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Suh MH, Weinreb RN, Zangwill LM. Optic Disc Microvasculature Dropout in Preperimetric Glaucoma. J Glaucoma 2024; 33:490-498. [PMID: 38619387 DOI: 10.1097/ijg.0000000000002403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/29/2024] [Indexed: 04/16/2024]
Abstract
PRCIS Optic disc microvasculature dropout (MvD-D) was associated with worse disease severity in pre-perimetric glaucoma. MvD-D was not accompanied by focal lamina cribrosa defect or parapapillary deep-layer microvasculature dropout in 62.3% and 71.0% of eyes, respectively. PURPOSE To investigate factors associated with optic disc microvasculature dropout (MvD-D) in patients with preperimetric primary open angle glaucoma (PPG). METHODS One hundred thirty nine eyes of PPG patients were categorized according to the presence of MvD-D with optical coherence tomography angiography (OCTA). Factors including visual field (VF) mean deviation (MD), retinal nerve fiber layer (RNFL) thickness, focal lamina cribrosa (LC) defect, optic disc hemorrhage (DH), and parapapillary deep-layer microvasculature dropout (MvD-P) were compared between eyes with and without MvD-D. RESULTS MvD-D was observed in 69 PPG eyes (49.6%). Compared with eyes without MvD-D, the ones with MvD-D had a significantly thinner RNFL in all areas except the nasal sector, worse VF MD, and a focal LC defect and MvD-P ( P <0.05): male gender also was more highly prevalent. A considerable number of eyes with MvD-D lacked focal LC defect (62.3% [43/69]) or MvD-P (71.0% [49/69]), while a few eyes without MvD-D had focal LC defect (10.0% [7/70]) or MvD-P (2.9% [2/70]). In a multivariable logistic regression analysis, male gender (odds ratio [OR], 3.96; P <0.001), worse VF MD (OR, 1.44; P =0.019), thinner global RNFL (OR, 1.13; P <0.001), higher prevalence of focal LC defect (OR, 3.71; P =0.014) and MvD-P (OR, 7.85; P <0.001) were significantly associated with MvD-D. CONCLUSIONS MvD-D was related to worse disease severity in patients with PPG, and often was not accompanied by focal LC defect or MvD-P. This suggests that impaired optic disc circulation can be an early sign of glaucoma without noticeable changes in functional or structural features (i.e., VF, focal LC defect, MvD-P).
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Affiliation(s)
- Min Hee Suh
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Robert N Weinreb
- Viterbi Family Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, La Jolla, CA
| | - Linda M Zangwill
- Viterbi Family Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, La Jolla, CA
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Micheletti E, El-Nimri N, Nishida T, Moghimi S, Rezapour J, Fazio MA, Suh MH, Bowd C, Belghith A, Christopher M, Jonas JB, Weinreb RN, Zangwill LM. Central visual field damage in glaucoma eyes with choroidal microvasculature dropout with and without high axial myopia. Br J Ophthalmol 2024; 108:372-379. [PMID: 36805846 DOI: 10.1136/bjo-2022-322234] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/09/2023] [Indexed: 02/22/2023]
Abstract
PURPOSE To characterise the relationship between a deep-layer microvasculature dropout (MvD) and central visual field (VF) damage in primary open-angle glaucoma (POAG) patients with and without high axial myopia. DESIGN Cross-sectional study. METHODS Seventy-one eyes (49 patients) with high axial myopia and POAG and 125 non-highly myopic POAG eyes (97 patients) were enrolled. Presence, area and angular circumference of juxtapapillary MvD were evaluated on optical coherence tomography angiography B-scans and en-face choroidal images. RESULTS Juxtapapillary MvD was detected more often in the highly myopic POAG eyes (43 eyes, 86%) than in the non-highly myopic eyes (73 eyes, 61.9%; p=0.002). In eyes with MvD, MvD area and angular circumference (95% CI) were significantly larger in the highly myopic eyes compared with the non-highly myopic eyes (area: (0.69 (0.40, 0.98) mm2 vs 0.31 (0.19, 0.42) mm2, p=0.011) and (angular circumference: 84.3 (62.9, 105.8) vs 74.5 (58.3, 90.9) degrees, p<0.001), respectively. 24-2 VF mean deviation (MD) was significantly worse in eyes with MvD compared with eyes without MvD in both groups (p<0.001). After adjusting for 24-2 MD VF, central VF defects were more frequently found in eyes with MvD compared with eyes without MvD (82.7% vs 60.9%, p<0.001). In multivariable analysis, higher intraocular pressure, worse 24-2 VF MD, longer axial length and greater MvD area and angular circumference were associated with worse 10-2 VF MD. CONCLUSIONS MvD was more prevalent and larger in POAG eyes with high myopia than in non-highly myopic POAG eyes. In both groups, eyes with MvD showed worse glaucoma severity and more central VF defects.
