Will my Glaucoma patient lose vision ?
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WILL MY GLAUCOMA PATIENT LOSE VISION ?
Rohit Varma, MD, MPHProfessor and ChairmanIllinois Eye and Ear InfirmaryUniv. of Illinois at Chicago
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DisclosureI have no financial
disclosures related to the content of this talk
National Institutes of Health Grants: NEI U10-EY-11753 and EY-03040 and an unrestricted grant from the
Research to Prevent Blindness, New York, NY.
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Worldwide burden of Glaucoma
• Glaucoma is the leading cause of irreversible blindness in the world, estimated to affect up to 79.6 million people by 2020.
• Of these, 74% have POAG and 26% have primary angle-closure glaucoma (PACG).
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POAG related Blindness
• Blindness from POAG in at least 1 eye of between 15% and 27% after 15 to 20 years of follow-up
• 20% over a 34-year follow-up period.
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POAG related VF Progression
• VF progression of between 21% and 44% over 10 years in US
• 16% to 37% of treated POAG patients experienced progressive VF loss over a 5-year period in Australia.
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Comparison of Glaucoma Blind vs. Non-Blind PersonsCharacteristics Blind (n = 56) Non-blind (n = 234)Age at diagnosis of glaucoma 69 ± 12† 65 ± 14
Gender - Male 36% (20/56) 37% (87/234)
Family history of glaucoma 21% (12/56) 21% (48/234)
Diabetes 4% (2/56) 9% (21/234)
Myopia > 3 diopters 18% (10/56) 16% (37/234)IOP at diagnosis of glaucoma (before Rx) 27.0 ± 7.2 mm Hg 27.8 ± 6.0 mm Hg
IOP at final visit (on Rx)‡ 16.3 ± 6.1 mm Hg§ 18.4 ± 5.5 mm Hg
Mean Individual IOP range 9.9 ± 8.8 mm Hg 6.8 ± 6.8 mm Hg
Normal field at diagnosis 34% (19/56) 75% (162/216)
% having filtration surgery 38% (21/56)∥ 14% (32/234)
Oliver et al 2002
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Comparison of Glaucoma Blind vs. Non-Blind Persons• The mean IOP on therapy in the patients progressing
to blindness was lower than, or similar to, those who did not become blind.
• The group progressing to blindness had a greater variability of IOP while on therapy than the non-blind group.
• Even in patients with low IOP, however, glaucoma could progress.
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Comparison of Glaucoma Blind vs. Non-Blind Persons• The different sensitivities of patients to IOP
indicate that ongoing monitoring of glaucomatous damage remains essential.
• While establishment of a target IOP is a cornerstone of modern glaucoma practice, such target pressures should be adjusted if the patients’ condition changes.
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Predictors for Progressive Visual Field Loss
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IOP and Progressive Visual Field Loss
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Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression
De Moraes et al 2009
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Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression
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Factors for Glaucoma Progression and the Effect of Treatment: The Early Manifest Glaucoma Trial
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Risk Factors for the Progression of Open-angle Glaucoma: Canadian Glaucoma Study
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Progressive VF Loss - CIGTS
• After 8-year of follow-up substantial worsening (≥3 dB) of Visual fields was found in 21.3% and 25.5% of the initial surgery and initial medicine groups.
• In patients with advanced visual field loss, Initial surgery led to less VF progression than initial medicine
• Persons with diabetes had more VF loss over time if treated initially with surgery.
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POAG related Blindness and Progressive
VF Loss• Higher IOP and Greater Variability of IOP
• Greater Visual Field Loss at baseline
• Diabetes
• Low ocular perfusion pressure
• In advanced cases, treatment with medicine vs. surgery
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PACG and Progressive VF Loss
• Progression of Visual Field defects in 10% of treated PACG eyes over 6 years of follow-up.
• Another study examining 101 patients with chronic PACG reported progression in 25% of patients over 5 years.
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PACG and Progressive Visual Field Loss
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Risk Factors for Progressive Visual Field
Loss in PACG Risk Factor Multivariate Odds
Ratioa (95% CI) P Value
Mean overall IOP 1.59(1.22,2.08) .001
Previous acute angle closure 4.59(1.47,14.38) .009
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PACG related Blindness and Progressive
VF Loss• Higher IOP
• Previous Episodes of Acute angle closure
• Not enough data
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Will my glaucoma patient lose vision? Summary
Primary Open Angle Glaucoma
Higher IOP and greater variation of IOPGreater initial visual field loss
DiabetesPseudoexfoliation
Treatment with medication compared with surgery
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Will my glaucoma patient lose vision? Summary
Primary Angle Closure Glaucoma
Higher IOP
Previous episodes of acute angle closure
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Thank you