Qualitative evaluation of neuroretinal rim and retinal nerve fibre layer on optical coherence tomography to detect glaucomatous damage.

PURPOSE: To understand the added value of Bruch's membrane opening-minimum rim width (BMO-MRW) measurements to conventional circumpapillary retinal nerve fibre layer (cpRNFL) thickness measurements on optical coherence tomography (OCT) imaging for discriminating between perimetric glaucoma and healthy eyes, evaluated through a qualitative evaluation. METHODS: 384 healthy eyes and 188 glaucoma eyes were evaluated, and glaucoma eyes were categorised as perimetric (n=107) based on a history of ≥3 consecutive abnormal 24-2 visual field tests or suspected glaucoma if they did not (n=81). OCT-derived BMO-MRW and cpRNFL reports were qualitatively evaluated by two experienced graders in isolation at first, and then by using both reports combined. The diagnostic performance (sensitivity at 95% specificity, total and partial area under the receiver operating characteristic curve) of detecting perimetric glaucoma with each method were compared. RESULTS: All diagnostic performance measures for detecting perimetric glaucoma eyes were not significantly different when using either the cpRNFL or BMO-MRW reports alone compared with using both reports combined (p≥0.190), nor when comparing the use of each report in isolation (p≥0.500). CONCLUSIONS: Experienced graders exhibited no difference in discriminating between perimetric glaucoma and healthy eyes when using a cpRNFL report alone, the BMO-MRW report alone or the two reports combined. Therefore, either OCT imaging report of the neuroretinal tissue could be used effectively for detecting perimetric glaucoma, but further studies are needed to determine whether there are specific advantages of each method, or the combination of both, when evaluating eyes that have a greater degree of diagnostic uncertainty.

Relationship between optic disc hemorrhage and corneal hysteresis.

OBJECTIVE: To determine the relationship between optic disc hemorrhage (DH) and corneal hysteresis (CH). METHODS: Consecutive patients with prior or current photographic evidence of unilateral DH who had undergone CH measurement with the Ocular Response Analyzer (ORA; Reichert, Buffalo, NY) were enrolled. Eyes with a history of corneal disease, refractive surgery, or bilateral DH were excluded. Central corneal thickness (CCT), visual field data, 5 consecutive previous intraocular pressures (IOPs), and maximum documented peak IOP were obtained by chart review. Vertical cup-to-disc ratio (VCDR), the presence of neuroretinal rim notching, number of clock hours of beta zone parapapillary atrophy (ßPPA), and eye with greater ßPPA width were determined from photographs by 2 masked expert examiners. RESULTS: We identified and analyzed 49 patients with photographically documented unilateral DH. Compared to fellow non-DH eyes, eyes with DH had lower CH (8.7 ± 1.9 vs 9.2 ± 1.7; p = 0.002), higher IOP (15.6 ± 3.6 vs 14.3 ± 4.1; p = 0.017), and greater VCDR (0.79 ± 0.13 vs 0.68 ± 0.23; p < 0.001), but were similar with respect to CCT, ßPPA extent, rim notching, peak IOP, and visual field damage (all p > 0.05). Using multivariate conditional logistic regression analysis, only CH (p = 0.012) and VCDR (p = 0.004) predicted the laterality of the DH. CONCLUSIONS: Lower CH and greater VCDR are independently associated with DH. This suggests that CH may be a structural biomarker for an abnormality of the optic nerve complex that may be associated with progressive glaucoma. Eyes in which DH were detected had lower CH.

Glaucomatous damage of the macula.