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Affiliation(s)
- Eleonora Micheletti
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Nevin El-Nimri
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Takashi Nishida
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Sasan Moghimi
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Jasmin Rezapour
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Massimo A Fazio
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Min Hee Suh
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
- Department of Ophthalmology, Inje University Busan Paik Hospital, Busan, Korea (the Republic of)
| | - Christopher Bowd
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Akram Belghith
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Mark Christopher
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Jost B Jonas
- Department of Ophthalmology, University of Heidelberg Faculty of Medicine Mannheim Institute of Public Health, Mannheim, Germany
| | - Robert N Weinreb
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
| | - Linda M Zangwill
- Department of Ophthalmology at the Shiley Eye Institute, University of California at San Diego, La Jolla, California, USA
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Latif K, Nishida T, Moghimi S, Micheletti E, Du K, Weinreb RN. Relationship of Choroidal Microvasculature Dropout and Beta Zone Parapapillary Area With Visual Field Changes in Glaucoma. Am J Ophthalmol 2024; 257:16-24. [PMID: 37573989 DOI: 10.1016/j.ajo.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE To evaluate the association between rates of choroidal microvasculature dropout (MvD) change, beta zone parapapillary atrophy (β-PPA) area change, and visual field (VF) changes in eyes with primary open-angle glaucoma (POAG). DESIGN Retrospective, observational cohort study. METHODS In a tertiary glaucoma clinic, we included 76 eyes from 58 patients with POAG with and without localized MvD, who had ≥2 years of follow-up with a minimum of 4 visits with optical coherence tomography angiography and optical coherence tomography scans. β-PPA area was evaluated using scanning laser ophthalmoscopy-like images and compared with the area of MvD on an en face choroidal vessel density map during the follow-up period. Joint longitudinal mixed effects models were used to estimate the rates of change in β-PPA area or MvD area and VF mean deviation (MD). RESULTS Mean rates of change in β-PPA and MvD area were 0.037 mm2 (95% confidence interval [CI] 0.030-0.043 mm2) per year and 0.039 mm2 (95% CI 0.029-0.048 mm2) per year, respectively, over the mean follow-up of 4.1 years. In multivariable models, MvD area enlargement was significantly associated with faster rates of VF MD loss (0.03 mm2 [95% CI 0.02-0.04 mm2] per 1-dB worse, P < .001) but not β-PPA area enlargement (0.04 mm2 [95% CI 0.03-0.05 mm2] per 1-dB worse, P = .252). CONCLUSION MvD area rates, but not β-PPA area rates, were associated with VF MD loss changes in eyes with POAG. Assessment of MvD is useful for the detection of patients with glaucoma who are at an increased risk of faster VF loss.
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Affiliation(s)
- Kareem Latif
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Takashi Nishida
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Sasan Moghimi
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Eleonora Micheletti
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Kelvin Du
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Robert N Weinreb
- From the Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA.
