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Patients with low-pressure glaucoma may benefit from aggressive treatment
Several factors may help identify low-pressure glaucoma patients at risk for progression, according to a study recently published in the European Journal of Ophthalmology.
Erdem and colleagues conducted a retrospective review of 49 eyes of 49 patients to evaluate risk factors for progression of low-pressure glaucoma (LPG).
They noted the following over a period of greater than 8 years for each patient: family history of glaucoma, refractive error, central corneal thickness (CCT), intraocular pressure change after pupil dilation, visual field mean deviation, time to progression, systemic diseases, best-corrected visual acuity, treatments, IOP, optic disc assessment and visual field grading.
Researchers classified progression as a worsening of both disc and visual field.
Results showed that glaucoma progressed in 25 eyes. Researchers reported that eyes that had progressed had higher peak IOP as well as thinner CCT and disc hemorrhage.
"Higher peak IOP was the major risk factor for long-term glaucoma progression in patients with LPG," the authors concluded. "Patients with more severe baseline visual field damage were slightly more likely to show progression, and there was a trend toward significance, suggesting that disc hemorrhage and thin CCT may also be risk factors for progression."
They suggested: "It may be prudent to monitor closely patients at risk for progression and consider treating them more aggressively to prevent further disease progression." – by Chelsea Frajerman Pardes
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Up to 50% of patients with glaucomatous optic neuropathy will present with statistically normal IOPs. Erdem and colleagues have demonstrated that nearly two-thirds will subsequently demonstrate structural or functional progression.
Clinicians cannot be lulled into a false sense of security by “normal” pressures, but must remain vigilant in their optic nerve head assessment, particularly in the presence of: female gender; disc hemorrhage (which confers a sixfold increased risk of progression); thinner central corneal thickness; higher peak IOP (at the high end of “normal”) and/or IOP fluctuation; a history of migraine, Raynaud’s and/or sleep apnea (as surrogates for vascular dysregulation); systemic hypotension (including iatrogenic nocturnal blood pressure dips coinciding with physiologic IOP peaks, reducing ocular perfusion pressure); and inferior optic nerve head damage (Hood’s macular vulnerability zone), which may be accompanied by initial deep superior visual field defects encroaching on fixation, best assessed with 10-2 analysis.
Although 15 years have passed, normal-tension glaucoma remains “a common form of glaucoma that is not commonly ‘detected,’ and ‘the offices of glaucoma specialists have far too many patients who have progressed to blindness under ‘observation.’”
Risk factor awareness and scrutiny of every optic nerve head are important steps in making these statements past, not present tense.
References:
Caprioli J. Am J Ophthalmol. 1998;126(4):578-581.
Caprioli J. Am J Ophthalmol. 2001;131(6):792-794. doi: http://dx.doi.org/10.1016/S0002-9394(01)00924-2.