Clinical Profiles of Glaucomatous Patients With High-tension and Low-tension Optic Disc Hemorrhages: A Comparative Study.

PRCIS: Patients with low-tension optic disc hemorrhages (DHs) are more frequently women, have a diagnosis of normal-tension glaucoma (NTG) diagnosis and greater visual field (VF) loss. Symptoms of vascular dysregulation and Asian race also seem to be more prevalent in this clinical subtype. PURPOSE: Optic DH is an important glaucoma risk factor, and occurs in a wide intraocular pressure (IOP) range. We sought to characterize distinct clinical subtypes of patients with high-tension disc hemorrhage (HTDH) and low-tension disc hemorrhage (LTDH). PATIENTS AND METHODS: In this cross-sectional study, treated glaucomatous patients with DHs from 2 glaucoma services were consecutively enrolled. Disc photographs were evaluated for the presence of DH by 2 glaucoma specialists. After inclusion, patients were classified on HTDH (IOP≥16 mm Hg) and LTDH (IOP<16 mm Hg; median split). Clinical and ocular data from the time of DH detection were compared between groups. RESULTS: One hundred thirty-three DH patients were included (LTDH=66 eyes; HTDH=67 eyes). Patients with LTDH were more often women than those with HTDH (77% vs. 42%; P=0.030). There was also a trend for a higher prevalence of Asian descendants (24% vs. 9%; P=0.058) and symptoms suggestive of vascular dysregulation (34% vs. 14%; P=0.057) in LTDH patients. Eyes with LTDH also had worse VF mean deviation index (P=0.037), higher prevalence of NTG diagnosis (46% vs. 17%; P<0.001), and tended to have thinner central corneas (P=0.066). CONCLUSIONS: Patients developing DHs with treated IOPs in the low teens seem to more frequently fit in a profile represented by women, NTG diagnosis and greater VF loss. The presence of symptoms suggestive of vascular dysregulation and race also seem to differ between these 2 clinical subtypes. A closer optic disc surveillance is recommended for patients with the LTDH subtype, as they may develop DHs despite seemingly well-controlled IOP.

Factors associated with the presence of parafoveal scotoma in glaucomatous eyes with optic disc hemorrhages.

PURPOSE: Glaucomatous eyes with disc hemorrhage (DH) have a greater risk of paracentral visual field (VF) loss. However, not every DH eye presents with parafoveal scotoma (PFS), and contributing factors are still to be determined. In the present study, we investigated clinical and ocular factors associated with the presence of PFS in glaucomatous eyes with DH. METHODS: A case-control study was carried out. One hundred thirty glaucomatous patients with DH were enrolled. They were divided into two groups based on two reliable 24-2 VF tests: those with PFS (defined as ≥3 adjacent points with p < 5% within the central 10 degrees of fixation, ≥1 point with p < 1% lying at the innermost paracentral points, in the same hemifield) and those without PFS. Clinical and ocular data from the time of DH detection were compared between groups. Factors associated with the presence of PFS were investigated through logistic regression. RESULTS: The PFS group had a higher prevalence of Caucasian patients (82 vs. 47%; p < 0.01). Eyes with PFS had a more negative spherical equivalent and worse VF mean deviation (MD) index (p ≤ 0.01). There was a marginally significant intraocular pressure (IOP) difference between eyes with (15 mmHg) and without PFS (18 mmHg) at the time of DH detection (p = 0.10). Univariable analysis revealed PFS to be significantly associated with Caucasian race (OR, 3.02; p = 0.004), myopia (<-3 diopters; OR, 3.44; p = 0.039), and lower IOP (≤16 mmHg; OR, 2.10; p ≤ 0.047). Multivariable analysis, controlling for VF MD, revealed that only Caucasian race and myopia (as a continuous or categorical variable) remained significant in this model (p ≤ 0.038). CONCLUSIONS: Caucasian race and the presence and magnitude of myopia were found to be significantly associated with the presence of PFS in glaucomatous eyes with DH. Our results may help clinicians in the identification and surveillance of these eyes at higher risk of central VF loss.

The Association Between Clinical Features Seen on Fundus Photographs and Glaucomatous Damage Detected on Visual Fields and Optical Coherence Tomography Scans.