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Wang D, Xiao H, Lin S, Fang L, Gan Y, Zhang Y, Chen X, Huang Z, Zheng S, Shi H, Xu Z, Li Y, Li J, Liu X, Zuo C. Comparison of the Choroid in Primary Open Angle and Angle Closure Glaucoma Using Optical Coherence Tomography. J Glaucoma 2023; 32:e137-e144. [PMID: 37671543 DOI: 10.1097/ijg.0000000000002303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/17/2023] [Indexed: 09/07/2023]
Abstract
PRCIS The current study highlights distinct choroidal alterations in primary open angle (POAG) and primary angle closure (PACG) glaucomas, underscoring the potential of the Choroidal Vascularity Index (CVI) as a valuable indicator for understanding glaucoma pathogenesis. PURPOSE To evaluate choroidal structural changes in patients with POAG and PACG and healthy controls utilizing the CVI and subfoveal choroidal thickness by enhanced depth imaging optical coherence tomography. METHODS This study was cross-sectional. A total of 171 eyes of 171 subjects, comprising 69 eyes with untreated POAG, 58 eyes with untreated PACG, and 44 healthy eyes, were enrolled in this study. Subfoveal choroidal thickness, luminal area (LA), stromal area (SA), and total choroidal area were measured on enhanced depth imaging-optical coherence tomography scans. The CVI parameter is calculated as the proportion of LA to the total choroidal area. RESULTS This study included 69 patients with POAG with a mean age of 51.4 ± 13.3 years, 58 patients with PACG with a mean age of 57.0 ± 7.3 years, and 44 healthy subjects with a mean age of 51.11 ± 10.7 years. The CVI in the POAG and PACG groups was significantly lower than that in the control group ( P = 0.001 and P = 0.005, respectively); however, not significantly different between the two glaucoma groups ( P = 1.000). POAG eyes had significantly lower LA than PACG and controls ( P = 0.014 and P = 0.049, respectively), whereas PACG eyes had significantly greater SA than controls ( P = 0.041). CONCLUSIONS The CVI of POAG and PACG eyes was significantly lower than that of normal eyes. A reduced LA was observed mainly in eyes with POAG, and an increased SA was observed mainly in eyes with PACG. The role of the choroid may differ between POAG and PACG eyes.
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Affiliation(s)
- Dingqiao Wang
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Hui Xiao
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Shufen Lin
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Lei Fang
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Yuhong Gan
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Yuxin Zhang
- Department of Ophthalmology, The First Affiliated Hospital of Kunming Medical University, Kunming Yunnan
| | - Xiangxi Chen
- Aier School of Ophthalmology, Wuhan Aier Eye Hospital, Central South University, Wuhan, China
| | - Zhihong Huang
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Shaoyang Zheng
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Huanyang Shi
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Zixing Xu
- Zhongshan School of Medicine Sun Yat-sen University Guangzhou, Guangzhou
| | - Yixuan Li
- Zhongshan School of Medicine Sun Yat-sen University Guangzhou, Guangzhou
| | - Junyi Li
- Zhongshan School of Medicine Sun Yat-sen University Guangzhou, Guangzhou
| | - Xing Liu
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
| | - Chengguo Zuo
- Department of Glaucoma, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science
- Guangdong Provincial Clinical Research Center for Ocular Diseases
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Lee JY, Shin JW, Lee A, Baek MS, Kook MS. Association of baseline optical coherence tomography angiography with the development of glaucomatous visual field defects in preperimetric glaucoma eyes. Br J Ophthalmol 2023; 107:1621-1629. [PMID: 37863500 DOI: 10.1136/bjo-2021-321025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/22/2022] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate whether baseline vessel density (VD) parameters derived from optical coherence tomography angiography (OCT-A) is associated with the development of glaucomatous visual field (VF) defects in preperimetric glaucoma (PPG) patients. METHODS One eye from each of 200 consecutive PPG patients with a normal standard automated perimetry and OCT-A at baseline was retrospectively analysed. OCT-A was used to measure the circumpapillary VD (cpVD) and the parafoveal and perifoveal VD. The retinal nerve fibre layer (RNFL) and macular ganglion cell-inner plexiform layer thicknesses were measured as reference standards. Two patient groups were stratified based on the development of repeatable glaucomatous VF loss. A Cox proportional hazards model was constructed to determine the predictive ability of OCT-A parameters for VF defects. The correlation between these baseline OCT-A parameters and the rate of global VF sensitivity loss (dB/year) was calculated using linear regression analysis. RESULTS During a 3.1-year average follow-up period, 18 eyes (9.0%) developed glaucomatous VF defects. At baseline, the lower inferior temporal cpVD (HR (95% CI)=0.934 (0.883 to 0.988); p=0.017) and thinner inferior RNFL (HR (95% CI)=0.895 (0.839 to 0.956); p=0.001) were predictive of glaucomatous VF loss. A lower inferior temporal cpVD and thinner RNFL at baseline were associated with faster rate of global VF sensitivity loss (β=0.015; p=0.001). CONCLUSION In PPG eyes, a lower baseline inferior temporal cpVD is significantly associated with glaucomatous VF defect development and a faster rate of global VF loss.
