contribute to impaired ocular blood flow and lead to glaucoma progression. However, no clinical study yet has evaluated the relationship between ocular blood flow and autonomic nervous function. We enrolled 152 open angle glaucoma patient. Ocular blood flow was assessed by measuring vessel density (VD) using optical coherence tomography angiography, and autonomic nervous function was evaluated with heart-rate variability (HRV) parameters. The low frequency/high frequency (LF/HF) ratio, which is one of the HRV parameters, quantified the degree of sympathovagal balance. This indicator could represent autonomic dysfunction. Higher LF/HF ratio was associated with reduction of the deep parapapillary VD (R = - 0.243, P = 0.003). Linear regression analysis showed a significant negative association between parapapillary choroidal VD and LF/HF ratio (ß = - 0.249; 95% confidential interval = - 1.193 to - 0.249; P = 0.002) in multivariate analysis. We demonstarted the association between impaired ocular blood flow (parapapillary choroidal vessel density) and autonomic dysfunction (LF/HF ratio). This study could help understand the role of the autonomic dysfunction in pathophysiology of glaucoma progression.

Optic Disc Vascular Density in Normal-Tension Glaucoma Eyes with or without Branch Retinal Vessel Occlusion.

We analyzed the vascular densities (VDs) of the optic disc areas in eyes with normal-tension glaucoma (NTG) according to their branch retinal vessel occlusion (BRVO) status. The VDs of the optic discs and peripapillary areas of 68 NTG patients with BRVO (BRVO group; BRVO eyes and fellow eyes) and 37 patients with NTG alone (control eyes) were measured on angiographic images obtained via swept-source optical coherence tomography angiography. VDs were compared among groups and correlations were assessed. The VD of the optic disc large vessel was the highest in BRVO eyes, followed by the fellow eyes and controls (all P < 0.05). Conversely, small and medium vessel VD was in the opposite order (all P < 0.05). Large vessel VD was negatively correlated with small and medium vessel VD (r = -0.697, P < 0.001). Peripapillary VD was lower in the BRVO eyes than in the control and fellow eyes (P < 0.001 and P = 0.861, respectively). In conclusion, significant changes in the distribution of VDs for optic disc larger vessel and small and medium vessels were observed in both eyes of NTG patients with BRVO, compared to NTG patients without BRVO.

Corneal biomechanical responses detected using corvis st in primary open angle glaucoma and normal tension glaucoma.

Structural differences have been reported between primary open angle glaucoma (POAG) and normal tension glaucoma (NTG), and biomechanical differences between POAG and NTG may account for why NTG patients are more vulnerable to lower intraocular pressure (IOP). This study compared the biomechanical properties of POAG and NTG patients using the Corvis scheimpflug technology (ST) non-contact Scheimpflug-based tonometer, and determined the factors associated with these properties.In this retrospective cross-sectional study, 46 eyes with POAG, 54 eyes with NTG, and 61 control eyes were included. A non-contact Scheimpflug-based tonometer was used to examine and compare the corneal biomechanical responses in the POAG, NTG, and normal groups. We used univariate and multivariate regression analyses to determine the factors associated with the deformation amplitude in each group.Baseline characteristics, including age, IOP, spherical equivalent, keratometry, axial length, and central corneal thickness, were similar among the 3 groups. Severity of glaucoma, as measured by mean deviation, was similar between POAG and NTG groups. Applanation 1 velocity and deformation amplitude were significantly smaller in POAG (0.13 ±â€Š0.02 and 1.06 ±â€Š0.14, respectively) than NTG (0.14 ±â€Š0.01 and 1.13 ±â€Š0.11, respectively) and normal groups (0.14 ±â€Š0.02 and 1.13 ±â€Š0.10, respectively). Radius of curvature was significantly larger in the POAG group compared to the normal group. In normal controls, IOP and keratometry were significant factors related to deformation amplitude. In POAG eyes, IOP was a statistically significant predictor of deformation amplitude. In NTG eyes, however, IOP , keratometry, and axial length were statistically significant predictors of deformation amplitude.POAG eyes showed less deformable corneas compared to NTG and normal controls. IOP was significantly correlated with deformation amplitude in all groups. However, axial length was positively correlated with deformation amplitude only in NTG eyes. Characterization of the differences in biomechanical properties between POAG and NTG may contribute to a better understanding of the underlying pathophysiologies associated with these diseases.