PURPOSE: To classify the appearance of the optic disc seen on fundus photographs of healthy subjects and patients with or suspected glaucoma whose diagnosis was based upon visual fields (VFs) and spectral-domain optical coherence tomography (sdOCT) results. PATIENTS AND METHODS: One eye of 100 patients with or suspected glaucoma and 62 healthy subjects were prospectively tested with 24-2 and 10-2 VF and macular and disc sdOCT cube scans. All eyes with or suspected glaucoma had a 24-2 mean deviation better than -6.0 dB and an abnormal appearing disc on stereophotographs. The retinal ganglion cell plus inner plexiform layer (RGC+) from the macular scans and the retinal nerve fiber layer (RNFL) from the macular and disc scans were segmented and converted to probabilities plots. An eye was considered "glaucoma" if the sdOCT probability plots showed an abnormality in a region that corresponded to a defect seen on the 24-2 and/or 10-2 VF total deviation plot. Similarly, an eye was considered "suspect" only if both the sdOCT and VF plots were normal. Healthy subjects (normal VFs and sdOCT) were classified as "controls" and used as reference for comparisons. Glaucoma specialists reviewed the stereophotographs and classified eyes based on the presence of signs suggestive of glaucomatous optic neuropathy. RESULTS: The pattern of clinical signs of glaucomatous optic neuropathy seen on stereophotographs was statistically different between glaucoma (P<0.001) and suspects (P<0.001) vs. controls and explained up to 68% of the total variance of the diagnosis based upon sdOCT and VFs. Vertical cup-to-disc>0.6, focal neuroretinal rim thinning, focal RNFL loss, and violation of the ISNT rule had the best performance to differentiate glaucoma and suspects from controls. Compared with the suspect group, glaucoma eyes (abnormal sdOCT and VF tests) were more likely to have vertical cup-to-disc>0.6 (92% vs. 69%, P=0.003), diffuse rim (53% vs. 9%, P<0.001) and RNFL (61% vs. 26%, P<0.001) thinning, and ß-zone parapapillary atrophy (68% vs. 17%, P<0.001). CONCLUSIONS: Focal and diffuse signs of glaucoma damage seen on stereophotographs often match damage shown on VFs and sdOCT. In addition, damage shown on VFs and sdOCT is often missed during clinical evaluation. Longitudinal studies ought to differentiate focal signs of glaucoma damage seen on stereophotography from false-positives or very early loss.

Central Glaucomatous Damage of the Macula Can Be Overlooked by Conventional OCT Retinal Nerve Fiber Layer Thickness Analyses.

PURPOSE: To assess the extent to which glaucomatous damage of the macula can be detected using the summary statistics of a commercial report based upon the circumpapillary retinal nerve fiber layer (cpRNFL) thickness obtained with frequency domain optical coherence tomography (fdOCT). METHODS: One hundred forty-three eyes of 143 open-angle glaucoma patients and suspects (56.4 ± 13.8 years) had 10-2 visual fields (VFs) and fdOCT macular and disc cube scans. RNFL and retinal ganglion cell plus inner plexiform layer thickness and probability maps were generated and combined with 10-2 VF information in a single-page, custom report previously described. Three graders evaluated these reports and classified each eye as "abnormal macula" or "normal macula." Commercially available fdOCT reports for cpRNFL thickness were generated using the automatic segmentation algorithm and norms from the machine. The ability of the reports to detect macular damage was analyzed in three ways: temporal quadrant (TQ) < 5%; TQ < 5% or clock hour 7 < 1% (TQ + CH7); and clock hours 7 through 10 with two sectors < 5% or one sector < 1% (CH7-10). RESULTS: Sixty-one (43%) eyes were classified "abnormal macula" and 41 (29%) as "normal macula"; the 10-2 VFs and OCT probability maps did not agree in the remaining eyes. Of the 61 abnormal eyes, the TQ criterion missed 47 (77%); TQ + CH7 missed 24 (39%); and CH7-10 missed 22 (36%). CONCLUSIONS: Conventional cpRNFL analyses on commercial OCT reports can miss macular (central field) damage. TRANSLATIONAL RELEVANCE: To detect glaucomatous damage of the macula, additional tests, such as macular cube scans and/or 10-2 VFs, should be performed.

Confocal Adaptive Optics Imaging of Peripapillary Nerve Fiber Bundles: Implications for Glaucomatous Damage Seen on Circumpapillary OCT Scans.