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Affiliation(s)
- Jin Yeong Lee
- Department of Ophthalmology, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Joong Won Shin
- Department of Ophthalmology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Anna Lee
- Department of Ophthalmology, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Min Su Baek
- Department of Ophthalmology, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Michael S Kook
- Department of Ophthalmology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea (the Republic of)
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Micheletti E, Moghimi S, Nishida T, El-Nimri N, Mahmoudinedzah G, Kamalipour A, Mohammadzadeh V, Zangwill LM, Weinreb RN. Factors associated with choroidal microvascular dropout change. Br J Ophthalmol 2023; 107:1444-1451. [PMID: 35803672 PMCID: PMC10464525 DOI: 10.1136/bjo-2022-321157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS To investigate the factors associated with choroidal microvasculature drop-out (MvD) enlargement detected by optical coherence tomography angiography (OCT-A) in glaucomatous eyes. METHODS Ninety-one eyes of 68 primary open-angle glaucoma patients were enrolled. Only eyes with a minimum of four good quality OCT-A and OCT scans of the optic nerve head acquired at least and with a minimum of 2 years follow-up were included. Area and angular circumference of MvD were analysed on en face images. Univariable and multivariable mixed effects models were constructed to identify the factors contributing to MvD area and angular circumference change over time. RESULTS Peripapillary MvD was detected in 53 (58.2%) eyes at baseline and in an additional 17 (18.6%) eyes during follow-up, whereas MvD was not detected in 21 (23.0 %) eyes during the entire follow-up period. In multivariable analysis, worse baseline visual field (VF) mean deviation (MD) (ß=0.27, 95% CI 0.10 to 0.44, p=0.002), greater intraocular pressure (IOP) fluctuations (ß=0.86, 95% CI 0.24 to 1.48, p=0.007), higher peak IOP (ß=0.17, 95% CI -0.01 to 0.35, p=0.067) and greater number of IOP lowering medications (ß=1.36, 95% CI 0.67 to 2.05, p<0.001) were associated with faster MvD area enlargement. Worse baseline VF MD and greater IOP fluctuation were also associated with significantly faster MvD circumferential enlargement in multivariable models. CONCLUSION Greater IOP fluctuation, higher peak IOP, worse baseline VF MD and greater number of glaucoma medications were significantly associated with MvD enlargement in glaucomatous eyes. The identification of factors associated with MvD enlargement may improve our understanding of the role of choroidal vasculature in glaucoma.
