Study: H. pylori may play a role in OAG

Additional research is needed to determine whether eradication of the bacteria could aid in glaucoma management.

Issue: September 1, 2002

ByMichael Piechocki

THESSALONIKI, Greece — Eradication of Helicobacter pylori infection may benefit management of patients with chronic open-angle glaucoma, according to a study performed here.

“Our study shows, for the first time, that patients with open-angle glaucoma are infected with H. pylori and that treating the infection improved their glaucoma parameters, intraocular pressure and visual field indices. Although the reduction of 1.2 mm Hg may not seem clinically significant, we should bear in mind the progressive nature of glaucoma and the fact that all our patients were maintained on the same regimen for 2 years,” Jannis Kountouras, MD, PhD, first author of the study, told Ocular Surgery News.

In a previous study, Dr. Kountouras and colleagues found an increased prevalence of H. pylori infection in patients with glaucoma compared to age-matched controls. Dr. Kountouras and colleagues performed the present study to evaluate the effect H. pylori eradication therapy had on elevated IOPs and visual field indices in patients with open-angle glaucoma.

According to Dr. Kountouras, demonstrating an association between H. pylori and glaucoma and showing a benefit of H. pylori eradication in the clinical course of the disease may have a major impact on the pathophysiology and management of glaucoma. Replication of their results by other investigators is also important, he said.

Recently, he said, another Greek research center in Athens confirmed an increased incidence of H. pylori infection in glaucoma patients.

“Nevertheless, before surgeons and other specialists begin to consider H. pylori eradication therapy as an established step in the management of chronic open-angle glaucoma, our findings need confirmation by other rigorously controlled epidemiologic studies,” he said.

Interesting possibility

When asked to comment on the study, Eve J. Higginbotham, MD, told Ocular Surgery News, “It is an interesting hypothesis that this could be a contributing factor, particularly if it relates to a vascular or autoimmune contribution to glaucoma.”

Dr. Higginbotham, who was not involved in the study, said the study does raise the interesting possibility that there could be another non-IOP related factor contributing to glaucoma progression in some patients.

“Certainly I think the study warrants additional research. It does raise a lot of questions. I would like to have had a more detailed analysis of the visual field,” she said.

The study researchers based their visual field measurements on the global indices.

“In terms of progression, it perhaps would have been better if they graded the visual field based on actual defects, as opposed to just a global index. Moreover, one can see improvement of the visual field because of long-term fluctuation as well as a learning curve,” Dr. Higginbotham said.

“As a clinician, I would have liked more detail. There were a lot more patients in the group who responded to therapy than there were in the other groups of patients, the groups that did not respond to therapy who had the H. pylori infection and who also had glaucoma. I think there needs to be additional study, as the authors themselves indicated,” she added.

Eradication study

According to the report, published in the Archives of Internal Medicine, the study was broken into two parts. One part included 41 patients with documented OAG and 30 age-matched controls. This part of the study was designed to evaluate the prevalence of H. pylori infection in chronic OAG.

The second part of the study involved the evaluation of H. pylori eradication therapy on glaucoma parameters. This included 36 patients who received H. pylori eradication therapy and five patients who tested negative for infection. During the 2-year follow-up, patients were evaluated for the effect of H. pylori eradication therapy on IOP and visual field parameters.

All patients included in the study were between the ages of 45 and 70 years, and had an IOP of 21 mm Hg or greater and typical glaucomatous optic nerve head changes and visual field loss.

All patients in the study underwent elective upper GI endoscopy combined with diagnostic biopsies at the study baseline. All patients with glaucoma also underwent the same procedure 3 months after the H. pylori eradication treatment.

Eradication therapy involved treatment with omeprazole (Prilosec, AstraZeneca), clarithromycin (Biaxin, Abbott) and amoxicillin for 1 week followed by omeprazole for 1 month.

All glaucoma patients also received topical glaucoma treatments.

High success rate

Dr. Kountouras and colleagues reported H. pylori eradication therapy was successful in 83% (30) of the patients who tested positive at baseline for the infection.

Adverse effects of the eradication therapy included mild abdominal pain, occasional nausea and vomiting, diarrhea, stomatitis and headache. The adverse events did not cause any patients to discontinue therapy.

Patients were separated into three groups for comparison. Group A was defined as the 30 patients in whom the eradication therapy was successful. Group B was composed of six remaining patients in whom eradication therapy was unsuccessful. Group C included five patients who did not receive H. pylori eradication therapy.

The researchers reported significant improvement in all glaucoma parameters at the treatment endpoints selected in the study (1 and 2 years), except mean defect in group A at 1-year follow-up. The change in mean defect at 1-year follow-up did not reach statistical significance (P = .25), they wrote.

In groups B and C, glaucoma parameters did not differ or slightly deteriorated statistically from study baseline. Interestingly, in Group C all baseline visual field indices were approximately within upper normal limit values and, in particular, two baseline visual field indices (mean defect and corrected loss variance) were significantly lower than in groups A and B, the authors wrote.

Patients successfully treated with eradication therapy showed a significant reduction of 1.2 mm Hg in IOP maintained over the 2 years of follow-up.

According to the report, H. pylori eradication seems beneficial for controlling IOP in patients with glaucoma, especially because the same decrease was not seen in Groups B and C even though they received the same anti-glaucoma regimen.

“Results of the present study suggest that eradication therapy may somehow improve the outflow facility of the eye,” the study authors wrote.

For Your Information:

Jannis Kountouras, MD, PhD, can be reached at 8 Fanariou St., Byzantio, Thessaloniki, Greece; (30) 31-438-714; fax: (30) 31-453-838; e-mail: jannis@med.auth.gr.

Eve J. Higginbotham, MD, can be reached at 419 West Redwood, Suite 58D, Baltimore, MD 21201; (410) 328-5929; fax: (410) 328-6346; e-mail: fcwejh6786@aol.com.

Reference:

Kountouras J, Mylopoulos N, et. al. Eradication of Helicobacter pylori may be beneficial in the management of chronic open-angle glaucoma. Arch Intern Med. 2002;162:1237-1244.