Quantitative analysis of retinal nerve fiber layer defect in early open-angle glaucoma with normal intraocular pressure.

PURPOSE: To quantitatively analyze the topographic features of localized retinal nerve fiber layer (RNFL) defects according to baseline intraocular pressure (IOP) level in cases of early primary open-angle glaucoma (POAG). STUDY DESIGN: Retrospective comparative study. METHODS: POAG patients meeting the following conditions were consecutively included: (1) baseline office-hour diurnal IOP ≤ 21 mmHg, (2) 1 localized RNFL defect as observed on red-free fundus photography, and (3) corresponding visual field defect. Defects' approximations to the macula (angle α) and width (angle ß) as well as the angle between the disc long axis and the vertical meridian line (angle Ɣ) were measured on red-free fundus photography. The corrected angle α was calculated as the difference between angles α and Ɣ. The defect area's RNFL thickness was calculated by means of optical coherence tomography's Advanced Extraction analysis utility. RESULTS: Comparative analysis was performed between 2 groups: 45 eyes of 45 patients with low-teen IOP (group A: highest IOP ≤ 15 mmHg) and 49 eyes of 49 patients with high-teen IOP (group B: lowest IOP > 15 mmHg). In group A, the mean baseline IOP was lower (12.9 ± 1.3 vs 17.1 ± 1.0 mmHg; P < .001), the corrected angle α was smaller (32.4 ± 15.1 vs 39.5 ± 13.1 degrees; P = .017), and the defect area's RNFL thickness was thinner (66.3 ± 16.8 vs 76.3 ± 14.9 µm; P = .003) than in group B; angle ß showed no intergroup difference (P = .230). CONCLUSIONS: In POAG patients with low-teen IOP relative to those with high-teen IOP, localized RNFL defects were closer to the macula. In addition, the RNFL thickness of the defect area was markedly thinner.

Serial Combined Wide-Field Optical Coherence Tomography Maps for Detection of Early Glaucomatous Structural Progression.

Importance: Both parapapillary and macular areas are important in determining the progression of early glaucoma. However, no attempt has been made to assess the progression of glaucoma in images that combine the 2 areas. Objective: To evaluate the potential usefulness of serial analysis of combined wide-field optical coherence tomography (OCT) maps for detection of structural progression in patients with early glaucoma. Design, Setting, and Participants: Retrospective observational study. Patients with early primary open-angle glaucoma with a minimum of 3-year follow-up involving serial spectral-domain OCT measurement were analyzed. Patients were divided into a nonprogressor group (n = 47) and a progressor group (n = 47) on the basis of serial stereo disc photography and red-free photography. Serial combined wide-field OCT maps integrating parapapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) maps were generated with the embedded software of serial spectral-domain OCT. Glaucoma specialists then assessed the structural progression detection ability of those serial wide-field OCT maps for early glaucomatous eyes and compared their sensitivity with those of RNFL and GCIPL guided progression analyses (GPAs). Main Outcomes and Measures: The diagnostic ability of the serial wide-field OCT maps for early glaucomatous structural progression. Results: Ninety-four patients (mean [SD] age, 51.4 [12.3] years; 48 [51.1%] women; all Korean) were included. The serial wide-field OCT map analysis showed good agreement for detection of structural progression between the 2 glaucoma graders (wide-field OCT thickness map: κ = 0.649; wide-field OCT deviation map: κ = 0.833). These maps showed early glaucomatous structural progression detection abilities comparable with those of RNFL and GCIPL GPAs (sensitivities of wide-field OCT thickness map, wide-field OCT deviation map, RNFL GPA, and GCIPL GPA = 63.8%, 83.0%, 83.0%, and 66.0%, respectively, all P > .05; specificities of wide-field OCT thickness map, wide-field OCT deviation map, RNFL GPA, and GCIPL GPA = 93.6%, 95.7%, 84.8%, and 93.6%, respectively, all P > .05). Conclusions and Relevance: The serial combined wide-field OCT maps integrating RNFL and GCIPL maps performed well in detecting structural progression in early glaucomatous eyes. Confirmation in an independent prospective study might provide greater confidence in this conclusion.

