|Year : 2017 | Volume
| Issue : 1 | Page : 1-6
Clinical profile and management of primary open-angle glaucoma patients above 40 years: A rural hospital-based study
Praveen Tidake, Surabhi Sharma
Department of Ophthalmology, Jawaharlal Nehru Medical College, DMIMSDU, Wardha, Maharashtra, India
|Date of Web Publication||25-Jul-2017|
Department of Ophthalmology, Jawaharlal Nehru Medical College, DMIMSDU, Sawangi (M), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim was to do appropriate screening of the patients of primary open angle glaucoma (POAG) visiting ophthalmology OPD in AVBRH, Sawangi(Meghe) and to compare Visual Acuity(VA), Intraocular Pressure(IOP) retinal nerve fiber layer (RNFL) thickness measurements using optical coherence tomography (OCT) and visual field defects(VFD) with age and sex. Materials and Methods: In this cross-sectional, observational, clinical study ,100 eyes of 50 patients with POAG above 40 years of age were examined. They underwent investigations like visual acuity, intra ocular pressure, fundus examination, gonioscopy, optical coherence tomography (OCT) of optic disc examination and perimetry. Only patients who had intraocular pressure (IOP) greater than 21 mmHg were enrolled into the study. Results: A total of 100 eyes of 50 patients were examined. Mean age of 50 patients was 54.22±13.28 (25-82 yrs), out of which, were 54% were females and 46% were males. At presentation,34% had blurring of vision and 16% had eye pain or photophobia. The mean IOP was 27.49±5.50 mmHg, and the mean CDR was 0.65±0.1. Conclusion: Visual Acuity(VA),Intraocular Pressure(IOP) retinal nerve fiber layer (RNFL) thickness measurements using optical coherence tomography (OCT) and visual field defects(VFD) are correlated to each other and show a correlation with age but not with gender.
Keywords: Intraocular pressure, primary open-angle glaucoma, retinal nerve fiber layer, using optical coherence tomography, visual field defects
|How to cite this article:|
Tidake P, Sharma S. Clinical profile and management of primary open-angle glaucoma patients above 40 years: A rural hospital-based study. J Datta Meghe Inst Med Sci Univ 2017;12:1-6
|How to cite this URL:|
Tidake P, Sharma S. Clinical profile and management of primary open-angle glaucoma patients above 40 years: A rural hospital-based study. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Aug 17];12:1-6. Available from: http://www.journaldmims.com/text.asp?2017/12/1/1/211577
| Introduction|| |
Glaucoma is the second leading cause of blindness in the world. It has been estimated that 80 million people worldwide will have glaucoma by the year 2020, of which 11.2 million will be blind. Primary open-angle glaucoma (POAG) is a chronic, bilateral, and often asymmetrical disease in adults in whom acquired loss of optic nerve fibers and abnormality in the visual field occur with an open anterior chamber angle of normal appearance and an intraocular pressure (IOP) which is detrimental to the structural and functional integrity of the optic nerve head. Other synonymous terms that may also appear in literature include chronic simple glaucoma, chronic open-angle glaucoma (COAG), and idiopathic open-angle glaucoma. Population-based studies show that a large portion of glaucoma remains undiagnosed. About 50% of the affected are not even aware of it  that so many with a potentially blinding and treatable condition are unaware of having the disease underscores the need for better screening strategies to identify those with glaucoma and bring them into care. Risk factors are clinically useful to assess the risk for glaucoma based on the characteristics of the individual patient. Most of the evidences for COAG have been obtained from prevalence surveys or case–control studies. Age and increased IOP are considered significant risk factors in the development of glaucoma.
Currently, the mainstay of treatment is reduction in IOP enough to achieve a therapeutic goal termed the “target IOP range”. This is the level of IOP at which further optic nerve and/or visual field damage is not expected to occur. There is now good evidence from randomized controlled trials that lowering IOP to target levels slows optic nerve and/or visual field damage.,,, IOP also appears to be the only risk factor that can be easily modified and objectively monitored by eye care professionals such as ophthalmologists and optometrists, thereby minimizing conversion rates of ocular hypertension to glaucoma and disease progression in established glaucoma.,,, Besides, appropriate and timely sharing of target IOP with patients and physician colleagues often helps to strengthen therapeutic and collegial relationships. In addition, in the developing countries, the algorithm of treatment may vary depending on factors such as patient affordability and availability for follow-up.