Metabolic Health, Obesity, and the Risk of Developing Open-Angle Glaucoma: Metabolically Healthy Obese Patients versus Metabolically Unhealthy but Normal Weight Patients.

BACKGROUND: This study sought to investigate the associations between metabolic health status, obesity, and incidence of primary open-angle glaucoma (POAG). METHODS: In this nationwide, population-based, longitudinal prospective cohort study conducted using the Korean National Health Insurance System, we categorized all subjects based on presence and severity of metabolic syndrome and obesity. Insurance claims data were used to identify POAG development. Then, Cox regression was applied to calculate the hazard of developing POAG in people with various components of metabolic syndrome, obesity, or their combination. RESULTS: Of the total 287,553 subjects, 4,970 (1.3%) developed POAG. High fasting glucose, blood pressure, and total cholesterol levels were all associated with increased risk of developing POAG. Regarding obesity level, people with body mass index (BMI) greater than 30 kg/m² were more likely to develop POAG than those with normal BMI. Also, people with greater number of metabolic syndrome components showed a greater POAG incidence. People who are metabolically unhealthy and obese (adjusted hazard ratio [HR], 1.574; 95% confidence interval [CI], 1.449 to 1.711) and those who are metabolically unhealthy nonobese (MUNO: adjusted HR, 1.521; 95% CI, 1.405 to 1.645) but not those who are metabolically healthy obese (MHO: adjusted HR, 1.019; 95% CI, 0.907 to 1.144) had an increased hazard of developing POAG compared with metabolically healthy nonobese (MHNO) subjects. CONCLUSION: Metabolic health status and obesity were significantly associated with increased risk of POAG incidence. MUNO subjects but not MHO subjects showed a higher risk of POAG development than did MHNO subjects, suggesting that metabolic status is more important than obesity in POAG.

Usefulness of 10-2 Matrix Frequency Doubling Technology Perimetry for Detecting Central Visual Field Defects in Preperimetric Glaucoma Patients.

It is generally acknowledged that structural loss can precede functional loss in some patients with early glaucoma. However, conventional standard automated perimetry (SAP) has limitations in the detection of functional loss, especially in the macular area. This study explores visual field loss in the macular areas of patients with preperimetric glaucoma exhibiting structural thinning in the area by examining the correlations between the ganglion cell-inner plexiform layer (GCIPL) and the results of matrix frequency-doubling technology (FDT) 10-2 tests. The structure-function relationships between the GCIPL thicknesses and the mean sensitivities (MSs) of the corresponding areas based on conventional SAP 24-2, FDT 10-2, and FDT 24-2 were examined in 62 patients. The highest correlation was found for FDT 10-2 (r = 0.544, P < 0.001) followed by FDT 24-2 (r = 0.433, P = 0.002) and SAP (r = 0.346, P = 0.007). The correlation coefficients between each GCIPL sector and the corresponding central MS according to FDT 24-2 and 10-2 were all statistically significant, and the correlations were significantly stronger for FDT 10-2 than 24-2 in the inferior and inferonasal sectors. In conclusion, preperimetric glaucoma patients with structural loss in the macula as indicated by GCIPL thinning also exhibited functional loss as revealed by FDT 10-2, and the functional loss was less evident with conventional SAP.

Characteristics of corneal biomechanical responses detected by a non-contact scheimpflug-based tonometer in eyes with glaucoma.