There is a growing body of evidence that early glaucomatous damage involves the macula. The anatomical basis of this damage can be studied using frequency domain optical coherence tomography (fdOCT), by which the local thickness of the retinal nerve fiber layer (RNFL) and local retinal ganglion cell plus inner plexiform (RGC+) layer can be measured. Based upon averaged fdOCT results from healthy controls and patients, we show that: 1. For healthy controls, the average RGC+ layer thickness closely matches human histological data; 2. For glaucoma patients and suspects, the average RGC+ layer shows greater glaucomatous thinning in the inferior retina (superior visual field (VF)); and 3. The central test points of the 6° VF grid (24-2 test pattern) miss the region of greatest RGC+ thinning. Based upon fdOCT results from individual patients, we have learned that: 1. Local RGC+ loss is associated with local VF sensitivity loss as long as the displacement of RGCs from the foveal center is taken into consideration; and 2. Macular damage is typically arcuate in nature and often associated with local RNFL thinning in a narrow region of the disc, which we call the macular vulnerability zone (MVZ). According to our schematic model of macular damage, most of the inferior region of the macula projects to the MVZ, which is located largely in the inferior quadrant of the disc, a region that is particularly susceptible to glaucomatous damage. A small (cecocentral) region of the inferior macula, and all of the superior macula (inferior VF), project to the temporal quadrant, a region that is less susceptible to damage. The overall message is clear; clinicians need to be aware that glaucomatous damage to the macula is common, can occur early in the disease, and can be missed and/or underestimated with standard VF tests that use a 6° grid, such as the 24-2 VF test.

Understanding disparities among diagnostic technologies in glaucoma.

OBJECTIVE: To investigate causes of disagreement among 3 glaucoma diagnostic techniques: standard automated achromatic perimetry (SAP), the multifocal visual evoked potential technique (mfVEP), and optical coherence tomography (OCT). METHODS: In a prospective cross-sectional study, 138 eyes of 69 patients with glaucomatous optic neuropathy were tested using SAP, the mfVEP, and OCT. Eyes with the worse and better mean deviations (MDs) were analyzed separately. If the results of 2 tests were consistent for the presence of an abnormality in the same topographic site, that abnormality was considered a true glaucoma defect. If a third test missed that abnormality (false-negative result), the reasons for disparity were investigated. RESULTS: Eyes with worse MD (mean [SD], -6.8 [8.0] dB) had better agreements among tests than did eyes with better MD (-2.5 [3.5] dB, P<.01). For the 94 of 138 hemifields with abnormalities of the more advanced eyes, the 3 tests were consistent in showing the same hemifield abnormality in 50 hemifields (53%), and at least 2 tests were abnormal in 65 of the 94 hemifields (69%). The potential explanations for the false-negative results fell into 2 general categories: inherent limitations of each technique to detect distinct features of glaucoma and individual variability and the distribution of normative values used to define statistically significant abnormalities. CONCLUSIONS: All the cases of disparity could be explained by known limitations of each technique and interindividual variability, suggesting that the agreement among diagnostic tests may be better than summary statistics suggest and that disagreements between tests do not indicate discordance in the structure-function relationship.

Enhanced depth imaging optical coherence tomography of deep optic nerve complex structures in glaucoma.

OBJECTIVE: To assess the usefulness of enhanced depth imaging (EDI) optical coherence tomography (OCT) for evaluating deep structures of the optic nerve complex (ONC; optic nerve head and peripapillary structures) in glaucoma. DESIGN: Prospective, observational study. PARTICIPANTS: Seventy-three established glaucoma patients (139 eyes) with a range of glaucomatous damage. METHODS: Serial horizontal and vertical EDI OCT images of the ONC were obtained from both eyes of each participant. Deep ONC structures, including the lamina cribrosa (LC), short posterior ciliary artery (SPCA), central retinal artery (CRA), central retinal vein (CRV), peripapillary choroid and sclera, and subarachnoid space around the optic nerve, were investigated for their visibility and morphologic features. MAIN OUTCOME MEASURES: Deep ONC structures identified in EDI OCT images. RESULTS: Visual field mean deviation of 139 included eyes was -11.8 ± 8.6 dB (range, -28.70 to -2.01 dB). The anterior laminar surface was identified in all eyes in the central laminar area and in 91 (65%) eyes in the periphery beneath the neuroretinal and scleral rims or vascular structures. The LC pores with various shapes and sizes were visualized in 106 (76%) eyes, mainly in the central and temporal areas of the LC. Localized LC lesions seen on optic disc photographs were identified as focal LC defects (partial loss of LC tissue) in the EDI OCT images. The locations of the CRA and CRV were identified in all eyes. In the LC, the CRA maintained a straight shape with a consistent caliber, but the CRV (and tributaries) assumed a more irregular shape. The SPCAs, their branches through the emissary canals in the sclera, or both were visualized in 120 (86%) eyes. The subarachnoid space around the optic nerve was identified with varying degrees of clarity in 25 eyes (18%): 17 had high myopia and extensive parapapillary atrophy. Intrachoroidal cavitation or choroidal schisis, which had been unrecognized clinically, was identified in 2 eyes (1%) with high myopia. CONCLUSIONS: Enhanced depth imaging OCT was able to visualize a wide variety of deep ONC structures in glaucoma patients and may be helpful in detecting, conceptualizing, and understanding basic and complicated in vivo anatomic and pathologic features of the ONC in glaucoma. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

The rate of visual field change in the ocular hypertension treatment study.