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Affiliation(s)
- Eleonora Micheletti
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Sasan Moghimi
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Takashi Nishida
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Nevin El-Nimri
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Golnoush Mahmoudinedzah
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Alireza Kamalipour
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Vahid Mohammadzadeh
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Linda M Zangwill
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Robert N Weinreb
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
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Micheletti E, Moghimi S, Nishida T, El-Nimri N, Mahmoudinezhad G, Kamalipour A, Rao HL, Zangwill LM, Weinreb RN. Rates of Choroidal Microvasculature Dropout and Retinal Nerve Fiber Layer Changes in Glaucoma. Am J Ophthalmol 2022; 241:130-138. [PMID: 35551906 DOI: 10.1016/j.ajo.2022.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/26/2022] [Accepted: 04/30/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the association between rates of choroidal microvasculature dropout (MvD) change and rates of circumpapillary retinal nerve fiber layer (cpRNFL) loss in primary open-angle glaucoma (POAG) eyes. DESIGN Cohort study from clinical trial data. METHODS A total of 91 eyes of 68 POAG patients with and without localized MvD at baseline with at least 4 visits and 2 years of follow-up with optical coherence tomography angiography (OCT-A) and OCT scans were included. Area and angular circumference of MvD were evaluated on OCT-A en face and B-scan choroidal vessel density images during the follow-up period. Joint longitudinal mixed effects models were used to estimate the rates of change in MvD area or angular circumference and RNFL thickness. Univariable and multivariable regressions were completed to identify the factors contributing to cpRNFL thinning. RESULTS MvD was identified in 53 eyes (58.2%) at baseline. Seventeen eyes (18.6%) that did not show MvD at baseline developed it over the follow-up period. Over a mean follow-up of 4.0 years, the mean rates of change in MvD area and angular circumference (95% CI) were 0.05 (0.04, 0.06) mm2 per year and 13.2° (10.7°, 15.8°) per year, respectively. In multivariable models, the rate of cpRNFL thinning was significantly associated with the rates of change in MvD area and angular circumference (P = .008 and P = .009, respectively). CONCLUSIONS Rates of MvD area and angular circumference change over time were associated with concurrent rates of cpRNFL loss in POAG eyes.
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Affiliation(s)
- Eleonora Micheletti
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Sasan Moghimi
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Takashi Nishida
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Nevin El-Nimri
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Golnoush Mahmoudinezhad
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Alireza Kamalipour
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Harsha L Rao
- Narayana Nethralaya (H.L.R.), Bangalore, India; University Eye Clinic Maastricht (H.L.R.), University Medical Center, Maastricht, the Netherlands
| | - Linda M Zangwill
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Robert N Weinreb
- From the Hamilton Glaucoma Center(E.M., S.M., T.N., N.E.N., G.M., A.K., L.M.Z., R.N.W.), Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA.
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Suh MH, Jung DH, Weinreb RN, Zangwill LM. Optic Disc Microvasculature Dropout in Glaucoma Detected by Swept-Source Optical Coherence Tomography Angiography. Am J Ophthalmol 2022; 236:261-270. [PMID: 34740630 DOI: 10.1016/j.ajo.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To assess the clinical utility of swept-source optical coherence tomography angiography (SS-OCTA) in detecting optic disc microvasculature dropout (MvD-D) in primary open-angle glaucoma (POAG) eyes. DESIGN Cross-sectional study. METHODS The study enrolled 197 eyes of 197 patients with POAG with acceptable-quality SS-OCTA (PLEX Elite 9000; Carl Zeiss Meditec) images. A whole-signal-mode 6.0- × 6.0-mm optic disc cube was obtained with projection artifact removal. Three groups were categorized: no MvD-D (group 1), MvD-D (group 2, complete loss of microvasculature within the optic disc), and indiscernible MvD-D (group 3, poor visualization of the anterior lamina cribrosa [LC]). RESULTS There were 82 (42.1%) and 81 (41.5%) eyes categorized as no MvD-D (group 1) and MvD-D (group 2), respectively. The remaining 32 eyes (16.4%), categorized as indiscernible MvD-D (group 3), had a significantly smaller anterior scleral canal opening (ASCO) area (P < .05). Group 2 had significantly worse visual field (VF) mean deviation (MD), thinner average retinal nerve fiber layer (RNFL), higher prevalence of focal LC defect, and parapapillary deep-layer microvasculature dropout (MvD-P) than the other 2 groups (P < .05). In the multivariable logistic regression analysis, higher prevalence of focal LC defect (odds ratio, 46.91; P < .001) and MvD-P (odds ratio, 48.94; P < .001) remained as factors associated with MvD-D. CONCLUSIONS The presence of MvD-D could be well determined by SS-OCTA in eyes with POAG. MvD-P and focal LC defects were strongly associated with MvD-D. This suggests that SS-OCTA can serve as a useful tool in detecting optic disc microvasculature damage.