| Materials and Methods|| |
- A detailed ocular examination, including visual acuity (VA), intraocular pressure, fundus examination, gonioscopy, and optical coherence tomography (OCT) of optic disc examination, was conducted in 100 eyes of 50 patients aged 25–82 years visiting ophthalmology outpatient department (OPD) of AVBRH, Sawangi (Meghe). It was a cross-sectional, observational, clinical study. Informed consent was obtained. Patients who did not give valid consent for the study were excluded from the study
- Best-corrected VA (BCVA) was taken on Snellen's chart. An optometrist then assessed the BCVA using the results of a handheld autorefractometer (TOPCON Autorefractometer KR-8900) with necessary subjective refraction given to those patients with presenting VA of <6/12
- Slit-lamp examination was performed to identify abnormalities of the anterior segment
- IOP measurement was done by pneumotonometry (TOPCON CT80), a computerizsed tonometer
- Gonioscopy was performed on all patients with a Goldmann-type four mirror lens (Haag Streit, Bern, Switzerland) in dim ambient illumination with a shortened slit that does not fall on the pupil. The angle was graded using the Shaffer's system
- Slit-lamp biomicroscopic examination of the optic nerve head was performed using a +90 diopter (D) lens. Standard disc images for vertical cup-disc ratio (VCDR) from 0.1 to 1.0 in 0.1 increments were used in the grading process. The pupil was dilated using 1% tropicamide plus 2.5% phenylephrine, The VCDR was measured and recorded
- A provisional diagnosis of suspected glaucoma was made when the patient had one or more of the following conditions: IOP ≥21 mmHg in either eye; VCDR ≥0.7 in either eye; or VCDR asymmetry ≥0.2; focal thinning, notching, or a splinter hemorrhage and gonioscopy showed open angle
- All patients were made to do get a visual field test by Humphrey perimetry
- These patients then underwent optic disc imaging with HD CIRRUS SD-OCT 500, software version-3.0 (Carl Zeiss Meditec, Dublin, CA, USA).
Purpose of study
We undertook this study for appropriate screening of the patients visiting ophthalmology OPD in AVBRH, Sawangi (Meghe) and to find the clinical profile of patients having POAG visiting our OPD, to compare VA, IOP, and retinal nerve fiber layer (RNFL) thickness measurements using OCT and visual field defects (VFDs) with age and sex and to provide them with proper management.
Statistics and data analysis
Statistical analysis was done using descriptive and inferential statistics using Student's unpaired t-test and one-way ANOVA. SPSS software version 17.0 (SPSS Inc, Chicago) and EPI-INFO (Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA)) are used for the analysis, and P< 0.05 is considered as level of significance. A total of 100 eyes of 50 patients are taken in this study.
Management of patients
Medical treatment was the most common initial management given to glaucoma patients in general while laser treatment was performed on follow-up patients who showed no signs of control with medical management. Surgical intervention was done in 20% of patients with trabeculectomy.
| Observation and Results|| |
A total of 100 eyes of fifty patients were examined. Mean age of the fifty patients was 54.22 ± 13.28 years (25–82 years), out of which, 54% were females and 46% were males. At presentation, 34% had blurring of vision and 16% had eye pain or photophobia. The mean IOP was 27.49 ± 5.50 mmHg, and the mean cup-to-disc ratio (CDR) was 0.65 ± 0.1.
[Graph 1] shows the age-wise distribution of patients in our study. The mean age was 54.22 ± 13.28 years (25–82 years). Maximum patients were in the 55–60 years' age group range which was 30%.
[Graph 2] shows the gender-wise distribution in the study. There were 27 females (54%) and 23 males in the study (46%).
[Graph 3] shows that the vision decreased in accordance to increase in cup to disc ratio. This correlation was highly statistically significant.
[Graph 4] shows that, as vision decreased, there was a decrease in thickness of retinal nerve fiber layer along with it. This correlation was highly statistically significant.
Furthermore, according to our perimetry findings, as the retinal nerve fiber thickness decreased, the VFD progressed which also correlated to decrease in VA of our patients [Table 1], [Table 2], [Table 3], [Table 4], [Table 5].
[Graph 5] shows that there was an increase in IOP with decrease in vision. This correlation was highly statistically significant.