PURPOSE: To assess the rate of change of visual field (VF) mean deviation (MD) in the Ocular Hypertension Treatment Study (OHTS). METHODS: OHTS data were filtered to exclude eyes that had fewer than 10 reliable VFs or less than 5 years of follow-up or that reached a nonglaucomatous endpoint. The rate of change of MD (MDR) was calculated for each eye. Differences were sought between groups of eyes differing in primary open angle glaucoma (POAG) outcome, how POAG was determined, and original randomization. RESULTS: In total, 2609 eyes (1379 participants) met the selection criteria. The mean MDR was -0.08 ± 0.20 dB/y (±SD). POAG eyes (n = 359) had significantly worse MDRs (-0.26 ± 0.36 dB/y) than non-POAG eyes (n = 2250; -0.05 ± 0.14 dB/y; P < 0.001). Eyes that reached POAG endpoints based on only VF change (n = 74; -0.29 ± 0.31 dB/y) or only optic disc change (n = 158; -0.12 ± 0.19 dB/y) had significantly worse MDRs than non-POAG eyes (both P < 0.001). Eyes that reached POAG endpoints for both VF and optic disc change (n = 127) deteriorated more rapidly (-0.42 ± 0.46 dB/y) than eyes showing only VF change (P = 0.017) or only optic disc change (P < 0.001). There was not a significant association between MDR and original OHTS randomization (observe vs. treat, P = 0.168). CONCLUSIONS: Eyes that develop POAG have significantly worse MDRs than eyes that do not. Eyes that reached endpoints due to both VF and optic disc change had worse MDRs than eyes displaying change in only one of these. MDR was not significantly associated with randomization, suggesting that MDR may not be the best measure of VF change in early-stage POAG. (ClinicalTrials.gov number, NCT00000125.).

Short duration transient visual evoked potentials in glaucomatous eyes.

PURPOSE: To investigate the correlation between structural and functional damage in patients with asymmetric glaucoma using a newly developed short duration transient visual evoked potential (SD-tVEP) device. METHODS: Twenty-five patients with visual acuity ≥20/30 and asymmetric visual field (VF) loss [inter-eye difference in mean deviation index (MD) of at least 3 dB] were enrolled. Patients underwent optical coherence tomography (OCT) for macular thickness measurement, scanning laser polarimetry with variable corneal compensation for retinal nerve fiber layer measurement, and SD-tVEP (10% and 85% Michelson contrast, acquisition time of 20 s) in both eyes within 2 months. We correlated VF MD and structural test results with SD-tVEP P100 latency and Delta Amplitude (N75-P100). RESULTS: Using 10% contrast, there was a significant difference in SD-tVEP latency and amplitude between eyes with better and worse VF MD (P<0.001). MD correlated significantly with both SD-tVEP parameters (r>0.33, P≤0.01). When using 85% contrast, SD-tVEP amplitude differed between eyes (P=0.01) and MD values correlated significantly with amplitude results (r=0.32, P=0.01), but not with latency (P=0.46). In eyes with more advanced VF loss, there was a positive and significant correlation between SD-tVEP amplitude (85% contrast) and macular thickness on OCT (r=0.47, P=0.01), but not with retinal nerve fiber layer measured with polarimetry (P=0.26). CONCLUSIONS: In cases of asymmetric glaucoma, SD-tVEP results correlate significantly with the level of VF damage as measured by MD. In the eyes with more advanced VF loss, reduced SD-tVEP amplitude was associated with decreased macular thickness on OCT. These findings suggest that SD-tVEP may be a fast and objective method to assess or screen for functional damage in glaucomatous eyes.

The Nature of Macular Damage in Glaucoma as Revealed by Averaging Optical Coherence Tomography Data.