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9
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Shin DY, Hong KE, Lee NY, Park CK, Park HYL. Association of choroidal blood flow with autonomic dysfunction in patients with normal tension glaucoma. Sci Rep 2022; 12:5136. [PMID: 35332217 PMCID: PMC8948179 DOI: 10.1038/s41598-022-09162-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/04/2022] [Indexed: 11/09/2022] Open
Abstract
There is increasing evidence that autonomic dysfunction is an important factor in the progression of glaucoma. Mechanism of the association between autonomic dysfunction and progression of glaucoma is poorly understood. Since blood circulation is basically regulated by the autonomic nervous system, autonomic dysfunction may contribute to unstable or fluctuating blood pressure. Therefore, It is hypothesized that autonomic dysfunction may contribute to impaired ocular blood flow and lead to glaucoma progression. However, no clinical study yet has evaluated the relationship between ocular blood flow and autonomic nervous function. We enrolled 152 open angle glaucoma patient. Ocular blood flow was assessed by measuring vessel density (VD) using optical coherence tomography angiography, and autonomic nervous function was evaluated with heart-rate variability (HRV) parameters. The low frequency/high frequency (LF/HF) ratio, which is one of the HRV parameters, quantified the degree of sympathovagal balance. This indicator could represent autonomic dysfunction. Higher LF/HF ratio was associated with reduction of the deep parapapillary VD (R = − 0.243, P = 0.003). Linear regression analysis showed a significant negative association between parapapillary choroidal VD and LF/HF ratio (β = − 0.249; 95% confidential interval = − 1.193 to − 0.249; P = 0.002) in multivariate analysis. We demonstarted the association between impaired ocular blood flow (parapapillary choroidal vessel density) and autonomic dysfunction (LF/HF ratio). This study could help understand the role of the autonomic dysfunction in pathophysiology of glaucoma progression.
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Affiliation(s)
- Da Young Shin
- Department of Ophthalmology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung Euy Hong
- Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Na Young Lee
- Department of Ophthalmology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Kee Park
- Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hae Young L Park
- Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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10
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Micheletti E, Moghimi S, El-Nimri N, Nishida T, Suh MH, Proudfoot JA, Kamalipour A, Zangwill LM, Weinreb RN. Relationship of macular ganglion cell complex thickness to choroidal microvasculature drop-out in primary open-angle glaucoma. Br J Ophthalmol 2022; 107:809-815. [PMID: 35027356 DOI: 10.1136/bjophthalmol-2021-320621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS To investigate the rate of ganglion cell complex (GCC) thinning in primary open-angle glaucoma (POAG) patients with and without deep-layer microvasculature drop-out (MvD). METHODS POAG patients who had at least 1.5 years of follow-up and a minimum of three visits were included from the Diagnostic Innovations in Glaucoma Study. MvD was detected at baseline by optical coherence tomography angiography (OCT-A). Area and angular circumference of MvD were evaluated on en face choroidal vessel density images and horizontal B-scans. Rates of global and hemisphere GCC thinning were compared in MvD and non-MvD eyes using linear mixed-effects models. RESULTS Thirty-six eyes with MvD and 37 eyes without MvD of 63 patients were followed for a mean of 3.3 years. In 30 out of 36 eyes, MvD was localised in the inferotemporal region. While mean baseline visual field mean deviation was similar between the two groups (p=0.128), global GCC thinning was significantly faster in eyes with MvD than in those without MvD (mean differences: -0.50 (95% CI -0.83 to -0.17) µm/year; p=0.003)). Presence of MvD, area and angular circumference of MvD were independently associated with a faster rate of thinning (p=0.002, p=0.031 and p=0.013, respectively). CONCLUSION In POAG eyes, GCC thinning is faster in eyes with MvD. Detection of MvD in OCT-A images can assist clinicians to identify patients who are at higher risk for central macula thinning and glaucomatous progression and may require more intensive management.
