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ZAPOROZHYE STATE MEDICAL UNIVERSITY OPHTHALMOLOGY DEPARTMENT Library-research work in Ophthalmology

PRIMARY GLAUCOMA- EARLY DIAGNOSTIC METHOD

Prepared by: Student of 4th course, 3A group, medical Faculty Adeniyi Jide Paul Lecturer: Bezugly Maxim Borosovich. MD,PHD

Zaporozhye 2010

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TABLE OF CONTENT 1.1 1.2 INTRODUCTION3 MAIN PART

1.2.1 DEFINITION AND CLASSIFICATION.4 1.2.2 RESEARCHES5 1.3 CONCLUSION.11 1.4 REFERENCES13

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INTRODUCTION Our understanding of glaucoma has undergone dramatic changes in the past decade. The ferment has derived from new epidemiologic information, important diagnostic methods and developments in surgical and drug therapy. This article concentrates on primary adult glaucoma, the most prevalent form of the disorder in western countries. Like they say a problem diagnosed is half way solved. We are going to outline and compare various opinions of experts in the field and try to figure out the appropriate approach, either based on the geographical area or the availability of the instruments to diagnosing the problem.

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DEFINITION WHAT IS GLAUCOMA? According to the world health organization (W.H.O), glaucoma is a chronic eye disease with its characteristic by optic nerve atrophy development with glaucomatous copping and peculiar visual field defects as well as a constant or periodic elevation of intraocular pressure. CLASSIFICATION A. Congenital and developmental glaucoma Primary congenital glaucoma Developmental glaucoma B. Primary glaucoma Primary open angle glaucoma Primary angle closure glaucoma C. Secondary Glaucoma Inflammatory phacogenice Vascular Dystrophic Traumatic Postoperative Neoplastic

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RESEARCHES In early diagnosis of primary glaucoma, a lot of factors must be taken into consideration. This segment of this article exposes us to various approach and methods experts have put forward in diagnosing primary glaucoma. We shall also discuss the efficiency or inefficiency of these various methods which will be based on either the geographical location of population suffering from this problem or the availability of the instruments.

1. A glaucoma screening survey using applanation tonometry was carried out on 5,941 persons in Bedford: The distribution of ocular tensions showed a divergence from a Gaussian curve for tensions of 21 mm. Hg and above. Age, sex, time of day, and menstruation were found to influence the tonometric readings. Fifty-five cases of primary glaucoma (0.93% of those screened) were detected as a result of the survey; these included 42 cases of chronic simple glaucoma, 3 cases of low tension glaucoma, and 10 cases of closed-angle glaucoma. An additional 180 persons (3% of the population studied) were found to have applanation tensions of 21 mm. Hg or more but without other evidence of glaucoma. Nearly 80% of the patients with glaucoma were over 60 years of age, suggesting that glaucoma detection programmes should concentrate on the older age groups.
J. L. K. BANKES,* MB., B.S., F.R.C.S., D.O.; E. S. PERKINS,* M.D., PH.D., F.R.C.S. S. TSOLAKIS,* M.D., D.O.; J. E. WRIGHT,* M.D., F.R.C.S., D.O.

2. Progression of Disc and Field Damage in Early Glaucoma To assess the temporal relationship between visual field progression and optic disc deterioration in early glaucoma, we studied 15 patients with unilateral visual field loss from primary open angle glaucoma. Planimetric optic disc measurements were compared with automated static threshold perimetry during a mean follow-up of 6.1 years. Eight (53%) of 15 eyes with an initially normal visual field showed progression of the disc; six of these eyes did not develop field abnormalities. The mean rates of rim-

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area loss were 1.7%/y in eyes with initially normal fields and 2.1%/y in eyes with initial field loss. The mean rate of visual field deterioration (change in corrected loss variance) was lower in the eyes with an initially normal field (0.3 dB2/y) than in eyes with initial field loss (3.6 dB2/y; P=.016). This longitudinal study documents progressive disc damage prior to field loss in early glaucoma.
Thierry G. Zeyen, MD; Joseph Caprioli, MD

