under pressure: a review of normal-tension glaucomaunder pressure: a review of normal-tension...

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.

Key words: normal-tension glaucoma (NTG), primary open-angle glaucoma (POAG), corneal hysteresis (CH), disc hemorrhage (DH), beta-zone peripapillary atrophy (!PPA), ocular perfusion pressure (OPP), vascular dysregulation, cerebrospinal #uid pressure (CSFP), trans-lamina cribrosa pressure di"erential, neuroprotection

ABSTRACT


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

-


-

-

-

Structural Change

-

migraine.

-

83-88

of migraine.

diagnosis.91

-83

overlooked during clinical exam as -

diagnosis.


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


114

of

-

Functional Change

118

-

93

year.99

-

119

-

-

measures.

-

Management

-

19

8

low pressures.

-ered.131-134

-135

-


135

-

-

-

-

-19

-

138

139

-

141

-

-

-


Conclusion

-

--

References

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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.

RIGHT EYEFIXATION LOSSES: 0/13FALSE POS ERRORS: 9%FALSE NEG ERRORS: 4%TEST DURATION: 03:28

Appendix – Illustrative Case Presentation

LEFT EYEFIXATION LOSSES: 5/12 xxFALSE POS ERRORS: 18% xxFALSE NEG ERRORS: 11%TEST DURATION: 03:45

EXCESSIVE HIGH FALSE POSITIVES***

GHTOUTSIDE NORMAL LIMITSVFI 97%MD –0.03 dBPSD 2.30 dB P<5%

GHTOUTSIDE NORMAL LIMITSVFI 97%MD –0.98 dBPSD 2.67 dB P<2%


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under pressure: a review of normal-tension glaucomaunder pressure: a review of normal-tension...

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