PURPOSE: To determine the corneal biomechanical properties in eyes with glaucoma using a non-contact Scheimpflug-based tonometer. METHODS: Corneal biomechanical responses were examined using a non-contact Scheimpflug-based tonometer. The tonometer parameters of the normal control group (n = 75) were compared with those of the glaucoma group (n = 136), including an analysis of glaucoma subgroups categorized by visual field loss. RESULTS: After adjusting for potential confounding factors, including the intraocular pressure (IOP), central corneal thickness (CCT), age and axial length, the deformation amplitude was smaller in the glaucoma group (1.09 ± 0.02 mm) than in the normal control group (1.12 ± 0.02 mm; p value = 0.031). The deformation amplitude and the deflection amplitude of the severe glaucoma group (1.12 ± 0.02 mm and 0.92 ± 0.01 mm) were significantly greater than that of the early glaucoma group (1.07 ± 0.01  mm and 0.88 ± 0.11 mm, p = 0.006 and p = 0.031), whereas that of the moderate glaucoma group (1.09 ± 0.02 mm and 0.90 ± 0.02 mm) was greater than that of the early glaucoma group, but this difference was not statistically significant. The deformation amplitude showed a negative correlation with the CCT in the normal control group (r = -0.235), with a weaker negative relationship observed in the early glaucoma group (r = -0.099). However, in the moderate and severe glaucoma groups, the deformation amplitude showed a positive relationship with the CCT, showing an inverse relationship. The duration and number of antiglaucomatous eyedrops used had negative correlations with the CCT in eyes with moderate and severe glaucoma. CONCLUSION: Overall, the glaucoma group showed significantly less deformable corneas than did the normal controls, even after adjusting for the IOP, CCT, age and axial length. However, there were also differences according to the severity of glaucoma, where the corneal deformation amplitude was greater in the severe glaucoma group compared to the early glaucoma group. The combined effects of stiffening due to glaucoma and increased viscoelastic properties caused by the chronic use of antiglaucomatous eyedrops may have resulted in the present findings.

Association between Corneal Deformation Amplitude and Posterior Pole Profiles in Primary Open-Angle Glaucoma.

PURPOSE: To investigate the relationships between corneal deformation amplitude and posterior pole profiles, including ß-zone parapapillary atrophy (ßPPA), optic disc tilt ratio, torsion degree, and disc-foveal angle, in patients with glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 107 patients with glaucoma. METHODS: Each patient underwent measurement of deformation amplitude with Corvis ST (Oculus Optikgeräte GmbH, Wetzlar, Germany), color optic disc photography, red-free retinal nerve fiber layer photography, axial length measurement, and 24-2 standard automated perimetry. From fundus photographs, the ßPPA area, optic disc tilt ratio, torsion degree, and disc-foveal angle were obtained. Pearson's correlation was used to determine the relationships between deformation amplitude and posterior pole profiles. To determine the factors associated with the posterior pole profiles, univariate and multivariate regression analyses were performed. MAIN OUTCOME MEASURES: Deformation amplitude, ßPPA area, optic disc tilt ratio, torsion degree, and disc-foveal angle. RESULTS: The study included 50 men (46.7%) and 57 women (53.3%). The mean age was 55.38±14.14 years. The mean tilt ratio, torsion degree, and disc-foveal angle were 1.16±0.14, 10.26±7.63°, and 7.60±3.64°, respectively. The mean ßPPA area was 18 211.00±28 725.53 pixels. The ßPPA (r = 0.391, P < 0.001) and tilt ratio (r = 0.408, P < 0.001) had significant relationships with deformation amplitude after adjusting for intraocular pressure (IOP). Torsion degree and disc-foveal angle showed no significant relationship with deformation amplitude. The ßPPA area was associated with deformation amplitude and axial length in both univariate (P = 0.008 and 0.006, respectively) and multivariate (P = 0.035 and <0.001, respectively) regression analyses. The tilt ratio was associated with deformation amplitude in univariate regression analysis (P = 0.002), but not in multivariate regression analysis. Axial length was significantly associated with the tilt ratio in both univariate (P < 0.001) and multivariate (P < 0.001) regression analyses. CONCLUSIONS: Deformation amplitude was associated with PPA area and tilt ratio in patients with glaucoma, although in our data set ßPPA area and tilt ratio were not associated with visual field mean deviation.

The Ability of 10-2 Short-Wavelength Perimetry in Detecting Functional Loss of the Macular Area in Preperimetric Glaucoma Patients.