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By applanation tonometry and gonioscopy

Glaucoma is fast emerging as a major cause of blindness in India. In order to estimate the prevalence of primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG) in an urban South Indian population, we examined 972 individuals aged 30-60 years, chosen using a cluster sampling technique from 12 census blocks of Vellore town. They underwent a complete ocular examination, including applanation tonometry and gonioscopy, at the Medical College Hospital. Characteristic field defects on automated perimetry were a diagnostic requisite for POAG. Prevalence (95% CI) of POAG, PACG, and ocular hypertension were 4.1 (0.08-8.1), 43.2 (30.14-56.3), and 30.8 (19.8-41.9) per 1,000, respectively. All the PACG cases detected were of the chronic type. Hitherto unavailable community-based information on primary glaucoma in our study population indicates that PACG is about five times as common as POAG.
A Jacob, R Thomas, SP Koshi, A Braganza, J Muliyil

4. Detecting Early Glaucoma by Assessment of Retinal Nerve Fiber Layer Thickness and Visual Function PURPOSE. To compare the abilities of scanning laser polarimetry (SLP), optical coherence tomography (OCT), short-wavelength automated perimetry (SWAP), and frequency-doubling technology (FDT) perimetry to discriminate between healthy eyes and those with early glaucoma, classified based on standard automated perimetry (SAP) and optic disc appearance. To determine the agreement among instruments for classifying eyes as glaucomatous.

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METHODS. One eye of each of 94 subjects was included. Healthy eyes (n= 38) had both normal-appearing optic discs and normal SAP results. Glaucoma by SAP (n =42) required a repeatable abnormal result (glaucoma hemifield test [GHT] or corrected pattern standard deviation [CPSD] outside normal limits). Glaucoma by disc appearance (n = 51) was based on masked stereoscopic photograph evaluation. Receiver operating characteristic (ROC) curve areas, sensitivities, and specificities were calculated for each instrument separately for each diagnosis. RESULTS. The largest area under the ROC curve was found for OCT inferior quadrant thickness (0.91 for diagnosis based on SAP, 0.89 for diagnosis based on disc appearance), followed by the FDT number of total deviation plot points of 5% (0.88 and 0.87, respectively), SLP linear discriminant function (0.79 and 0.81, respectively), and SWAP PSD (0.78 and 0.76, respectively). For diagnosis based on SAP, the ROC curve area was significantly larger for OCT than for SLP and SWAP. For diagnosis based on disc appearance, the ROC curve area was significantly larger for OCT than for SWAP. For both diagnostic criteria, at specificities of 90% and 70%, the most sensitive OCT parameter was more sensitive than the most sensitive SWAP and SLP parameters. For diagnosis based on SAP, the most sensitive FDT parameter was more sensitive than the most sensitive SLP parameter at specificities of 90% and 70% and was more sensitive than the most sensitive SWAP parameter at specificity of 70%. For diagnosis based on disc appearance at specificity of 90%, the most sensitive FDT parameter was more sensitive than the most sensitive SWAP and SLP parameters. At specificity 90%, agreement among instruments for classifying eyes as glaucomatous was poor. CONCLUSIONS. In general, areas under the ROC curve were largest (although not always significantly so) for OCT parameters, followed by FDT, SLP, and SWAP, regardless of the definition of glaucoma used. The most sensitive OCT and FDT parameters tended to be more sensitive than the most sensitive SWAP and SLP parameters at the specificities investigated, regardless of diagnostic criteria. Christopher Bowd, Linda M. Zangwill, Charles C. Berry, Eytan Z. Blumenthal, Cristiana Vasile, Cesar SanchezGaleana, Charles F. Bosworth, Pamela A. Sample and Robert N. Weinreb