PURPOSE: To improve our understanding of glaucomatous damage as seen on circumpapillary disc scans obtained with frequency-domain optical coherence tomography (fdOCT), fdOCT scans were compared to images of the peripapillary retinal nerve fiber (RNF) bundles obtained with an adaptive optics-scanning light ophthalmoscope (AO-SLO). METHODS: The AO-SLO images and fdOCT scans were obtained on 6 eyes of 6 patients with deep arcuate defects (5 points ≤-15 db) on 10-2 visual fields. The AO-SLO images were montaged and aligned with the fdOCT images to compare the RNF bundles seen with AO-SLO to the RNF layer thickness measured with fdOCT. RESULTS: All 6 eyes had an abnormally thin (1% confidence limit) RNF layer (RNFL) on fdOCT and abnormal (hyporeflective) regions of RNF bundles on AO-SLO in corresponding regions. However, regions of abnormal, but equal, RNFL thickness on fdOCT scans varied in appearance on AO-SLO images. These regions could be largely devoid of RNF bundles (5 eyes), have abnormal-appearing bundles of lower contrast (6 eyes), or have isolated areas with a few relatively normal-appearing bundles (2 eyes). There also were local variations in reflectivity of the fdOCT RNFL that corresponded to the variations in AO-SLO RNF bundle appearance. CONCLUSIONS: Relatively similar 10-2 defects with similar fdOCT RNFL thickness profiles can have very different degrees of RNF bundle damage as seen on fdOCT and AO-SLO. TRANSLATIONAL RELEVANCE: While the results point to limitations of fdOCT RNFL thickness as typically analyzed, they also illustrate the potential for improving fdOCT by attending to variations in local intensity.

Adaptive optics imaging of healthy and abnormal regions of retinal nerve fiber bundles of patients with glaucoma.

PURPOSE: To better understand the nature of glaucomatous damage of the macula, especially the structural changes seen between relatively healthy and clearly abnormal (AB) retinal regions, using an adaptive optics scanning light ophthalmoscope (AO-SLO). METHODS: Adaptive optics SLO images and optical coherence tomography (OCT) vertical line scans were obtained on one eye of seven glaucoma patients, with relatively deep local arcuate defects on the 10-2 visual field test in one (six eyes) or both hemifields (one eye). Based on the OCT images, the retinal nerve fiber (RNF) layer was divided into two regions: (1) within normal limits (WNL), relative RNF layer thickness within mean control values ±2 SD; and (2) AB, relative thickness less than -2 SD value. RESULTS: As seen on AO-SLO, the pattern of AB RNF bundles near the border of the WNL and AB regions differed across eyes. There were normal-appearing bundles in the WNL region of all eyes and AB-appearing bundles near the border with the AB region. This region with AB bundles ranged in extent from a few bundles to the entire AB region in the case of one eye. All other eyes had a large AB region without bundles. However, in two of these eyes, a few bundles were seen within this region of otherwise missing bundles. CONCLUSIONS: The AO-SLO images revealed details of glaucomatous damage that are difficult, if not impossible, to see with current OCT technology. Adaptive optics SLO may prove useful in following progression in clinical trials, or in disease management, if AO-SLO becomes widely available and easy to use.

Evaluation of a One-Page Report to Aid in Detecting Glaucomatous Damage.

PURPOSE: We assessed the use of a customized, one-page structure + function report for aiding in detection of glaucomatous damage. METHODS: Two individuals (report specialists), experienced in analyzing optical coherent tomography (OCT) and visual field (VF) results, examined a customized one-page report for 50 eyes from 50 patients who either had glaucoma or were glaucoma suspects. The report contained key features of OCT scans with VF information. All patients had 24-2 VFs with a mean deviation (MD) better than -6 dB. The report specialists classified each hemifield and eye as either glaucomatous or nonglaucomatous based upon only the customized report, either without (phase 1) or with (phase 2) 24-2 VF information included on the report. Their results were compared to the classifications made by 3 ophthalmologists (glaucoma specialists) based upon traditional measures, namely stereo photographs, 24-2 VFs, and a commercially available, OCT disc scan report. RESULTS: The two report specialists agreed on all but one eye and four hemifields in phase 1, and on all eyes and all but one hemifield in phase 2. In phase 2, they judged 31 eyes abnormal. Of these 31 eyes, 30 were judged abnormal by all three glaucoma specialists and the 31st by two of the three. Without the VF information (phase 1), one report specialist classified 1, and the other 2, of these 31 "abnormal" eyes as normal. CONCLUSIONS: When using the one-page report, the experienced readers showed excellent inter-rater repeatability and diagnostic ability relative to glaucoma specialists. TRANSLATIONAL RELEVANCE: This condensed report may help the clinician assess glaucomatous damage.

