VOL 74 | NO 4 2012 C ANADIAN J OURNAL OF O PTOMETRY | R EVUE CANADIENNE D ’ OPTOMÉTRIE 33 CLINICAL REVIEW BY DEREK MACDONALD, OD, FAAO Introduction F or a disease recognized as a common cause of irreversible vision loss, a universally agreed- XSRQ GHÀQLWLRQ RI JODXFRPD UH- PDLQV HOXVLYH *ODXFRPDWRXV RSWLF QHXURSDWK\ *21 LV FKDUDFWHUL]HG E\ D SURJUHVVLYH ORVV RI UHWLQDO JDQJOLRQ FHOOV 5*& UHVXOWLQJ LQ DQ H[FDYDWHG FXSSHG RSWLF QHUYH KHDG DQG ORVV RI YLVXDO ÀHOG VHQVL- WLYLW\ 1 Primary open-angle glaucoma 32$* WKH PRVW FRPPRQ IRUP RI WKH GLVHDVH LQ 1RUWK $PHULFD ZLWK D SUHYDOHQFH RI KDV EHHQ GHVFULEHG DV ´D PXOWLIDFWRULDO RSWLF QHXURSDWK\ FKDUDFWHUL]HG E\ DFTXLUHG ORVV RI UHWLQDO JDQJOLRQ FHOOV DQG RSWLF QHUYH DWURSK\µ 7KLV GHÀQLWLRQ KDV HYROYHG RYHU WLPH ZLWK VSHFLÀF PHQWLRQ RI LQWUDRFX- ODU SUHVVXUH ,23 QRZ FRQVSLFX- RXVO\ DEVHQW 7KLV LV DW OHDVW LQ SDUW LQ UHFRJQLWLRQ RI WKH SDUDGR[ RI RFXODU K\SHUWHQVLRQ 2+7 ZLWKRXW DFFRPSDQ\LQJ *21 DQG RI *21 LQ WKH SUHVHQFH RI ¶QRUPDO· ,23 LW FRXOG EH VWDWHG WKDW LQFUHDVHG ,23 LV VXIÀFLHQW DOWKRXJK QRW QHFHVVDU\ IRU WKH GHYHORSPHQW RI JODXFRPD 1RUPDOWHQVLRQ JODXFRPD 17* KDV EHHQ GHÀQHG DV 32$* ZLWK XQWUHDWHG ,23 ZLWKLQ WKH VWDWLVWLFDOO\ QRUPDO UDQJH RI PP+J RWKHUV VSHFLI\ WKDW KLJKZDWHU ,23 FDQQRW H[FHHG PP+J DW ZKLFK SRLQW D GLDJQRVLV RI 32$* LV HVWDEOLVKHG 3 ,QWHUHVWLQJO\ ZKLOH ,23 QR ORQJHU GHÀQHV 32$* LW GRHV GHÀQH 17* DQG UHPDLQV WKH VLQJOH PRVW LPSRU - WDQW DQG WKH RQO\ FXUUHQWO\ PRGLÀ- DEOH ULVN IDFWRU LQ WKH GHYHORSPHQW RI JODXFRPD )XUWKHU SDWLHQWV ZLWK 17* PD\ GHPRQVWUDWH D PRUH DJJUHVVLYH GLVHDVH LI OHIW XQWUHDWHG EXW RIWHQ UHVSRQG IDYRXUDEO\ WR ,23ORZHULQJ WUHDWPHQW 4 7KLV KDV OHG LQYHVWLJDWRUV WR VXJJHVW WKDW WKH JODXFRPD SHQGXOXP KDV VZXQJ WRR IDU DZD\ IURP ,23 DQG WKDW WKH GLVHDVH PD\ EH EHVW GHÀQHG DV WKH only pressure-dependent optic neuropathy. 5 ,QGHHG PDQ\ UHFRPPHQG WKDW WKH FRQFHSW RI GLVWLQFW FOLQLFDO HQWLWLHV be abandoned in favour of viewing JODXFRPD DV D FRQWLQXXP IURP SUL- PDULO\ ,23GHSHQGHQW 32$* WR ,23LQGHSHQGHQW 17* GLVHDVH *LYHQ WKDW DV PDQ\ DV ÀYH RI HYHU\ WHQ SDWLHQWV ZLWK JODXFRPD ZLOO SUHV- HQW ZLWK VWDWLVWLFDOO\ QRUPDO ,23 DQ XQGHUVWDQGLQJ RI WKH PXOWLIDFWRULDO QDWXUH RI ZKDW WKLV UHYLHZ ZLOO WHUP 17* LV RI FULWLFDO LPSRUWDQFH WR WKH H\H FDUH SUDFWLWLRQHU Epidemiology and Risk Factors (YHQ PRUH WKDQ 32$* 17* WHQGV WR EH D GLVHDVH RI WKH HOGHUO\ ZLWK D SUHYDOHQFH RI LQ WKH SRSXODWLRQ RYHU WKH DJH RI XS WR RI SDWLHQWV ZLWK 17* KRZHYHU ZLOO EH XQGHU WKH DJH RI 8SRQ GLDJQRVLV WKH UDWH RI SURJUHVVLRQ DQG UHVSRQVH WR WUHDWPHQW DSSHDU XQUHODWHG WR DJH 8 7KHUH LV HYLGHQFH WKDW 17* LV PRUH common, more severe, and more UHVLVWDQW WR WUHDWPHQW LQ IHPDOHV 7KHUH DOVR DSSHDUV WR EH DQ HWKQLF SUHGLOHFWLRQ DV XSZDUGV RI RI -DSDQHVH DQG 0RQJROLDQ SDWLHQWV ZLWK 32$* SUHVHQW ZLWK ,23 OHVV WKDQ PP+J &DXFDVLDQV KRZHYHU WHQG WR PDQLIHVW PRUH serious disease. 