When age was compared to RNFL thickness, it showed a thinning as age of the patients progressed. This comparison was statistically significant in our study [Table 6].
|Table 6: Correlation of age with retinal nerve fiber layer thickness, cup-to-disc ratio, and intraocular pressure|
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When we compared age to CDR, it first showed a slightly larger CDR in the first age group, then slightly smaller in the middle age group and then again slightly larger in the third age group. This result was not statistically significant.
When we compared age to IOP, there was a slight increase in the first age group, then slight decrease in the second age group and then again slight increase in the third age group. This result again was not statistically significant.
[Table 7] shows the correlation between sex and the different parameters. When sex of the patient was correlated with RNFL thickness, it was found that it was more in males than females. This correlation was not statistically significant.
When sex of the patient was correlated with CDR, it showed a lot of similar values in both males and females. This result was again not statistically significant.
When sex of the patient was correlated with IOT, it showed similar values in both males and females, which was also not statistically significant [Figure 1], [Figure 2], [Figure 3].
|Figure 2: Perimetry charts of poag patients showing visual field defects|
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Fundus photographs of POAG patients showing large C/D ratio.
Perimetry charts of POAG patients showing visual field defects.
OCT of POAG patients showing RNFL thinning.
| Discussion|| |
According to our study, the mean age was 54.22 ± 13.28 years (25–82 years). Maximum patients were in the 55–60 years' age group range which was 30%. There were 23 females (23%) and 27 males in the study (27%).
In our study, as vision decreased, there was a decrease in retinal nerve fiber layer along with it. This correlation was highly statistically significant. There was an increase in IOP with decrease in vision. This correlation was highly statistically significant. Vision decreased in accordance to increase in cup-to-disc ratio. This correlation was highly statistically significant. In addition, as vision decreased and RNFL thickness decreased, the VFD progressed.
A study by Badlani et al. highlights RNFL thinning in corresponding hemifields of glaucomatous eyes with minimal VFD and correlated with visual field sensitivity loss. Measurement of retinal nerve fiber layer thickness has potential for detection of early nerve fiber loss owing to glaucoma.
A study by de la Rosa et al. highlights best correlation of RNFL thickness and optic disc parameters with visual field indices in clearly established or advanced glaucoma.
A study by Asrani et al. highlights the correlation of RNFL thickness and optic nerve head cupping with severity of visual field loss. Retinal thickness measurements at the posterior pole provide another measure of neural loss in glaucoma and may help in the clinical assessment of optic nerve cupping.
According to our study, when age was compared to RNFL thickness, it showed a thinning as age of the patients progressed. This comparison was statistically significant in our study.
When we compared age to CDR, it first showed a slightly larger CDR in the first age group, then slightly smaller in the middle age group, and then again slightly larger in the third age group. This result was not statistically significant.
When we compared age to IOP, there was a slight increase in the first age group, then slight decrease in the second age group, and then again slight increase in the third age group. This result again was not statistically significant.
According to Kim et al. in 2014, a multivariate analysis showed that the progression from POAG suspect to definite POAG was significantly associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03–1.10) and higher baseline IOP (OR, 1.10; 95% CI, 1.01–1.24). The authors observed that the 5-year incidence of POAG was 0.72%, and the rate of progression from POAG suspect to definite POAG was 4.75% per year. This study identified old age and high baseline IOP as significant risk factors for incident POAG.
According to Vijaya et al. in 2014, baseline age was a risk factor. In reference to the 40–49 years' age group, the incidence increased from 2.3 (95% CI, 1.4–3.7) for 50–59 years' age group to 3.5 (95% CI, 2.2–5.7) for 60–69 years' age group (P < 0.001).
In the Beaver Dam Eye Study by Klein et al., the prevalence increased with age from 0.9% in people aged 43–54 years to 4.7% in people aged 75 years or older.
According to Sun et al. in 2012, on multivariate analysis, age and IOP were regarded as significant independent risk factors.
In our study, when sex of the patient was correlated with RNFL thickness, it was found that it was more in males than females. This correlation was not statistically significant.
When sex of the patient was correlated with CDR, it showed a lot of similar values in both males and females. This result was again not statistically significant.
When sex of the patient was correlated with IOT, it showed similar values in both males and females, which was also not statistically significant.
In the Beaver Dam Eye Study by Klein et al., there was no significant effect of sex after adjusting for age.
According to a study of retinal nerve fiber layer thickness with the help of Optical Coherence Tomography (OC) in normal persons, ocular hypertensives, and POAG patients by Mahant et al., the various parameters when compared to gender were not statistically significant.