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Affiliation(s)
- Eleonora Micheletti
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Sasan Moghimi
- Viterbi Family Department of Ophthalmology, University of California at San Diego Department of Ophthalmology at the Shiley Eye Institute, La Jolla, California, USA
| | - Nevin El-Nimri
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Takashi Nishida
- Viterbi Family Department of Ophthalmology, University of California at San Diego Department of Ophthalmology at the Shiley Eye Institute, La Jolla, California, USA
| | - Min Hee Suh
- Ophthalmology, Inje University College of Medicine, Busan, Korea (the Republic of)
| | - James A Proudfoot
- Hamilton Glaucoma Center, University of California San Diego, La Jolla, California, USA
| | - Alireza Kamalipour
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Linda M Zangwill
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Robert N Weinreb
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
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11
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El-Nimri NW, Manalastas PIC, Zangwill LM, Proudfoot JA, Bowd C, Hou H, Moghimi S, Penteado RC, Rezapour J, Ekici E, Shoji T, Ghahari E, Yarmohammadi A, Weinreb RN. Superficial and Deep Macula Vessel Density in Healthy, Glaucoma Suspect, and Glaucoma Eyes. J Glaucoma 2021; 30:e276-e284. [PMID: 33899812 PMCID: PMC8169636 DOI: 10.1097/ijg.0000000000001860] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/16/2021] [Indexed: 11/27/2022]
Abstract
PRECIS Macular superficial capillary plexus (SCP) vessel density is more informative than deep capillary plexus (DCP) vessel density for the detection of glaucoma. PURPOSE The purpose of this study was to characterize optical coherence tomography angiography macular SCP and projection-resolved DCP vessel densities and compare their diagnostic accuracies with ganglion cell complex (GCC) thickness in healthy, glaucoma suspect, and glaucoma eyes. MATERIALS AND METHODS Sixty-eight eyes of 44 healthy subjects, 26 eyes of 16 preperimetric glaucoma suspects, and 161 eyes of 124 glaucoma patients from the Diagnostics Innovations in Glaucoma Study with good quality high-density 6×6 mm2 macula optical coherence tomography angiography images were included. The diagnostic accuracy of SCP vessel density, projection-resolved DCP vessel density and GCC thickness were compared among groups. RESULTS Mean whole image vessel density (wiVD; % of area occupied by vessels containing flowing blood) in the SCP layer was highest in healthy eyes (49.7%), followed by glaucoma suspect eyes (46.0%), and glaucoma eyes (40.9%) (P<0.001). Mean wiVD in the DCP layer was similar in healthy (50.6%), glaucoma suspect (47.3%), and glaucoma eyes (45.7%) (P=0.925). Diagnostic accuracy of both GCC thickness and SCP wiVD was significantly higher than DCP wiVD for classifying healthy and glaucoma eyes [adjusted area under the receiver operating characteristic curve (95% confidence interval): GCC=0.86 (0.72, 0.94), SCP=0.80 (0.66, 0.91) and DCP=0.44 (0.30, 0.57)] (P<0.001). CONCLUSIONS SCP vessel densities have better diagnostic accuracy for detecting glaucoma than DCP vessel densities. Although the diagnostic accuracy of the macula SCP is relatively modest, it is more informative than the DCP.
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Affiliation(s)
- Nevin W. El-Nimri
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Patricia Isabel C. Manalastas
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Linda M. Zangwill
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - James A. Proudfoot
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Christopher Bowd
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Huiyuan Hou
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Sasan Moghimi
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Rafaella C. Penteado
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Jasmin Rezapour
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Eren Ekici
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
- Department of Ophthalmology, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey
| | - Takuhei Shoji
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
- Department of Ophthalmology, Saitama Medical University, Iruma, Saitama, Japan
| | - Elham Ghahari
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
- Department of Ophthalmology, University of Kentucky, Lexington, KY, United States
| | - Adeleh Yarmohammadi
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
| | - Robert N. Weinreb
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, United States
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12
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Chen YH, Wei RH, Hui YN. Commentary review on peripapillary morphological characteristics in high myopia eyes with glaucoma: diagnostic challenges and strategies. Int J Ophthalmol 2021; 14:600-605. [PMID: 33875954 DOI: 10.18240/ijo.2021.04.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022] Open
Abstract
The incidences of open angle glaucoma (OAG) and high myopia are increasing concomitantly. Considering the aging population and concurrent rapid increase in the number of individuals with myopia, the risk of visual defects caused by highly myopic OAG is likely to increase dramatically over the next few decades. However, precise screening and diagnosis of OAG is challenging because of the tilt and rotation of the optic disc, as well as extensive β-zone parapapillary atrophy in highly myopic eyes. Recent advances in optical coherence tomography (OCT) and OCT angiography (OCTA) technologies imply that both modalities are promising tools for the detection of highly myopic OAG. Notably, the diagnosis of OAG remains to be determined with the longitudinal changes of functional damages (e.g. visual field defect, visual electrophysiological changes). We herein describe some aspects of microvascular and microstructural pathology in patients with highly myopic OAG and proposes a framework for the development of novel diagnostic and therapeutic strategies.