11-13 $ IDPLO\ KLV- WRU\ RI JODXFRPD LV UHSRUWHG E\ WR RI SDWLHQWV ZLWK 17* ,QYHVWLJDWRUV KDYH REVHUYHG WKDW SDWLHQWV ZLWK 17* WHQG WR EH RI ORZHU ERG\ ZHLJKW DQG ERG\PDVV Under pressure: a review of normal-tension glaucoma En moyenne, un patient sur trois atteint de neuropathie optique glaucomateuse aura une pression intraoculaire se situant à l’intérieur des limites de la normale et recevra le diagnostic de glaucome à tension normale. Les professionnels des soins oculovisuels (et leurs patients) auront intérêt à bien connaître le diagnostic, le traitement et le pronostic de cette condition et à bien comprendre non seulement les similitudes et les diérences avec le glaucome primaire à angle ouvert mais les rôles importants joués par le système nerveux central et l’état vasculaire systémique. Mots clés : Glaucome à tension normale (GTN), glaucome primaire à angle ouvert (GPAO), hystérèse cornéenne (HC), hémorragie discale (HD), atrophie péripapillaire de la zone bêta (APPβ), pression de perfusion oculaire (PPO), dysrégulation vasculaire, pression du liquide céphalorachidien (PLCR), diérence de pression à travers la lame criblée, neuroprotection RÉSUMÉ
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Under pressure: a review of normal-tension glaucomaUnder pressure: a review of normal-tension glaucoma En moyenne, un patient sur trois atteint de neuropathie optique glaucomateuse
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VOL 74 | NO 4 2012C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I E 33
CLINICAL REVIEW
BY DEREK MACDONALD, OD, FAAO
Introduction
For a disease recognized as a common cause of irreversible
vision loss, a universally agreed--
-1 Primary open-angle glaucoma
--
3
--
4
only pressure-dependent optic neuropathy.5
be abandoned in favour of viewing -
-
Epidemiology and Risk Factors
8
common, more severe, and more
serious disease.11-13 -
Under pressure: a review of normal-tension glaucoma
En moyenne, un patient sur trois atteint de neuropathie optique glaucomateuse aura une pression intraoculaire se situant à l’intérieur des limites de la normale et recevra le diagnostic de glaucome à tension normale. Les professionnels des soins oculovisuels (et leurs patients) auront intérêt à bien connaître le diagnostic, le traitement et le pronostic de cette condition et à bien comprendre non seulement les similitudes et les di!érences avec le glaucome primaire à angle ouvert mais les rôles importants joués par le système nerveux central et l’état vasculaire systémique.
