Systemic Diseases in Primary Open-Angle Glaucoma. / Internistische Erkrankungen und Zusammenhang mit dem primären Offenwinkelglaukom.

Primary open-angle glaucoma is a neurodegenerative disease with progressive chronic optic neuropathy and corresponding visual field defects. In this literature review, we discuss systemic diseases and their mechanism for developing glaucoma, including systemic hypertension and hypotension, diabetes, dyslipidemia, obstructive sleep apnoea syndrome, chronic kidney disease, migraine, and polypharmacy.

Adults Born Small for Gestational Age at Term Have Thinner Peripapillary Retinal Nerve Fiber Layers Than Controls.

Purpose: Prenatal growth restriction is associated with impaired neurodevelopment in childhood. This study investigated the effects of being born small for gestational age (SGA) on peripapillary retinal nerve fiber layer (pRNFL) thickness in adults born at term. Methods: A retrospective cohort study was conducted with a prospective ophthalmologic examination of participants born at full-term (gestational age ≥37 weeks) between 1969 and 2002. All participants were examined with spectral-domain optical coherence tomography and grouped according to their birth weight in correlation to gestational age as former moderate (birth weight (BW) percentile 3rd to <10th) and severe SGA (<3rd percentile), normal (10th-90th percentile, AGA), and moderately (>90th to 97th percentile) and severely (>97th percentile) large for gestational age (LGA) adults (18 to 52 years). Results: Overall, 547 eyes of 285 individuals (age 29.9±9.4 years, 151 females) born at term were included. Multivariable regression analyses revealed a strong association between a lower global pRNFL thickness in the severe SGA (B=-8.99 [95%-CI: -12.68; -5.30] µm; p<0.001) and in the moderate SGA groups (B=-6.40 [95%-CI: -10.29; -2.50] µm; p=0.001) compared to the reference AGA group. Conclusion: Our results indicate that restricted fetal growth affects neurologic tissue development of the optic nerve head, particularly in individuals born severely SGA at term. This indicates that fetal growth restriction may exert disturbances in the development of neurologic tissue, which persists in adulthood.

Twenty-Years of Experience in Childhood Glaucoma Surgery.

To quantify the results of childhood glaucoma treatment over time in a cohort of children with different types of childhood glaucoma. A retrospective cohort study of consecutive cases involving children with primary congenital glaucoma, primary juvenile, and secondary juvenile glaucoma at the Childhood Glaucoma Center, University Medical Center Mainz, Germany from 1995 to 2015 was conducted. The main outcome measure was the long-term development of intraocular pressure. Further parameters such as surgical success, refraction, corneal diameter, axial length, and surgical procedure in children with different types of childhood glaucoma were evaluated. Surgical success was defined as IOP < 21 mmHg in eyes without a need for further intervention for pressure reduction. A total of 93 glaucomatous eyes of 61 childhood glaucoma patients with a mean age of 3.7 ± 5.1 years were included. The overall mean intraocular pressure at first visit was 32.8 ± 10.2 mmHg and decreased to 15.5 ± 7.3 mmHg at the last visit. In the median follow-up time of 78.2 months, 271 surgical interventions were performed (130 of these were cyclophotocoagulations). Many (61.9%) of the eyes that underwent surgery achieved complete surgical success without additional medication. Qualified surgical success (with or without additional medication) was reached by 84.5% of the eyes.

Impact of intraocular pressure fluctuations on progression of normal tension glaucoma.

AIM: To investigate short- and long-term intraocular pressure (IOP) fluctuations and further ocular and demographic parameters as predictors for normal tension glaucoma (NTG) progression. METHODS: This retrospective, longitudinal cohort study included 137 eyes of 75 patients with NTG, defined by glaucomatous optic disc or visual field defect with normal IOP (<21 mm Hg), independently from therapy regimen. IOP fluctuation, mean, and maximum were inspected with a mean follow-up of 38mo [standard deviation (SD) 18mo]. Inclusion criteria were the performance of minimum two 48-hour profiles including perimetry, Heidelberg retina tomograph (HRT) imaging, and optic disc photographs. The impact of IOP parameters, myopia, sex, cup-to-disc-ratio, and visual field results on progression of NTG were analyzed using Cox regression models. A sub-group analysis with results from optical coherence tomography (OCT) was performed. RESULTS: IOP fluctuations, average, and maximum were not risk factors for progression in NTG patients, although maximum IOP at the initial IOP profile was higher in eyes with progression than in eyes without progression (P=0.054). The 46/137 (33.5%) eyes progressed over the follow-up period. Overall progression (at least three progression confirmations) occurred in 28/137 eyes (20.4%). Most progressions were detected by perimetry (36/46). Long-term IOP mean over all pressure profiles was 12.8 mm Hg (SD 1.3 mm Hg); IOP fluctuation was 1.4 mm Hg (SD 0.8 mm Hg). The progression-free five-year rate was 58.2% (SD 6.5%). CONCLUSION: Short- and long-term IOP fluctuations do not result in progression of NTG. As functional changes are most likely to happen, NTG should be monitored with visual field testing more often than with other devices.