PURPOSE: To better understand the nature of glaucomatous damage, especially to the macula, the inner retinal thickness maps obtained with frequency domain optical coherence tomography (fdOCT) were averaged. METHODS: Frequency domain optical coherence tomography macular and optic disc cube scans were obtained from 54 healthy eyes and 156 eyes with glaucomatous optic neuropathy. A manually corrected algorithm was used for layer segmentation. Patients' eyes were grouped both by mean deviation (MD) and hemifield classification using standard categories and 24-2 (6° grid) visual fields (VFs). To obtain average difference maps, the thickness of retinal nerve fiber (RNF) and retinal ganglion cell plus inner plexiform (RGC+) layers were averaged and subtracted from the average control values. RESULTS: On the average difference maps, RGC+ and RNF layer thinning was seen in the patient groups with VFs classified as normal. The pattern of the thinning was the same, but the degree of thinning increased with decreased MD and with classification category (from normal to arcuate). This RGC+ thinning was largely within the central four points of the 24-2 (6° grid) field, after correcting for RGC displacement. CONCLUSION: 1. VF categories represent different degrees of the same pattern of RGC+ and RNFL layer thinning. 2. RGC+ damage occurs in the central macula even in patients with VFs classified as normal. 3. The 6° grid (24-2) pattern is not optimally designed to detect macular damage. 4. A schematic model of RGC projections is proposed to explain the pattern of macular loss, including the greater vulnerability of the inferior retinal region. TRANSLATIONAL RELEVANCE: The 24-2 is not an optimal test pattern for detecting or following glaucomatous damage. Further, we suggest clinical fdOCT reports include RGC+ and RNFL probability plots combined with VF information.

Short-duration transient visual evoked potential for objective measurement of refractive errors.

This study examined effects of uncorrected refractive errors (RE) in a short-duration transient visual evoked potential (SD t-VEP) system and investigated their role for objective measurement of RE. Refractive errors were induced by means of trial lenses in 35 emmetropic subjects. A synchronized single-channel EEG was recorded for emmetropia, and each simulated refractive state to generate 21 VEP responses for each subject. P100 amplitude (N75 trough to P100 peak) and latency were identified by an automated post-signal processing algorithm. Induced hypermetropia and myopia correlated strongly with both P100 amplitude and latency. To minimize the effect of baseline shift and waveform fluctuations, a VEP scoring system, based on software-derived P100 latency, amplitude and waveform quality, was used to estimate the RE. Using the VEP scores, a single VEP response had a high sensitivity and specificity for discerning emmetropia, small RE (<2 diopter) within a 2 diopter range and large RE (2-14 diopter) within a 4 diopter range. The VEP scoring system has a potential for objective screening of RE and for a more accurate 3-step objective refraction.

Hypodense regions (holes) in the retinal nerve fiber layer in frequency-domain OCT scans of glaucoma patients and suspects.

PURPOSE: To better understand hypodense regions (holes) that appear in the retinal nerve fiber layer (RNFL) of frequency-domain optical coherence tomography (fdOCT) scans of patients with glaucoma and glaucoma suspects. METHODS: Peripapillary circle (1.7-mm radius) and cube optic disc fdOCT scans were obtained on 208 eyes from 110 patients (57.4 ± 13.2 years) with glaucomatous optic neuropathy (GON) and 45 eyes of 45 controls (48.0 ± 12.6 years) with normal results of fundus examination. Holes in the RNFL were identified independently by two observers on the circle scans. RESULTS: Holes were found in 33 (16%) eyes of 28 (25%) patients; they were not found in any of the control eyes. Twenty-four eyes had more than one hole. Although some holes were relatively large, others were small. In general, the holes were located adjacent to blood vessels; only three eyes had isolated holes that were not adjacent to a vessel. The holes tended to be in the regions that are thickest in healthy controls and were associated with arcuate defects in patients. Holes were not seen in the center of the temporal disc region. They were more common in the superior (25 eyes) than in the inferior (15 eyes) disc. Of the 30 eyes with holes with reliable visual fields, seven were glaucoma suspect eyes with normal visual fields. CONCLUSIONS: The holes in the RNFL seen in patients with GON were probably due to a local loss of RNFL fibers and can occur in the eyes of glaucoma suspects with normal visual fields.

Risk factors for visual field progression in treated glaucoma.