Mots clés : Glaucome à tension normale (GTN), glaucome primaire à angle ouvert (GPAO), hystérèse cornéenne (HC), hémorragie discale (HD), atrophie péripapillaire de la zone bêta (APP!), pression de perfusion oculaire (PPO), dysrégulation vasculaire, pression du liquide céphalorachidien (PLCR), di"érence de pression à travers la lame criblée, neuroprotection
RÉSUMÉ
C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I EVOL 74 | NO 4 201234
14 -
-
-
Pathophysiology – Under Pressure
-
-versally.19
-
-
-
-
-
-
31
cc
encompassing a more global corneal
cc
33
-34
35
On average, every third patient with glaucomatous optic neuropathy will present with intraocular pressure within the statistically normal range, manifesting normal-tension glaucoma. Eye care practitioners (and their patients) will bene"t from a familiarity with the diagnosis, treatment, and prognosis of this condition, including similarities to, and di!erences from, primary open-angle glaucoma, and the important roles played by the central nervous system and systemic vascular status.
VOL 74 | NO 4 2012C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I E 35
in generalized poor perfusion. -
decreased vascular perfusion,
demands.38
without cardio-
-
-
8,38
-sion causing low ocular perfusion
39-41
44,45
48,49
without -
-
53
-
-
4,14
-
-
-55
Episodic vaso-
35
-
39
-
58,59
-
C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I EVOL 74 | NO 4 201236
-
-
-
Structural Change
-
migraine.
-
83-88
of migraine.
diagnosis.91
-83
overlooked during clinical exam as -
diagnosis.
VOL 74 | NO 4 2012C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I E 37
loss.
-ing conversion.94
99
Eyes
-
progression.
-
-
-
requiring more aggressive pressure
-
parapapillaryperipapillary
-mal eyes,
Many believe
severe disease. -
-
diagnosis.113-115
large areas of
115
secondary
C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I EVOL 74 | NO 4 201238
114
of
-
Functional Change
118
-
93
year.99
-
119
-
-
measures.
-
Management
-
19
8
low pressures.
-ered.131-134
-135
-
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135
-
-
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-19
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138
139
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141
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C A N A D I A N J O U R N A L O F O P T O M E T R Y | R E V U E C A N A D I E N N E D ’ O P T O M É T R I EVOL 74 | NO 4 201240
Conclusion
-
--
References
Arch Ophthalmol
Can J Ophthalmol
Arch Ophthalmol
Can J Ophthalmol
Arch Ophthalmol
glaucoma. Arch Ophthalmol
Br J Ophthalmol
glaucoma. Am J Ophthalmol
Ophthalmol
Br J Ophthalmol
angle glaucoma? Curr Opin Ophthalmol
Am J Ophthalmol
glaucoma under ß-blocker Acta Ophthalmol
primary open angle glaucoma versus
Curr Eye Research
glaucoma. J Glaucoma
Open Ophthalmol J
Mol Vis
PLoS Genetics
progression. Arch Ophthalmol
Curr Opin Ophthalmol
Invest Ophthalmol Vis Sci
lens sensor. Arch Ophthalmol
Acta Ophthalmol Scand
Arch Ophthalmol
differences in glaucoma: prevalence, Curr Opin
Ophthalmol
and prevalence of primary open-angle glaucoma. J Nat Med Assoc
Arch Ophthalmol
Arch Ophthalmol
Eye
of glaucoma. Curr Opin Ophthalmol
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This case encapsulates the diagnostic dilemma of NTG.The patient in question is a 51-year old myopic (-7.00D) Asian female who discontinued treatment with prostaglandin analog two years ago. She takes no systemic medications, and denies any symptoms of sys-temic vascular dysregulation. Her IOPs are 14 and 15mmHg; her CCTs are 494 and 493 microns.The right ONH (top photo) is obliquely inserted, with superior temporal DH, inferior temporal #PPA, and adjacent RNFL defect. The left ONH shows inferior temporal NRR thinning with adjacent RNFL defect. Initial VF analysis (albeit with questionable reliability; con"rma-tion pending) shows an early supe-rior nasal step in both right and left. Her GP is being consulted to ensure that her systemic vascular status is satisfactory. Pending con"rmatory VF analyses, topical treatment with prostaglandin analog (with a target pressure approaching the episcleral venous pressure of ~10mmHg) is likely to be initiated.