PURPOSE: To better understand functional loss in the macular area of preperimetric glaucoma patients exhibiting structural loss by exploring correlations between parameters of the ganglion cell-inner plexiform layer (GCIPL) and 10-2 short-wavelength perimetry (SWAP). METHODS: One hundred thirty-four patients underwent 10-2 SWAP and conventional 24-2 visual field (VF) testing using a Humphrey field analyzer and macular scanning via Cirrus optical coherence tomography (OCT). Correlations between GCIPL thickness (GCIPLT) and the mean sensitivity (MS) of topographically corresponding areas explored in various VF tests were calculated. Correlations between GCIPL parameters and MS of the VF, in terms of the asymmetries of various VF sectors, were also determined. RESULTS: Glaucoma patients, preperimetric by standard 24-2 VF analysis but exhibiting GCIPL thinning, had lower MS in 10-2 SWAP and central 24-2 VF analyses. The correlations between average GCIPLT and the corresponding MS were significant for both 10-2 SWAP (r = 0.291, P = 0.018) and 24-2 standard automated perimetry (r = 0.235, P = 0.029). The associations between sectoral GCIPLT and the corresponding 10-2 SWAP MS were significant for all sectors, with the highest correlation evident in the inferotemporal (r = 0.324, P = 0.009) and the lowest in the superonasal GCIPL sectors (r = 0.214, P = 0.043). Asymmetric relationships between GCIPLT and 10-2 SWAP MS exhibited similar yet stronger correlations. CONCLUSIONS: Preperimetric glaucoma patients exhibiting structural loss in the macula also had functional loss revealed by 10-2 SWAP, which was less prominent in conventional 24-2 VF. Therefore, if structural abnormality is evident in the macular area, the central VF areas should be further examined even if the standard 24-2 data appear to be normal.

Difference in Outcomes between First-Operated vs. Fellow-Operated Eyes in Patients Undergoing Bilateral Trabeculectomies.

MAIN OBJECTIVE: To compare the course and outcome of first- and fellow-operated eyes in patients who underwent bilateral trabeculectomies and to investigate the factors associated with the difference. METHODS: Preoperative characteristics, including the interval between surgeries, were compared between the first- and fellow-operated eyes in 42 patients who underwent bilateral trabeculectomies. Postoperative intraocular pressure and bleb vascularity, using postoperative anterior segment photos, were compared at various time points between the first- and fellow-operated eyes. Surgical success was evaluated at 1 year after surgery and at the final follow-up. Factors affecting the difference between the first and fellow eyes were analyzed. RESULTS: There was no significant difference in success or failure rates at 1 year postoperatively and at the final follow-up between the first- and fellow-operated eyes. Early postoperative IOP and the degree of bleb vascularity were higher in the fellow-operated eyes (P = 0.001 and 0.003, respectively at week 1 postoperative). The difference in IOP between the first- and fellow-operated eyes was greater in patients whose interval between surgeries was shorter than 3 weeks (P = 0.026). CONCLUSIONS: In patients undergoing bilateral trabeculectomies, early postoperative IOP was higher in the fellow-operated eyes than the first-operated eyes; the difference was greater when the interval between surgeries was shorter. The first-operated eye may influence the early postoperative inflammatory response in the fellow-operated eye. Our findings have clinical implications for planning treatment of patients who may need bilateral surgery.

Comparison of prelaminar thickness between primary open angle glaucoma and normal tension glaucoma patients.

MAIN OBJECTIVE: The thinning of prelaminar tissue and prelamina cupping is known to occur by ischemia, as we see in anterior ischemic optic neuropathy. Since normal tension glaucoma (NTG) is thought to be more related to vascular factor than in primary open-angle glaucoma (POAG), we hypothesized that prelamina thinning may occur prominently in NTG patients. This study investigated the difference in prelaminar tissue thickness between patients with POAG and NTG and verified the factors related to prelaminar thinning. METHODS: Complete ophthalmic examination including standard automatic perimetry was performed in all patients. The prelaminar tissue thickness was measured in all patients by performing enhanced depth imaging with a Heidelberg Spectralis Optical Coherence Tomography. The retinal nerve fiber layer and optic nerve head parameters were obtained using the Heidelberg Retina Tomography II and Cirrus Optical Coherence Tomography. Various ocular factors and their relationships with prelaminar thickness were analyzed. RESULTS: The mean prelaminar tissue thickness was significantly thinner in patients with POAG than in those with NTG. The difference in the prelaminar thickness between patients with POAG and those with NTG was greater in the early field defect group than in the moderate and severe field groups. In multivariate analysis, the mean prelaminar thickness was related to the intraocular pressure, mean deviation, cup-disc ratio, and cup volume. CONCLUSIONS: The prelaminar tissue was thinner in patients with POAG than in patients with NTG, and intraocular pressure had a strong influence on the prelaminar thickness in both POAG and NTG. This may indicate that mechanical compression is the main pathogenic factor in both POAG and NTG.

Torsion of the optic nerve head is a prominent feature of normal-tension glaucoma.