Baseline Lamina Cribrosa Curvature and Subsequent Visual Field Progression Rate in Primary Open-Angle Glaucoma.

PURPOSE: To investigate the relationship between the degree of posterior bowing of the lamina cribrosa (LC) at baseline and the rate of subsequent visual field (VF) progression in eyes with primary open-angle glaucoma (POAG). DESIGN: Prospective, observational study. PARTICIPANTS: One hundred one early-stage (VF mean deviation [MD], -5.0 to -0.01 dB) POAG eyes that met the following conditions: (1) follow-up longer than 3.5 years, (2) more than 5 reliable standard automated perimetry tests, and (3) medically well-controlled intraocular pressure during follow-up. METHODS: All participants underwent swept-source OCT scanning of the LC at baseline. The area enclosed by a vertical line at the anterior laminar insertion, anterior LC plane, and reference plane of Bruch's membrane opening (BMO) was divided by D (distance between the 2 cross-points made by vertical lines drawn from the anterior laminar insertion to the reference plane of BMO) to approximate the LC depth (LCD). The difference between the LCD and mean anterior laminar insertion depth was defined as the LC curvature index (LCCI). To consider the steepness of the LC curve, the adjusted LCCI (aLCCI) was calculated as LCCI divided by D and multiplied by 100. The mean LCD (mLCD), mean LCCI (mLCCI), and mean aLCCI (maLCCI) were computed by averaging the measurements on 12 radial scans. The subsequent MD slope and associated factors were analyzed. MAIN OUTCOME MEASURES: Lamina cribrosa parameters and subsequent MD slope. RESULTS: The participants' mean baseline MD was -3.8 ± 3.4 dB. The mean baseline mLCD, mLCCI, and maLCCI were 419.0 ± 111.2 µm, 76.4 ± 29.0 µm, and 4.8 ± 1.9, respectively. A greater MD slope was associated with a greater baseline maLCCI (P < 0.001). We found a statistically significant breakpoint for the maLCCI (4.12) above which a larger maLCCI showed a steeper MD slope (P < 0.001). Analysis by age revealed that significantly more VF progression with maLCCI changes occurred in the relatively younger group (≤69 years; P = 0.043). CONCLUSIONS: The baseline maLCCI showed a significant correlation with the rate of subsequent VF deterioration. This suggests that, in POAG eyes with greater posterior bowing of the LC, the axons of retinal ganglion cells may be more vulnerable to further glaucomatous injury.

Comparison of 1-year outcomes after Ahmed glaucoma valve implantation with and without Ologen adjuvant.

BACKGROUND: Many studies have investigated the clinical benefits of Ologen for trabeculectomy. However, its benefits for Ahmed glaucoma valve (AGV) implantation have not been investigated as extensively. The aim of this study was to compare the 1-year outcomes of AGV implantation with and without Ologen adjuvant for the treatment of refractory glaucoma. METHODS: This retrospective study included a total of 20 eyes of 20 glaucoma patients, who were followed for at least 1-year after undergoing AGV implantation. In 12 eyes of 12 patients, conventional AGV (CAGV) surgery was performed, while in 8 eyes of 8 patients, Ologen-augmented AGV (OAGV) implantation was performed. The outcomes were evaluated according to intraocular pressure (IOP) and the number of IOP-lowering medications. Complete success was defined as IOP ≤ 21 mmHg without medications throughout the 1-year follow-up period, and qualified success was defined as IOP ≤ 21 mmHg with or without medications throughout the 1-year follow-up period. RESULTS: The rate of complete success was significantly higher in the OAGV group (50.0%) than in the CAGV group (8.3%) (p = 0.035). There were no significant differences between the two groups in terms of qualified success or incidence of the early hypertensive phase. The IOP changes were similar between the groups within 1-year postoperatively, though the number of IOP-lowering medications was significantly lower in the OAGV group during the early hypertensive phase (p = 0.031, 0.031, and 0.025 at postoperative months 1, 2, and 3, respectively). When subjects were divided into groups according to the occurrence of the early hypertensive phase, the group with early hypertensive phase was more likely to use IOP-lowering medications at postoperative 6 months and 1 year (p = 0.002 and 0.005, respectively). CONCLUSIONS: OAGV surgery shows encouraging results for patients with refractory glaucoma, specifically with respect to the achievement of complete success and the reduction of the number of IOP-lowering medications during the early hypertensive phase. Furthermore, our results suggest that occurrence of the early hypertensive phase is predictive of which patients will require IOP-lowering medications at postoperative 6 months and 1 year.