OBJECTIVE: To determine intraocular pressure (IOP)-dependent and IOP-independent variables associated with visual field (VF) progression in treated glaucoma. DESIGN: Retrospective cohort of the Glaucoma Progression Study. METHODS: Consecutive, treated glaucoma patients with repeatable VF loss who had 8 or more VF examinations of either eye, using the Swedish Interactive Threshold Algorithm (24-2 SITA-Standard, Humphrey Field Analyzer II; Carl Zeiss Meditec, Inc, Dublin, California), during the period between January 1999 and September 2009 were included. Visual field progression was evaluated using automated pointwise linear regression. Evaluated data included age, sex, race, central corneal thickness, baseline VF mean deviation, mean follow-up IOP, peak IOP, IOP fluctuation, a detected disc hemorrhage, and presence of beta-zone parapapillary atrophy. RESULTS: We selected 587 eyes of 587 patients (mean [SD] age, 64.9 [13.0] years). The mean (SD) number of VFs was 11.1 (3.0), spanning a mean (SD) of 6.4 (1.7) years. In the univariable model, older age (odds ratio [OR], 1.19 per decade; P = .01), baseline diagnosis of exfoliation syndrome (OR, 1.79; P = .01), decreased central corneal thickness (OR, 1.38 per 40 µm thinner; P < .01), a detected disc hemorrhage (OR, 2.31; P < .01), presence of beta-zone parapapillary atrophy (OR, 2.17; P < .01), and all IOP parameters (mean follow-up, peak, and fluctuation; P < .01) were associated with increased risk of VF progression. In the multivariable model, peak IOP (OR, 1.13; P < .01), thinner central corneal thickness (OR, 1.45 per 40 µm thinner; P < .01), a detected disc hemorrhage (OR, 2.59; P < .01), and presence of beta-zone parapapillary atrophy (OR, 2.38; P < .01) were associated with VF progression. CONCLUSIONS: IOP-dependent and IOP-independent risk factors affect disease progression in treated glaucoma. Peak IOP is a better predictor of progression than is IOP mean or fluctuation.

Modified visual field trend analysis.

PURPOSE: Visual field trend analysis can be influenced by outlying values that may disproportionately affect estimation of the rate of change. We tested a modified approach to visual field trend analysis to minimize this problem. METHODS: Automated pointwise linear regression (PLR) was used in glaucoma patients with ≥13 SITA-Standard 24-2 VF tests in either eye. In the control group (Group A), conventional PLR using the entire set of VF tests was carried out. In the other 3 groups (study groups), a truncated analysis was done using only the first and last 3 (Group B), first and last 4 (Group C), or first and last 5 (Group D) VF tests. We compared the global slopes (dB/y), number of eyes experiencing significant progression, and significant improvement between groups. RESULTS: Ninety eyes of 90 patients were evaluated. The mean number±SD of VF tests was 15.7±2.6, spanning 7.8±1.7 years. The study groups showed similar global rates of VF change as the control group (Group A=-0.48±0.5, Group B=-0.48±0.6, Group C=-0.48±0.6, Group D=-0.48±0.5 dB/y, P>0.05), and a similar number of eyes reaching a progression endpoint (Group A=53, Group B=52, Group C=49, Group D=53, P>0.05). However, Group B showed fewer eyes presenting VF improvement (false-positives). CONCLUSIONS: The modified VF trend-analysis showed greater specificity than conventional PLR in a population with glaucoma.

Initial arcuate defects within the central 10 degrees in glaucoma.

PURPOSE: To better understand the relationship between the spatial patterns of functional (visual field [VF] loss) and structural (axon loss) abnormalities in patients with glaucomatous arcuate defects largely confined to the central 10° on achromatic perimetry. METHODS: Eleven eyes (9 patients) with arcuate glaucomatous VF defects largely confined to the macula were selected from a larger group of patients with both 10-2 and 24-2 VF tests. Eyes were included if their 10-2 VF had an arcuate defect and if the 24-2 test was normal outside the central 10° (i.e., did not have a cluster of three contiguous points within a hemifield). For the structural analysis, plots of retinal nerve fiber layer (RNFL) thickness of the macula were obtained with frequency-domain optical coherence tomography (fdOCT). The optic disc locations of the RNFL defects were identified on peripapillary fdOCT scans. RESULTS: The VF arcuate defects extended to within 1° of fixation on the 10-2 test and were present in the superior hemifield in 10 of the 11 eyes. The arcuate RNFL damage, seen in the macular fdOCT scans of all 11 eyes, involved the temporal and inferior temporal portions of the disc on the peripapillary scans. CONCLUSIONS: Glaucomatous arcuate defects of the macula's RNFL meet the disc temporal to the peak of the main arcuate bundles and produce a range of macular VF defects from clear arcuate scotomas to a papillofoveal horizontal step ("pistol barrel scotoma"). If RGC displacement is taken into consideration, the RNFL and VF defects can be compared directly.

