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The Association Between Retinal Vessel Diameter and Retinal Nerve Fiber Layer Thickness in Asymmetric Normal Tension Glaucoma Patients

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The Association Between Retinal Vessel Diameter and Retinal Nerve Fiber Layer Thickness in Asymmetric Normal Tension Glaucoma Patients Glaucoma The Association between Retinal Vessel Diameter and Retinal Nerve Fiber Layer Thickness in Asymmetric Normal Tension Glaucoma Patients Joon Mo Kim,1 Mo Sae Kim,2 Hyo Ju Jang,1 Ki Ho Park,3 and Joseph Caprioli4 PURPOSE. The aim of this study was to evaluate the associations levated intraocular pressure (IOP) is a major risk factor for between retinal vessel diameter and retinal nerve fiber layer Eprimary open-angle glaucoma (POAG). In addition, re- (RNFL) thickness in patients with normal tension glaucoma search suggests that abnormalities of blood flow contribute to (NTG). the development and progression of POAG, such as in systemic 1 2 3 4 METHODS. This study included 67 untreated patients with hypertension, vasospasm, diabetes, and migraine. Although asymmetric NTG, with no evidence of glaucoma in the normal tension glaucoma (NTG) is considered a form of contralateral eyes, and 48 age- and sex-matched normal control chronic OAG and IOP is still widely recognized as a major risk 5 subjects. We included patients from 20 to 70 years of age who factor for progression, whether NTG and high-tension had no history of hypertension, diabetes, or other vascular glaucoma differ in their pathogenesis remains controversial. diseases. All subjects underwent detailed eye examinations that Some patients still suffer glaucomatous optic nerve damage included red-free photography, stereoscopic optic disc pho- despite IOP within the ‘‘statistically normal’’ range. Therefore, tography, automated perimetry, and measurement of RNFL additional causes of NTG have been suggested, such as vascular thickness with optical coherence tomography. We compared factors.6 RNFL thicknesses, temporal retinal arteriolar diameters Blood flow can be regulated depending on changing (TRAD), and temporal retinal venular diameters (between metabolic needs, local vascular resistance, and other process- quadrants with and without RNFL defects) with computer- es.6 If local blood supply does not meet the demand of local assisted imaging software. tissue, ischemic damage can result. If the needs of the local tissue require less supply, blood flow will be reduced through RESULTS. The mean diameter of the temporal retinal vessels in the quadrants with RNFL defects were significantly smaller in autoregulatory mechanisms. Prior studies have examined the patients with NTG than in those with quadrants without RNFL relationship between retinal vascular diameter and retinal nerve fiber layer (RNFL) thickness in patients with OAG. Rader defects (P < 0.001) and in control subjects (P < 0.001). TRADs 7 were correlated with RNFL defects and RNFL thicknesses (P < et al. reported that the location of proximal constriction in 0.05) in binary logistic regression analysis and in multiple glaucoma corresponded to the sector with the greatest linear regression analysis (P < 0.001). There were no cupping, and a generalized narrowing of the retinal arteries statistically significant differences between vessel diameters was related to the severity of optic nerve damage regardless of 8 in control subjects and those in nondefective quadrants of the the cause. Similarly, studies by Jonas et al. and Jonas and 9 affected NTG eyes or the unaffected eyes of patients with NTG. Naumann demonstrated that parapapillary retinal vessel diameters may reflect the need of vascular supply in the CONCLUSIONS. Our results show that narrower retinal vessels are corresponding superficial retinal area, and it decreases with found in areas of RNFL defects. Considering previous reports advanced glaucomatous optic nerve damage. Mitchell et al.10 and our analysis, this is likely due to the decreased demand for reported that eyes with OAG had retinal arteriolar diameters retinal blood flow in damaged areas of the retina. ( Invest that were significantly smaller than those of either normal eyes 2012;53:5609–5614) DOI:10.1167/ Ophthalmol Vis Sci. or eyes with ocular hypertension. Although many studies have iovs.12-9783 tried to determine whether vascular narrowing was a cause or an effect of glaucomatous damage, additional work is required to address this issue. We investigated here the associations between retinal vessel diameters and RNFL thicknesses in affected and unaffected areas of the retina in patients with From the 1Department of Ophthalmology, Kangbuk Samsung NTG and in normal controls to help clarify whether retinal Hospital, Sungkyunkwan University College of Medicine, Seoul, vascular narrowing is a cause or an effect of glaucomatous Korea; the 2Department of Ophthalmology, National Cancer