1. Will my Glaucoma patient lose vision ?
Rohit Varma, MD, MPH
Professor and Chairman
Illinois Eye and Ear Infirmary
Univ. of Illinois at Chicago

2. I have no financial disclosures related to the content of this talk
National Institutes of Health Grants:
NEI U10-EY and EY and an unrestricted grant from the Research to Prevent Blindness, New York, NY.

3. Worldwide burden of Glaucoma
Glaucoma is the leading cause of irreversible blindness in the world, estimated to affect up to 79.6 million people by 2020.
Of these, 74% have POAG and 26% have primary angle-closure glaucoma (PACG).

4. POAG related Blindness
Blindness from POAG in at least 1 eye of between 15% and 27% after 15 to 20 years of follow-up
20% over a 34-year follow-up period.

5. POAG related VF Progression
VF progression of between 21% and 44% over 10 years in US
16% to 37% of treated POAG patients experienced progressive VF loss over a 5-year period in Australia.

6. Comparison of Glaucoma Blind vs. Non-Blind Persons
Characteristics
Blind (n = 56)
Non-blind (n = 234)
Age at diagnosis of glaucoma
69 ± 12†
65 ± 14
Gender - Male
36% (20/56)
37% (87/234)
Family history of glaucoma
21% (12/56)
21% (48/234)
Diabetes
4% (2/56)
9% (21/234)
Myopia > 3 diopters
18% (10/56)
16% (37/234)
IOP at diagnosis of glaucoma (before Rx)
27.0 ± 7.2 mm Hg
27.8 ± 6.0 mm Hg
IOP at final visit (on Rx)‡
16.3 ± 6.1 mm Hg§
18.4 ± 5.5 mm Hg
Mean Individual IOP range
9.9 ± 8.8 mm Hg
6.8 ± 6.8 mm Hg
Normal field at diagnosis
34% (19/56)
75% (162/216)
% having filtration surgery
38% (21/56)∥
14% (32/234)
Oliver et al 2002

7. Comparison of Glaucoma Blind vs. Non-Blind Persons
The mean IOP on therapy in the patients progressing to blindness was lower than, or similar to, those who did not become blind.
The group progressing to blindness had a greater variability of IOP while on therapy than the non-blind group.
Even in patients with low IOP, however, glaucoma could progress.

8. Comparison of Glaucoma Blind vs. Non-Blind Persons
The different sensitivities of patients to IOP indicate that ongoing monitoring of glaucomatous damage remains essential.
While establishment of a target IOP is a cornerstone of modern glaucoma practice, such target pressures should be adjusted if the patients’ condition changes.

9. Predictors for Progressive Visual Field Loss

10. IOP and Progressive Visual Field Loss

11. Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression
De Moraes et al 2009

12. Glaucoma With Early Visual Field Loss Affecting Both Hemi-fields and the Risk of Disease Progression

13. Factors for Glaucoma Progression and the Effect of Treatment: The Early Manifest Glaucoma Trial

14. Risk Factors for the Progression of Open-angle Glaucoma: Canadian Glaucoma Study

15. Progressive VF Loss - CIGTS
After 8-year of follow-up substantial worsening (≥3 dB) of Visual fields was found in 21.3% and 25.5% of the initial surgery and initial medicine groups.
In patients with advanced visual field loss, Initial surgery led to less VF progression than initial medicine
Persons with diabetes had more VF loss over time if treated initially with surgery.

16. IOP and Progressive VF Loss - CIGTS

17. POAG related Blindness and Progressive VF Loss
Higher IOP and Greater Variability of IOP
Greater Visual Field Loss at baseline
Diabetes
Low ocular perfusion pressure
In advanced cases, treatment with medicine vs. surgery

18. PACG and Progressive VF Loss
Progression of Visual Field defects in 10% of treated PACG eyes over 6 years of follow-up.
Another study examining 101 patients with chronic PACG reported progression in 25% of patients over 5 years.

19. PACG and Progressive Visual Field Loss

20. PACG, VF Loss and Blindness
Over a 10 year follow-up period, VF progression 32.5% of patients.
7.2% progressed to blindness

21. Risk Factors for Progressive Visual Field Loss in PACG
Multivariate Odds Ratioa (95% CI)
P Value
Mean overall IOP
1.59(1.22,2.08)
.001
Previous acute angle closure
4.59(1.47,14.38)
.009

22. PACG related Blindness and Progressive VF Loss
Higher IOP
Previous Episodes of Acute angle closure
Not enough data

23. Will my glaucoma patient lose vision? Summary
Primary Open Angle Glaucoma
Higher IOP and greater variation of IOP
Greater initial visual field loss
Diabetes
Pseudoexfoliation
Treatment with medication compared with surgery

24. Will my glaucoma patient lose vision? Summary
Primary Angle Closure Glaucoma
Higher IOP
Previous episodes of acute angle closure

25. Thank you