Characteristics of Primary Angle-Closure Glaucoma Patients with Normal Intraocular Pressure at the First Visit Won Hyuk Oh1, Bum Gi Kim1, Joo Hwa Lee2.

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Characteristics of Primary Angle-Closure Glaucoma Patients with Normal Intraocular Pressure at the First Visit Won Hyuk Oh1, Bum Gi Kim1, Joo Hwa Lee2 Department of Ophthalmology, Inje University Sanggye Paik Hospital, Seoul, Korea1 Good morning 102 Eye Clinic, Busan, Korea2 Table 1. Demographics of patients Introduction In primary angle-closure glaucoma (PACG), the glaucomatous optic neuropathy occurs as a direct consequence of elevated intraocular pressure (IOP) caused by physical obstruction of aqueous outflow, or degenerative changes in the trabecular meshwork resulting from iridotrabecular contact. Purpose Patients with PACG are known to have high IOP. However, in some of the patients diagnosed with PACG, IOP did not exceed the normal range in office. We compared the ophthalmic biometric values and the frequency of optic disc hemorrhage in PACG patients with normal IOP (≤ 21 mmHg) and those with high IOP (> 21 mmHg) at baseline. Methods PACG patients who visited our teaching hospital from June 2014 to February 2017 were enrolled the study. PACG was defined as follows; glaucomatous optic nerve damage with narrow angle (non-visibility of the filtering trabecular meshwork over 180 degrees with static gonioscopy in the dark room or presence of peripheral anterior synechiae), regardless of IOP levels. We analyzed the differences in the ophthalmic biometric measurements [central corneal thickness (CCT), axial length (AL), anterior chamber depth (ACD) and the ratio of ACD to AL] and frequency of optic disc hemorrhage in the PACG patients with normal IOP and those with high IOP. The refractive error was measured with the automatic refractometer (KR-8800, Topcon, Japan). Keratometry, AL and ACD were measured with the optical biometer (AL-Scan®, Nidek Co.,” Ltd., Japan) and the CCT was measured with the ultrasound pachymeter (PacScan 300A, SONOMED Inc, U.S.A). The age at the first visit, refractive error, corneal curvature, CCT, AL, ACD, ACD/AL between the two groups were analyzed by independent T test and frequency of optic disc hemorrhage by chi square test. Results A total of 169 eyes in the 169 PACG patients were included in the study. 52.7% (89/169) of PACG patients had normal IOP at the first visit. In PACG patients with normal IOP at the first visit, the age at the first visit was older (65.52 ± 0.89 vs. 62.71 ± 1.03), and the CCT was thinner (534 ± 3.35 vs. 546 ± 3.61), and the AL was longer (23.06 ± 0.08 vs. 22.68 ± 0.08), the ACD was deeper (2.11 ± 0.28 vs. 1.87 ± 0.33), the ACD/AL was greater (9.14 ± 1.06 vs. 8.23 ± 1.41), and the average keratometry was smaller (43.83 ± 1.43 vs. 44.48 ± 1.25) than in those with high IOP at the first visit, which were all statistically significant (p < 0.05, independent sample T test). There was, however, no statistical difference in refractive error between the two groups (0.85 ± 1.27 vs 0.59 ± 1.64, p = 0.259). Normal IOP High IOP p-value Number of subjects 89 80 Sex (M/F) 19/70 15/65 0.676 Age at the first visit (mean ± SD, range) 65.52 ± 8.41 (47 - 83) 62.71 ± 9.18 (46 - 83) <0.05 Follow-up, months (median ± SD) 30.32 ± 17.00 29.01 ± 16.32 0.612 Acute angle closure attack 30 <0.001 Table 2. Biometric measurements of normal & high IOP patients Normal IOP High IOP p-value Refractive error (D) (mean ± SD, range) 0.85 ± 1.27 (-4.00 - +3.50) 0.59 ± 1.64 (-2.00 - +10.63) 0.259 Average keratometry (D) (mean ± SD, range) 43.83 ± 1.43 (39.34 - 47.34) 44.48 ± 1.25 (41.31 - 48.21) <0.05 CCT (μm) 534 ± 3.35 (457 - 609) 546 ± 3.61 (453 - 642) AL (mm) 23.06 ± 0.08 (21.51 - 25.29) 22.68 ± 0.08 (19.25 - 24.00) ACD (mm) 2.11 ± 0.28 (1.55 - 2.72) 1.87 ± 0.33 (0.98 - 2.46) <0.001 ACD/AL 9.14 ± 1.06 (6.79 - 11.56) 8.23 ± 1.41 (4.35 - 10.77) (PD) CCT: central corneal thickness, AL: axial length, ACD: anterior chamber depth Table 3. Presence of disc hemorrhage related to IOP level of the first visit Normal IOP High IOP Optic disc hemorrhage (+) 18 6 Optic disc hemorrhage (-) 71 74 Figure 1. Scheimpflug image on AL-Scan® Anterior chamber depth (ACD) was defined as the distance from the posterior surface of cornea to the anterior surface of the lens. The frequency of optic disc hemorrhage was higher in PACG patients with normal IOP at the first visit than those with high IOP at the first visit (20.2%, 18/89 vs. 7.5%, 6/80, p = 0.03, chi-square test). Conclusion More than half of PACG patients had normal IOP at the first visit. These patients had thinner CCT, longer AL, ACD and more frequent episode of optic disc hemorrhage than PACG patients with high IOP at the first visit, and could be misdiagnosed with normal tension glaucoma, whose treatment strategy is different from PACG. So a careful gonioscopic examination is necessary in eyes with glaucoma regardless of IOP levels, especially in eyes with short AL. Financial Disclosure The authors do not have any financial supports to disclose.