Center, damage. Goyang,Gyeonggi,Korea;the3Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea; and the 4 Department of Ophthalmology, Jules Stein Eye Institute, University MATERIALS AND METHODS of California, Los Angeles, California. Supported by an Association for Research in Vision and We retrospectively reviewed medical records of patients who visited Ophthalmology travel grant. the outpatient glaucoma clinic of Kangbuk Samsung Hospital in Seoul, Submitted for publication March 1, 2011; revised May 2, June Korea, from January 2010 to December 2010. At the same clinic during 13, and July 18, 2012; accepted July 21, 2012. the same period, age- and sex-matched consecutive control subjects Disclosure: J.M. Kim,None;M.S. Kim,None;H.J. Jang,None; K.H. Park,None;J. Caprioli,None were recruited. Control subjects were recruited from among patients Corresponding author: Ki Ho Park, Department of Ophthalmology, referred for mass routine health check-ups, from among those with Seoul National University College of Medicine, Seoul, Korea Youngeon- mild cataracts in whom surgery was deemed unnecessary, and from dong, Jongno-gu, Seoul, Korea 110-746; [email protected]. among patients referred for dry eye care. This study was approved by Investigative Ophthalmology & Visual Science, August 2012, Vol. 53, No. 9 Copyright 2012 The Association for Research in Vision and Ophthalmology, Inc. 5609 Downloaded from tvst.arvojournals.org on 10/01/2021 5610 Kim et al. IOVS, August 2012, Vol. 53, No. 9 assisted software (Visupac/system version 4.2.1 software; Carl Zeiss, Pirmasens, Germany). Visupac software was a customized program that provided the real size of an object on the fundus with an adjusted value that incorporated Littmann’s correction.11 The AV ratio program was used to select vessels of interest from the fundus photograph and gave the measurement of the TRA diameter (TRAD) and TRV diameter (TRVD), which were provided automatically based on the value by Visuapc (Fig. 1). The algorithm calculated the average value of the selected vessel within a zone of 0.5 to 1 disc diameter from the optic disc margin. Vessel diameters were obtained automatically once the vessel was selected by the investigator. Because such an automated process may result in inaccurate measurements if the quality of the image is poor, we included only subjects with high-quality images showing the optic disc margin and vessel borders clearly. Two readings were obtained, and the average value was used for subsequent analyses. Each TRAD and TRVD was measured in four quadrants (superonasal, superotemporal, inferonasal, and inferotemporal). To localize and match the vessels with a RNFL defect, we used TRADs and TRVDs of the superotemporal or inferotemporal quadrant associated with RNFL defects. We compared demographic data (age, sex, IOP, refractive error), RNFL thickness, TRAD, TRVD, and AV ratio between patients with NTG and control subjects without glaucoma, using the independent t-test, FIGURE 1. Dilated 308 stereoscopic disc photograph. Diameters of chi-squared test, ANOVA, and binary logistic regression analysis. Age, central retinal arterioles and venules passing completely through a sex, and factors with a P value of <0.2 on univariate analysis were circumferential zone from 0.5 to 1 disc diameter from the optic disc included in the logistic regression analysis model. TRADs, TRVDs, and margin were measured in micrometers with an automated program. RNFL thicknesses within the quadrants with RNFL defects were compared with those of each quadrant in the controls as follows: (1) the Kangbuk Samsung Institutional Review Board, and adhered to the affected and unaffected quadrants in the same eye; (2) affected Declaration of Helsinki. quadrants and each corresponding area of the superotemporal or All study subjects underwent ophthalmological examinations that inferotemporal quadrants of the unaffected eye; (3) affected quadrants included autorefraction, Goldmann applanation tonometry, visual field and the same quadrant of the eyes of normal controls; and (4) testing (Zeiss-Humphrey, San Leandro, CA), measurement of retinal unaffected quadrants and the same quadrants of unaffected NTG eyes nerve fiber layer thickness with optical coherence tomography (OCT, or the same quadrant of the eyes of normal controls. We also used version 3.0; Carl Zeiss Meditec, Inc., Dublin, CA), stereoscopic optic multivariate linear regression analysis to evaluate associations among disc photography, and red-free fundus photography (Visucam Pro NM TRAD, TRVD, and RNFL thickness adjusted for age, IOP, and refractive model; Carl Zeiss Meditec, Inc.). error. P values less than 0.05 were considered statistically significant. NTG was diagnosed by a glaucoma specialist using the following All statistical analyses were performed with PASW version 17.0 criteria: typical glaucomatous optic neuropathy including rim thinning software (SPSS, Chicago, IL). or notching
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