Peripapillary Retinal Nerve Fiber Layer Profile in Relation to Refractive Error and Axial Length: Results From the Gutenberg Health Study.

Purpose: To investigate the retinal nerve fiber layer profile measured by optical coherence tomography and its relation to refractive error and axial length. Methods: The Gutenberg Health Study is a population-based study in Mainz, Germany. At the five-year follow-up examination, participants underwent optical coherence tomography, objective refraction and biometry. Peripapillary retinal nerve fiber layer (pRNFL) was segmented using proprietary software. The pRNFL profiles were compared between different refraction groups and the angle between the maxima, i.e., the peaks of pRNFL thickness in the upper and lower hemisphere (angle between the maxima of pRNFL thickness [AMR]) was computed. Multivariable linear regression analysis was carried out to determine associations of pRNFL profile (AMR) including age, sex, optic disc size, and axial length in model 1 and spherical equivalent in model 2. Results: A total of 5387 participants were included. AMR was 145.3° ± 23.4° in right eyes and 151.8° ± 26.7° in left eyes and the pRNFL profile was significant different in the upper hemisphere. The AMR decreased with increasing axial length by -5.86°/mm (95% confidence interval [CI]: [-6.44; -5.29], P < 0.001), female sex (-7.61°; 95% CI: [-8.71; -6.51], P < 0.001) and increased with higher age (0.08°/year; 95% CI: [0.03; 0.14], P = 0.002) and larger optic disc size (2.29°/mm2; 95% CI: [1.18; 3.41], P < 0.001). In phakic eyes, AMR increased with hyperopic refractive error by 2.60°/diopters (dpt) (95% CI: [2.33; 2.88], P < 0.001). Conclusions: The pRNFL profiles are related to individual ocular and systemic parameters. Translational Relevance: Biometric parameters should be considered when pRNFL profiles are interpreted in diagnostics, i.e., in glaucoma.

Efficacy and safety of XEN®-Implantation vs. trabeculectomy: Data of a "real-world" setting.

OBJECTIVE: To compare surgical success, postoperative intraocular pressure and complication rates between trabeculectomy and XEN gelstent surgery in a cohort of glaucoma patients in a typical clinical setting. METHODS: A retrospective cohort study of consecutive patients with refractory open-angle glaucoma including patients who underwent either stand-alone XEN gelstent insertion with Mitomycin C or trabeculectomy with Mitomycin C between 2016 and 2018 at the University Eye Hospital Mainz, Germany. Primary outcome measure was the proportion of surgical success 1 year after surgery. Patients with an IOP ≤18mmHg, an intraocular pressure reduction of >20% and in no need of revision surgery or topical medication were considered a complete surgical success. If topical therapy was necessary, they were considered a qualified success. Multivariable logistic regression analysis was carried out for the primary outcome including gender, age, preoperative intraocular pressure and number of medication classes used preoperatively as adjustment variables. RESULTS: 171 eyes of 144 patients were included, including 82 eyes of 58 patients in the XEN group and 89 eyes of 86 patients in the trabeculectomy group. The primary outcome defined as the proportion of surgical success after 1 year (mean 11.1 months ± 2.2) was similar for both groups. The complete success proportion was 65.5% (95%-CI: 55.6-75.9%) in the trabeculectomy group, and 58.5% (95%-CI: 47.6-69.4%) in the XEN group and not statistically different in our analysis model (crude OR = 0.61; 95%-CI: 0.31-1.22; adjusted OR = 0.66; 95%-CI: 0.32-1.37). The intraocular pressure reduction, as secondary outcome measure, was higher in the trabeculectomy group (10.5 mmHg) compared to the XEN group (7.2 mmHg; p = 0.003) at the 12-month follow-up. CONCLUSION: Both XEN gelstent implantation and trabeculectomy show similar proportions of surgical success and of complications and are therefore both recommendable for clinical routine. However, trabeculectomy seems to be more effective in lowering intraocular pressure than the XEN implantation. A prospective randomized clinical trial is necessary to evaluate differences in the long-term clinical outcome.

The impact of intraocular pressure fluctuations and other factors on conversion of ocular hypertension to primary open-angle glaucoma.