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5. Detection of mutations in chromosome 1 open angle glaucoma gene. BACKGROUND A substantial proportion of cases of glaucoma have a genetic basis. Mutations causing glaucoma have been identified in the chromosome 1 open-angle glaucoma gene (GLC1A), which encodes a 57-kd protein known as myocilin. The normal role of this protein and the mechanism by which mutations cause glaucoma are not known. CONCLUSIONS A variety of mutations in the GLC1A gene are associated with glaucoma. The spectrum of disease can range from juvenile glaucoma to typical late-onset primary open-angle glaucoma.
Wallace L.M. Alward, M.D., John H. Fingert, B.A., Michael A. Coote, M.B., B.S., A. Tim Johnson, M.D., Ph.D., S. Fabian Lerner, M.D., Denise Junqua, M.D., Fiona J. Durcan, M.D., Paul J. McCartney, M.B., B.S., David A. Mackey, M.B., Val C. Sheffield, M.D., Ph.D., and Edwin M. Stone, M.D., Ph.D.

6. Comparison of psychophysical and electrophysiological testing in early glaucoma. PURPOSE: To compare the sensitivity and specificity of a wide range of psychophysical and electrophysiological tests in the detection of early glaucomatous damage. METHODS Forty-three normals and 43 patients with early glaucoma, some still without field defects, were tested with differential light threshold perimetry, short-wavelength automated perimetry, highpass resolution perimetry, motion detection, flicker contrast sensitivity, flickering and isoluminantly matched letter tests, and pattern and flash electroretinography, including photopic, scotopic, oscillatory potentials, and 30 Hz flicker. Receiver operating characteristic analysis was applied to continuous variables derived from each of the tests. RESULTS Most parameters reflected glaucomatous loss to some degree, even though only single variables were analyzed separately in the receiver operating characteristic analysis. The pattern

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electroretinogram and some of the letter acuity tests had the best sensitivity and specificity, followed by short-wavelength automated perimetry and high-pass resolution-perimetry. Motion detection, flicker contrast, and flash electroretinogram parameters scored poorly. Six patients with normal results on the Humphrey field test had abnormal results on many of the other tests. CONCLUSIONS Applying different psychophysical and electrophysiological tests may add to our ability to detect early glaucomatous damage.
S L Graham, S M Drance, B C Chauhan, N V Swindale, P Hnik ,F S Mikelberg and G R Douglas.

7. The S-Cone PhNR and Pattern ERG in Primary Open Angle Glaucoma PURPOSE. To compare the sensitivity of the photopic negative response (PhNR) from the shortwave (S)-sensitive and the long (L)- and medium (M)-wavesensitive cone electroretinograms (ERGs), with the pattern electroretinogram (PERG) in the early stages of primary open-angle glaucoma (POAG). METHODS. Eighteen patients under treatment for diagnosed POAG and 19 normal control subjects were investigated. S-cone ERGs were elicited using adaptation to 650-nm light to suppress L-cone activity, and substitution between 450 nm and 535 nm to silence M-cone response at luminances higher than rod saturation. PhNRs from the L&M-cone pathways were elicited by a 200-msec pulse of red light (650 nm) on a continuous blue (450 nm) background. PERGs were recorded in accordance with the International Society for Clinical Electrophysiology of Vision (ISCEV) standard. RESULTS. Each method showed a statistically significant difference in the two groups. The S-cone PhNR was the most sensitive test and provided the most statistically significant results, with the largest area enclosed by the receiver operating characteristic (ROC) curve. CONCLUSION. The findings indicate that all three types of ERG may be useful in glaucoma investigation. The L- and M-cone PhNRs may have a role in monitoring established glaucoma. The previously reported high sensitivity of the PERG was confirmed. Extensive diffuse damage to S-cone bipolar and bistratified ganglion cells appears to occur at a very early stage in POAG, owing to a pressure-related

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mechanism and the S-cone PhNR was the most sensitive test. It may in future have an important role in diagnosis and monitoring of early glaucoma. Further investigation of this possibility is recommended.