PURPOSE: To compare optic nerve head (ONH) morphology between eyes with normal-tension glaucoma (NTG) and primary open-angle glaucoma (POAG). METHODS: Seventy-eight NTG patients and 78 POAG patients matched according to age and axial length were analyzed. Optic nerve head tilt and torsion were identified from cross-sectional images of optical coherence tomography. The degree of horizontal, vertical, and maximum ONH tilt and torsion was compared between NTG and POAG eyes, and additional comparisons were based on the presence of myopia and the location of the visual field defect. Logistic regression analysis was used to determine the factors related to the degree of ONH torsion. RESULTS: Vertical (P = 0.610) and horizontal tilt degree (P = 0.746) did not differ between NTG and POAG eyes. However, torsion degree (P = 0.022) differed significantly between NTG and POAG eyes. Direction of vertical tilt (P = 0.040) and torsion (P < 0.001) showed more prevalent superior tilt and torsion in NTG eyes (21.8% and 33.3%, respectively) compared to POAG eyes (10.3% and 10.3%, respectively). Myopic NTG eyes showed greater torsion degree (P = 0.014) than nonmyopic NTG eyes, which was not observed in the comparison between myopic and nonmyopic POAG eyes. Only NTG eyes showed a significant difference in the degree of maximum tilt (P < 0.001) and torsion (P < 0.001) and the direction of vertical tilt (P < 0.001) and torsion (P = 0.010) by the location of visual field defect. Longer axial length, maximum tilt degree, and diagnosis of NTG were the factors related to the degree of ONH torsion. CONCLUSIONS: Normal-tension glaucoma eyes had a greater ONH torsion compared to POAG eyes with matched axial length. The direction of the ONH tilt and torsion was related to the location of the visual field defect only in NTG eyes.

VEGF induces TGF-ß1 expression and myofibroblast transformation after glaucoma surgery.

Subconjunctival fibrosis at the surgical site determines the outcome of glaucoma surgery. Myofibroblast transformation has a significant role in fibrosis, and vascular endothelial growth factor (VEGF) is reported to trigger myofibroblast transformation by inducing transforming growth factor (TGF)-ß1. In the present study, we used IHC, Western blot analysis, enzyme-linked immunosorbent assay, and electron microscopy to determine the contribution of VEGF to myofibroblast transformation in subconjunctival fibrosis after glaucoma surgery. A rabbit trabeculectomy model was generated, and VEGF stimulation or VEGF inhibition was performed during surgery. VEGF stimulation induced TGF-ß1 expression in a dose-dependent manner. Down-regulation of epithelial markers (E-cadherin and ß-catenin) and up-regulation of mesenchymal marker (α-smooth muscle actin) were observed in the subconjunctival layers after trabeculectomy with VEGF stimulation. Up-regulations of Smad and Snail, which play a central role in myofibroblast transformation, were observed in the conjunctival and subconjunctival layers at the site of trabeculectomy. Electron microscopy revealed changes of the conjunctival epithelial cells, especially the presence of myofilaments and increased rough endoplasmic reticulum in the cytoplasm. Myofibroblast transformation was activated by VEGF stimulation and decreased by VEGF inhibition. These findings suggest that VEGF potentially affected the TGF-ß1/Smad/Snail pathway, thereby triggering myofibroblast transformation. Therapeutic approaches modulating VEGF may control myofibroblast transformation and reduce subconjunctival fibrosis after glaucoma surgery.

Visualization of blebs using anterior-segment optical coherence tomography after glaucoma drainage implant surgery.