PURPOSE: To evaluate the role of intraocular pressure (IOP) fluctuations and other factors on conversion of ocular hypertension to open-angle glaucoma (OAG) within a retrospective, longitudinal cohort study. PATIENTS AND METHODS: The study population included patients with ocular hypertension defined by IOP > 21 mmHg with normal appearing optic discs and no visual field defect. IOP fluctuation, mean and maximum were examined in 61 eyes over a follow-up period of 36 months (standard deviation (SD) 24). All patients underwent at least two 48-h IOP profiles including night-time IOP measurements in the supine position, visual field examinations, Heidelberg retina tomograph analyses (HRT) and optic disc photographs. Regression analyses were performed to demonstrate the impact of IOP parameters, myopia, sex, cup/disc ratio and visual field results on conversion to glaucoma. RESULTS: While IOP fluctuation and mean did not impact conversion, myopia proved to be a risk factor (HR 14.4; 95% CI: [3.9-53.0]; p ≤ 0.001). Over an average of three years, 6/61 converted to OAG. The study yielded a mean long-term IOP over all available pressure profiles of 18.1 mmHg (SD 3.2) and an IOP fluctuation of 1.9 mmHg (SD 1.1) within a mostly treated cohort. Conversion-free five-year rate was 59.8%. CONCLUSIONS: The amount of fluctuation we measured in our study sample did not result in the development of glaucoma in treated ocular hypertension patients. Myopic subjects with ocular hypertension are at a higher risk for glaucoma conversion than non-myopic ocular hypertensive subjects are.

[The Role of Intraocular Pressure Fluctuation in the Development and Progression of Glaucoma]. / Der Einfluss intraokularer Druckschwankungen auf die Glaukomerkrankung.

Intraocular pressure fluctuation has been discussed as a risk factor for glaucoma development and glaucoma progression. Two clinical trials (Sweden and USA) have evaluated the relationship between IOP and glaucoma progression. Both studies will be discussed in this review. Additionally, some smaller studies exist that are mentioned and discussed as well. This review summarizes the most important studies.

A New Method for Revision of Encapsulated Blebs after Trabeculectomy: Combination of Standard Bleb Needling with Transconjunctival Scleral Flap Sutures Prevents Early Postoperative Hypotony.

PURPOSE: A simple needling procedure is the standard method for restoring the function of an encapsulated bleb after trabeculectomy. However, postoperative hypotony represents a possible hazard. This study describes a new surgical approach for treating encapsulated blebs with reduced risk of early postoperative hypotony: bleb needling combined with transconjunctival sutures tightening the scleral flap directly. METHODS: The study included two groups of 23 patients with failing bleb following trabeculectomy: "Group 1" underwent simple needling revision of the filtering bleb and served as a control group, while "Group 2" received needling revision with additional transconjunctival scleral flap sutures, if intraoperatively the intraocular pressure was estimated to be very low. Intraocular pressure (IOP), postoperative management and complications were analyzed over a follow-up period of 4 weeks postoperatively. Results were compared using t-test or Mann-Whitney U-tests. RESULTS: Adverse effects occurred with a higher frequency after sole needling of the bleb (5 cases of choroidal effusion and 1 case of choroidal hemorrhage) than after the combined method with additional scleral sutures (1 case of choroidal effusion). The IOP on the first postoperative day was significantly lower in group 1, with 9.43 ± 9.01 mm Hg vs. 16.43 ± 8.35 mm Hg in group 2 (P = 0.01). Ten patients with ocular hypotony (IOD of 5 mmHg or lower) were found in group 1 and only two in group 2. One week and one month after surgery the intraocular pressure was similar in both groups (P>0.05). CONCLUSIONS: This new needling technique with additional transconjunctival scleral flap sutures appears to reduce postoperative hypotony, and may thus protect from further complications, such as subchoroidal hemorrhage.

Long-term results after transconjunctival resuturing of the scleral flap in hypotony following trabeculectomy.

PURPOSE: To present the 4-year follow-up results in the surgical treatment of hypotony following trabeculectomy with mitomycin C in glaucoma patients with additional flap sutures. DESIGN: Retrospective interventional case series. METHODS: Since 2006, 53 patients with hypotony maculopathy attributable to overfiltration following glaucoma surgery (trabeculectomy with mitomycin C) were included in this institutional study. We were able to follow up intraocular pressure (IOP) and distance-corrected visual acuity in 33 (62%) over 4 years, whereas all were followed over 2 years. To elevate IOP, we placed tangential transconjunctival sutures through the scleral flap and connected them to the adjacent sclera in all 53 patients. RESULTS: Mean IOP prior to surgery was 3.55 mm Hg (± 2.05; range 0-8 mm Hg), 20.08 mm Hg (± 12.48) on the first postoperative day, 10.69 mm Hg (± 4.73) after 1 month, 10.12 mm Hg (± 3.95) after 6 months, 10.42 mm Hg (± 4.17) after 2 years, and 9.5 mm Hg (± 3.93) after 4 years. Mean visual acuity (VA) improved from 0.8 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.5 after 1 month, and remained stable after 6 months at 0.3. Macular folds resolved in all patients and choroidal detachment in 51 patients (96%) after 6 months. IOP increase and vision improvement were statistically significant (<.05). CONCLUSION: Even 4 years after resuturing of the scleral flap through the intact conjunctiva, there is evidence that this surgical method is an effective and simple technique to treat hypotony maculopathy after glaucoma surgery.