Evaluation of tear film function, ocular surface and tear film in HIV-seropositive patients / Avaliação da função lacrimal, da superfície ocular e do filme lacrimal em pacientes soropositivos para o HIV

Objective: Evaluate tear function, tear film and ocular surface in patients with positive serology for HIV. Methods: Observational, cross-sectional, quantitative and analytical study, performed between june and october 2011, in the HSPE-SP Ophthalmology Department, including 32 patients. Sixteen were HIV-positive patients and 16 HIV-negative. Results: There was no significant statistical difference in the middle age between both groups (p=0.083). The ferning test was statistically different in HIV group (with predominance of III and IV) compared to the control group (in which predominated the patterns I and II), both in the right and the left eye (p = 0.019 and p < 0.001, respectively). Other parameters were not statistically significant between the groups. Conclusions: HIV-positive patients had no changes in lacrimal function and ocular surface, however, samples of tears showed differences considered statistically significant in the crystallization test, compared with samples obtained from controls.

Objetivo: Avaliar a função lacrimal, a superfície ocular e o filme lacrimal de pacientes com sorologia positiva para o vírus HIV. Métodos: Estudo observacional, transversal, quantitativo e analítico, realizado entre junho e outubro de 2011, no Departamento de Oftalmologia do HSPE-SP, com 32 pacientes no total, sendo 16 soropositivos para o HIV e 16 soronegativos. Resultados: Não houve diferença estatística significante na média da idade entre os grupos estudados (p = 0,083). O padrão do teste de cristalização da lágrima foi estatisticamente diferente no grupo de pacientes HIV (com predomínio dos padrões III e IV) em relação ao grupo controle (no qual predominaram os padrões I e II), tanto no olho direito como no esquerdo (p = 0,019 e p < 0,001, respectivamente). As demais variáveis estudadas não mostraram-se estatisticamente relevantes entre os grupos. Conclusão: Os pacientes soropositivos para o HIV não apresentaram alterações da função lacrimal e da superfície ocular, porém amostras de lágrimas evidenciaram diferenças consideradas estatisticamente significantes nos padrões dos testes de cristalização do filme lacrimal, quando comparadas com amostras obtidas de pacientes controles.

Avaliação da função lacrimal, da superfície ocular e do filme lacrimal em pacientes soropositivos para o HIV / Evaluation of tear film function, ocular surface and tear film in HIV-seropositive patients

Objetivo Avaliar a função lacrimal, a superfície ocular e o filme lacrimal de pacientes com sorologia positiva para o vírus HIV. Métodos Estudo observacional, transversal, quantitativo e analítico, realizado entre junho e outubro de 2011, no Departamento de Oftalmologia do Hospital do Servidor Público Estadual “Francisco Morato de Oliveira”, com 32 pacientes no total, sendo 16 soropositivos para o HIV e 16 soronegativos. Resultados Não houve diferença estatística significante na média de idade entre os grupos estudados (p = 0,083). O padrão do teste de cristalização da lágrima foi estatisticamente diferente no grupo de pacientes HIV (com predomínio dos padrões III e IV) em relação ao grupo controle (no qual predominaram os padrões I e II), tanto no olho direito como no esquerdo (p = 0,019 e p < 0,001, respectivamente). As demais variáveis estudadas não mostraram-se estatisticamente relevantes entre os grupos. Conclusão Os pacientes soropositivos para o HIV não apresentaram alterações da função lacrimal e da superfície ocular, porém amostras de lágrimas evidenciaram diferenças consideradas estatisticamente significantes nos padrões dos testes de cristalização do filme lacrimal, quando comparadas com amostras obtidas de pacientes controles...

Objective Evaluate tear function, tear film and ocular surface in patients with positive serology for HIV. Methods Observational, cross-sectional, quantitative and analytical study, performed between june and october 2011, in the HSPE-FMO, SP, Ophthalmology Department, including 32 patients. Sixteen were HIV-positive patients and 16 HIV-negative. Results There was no significant statistical difference in the middle age between both groups (p=0.083). The ferning test was statistically different in HIV group (with predominance of III and IV) compared to the control group (in which predominated the patterns I and II), both in the right and the left eye (p = 0.019 and p=0.001, respectively). Other parameters were not statistically significant between the groups Conclusion HIV-positive patients had no changes in lacrimal function and ocular surface, however, samples of tears showed differences considered statistically significant in the crystallization test, compared with samples obtained from controls...