In-vivo microstructural anatomy of beta-zone parapapillary atrophy in glaucoma.

PURPOSE: To assess the microstructural anatomy of clinical ß-zone parapapillary atrophy (ßPPA) by using Fourier-domain optical coherence tomography (FD-OCT). METHODS: Color photographs and horizontal cross-sectional FD-OCT images of the optic disc and parapapillary retina were obtained in 24 eyes (24 patients with glaucoma or suspected glaucoma) with ßPPA. The distances between the temporal disc margin and parapapillary landmarks (clinical ßPPA margin and the edges of the retinal pigment epithelium [RPE], Bruch's membrane [BM], and the photoreceptor inner/outer segment [IS/OS] junction) were measured in 5 equally spaced horizontal meridians (total, 120 meridians). RESULTS: The mean age was 56 ± 13 (SD) years. In the five meridians, the mean distances from the temporal disc margin to the temporal ßPPA margin and the edges of RPE, BM, and the IS/OS junction were 388 ± 173, 371 ± 174, 214 ± 204, and 502 ± 167 µm, respectively. The RPE edge corresponded to the ßPPA margin in 78 (65%) of 120 meridians and ended within the ßPPA in 42 (35%) of 120 meridians. The BM edge corresponded to the RPE edge in 13 (11%) of 120 meridians and was closer to the disc in 107 (89%) of 120 meridians. The disc margin corresponded to the BM edge in 20 (17%) of 120 meridians and to the edge of the border tissue of Elschnig in 100 (83%) of 120 meridians. The IS/OS junction edge was farther from the disc than the temporal ßPPA margin was in all 24 eyes. CONCLUSIONS: The ßPPA was not completely denuded of RPE, and there was a crescent-shaped area of photoreceptor degeneration or atrophy peripheral to the ßPPA. The termination of the border tissue of Elschnig constituted the temporal disc margin in most eyes with ßPPA.

Corneal hysteresis and visual field asymmetry in open angle glaucoma.

PURPOSE: To investigate the association between corneal biomechanical parameters and asymmetric primary open angle glaucoma (POAG) using the Ocular Response Analyzer (ORA). METHODS: In a prospective cross-sectional study, ORA parameters were measured in 117 POAG patients with asymmetric visual fields (VF). The asymmetry in VF was defined as a five point difference between the eyes using the Advanced Glaucoma Intervention Study (AGIS) scoring system. Subjects with previous intraocular or refractive surgery, ocular comorbidities and diabetes were excluded. RESULTS: In worse eyes, mean AGIS scores were significantly higher (8.1 ± 4.3 vs. 1.0 ± 1.6; P < 0.001) and mean corneal hysteresis (CH) was significantly lower (8.2 ± 1.9 vs. 8.9 ± 1.9 mm Hg; P < 0.001). Median ORA-corrected intraocular pressure was higher in the worse eyes (IOP(cc), 17.4 mm Hg vs. 16.9 mm Hg; P < 0.001). Worse eyes had a slightly lower mean corneal resistance factor (P = 0.04) and more myopic mean spherical equivalent (P = 0.02). No difference was seen in the central corneal thickness (CCT; P = 0.63) and Goldmann applanation tonometry (GAT; P = 0.32). On multivariate analysis, only CH retained an association with the worse eye (odds ratio, 25.9; 95% confidence interval, 10.1-66.5). ROC curves showed that only CH and IOP(cc) had a discriminative ability for the eye with worse VF (AUC, 0.82 and 0.70, respectively). CONCLUSIONS: Asymmetric POAG was associated with asymmetry in ORA parameters but not in CCT and GAT. Lower CH was associated with worse eyes independently of its effect on IOP measurement and had the best discriminability for the eye with the worse VF.