A study by Chauhan et al. showed that glaucomatous disc changes occurred more frequently than visual field changes. Most patients with field changes also had disc changes; however, less than half of those with disc changes had field changes. This finding correlated with our study as in our study also glaucomatous disc changes were more as compared to field changes.
VA, IOP, and RNFL thickness measurements using OCT and VFD are positively correlated to each other and show a correlation with age but not with gender. Furthermore, a treatment plan tailored to the patient's needs, proper counseling of the patient, realistic expectations, and timely monitoring of progression of disease all contribute to halting of signs of POAG and improving the quality of life of the patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90:262-7.
Saeedi OJ, Ramulu P, Friedman DS. Epidemiology of glaucoma. In: Yanoff M, Duker JS, editors. Ophthalmology. 4th
ed. Printed in China: Copyright©Mosby International Ltd.; 2014. p. 1001-6.
Lowe RF. Primary angle-closure glaucoma: A short history. Trans Ophthalmol Soc Aust 1965;24:80.
Bajantri YB, Rajshekar D, Parande M, Hemalatha A, Hegde SN. Modalities of management of vernal keratoconjunctivitis. J Evid Based Med Healthc 2015;2:2077-86.
Damji KF, Behki R, Wang L; Target IOP workshop participants. Canadian perspectives in glaucoma management: Setting target intraocular pressure range. Can J Ophthalmol 2003;38:189-97.
The effectiveness of intraocular pressure reduction in the treatment of normal-tension glaucoma. Collaborative Normal-Tension Glaucoma Study Group. Am J Ophthalmol 1998;126:498-505.
Kass MA, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, et al.
The Ocular Hypertension Treatment Study: A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120:701-13.
Leske MC, Heijl A, Hussein M, Bengtsson B, Hyman L, Komaroff E; Early Manifest Glaucoma Trial Group. Factors for glaucoma progression and the effect of treatment: The early manifest glaucoma trial. Arch Ophthalmol 2003;121:48-56.
Nemesure B, Honkanen R, Hennis A, Wu SY, Leske MC; Barbados Eye Studies Group. Incident open-angle glaucoma and intraocular pressure. Ophthalmology 2007;114:1810-5.
Badlani V, Shahidi M, Shakoor A, Edward DP, Zelkha R, Wilensky J. Nerve fiber layer thickness in glaucoma patients with asymmetric hemifield visual field loss. J Glaucoma 2006;15:275-80.
de la Rosa MG, Gonzalez-Hernandez M, Lozano-Lopez V, Mendez MS, de la Vega RR. Optic disc tomography and perimetry in controls, glaucoma suspects, and early and established glaucomas. Optom Vis Sci 2007;84:33-41.
Asrani S, Challa P, Herndon L, Lee P, Stinnett S, Allingham RR. Correlation among retinal thickness, optic disc, and visual field in glaucoma patients and suspects: A pilot study. J Glaucoma 2003;12:119-28.
Kim YK, Choi HJ, Jeoung JW, Park KH, Kim DM. Five-year incidence of primary open-angle glaucoma and rate of progression in health center-based Korean population: The Gangnam Eye Study. PLoS One 2014;9:e114058.
Vijaya L, Asokan R, Panday M, Choudhari NS, Ramesh SV, Velumuri L, et al.
Baseline risk factors for incidence of blindness in a South Indian population: The Chennai eye disease incidence study. Invest Ophthalmol Vis Sci 2014;55:5545-50.
Klein BE, Klein R, Sponsel WE, Franke T, Cantor LB, Martone J, et al.
Prevalence of glaucoma. The Beaver Dam Eye Study. Ophthalmology 1992;99:1499-504.
Sun J, Zhou X, Kang Y, Yan L, Sun X, Sui H, et al.
Prevalence and risk factors for primary open-angle glaucoma in a rural Northeast China population: A population-based survey in Bin County, Harbin. Eye (Lond) 2012;26:283-91.
Mahant AJ, Saghavi KN, Trivedi NV. Study of retinal nerve fibre thickness by optical coherence tomography in normal persons, ocular hypertensives and primary open angle glaucoma patients. Gujarat Med J 2011;66:16-21.
Chauhan BC, McCormick TA, Nicolela MT, LeBlanc RP. Optic disc and visual field changes in a prospective longitudinal study of patients with glaucoma: Comparison of scanning laser tomography with conventional perimetry and optic disc photography. Arch Ophthalmol 2001;119:1492-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]