OBJECTIVE: The current study investigated the internal structure of blebs using anterior-segment optical coherence tomography (AS-OCT) in patients who had undergone Ahmed glaucoma valve (AGV) (New World Medical Inc, Rancho Cucamonga, CA) implantation and compared the differences between successful and failed surgeries. DESIGN: Cross-sectional, observational study. PARTICIPANTS: A total of 76 patients who had undergone AGV implantation. METHODS: The blebs after AGV implantation were examined using AS-OCT. The relationship between intraocular pressure (IOP) or the number of glaucoma medications and intrableb parameters was evaluated. Success was defined as IOP ≤ 21 mmHg with a maximum of 2 glaucoma medications, and the remaining cases were assigned to the "failed surgery group." Logistic regression was used to determine the predictive value of various bleb parameters measured by AS-OCT for bleb success. MAIN OUTCOME MEASURES: The bleb wall thickness (minimum and maximum) and the reflectivity of the bleb wall (mean, modal value, minimum, and maximum). RESULTS: Blebs from 46 successful (60.5%) and 30 failed (39.5%) AGV implantation surgeries were analyzed. The AS-OCT imaging of the intrableb configuration revealed a relatively regular surface and a homogeneous and hyperreflective bleb wall. The maximum and minimum bleb wall thicknesses were significantly different between the 2 groups (P<0.001, P<0.005). No significant differences were observed between the 2 groups in mean, modal, maximum, or minimum reflectivity of the bleb wall. The maximum and minimum bleb wall thicknesses were significantly correlated with the postoperative maximum IOP (r = 0.402, P<0.001; r = 0.280, P = 0.014). The maximum and minimum bleb wall thicknesses showed a significant correlation with the number of postoperative glaucoma eye drops (r = 0.452, P<0.001; r = 0.327, P = 0.004). Maximum bleb wall thickness was significantly associated with the success of AGV surgery by multivariate analysis (P<0.001). CONCLUSIONS: Anterior-segment OCT can be used for bleb imaging after glaucoma valve implantation. The AS-OCT results revealed that the maximum bleb wall was significantly thinner in successful AGV implant surgeries compared with unsuccessful AGV implant surgeries. This technique may facilitate the investigation of surgical outcomes and pathogenesis in patients receiving glaucoma valve implants. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Structure-function relationship and diagnostic value of RNFL Area Index compared with circumpapillary RNFL thickness by spectral-domain OCT.

PURPOSE: The purpose of the study was to evaluate the structure-function relationship and diagnostic value of retinal nerve fiber layer (RNFL) Area Index from the RNFL thickness deviation map of Cirrus SD-OCT. METHODS: : A total of 84 normal control eyes, 88 preperimetric eyes, and 146 perimetric glaucoma eyes were analyzed. The area of the RNFL defect in the RNFL thickness deviation map was expressed as RNFL Area Index: 1-[area of superpixels coded in red/(6×6-optic disc area)]. The diagnostic performance of RNFL Area Index and that of circumpapillary RNFL thickness were compared with the area under the receiver operating characteristic curve. Regression analysis was performed with the OCT measurements and the mean retinal sensitivity of the corresponding fields. RESULTS: : The RNFL Area Index was 96.63±14.22%, 89.89±14.54%, and 81.65±17.11% in the control, preperimetric, and perimetric glaucoma group. The RNFL Area Index had the largest area under the receiver operating characteristic curve to discriminate preperimetric and perimetric glaucoma from normal eyes. The RNFL Area Index showed a strong correlation with circumpapillary RNFL thicknesses in perimetric glaucoma, however, only modest correlation was shown in preperimetric glaucoma. In preperimetric glaucoma, the RNFL Area Index had the strongest associations with mean retinal sensitivity and it was significantly different from those of circumpapillary RNFL thicknesses. CONCLUSIONS: : The RNFL Area Index showed better diagnostic performance for glaucoma detection and stronger structure-function relationships in preperimetric glaucoma. The RNFL thickness deviation map of Cirrus SD-OCT may be useful to correlate with functional loss in early glaucomatous eyes.

Characteristics of optic disc morphology in glaucoma patients with parafoveal scotoma compared to peripheral scotoma.

PURPOSE: We investigated the amount and location of optic nerve head (ONH) abnormal points and the retinal nerve fiber layer (RNFL) thickness with paracentral scotoma compared to peripheral scotoma. METHODS: Totals of 35 normal tension glaucoma (NTG) patients with isolated parafoveal scotoma (PFS) within a 10° radius in one hemifield, and 35 patients with isolated peripheral nasal step (PNS) within the nasal periphery outside 10° of fixation in one hemifield were enrolled if their mean deviation was greater than -10 decibels (dB). Global and sector optic disc stereometric parameters obtained by Heidelberg retina tomography and analyzed by Moorfields regression analysis (MRA), and retinal RNFL thickness measured using Cirrus spectral domain-optical coherence tomography were compared between the two groups. The percentages of superior and inferior field defects were evaluated. RESULTS: In PFS, superior field defects (82.9%) were found to be dominant, whereas PNS showed a predominance of inferior field defects (80.0%). The PFS group revealed smaller rim area, more glaucomatous cup shape than the PNS group (P = 0.036, 0.012, respectively). In MRA classification, the percentage outside of normal limits (ONL) was greater in the PFS group (P = 0.006). Compared to the PNS group, the PFS group exhibited more glaucomatous ONH morphology in the temporal and inferotemporal sectors in a sector analysis of optic disc parameters, and had thinner RNFLs in the inferior quadrant, and at 7 and 8 o'clock (P = 0.007, 0.003, 0.005, respectively). CONCLUSIONS: In early NTG, paracentral scotoma may be more significant than peripheral scotoma because of narrower optic disc rim and larger cup, especially inferotemporally.