Beta-Zone parapapillary atrophy and the velocity of glaucoma progression.

PURPOSE: Beta-Zone parapapillary atrophy (PPA) occurs more commonly in eyes with glaucoma. Rates of glaucomatous visual field (VF) progression in eyes with and without beta-zone PPA at the time of baseline assessment were compared. DESIGN: Retrospective, comparative study. PARTICIPANTS: Two hundred forty-five patients from the New York Glaucoma Progression Study. METHODS: Subjects with glaucomatous optic neuropathy and repeatable VF loss were assessed for eligibility. Eyes with a Heidelberg Retina Tomograph II (HRT) examination, at least 5 visual field tests after the HRT in either eye, optic disc photographs, and <6 diopters of myopia were enrolled. beta-Zone PPA was defined as a region of chorioretinal atrophy with visible sclera and choroidal vessels adjacent to the optic disc. Global rates of VF progression were determined by automated pointwise linear regression analysis. Univariate analysis included age, gender, ethnicity, central corneal thickness (CCT), refractive error, baseline mean deviation, baseline intraocular pressure (IOP), mean IOP, IOP fluctuation, disc area, rim area, rim area-to-disc area ratio, beta-zone PPA area, beta-zone PPA area-to-disc area ratio, and presence or absence of beta-zone PPA. MAIN OUTCOME MEASURES: The relationship between beta-zone PPA and the rate and risk of glaucoma progression. RESULTS: Two hundred forty-five eyes of 245 patients (mean age, 69.6+/-12.3 years) were enrolled. The mean follow-up was 4.9+/-1.4 years and the mean number of VFs after HRT was 9.3+/-2.7. beta-Zone PPA was present in 146 eyes (65%). Eyes with beta-zone PPA progressed more rapidly (-0.84+/-0.8 dB/year) than eyes without it (-0.51+/-0.6 dB/year; P<0.01). Multivariate regression showed significant influence of mean IOP (hazard ratio [HR], 1.11; P<0.01), IOP fluctuation (HR, 1.17; P = 0.02), and presence of beta-zone PPA (HR, 2.59; P<0.01) on VF progression. Moderate (0.5-1.5 dB/year; P = 0.01) and fast (>1.5 dB/year; P = 0.08) global rates of progression occurred more commonly in eyes with beta-zone PPA than in eyes without it. Thinner CCT (<525 microm) had a weak but significant correlation with presence of beta-zone PPA (kappa = 0.13). CONCLUSIONS: Eyes with beta-zone PPA are at increased risk for glaucoma progression and warrant close clinical surveillance.

Recurrent disc hemorrhage does not increase the rate of visual field progression.

AIMS: To determine whether recurrent disc hemorrhage (DH) accelerates glaucomatous visual field (VF) loss compared to an isolated, single, detected DH. METHODS: We evaluated the disc photographs of consecutive patients with >/=5 SITA-Standard fields for DH. Group A had patients with a single DH in one eye, and group B had at least one recurrence in the same eye. Automated pointwise linear regression analysis was used to calculate rates of progression. Logistic regression was used to determine ocular or systemic variables associated with DH recurrence after baseline assessment. RESULTS: One hundred and seventeen patients were enrolled (group A = 72, group B = 45). The mean age was 67.1 +/- 10.8 years; most patients were women (65%) of European ancestry (92%) diagnosed with primary open-angle glaucoma (47%). The mean number of VF after the initial DH was 7.9 +/- 2.9, spanning a mean of 4.6 +/- 2.2 years. None of the ocular or systemic characteristics revealed a significant difference between groups. The mean global rate of progression (group A, -0.8 +/- 0.6 vs group B, -0.8 +/- 0.7 dB/year, p = 0.93) and number of eyes reaching a progression endpoint (group A, 70% vs group B, 73%, p = 0.80) did not differ between groups. Recurrent DH eyes showed a tendency to be followed longer, with a greater number of disc photographs, which was not significant in the multivariate analysis. The global rates of progression between groups remained non-significant even after adjusting to follow-up time and number of VF tests (p = 0.69). CONCLUSION: Recurrent DH does not result in a faster rate of VF progression compared to a single detected DH. Eyes with single or recurrent DH have similar risks for future disease progression.