Long-term IOP, disc hemorrhage risk factors for visual field progression
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Long-term IOP fluctuations and disc hemorrhage increased the risk for visual field loss in patients with advanced primary open-angle glaucoma, according to a study published in the Journal of Glaucoma.
“Patients at an advanced stage of the disease with severe loss of visual field are especially at risk of serious disability,” Jihei Sara Lee, MD, of Yonsei University College of Medicine in South Korea, and colleagues wrote. “Studies on advanced glaucoma, however, are relatively few, because not only is advanced glaucoma a challenging topic, it also lacks a clear definition. ... However, considering the devastating consequences of serious visual field loss, advanced glaucoma merits detailed investigations.”
To better understand risk predictors for progression of visual field, Lee and colleagues conducted a retrospective review of medical records to enroll 122 patients with advanced primary open-angle glaucoma, all of whom underwent IOP measurement, standard automated perimetry, Cirrus OCT (Zeiss) and fundus photography at 6-month intervals.
Thirty-six patients (mean age, 51.9 years; 56.8% men) had VF progression and showed greater long-term IOP fluctuations vs. the no progression group (2.6 mm Hg vs. 2 mm Hg; P = .008). Researchers also detected disc hemorrhage more frequently in the progression group (40.5% vs. 17.4%; P = .005).
Although long-term IOP fluctuations and disc hemorrhage were independent risk factors for visual field progression, patients with both conditions were at greater risks for progression (P = .035).
“Patients with advanced nerve damage and field loss, especially those in whom these factors are recognized, need vigorous treatment and close monitoring,” Lee and colleagues concluded.
Perspective
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Elevated IOP, whether peak or mean, has long been acknowledged as a risk factor for the onset and progression of glaucomatous optic neuropathy. The role of IOP fluctuation, both short- and long-term, has remained less certain.
Post-hoc analyses of Advanced Glaucoma Intervention Study data suggested that IOP variability was a driver of disease progression, particularly when absolute IOP was relatively low. Other investigations, including the Early Manifest Glaucoma Trial and Ocular Hypertension Treatment Study, have concluded otherwise.
Through retrospective chart review of patients with advanced glaucoma (MD worse than -12 dB) and mean IOP of about 13.5 mm Hg over an average of 8 years of follow-up, Lee and colleagues have found that both long-term (between-visit) IOP fluctuation and disc hemorrhage increase risk of VF progression, nearly threefold when concurrent.
Detecting progression in advanced glaucoma is challenging, as conventional OCT may be at its measurement floor, and VF testing can be extremely variable. Leveraging OCT angiography and the central 10-2 VF grid can be helpful, but this paper reinforces the value of routine tonometry and clinical optic nerve head examination/photography, perhaps the oldest tools in our shop, to assess IOP magnitude and stability and detect disc hemorrhage, at all stages of the glaucoma continuum.
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