Prophylactic removal and microbiological evaluation of calcified plaques after pterygium surgery.

PURPOSE: The aim of this study was to investigate microbiological characteristics of prophylactically removed calcified plaques developed after pterygium excision, and to evaluate risk factors for the growth of microorganisms. METHODS: Only exposed calcified plaques developed at the same site of previous pterygium excision were prospectively removed in 15 eyes of 14 patients. Plaques were completely removed, divided into small pieces and evaluated for microbiological identification. Underlying scleral defects were reconstructed using a conjunctival autograft, amniotic membranes and scleral patch grafts according to the size and depth of the defects. Based on the results of microbiologic cultures, eyes were divided into two groups and risk factors for microbial growth were analyzed. RESULTS: At surgery, the mean age of the patients was 71.2 ± 5.8 years and 71.4 % were females. The mean time interval between pterygium excision and calcified plaque removal was 19.3 ± 13.8 years. Six of 15 (40 %) removed plaques showed bacterial growth, and Stenotrophomonas maltophilia was the most frequently isolated microorganism. The size of calcified plaques was the only risk factor for culture-positive results (p = 0.045). Underlying scleral defects were successfully repaired without any serious complication. CONCLUSIONS: Microorganisms can be isolated from calcified plaques developed at the site of previous pterygium excision, and the size of plaques is the only risk factor for culture-positive results. To remove potential source of infection, prophylactic removal of calcified plaques and scleral surface reconstruction should be considered, especially when the plaques are exposed and large.

Patterns of subsequent progression of localized retinal nerve fiber layer defects on red-free fundus photographs in normal-tension glaucoma.

PURPOSE: To investigate patterns of subsequent progression of localized retinal nerve fiber layer (RNFL) defects and to quantify the extent of progression in normal-tension glaucoma (NTG) patients. METHODS: Thirty-three eyes of 33 consecutive NTG patients who had shown continuous progression of localized RNFL defect on serial red-free fundus photographs were selected for the study. Patterns of subsequent progression of localized RNFL defects were categorized, and extents of progression were quantified. Serial evaluations of disc stereophotographs and visual fields were also performed to detect progression. RESULTS: The most common pattern was continuous widening of the defect towards the macula (n = 11, 33.3%) followed by sharpening of the defect border after widening of the defect towards the macula (n = 5, 15.2%), continuous widening of the defect away from the macula (n = 2, 6.1%), and deepening of the defect after appearance of a new defect (n = 2, 6.1%). Four eyes (12.1%) simultaneously showed two patterns of subsequent progression. In 13 eyes that showed continuous widening of the defect, subsequent angular widening towards the macula and away from the macula were 9.2 ± 6.0° (range, 1.1° to 24.4°; n = 11) and 5.2 ± 4.9° (range, 0.3° to 11.3°; n = 2), respectively. Thirty-two eyes showed no progression of optic disc cupping. Out of the 21 eyes in which Humphrey central 30-2 threshold visual field tests were performed after progression of RNFL defects, 15 eyes showed no deterioration in the visual field. CONCLUSIONS: There were nine patterns of subsequent progression of localized RNFL defects. Among them, continuous RNFL loss proceeding temporally was the most common one. Initial progression of the defect proceeded temporally, especially in the defect located at the inferior fundus, might be at a risk of further RNFL loss temporally.