WILL MY GLAUCOMA PATIENT LOSE VISION ?

Rohit Varma, MD, MPHProfessor and ChairmanIllinois Eye and Ear InfirmaryUniv. of Illinois at Chicago

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.

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).

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.

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.

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

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.

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.

Predictors for Progressive Visual Field Loss

IOP and Progressive Visual Field Loss

Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression

De Moraes et al 2009

Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression

Factors for Glaucoma Progression and the Effect of Treatment: The Early Manifest Glaucoma Trial

Risk Factors for the Progression of Open-angle Glaucoma: Canadian Glaucoma Study

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.

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

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.

PACG and Progressive Visual Field Loss

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

PACG related Blindness and Progressive

VF Loss• Higher IOP

• Previous Episodes of Acute angle closure

• Not enough data

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

Will my glaucoma patient lose vision? Summary

Primary Angle Closure Glaucoma

Higher IOP

Previous episodes of acute angle closure

Thank you