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Affiliation(s)
- Yan-Hui Chen
- Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Tianjin 300070, China.,Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Rui-Hua Wei
- Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Tianjin 300070, China.,Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Yan-Nian Hui
- Department of Ophthalmology, Xijing Hospital, Fourth Military Medical University, Xi'an 710023, Shaanxi Province, China
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13
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Betzler BK, Ding J, Wei X, Lee JM, Grewal DS, Fekrat S, Sadda SR, Zarbin MA, Agarwal A, Gupta V, Schmetterer L, Agrawal R. Choroidal vascularity index: a step towards software as a medical device. Br J Ophthalmol 2021; 106:149-155. [PMID: 33514528 DOI: 10.1136/bjophthalmol-2021-318782] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/04/2022]
Abstract
The choroidal vascularity index (CVI) is a relatively new parameter, calculated off optical coherence tomography (OCT) images, for the quantitative evaluation of choroid vascularity. It is defined as the ratio of vascular area to the total choroidal area, presented as a percentage. The choroid is an important vascular bed, often implicated in ocular and systemic conditions. Since the introduction of CVI, multiple studies have evaluated its efficacy as a tool for disease prognostication and monitoring progression, with promising results. The CVI was born out of the need for more robust and accurate evaluations of choroidal vasculature, as prior parameters such as choroidal thickness and choroidal vessel diameter had their limitations. In this review, we summarise current literature on the CVI, explain how the CVI is derived and explore its potential integration into future research and translation into clinical care. This includes the application of CVI in various disease states, and ongoing attempts to produce an automated algorithm which can calculate CVI from OCT images.
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Affiliation(s)
| | - Jianbin Ding
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Xin Wei
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Jia Min Lee
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Dilraj S Grewal
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharon Fekrat
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Srinivas R Sadda
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marco A Zarbin
- Rutgers-New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Aniruddha Agarwal
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Leopold Schmetterer
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore.,SERI-NTU Advanced Ocular Engineering (STANCE), Singapore
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore.,Singapore Eye Research Institute, Singapore National Eye Center, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
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14
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Aghsaei Fard M, Ritch R. Optical coherence tomography angiography in glaucoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1204. [PMID: 33241053 PMCID: PMC7576046 DOI: 10.21037/atm-20-2828] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Assessment of the vasculature within the optic nerve, peripapillary superficial retina, macula, and peripapillary choroid can be determined in glaucoma using optical coherence tomography angiography (OCTA). Decreased perfusion within the pre-laminar layer of the optic nerve has been correlated with glaucoma severity. The peripapillary superficial retinal vessel density allows diagnosis and detection of glaucoma progression in a manner similar to the peripapillary retinal nerve fiber layer (RNFL) thickness. Furthermore, decreased peripapillary vessel density of the intact hemiretina or unaffected eye of glaucomatous eyes suggests that vascular changes can occur prior to detectable visual field damage. The accuracy for glaucoma detection of the macular ganglion cell (MGC) thickness compared to macular vessel density has differed among studies. Several studies have reported reduction of macular vessel density as well as its ganglion cell thickness. Results of studies evaluating the parapapillary choroid have shown a greater prevalence of choroidal microvasculature dropout in glaucomatous eyes with a parapapillary gamma zone, which is associated with central visual field defects or glaucoma progression. It remains unclear whether the reduced vessel density in glaucoma is a primary event or secondary to glaucomatous damage. Further studies are warranted to elucidate this question.
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Affiliation(s)
- Masoud Aghsaei Fard
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Robert Ritch
- Einhorn Clinical Research Center, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
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