The effects of peripapillary atrophy on the diagnostic ability of Stratus and Cirrus OCT in the analysis of optic nerve head parameters and disc size.

PURPOSE: We compared the diagnostic ability of Stratus and Cirrus optical coherence tomography (OCT) in optic nerve head (ONH) analysis, and examined the effects of optic disc size and peripapillary atrophy (PPA) on their diagnostic capacity. METHODS: Stratus and Cirrus OCT was performed in 28 control and 78 glaucomatous eyes. ONH parameters and diagnostic capacity calculated from the area under the receiver operating characteristics curve (AUC) were compared between the two modalities. Glaucomatous eyes were classified by optic disc size and the presence/absence of PPA, and their AUCs were compared. RESULTS: Rim area (AUC 0.936) and rim volume (AUC 0.824) showed the best diagnostic capacity in Cirrus and Stratus OCT, respectively. Cirrus OCT showed greater diagnostic ability over Stratus OCT for all ONH parameters. With increasing ONH size, diagnostic ability declined in rim and disc areas, while it improved in average cup-to-disc ratio (CDR), vertical CDR, and cup volume for both modalities. Optic disc size as measured by Stratus OCT was significantly larger than that by Cirrus OCT in glaucomatous eyes with PPA. In addition, the diagnostic capacity of all ONH parameters declined significantly for glaucomatous eyes with PPA, especially for Stratus OCT. In Cirrus OCT, retinal nerve fiber layer (RNFL) thickness showed poorer diagnostic ability than rim area in the glaucoma with PPA group. CONCLUSIONS: The diagnostic capacity of Cirrus OCT was superior to that of Stratus OCT. Considering the principle of determining the disc margin, as Stratus OCT tends to make excessive measurements of the optic disc in PPA, caution is required in analyzing the results.

Optic disc torsion direction predicts the location of glaucomatous damage in normal-tension glaucoma patients with myopia.

OBJECTIVE: To characterize optic disc tilt and torsion in normal-tension glaucoma (NTG) patients with myopia and to evaluate the relationship between optic disc tilt and torsion with the location of visual field (VF) defect. DESIGN: Retrospective, case-control design. PARTICIPANTS: Two hundred twenty-five NTG patients. METHODS: Patients were divided into a myopic NTG group (spherical equivalent more than -2.00 diopters [D] or axial length more than 24.0 mm; n = 166) and nonmyopic NTG group (spherical equivalent less than -0.50 D or axial length less than 24.0 mm; n = 59). Disc tilt, which was identified by the tilt ratio, disc torsion, and area of peripapillary atrophy (PPA), was measured from disc photographs. Patients were divided further into superior and inferior defect groups according to the location of the VF defect in the pattern deviation map. Logistic regression analysis was used to determine the relationship between ocular factors, including tilt ratio, torsion degree, and the VF defect location. MAIN OUTCOME MEASURES: Tilt ratio, torsion degree, PPA area, and location of VF defect. RESULTS: Among 225 NTG eyes, 166 (73.8%) were myopic eyes. The myopic NTG group was significantly younger (42.85 years) than the nonmyopic NTG group (60.73 years). Disc tilt (45.8%) and torsion (75.9%) were significantly more prevalent in the myopic NTG group than in the nonmyopic NTG group. Although just short of statistical significance (P = 0.057), PPA area was larger in the myopic NTG group. The VF defect location was significantly different between the 2 groups, with superior defects more prevalent in the myopic NTG group (69.9%; P<0.001). Torsion degree was significantly different in the superior defect group (18.45°) compared with the inferior defect group (-3.81°; P = 0.001). Torsion degree was the only factor related to VF defect location in both univariate (P = 0.001) and multivariate (P = 0.014) logistic regression analyses. CONCLUSIONS: Korean NTG patients had a high prevalence of myopia and young age. Optic disc tilt and torsion were highly prevalent in Korean NTG patients with myopia. The direction of the optic disc torsion may predict the location of damage.