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גורמי סיכון מנבאים שיטות מעשיות לאבחון

Glaucoma Progression. גורמי סיכון מנבאים שיטות מעשיות לאבחון. Introduction. Glaucoma patients must be tested frequently in order to detect progression The most important barrier to detecting progression is variability (both in structural and functional tests)

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גורמי סיכון מנבאים שיטות מעשיות לאבחון

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  1. Glaucoma Progression • גורמי סיכון מנבאים • שיטות מעשיות לאבחון

  2. Introduction • Glaucoma patients must be tested frequently in order to detect progression • The most important barrier to detecting progression is variability (both in structural and functional tests) • Changes in the optic nerve head and NRFL usually occur before the detection of visual field loss

  3. Progression Rates in Clinical Studies Study Patients N Follow Up (Years) Glaucoma Deterioration in group without Rx (%) Glaucoma Deterioration in group with Rx (%) EMGT Patients with early glaucoma 255 6 62% 45% CNTG Patients with Normal tension Glaucoma 140 8 60% 20% CIGTS (Rx) Patients with newly diagnosed open angle glaucoma 607 4 – 5 Not Relevant 13% References: EMGT: Heijl et al. Arch Ophthalmol 2002; 120:1268-1279. CNTG: Am j Ophthamol 1998;126:487-497. CIGTS: Lichter et al. Ophthalmolgy 2001; 108:1943-1953.

  4. Progression Rates Although the method of evaluation of the visual field, the method of analysis, and the lengths of follow-up differed among studies, most of them conclude that approximately half the patients with glaucoma worsened in terms of visual field over a 5-year period Tarek M et. al. Ophthalmology 2003;110:900–907

  5. Risk Factors For Glaucoma Progression

  6. Early Manifest Glaucoma Study (EMGT) • 255 patients with Early VF Loss • 6 years follow up mainly by VF and C/D • Risk Factors for Progression: • Higher baseline IOP (>21 mmHg) • PXF • Greater visual field loss in baseline (MD < -4 dB) • Bilateral glaucoma • 4. Older age • 5. Disc hemorrhage Friedman et. al. American Journal of Ophthalmology 2004;38:S19-S31

  7. Collaborative Initial Glaucoma Treatment Study (CIGTS) • 607 patients with newly diagnosed POAG • 4-5 years follow up Risk Factors for Progression: 1. Older Age 2. Non White Race 3. Diabetes Friedman et. al. American Journal of Ophthalmology 2004;38:S19-S31 Lichter et al. Ophthalmolgy 2001; 108 (11):1943-1953

  8. Collaborative Normal-Tension Glaucoma Study (CNTG) • 160 patients with Normal Tension Glaucoma • 6 years follow up mainly by VF and IOP Risk Factors for Progression: 1. Female Sex 2. Disc Hemorrhage 3. Migraine Friedman et. al. American Journal of Ophthalmology 2004;38:S19-S31

  9. Advanced Glaucoma Intervention Study (AGIS) • 591 patients with advanced glaucoma • 8-13 (mean 7.5) years follow up mainly by VF & VA • Risk Factors for Progression: • Older age • Inter-visit IOP fluctuations > 3 mmHg • Male sex • Diabetes Friedman et. al. American Journal of Ophthalmology 2004;38:S19-S31

  10. IOP Fluctuations > 3 mmHg Increase The Risk For Progression Adapted from Kouros NM et. al. Ophthalmology 2004; 111:1627-1635

  11. Advanced Glaucoma Intervention Study (AGIS) Both increasing age and greater IOP fluctuation increase the odds of VF progression by 30% Increased Risk For each 5-year increment in age and 1-mmHg increase in IOP fluctuation Kouros NM et. al. Ophthalmology 2004; 111:1627-1635

  12. Summary of Evidence Based Risk Factors for Progression of Glaucoma • Older age • Disc hemorrhage • Diabetes • Higher IOP in baseline • PXF • Greater visual field loss in baseline (MD < -4 dB) • Male/Female sex • Non white race Friedman et. al. American Journal of Ophthalmology 2004;38:S19-S31

  13. Detection of Progression

  14. Structural vs. Functional ChangesThe Glaucoma Continuum Adapted from Weinreb et. al.Am J Ophthalmol 2004;138:458–467

  15. Structural Changes

  16. Evaluation of The Optic Nerve Head and Retinal Nerve Fiber Layer (EGS) Qualitative: • Contour of the neuroretinal rim • Optic disc hemorrhages • Parapapillary atrophy • Bared circumlinear vessels • Appearance of the retinal nerve fiber layer Terminology and Guidelines for Glaucoma 11th Edition. European Glaucoma Society 2004

  17. Evaluation of The Optic Nerve Head and Retinal Nerve Fiber Layer (EGS) Quantitative: • Optic disc size (vertical disc diameter) • Cup/Disc Ratio (vertical) • Rim/Disc Ratio • Retinal Nerve Fiber Layer Height )GDX) Terminology and Guidelines for Glaucoma 11th Edition. European Glaucoma Society 2004

  18. Optic disc of a patientswith POAG, Age - 55 9 years later • Marked decrease of neuroretinal rim • Enlarged area of beta zone

  19. Patient with NTG exhibiting more advanced damage at baseline • 5 Years Later at follow up • Neural retinal rim area exhibits a progressive decrease

  20. Functional Changes

  21. There is no proven method to tell if VF damage is progressing or not • Always compare to clinical course of optic disc and IOP Quigley – Atlanta, 1995.

  22. Suggested Criteria For VF Progression (EGS) #1 For a new defect in previous normal area: • A cluster of 3 or more non edge points, each of which decline > 5 dB compared to baseline on 2 consecutive fields Or • A single non edge point that declines > 10 dB compared to baseline on 2 consecutive fields Or • A cluster of 3 or more non edge points each of which decline at a p < 5% level compare to baseline on 2 consecutive fields Terminology and Guidelines for Glaucoma 11th Edition. European Glaucoma Society 2004

  23. Suggested Criteria For VF Progression (EGS) # 2 For deepeningof preexisting defect: • A cluster of 3 non-edge points, each of which decline > 10 dB compared to baseline on 2 consecutive fields Or • A cluster of 3 non-edge points or 3 points that are part of the same scotoma, each of which worsens at least 5 dB and is depressed compared to baseline at a p< 5% level on 2 consecutive fields For expansion of preexisisting scotoma into contiguous points: • At least 2 previously normal points within the central 150 or 3 additional previously normal points outside at the central 150, each of which declines >10 dB on 2 consecutive fields Or • At least 2 previously normal points within the central 150 or 3 previously normal points outside 150, each of which is depressed at a p <5% level compared to baseline on 2 consecutive fields Terminology and Guidelines for Glaucoma 11th Edition. European Glaucoma Society 2004

  24. Suggested Criteria For VF Progression (EGS) # 3 Forgeneralized depression: • A decline in the mean deviation that is significant at thep <1% level and is not explained by media opacity or pupil size Or • A CPSD that shows an obvious trend based on the last 5 consecutive fields Or • A decline of >3 dB at all points on 2 consecutive field that is not explained by media opacity or pupil size Terminology and Guidelines for Glaucoma 11th Edition. European Glaucoma Society 2004

  25. WGC World Glaucoma Congress Vienna 2005 • Selective tests: • FDT - Frequency Doubling Technology • SITA - SWAP Test • None of the tests till today has shown to be more effective than the other in term of progression detection

  26. תודה רבה

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