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CONCLUSION From the researches conducted, we have seen various methods of early diagnosis of primary glaucoma. The methods include: 1. Applanation tonometry and gonioscopy: Although applanation tonometry is a fast, easy and noninvasive method for detection of early glaucoma, it is not a definite test because increased intraocular pressure does not always confirm glaucoma. So other tests are usually carried out as a follow up. In addition Age, sex, time of day, and menstruation were found to influence the tonometric readings, thus reducing the efficacy of this method. 2. Progression of Disc and Field Damage: In this study, early glaucoma was monitored by comparing optic disc change every year, because glaucoma is related to optic nerve damage which in turn can be linked to a progressive damage in the disc. Six of the subjects from the fifteen people used for the study did not show significant change in visual field abnormalities, it shows that visual field abnormalities may occur later in some individuals. This poses a problem in relying solely on this method for early diagnostics. 3. Detecting Early Glaucoma by Assessment of Retinal Nerve Fiber Layer Thickness and Visual Function: This method uses scanning laser polarimetry (SLP), optical coherence tomography (OCT), short-wavelength automated perimetry (SWAP), and frequency-doubling technology (FDT) to asses the retinal nerve fiber and visual function. The key benefits of OCT is that it allows live sub-surface images at near-microscopic resolution, Instant direct imaging of tissue morphology, no preparation of the sample or subject and no ionizing radiation is needed. 4. Detection of mutations in chromosome 1 open angle glaucoma gene: since glaucoma is not always associated with mutational changes this method is not applicable in all cases. Based on these studies, I can conclude that the most effective method for the early diagnosis of glaucoma is first checking for

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increase in intra ocular pressure using the method of applanation tonometry, then if an increase is observed the patient is then subjected to the more definitive method of scanning laser polarimetry (SLP) and optical coherence tomography (OCT) which gives the status of the optic nerve.

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REFERENCES 1. ENGLISH MEDICAL JORNAL 791 Bedford Glaucoma Survey J. L. K. BANKES,* MB., B.S., F.R.C.S., D.O.; E. S. PERKINS,* M.D., PH.D., F.R.C.S. S. TSOLAKIS,* M.D., D.O.; J. E. WRIGHT,* M.D., F.R.C.S., D.O. 30 March 1990. 2. Arch Ophthalmol: Thierry G. Zeyen, MD; Joseph Caprioli, MD 1993;111(1):62-65. 3. INDIAN JORNAL OF OPHTHALMOLOGY. A Jacob, R Thomas, SP Koshi, A Braganza, J Muliyil Schell Eye Hospital, Christian Medical College, Vellore, India 1998 Volume 46 , Issue 2, Page 81-86. 4. Christopher Bowd , Linda M. Zangwill, Charles C. Berry ,Eytan Z. Blumenthal , Cristiana Vasile , Cesar SanchezGaleana ,Charles F. Bosworth , Pamela A. Sample and Robert N. Weinreb // Invest. Ophthalmol. Vis. Sci.August 2001 vol. 42 no. 9. 5. The new England Journal of medicine Wallace L.M. Alward, M.D., John H. Fingert, B.A., Michael A. Coote, M.B., B.S., A. Tim Johnson, M.D., Ph.D., S. Fabian Lerner, M.D., Denise Junqua, M.D., Fiona J. Durcan, M.D., Paul J. McCartney, M.B., B.S., David A. Mackey, M.B., Val C. Sheffield, M.D., Ph.D., and Edwin M. Stone, M.D., Ph.D. N Engl J Med 1998; 338:1022-1027April 9, 1998. 6. S L Graham, S M Drance, B C Chauhan, N V Swindale, P Hnik, F S Mikelberg and G R Douglas // Invest. Ophthalmol. Vis. Sci. December 1996 vol. 37no. 13 2651-2662 7. Neville Drasdo , Yousef H. Aldebasi , Zohreh Chiti ,Katharine E. Mortlock , James E. Morgan and Rachel V. North // Invest. Ophthalmol. Vis. Sci. May 2001 vol. 42 no. 612661272.