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Clinical Significance of Central Corneal Thickness in the Managementof Glaucoma

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Clinical Significance of Central Corneal Thickness in the Managementof Glaucoma CLINICAL SCIENCES Clinical Significance of Central Corneal Thickness in the Management of Glaucoma Carolyn Y. Shih, MD; Joshua S. Graff Zivin, PhD; Stephen L. Trokel, MD; James C. Tsai, MD Objective: To evaluate the effect of central corneal thick- Results: Using the linear correction scale, 105 (55.9%) ness determination on the clinical management of pa- of 188 patients had at least a measurement-significant ad- tients with glaucoma and glaucoma suspect. justment in their IOP measurements: 67 (35.6%) had ad- justments between 1.5 and 3.0 mm Hg, while 38 (20.2%) Methods: A cross-sectional retrospective study was per- had an outcomes-significant IOP adjustment (Ն3.0 formed on 188 consecutive patients. Mean ultrasound mm Hg). Among the 188 patients, 16 (8.5%) had a change pachymetry measurements of central corneal thickness in eyedrop therapy, 4 (2.1%) had a change regarding laser and corresponding Goldmann applanation tonometry therapy, and 6 (3.2%) had a change in the decision re- measurements were obtained. Intraocular pressures (IOPs) garding glaucoma surgery. Using the exponential cor- were corrected using linear and mathematical (Orssengo- rection (Orssengo-Pye) scale, similar percentages were Pye) algorithms. Measurement-significant outcomes were obtained. defined as an IOP adjustment of 1.5 mm Hg or greater and outcomes-significant results as an IOP adjustment of Conclusion: Pachymetry-measured central corneal thick- 3.0 mm Hg or greater. Changes in therapy such as the ness has a significant effect on the clinical management use of eyedrops and addition or cancellation of laser of patients with glaucoma and glaucoma suspect. therapy or surgery were then noted for those individu- als with measurement- or outcomes-significant changes. Arch Ophthalmol. 2004;122:1270-1275 VER THE PAST 50 YEARS, pared with patients with CCTs of greater central corneal thick- than 588 µm. Moreover, with millions of ness (CCT) measure- individuals having undergone laser in situ ment has been an impor- keratomileusis surgery,5,6 there is a grow- tant variable in the ing concern that the process of removing Oassessment of intraocular pressure (IOP) corneal tissue during this surgery (with re- values in patients undergoing refractive sulting thinner corneas) will lead to an in- and corneal transplant surgery, as well as creased difficulty in diagnosing glau- in contact lens wearers.1 Studies by Ehlers coma, because this surgery tends to alter and Hansen2 and Whitacre et al3 stressed IOP measurements and may in turn re- that IOP measurements should be ad- quire greater emphasis on the assessment justed for CCT. However, the incorpora- of the optic disc and visual fields for the tion of CCT-adjusted IOP measurements diagnosis and treatment of glaucoma.7,8 into daily clinical practice was limited un- til recently, when the Ocular Hyperten- CME course available at From the Edward S. Harkness sion Treatment Study4 reported that CCT www.archophthalmol.com Eye Institute, Department of was a strong predictor for the develop- Ophthalmology, College of ment of primary open-angle glaucoma in As summarized in a meta-analysis by Physicians and Surgeons patients with ocular hypertension. In par- Doughty and Zaman1 on the effect of CCT (Drs Shih, Trokel, and Tsai), ticular, this study demonstrated that sub- on IOP measurements, studies9,10 have hy- and Department of Health jects with decreased CCT measurements pothesized that CCT and IOP are related Policy and Management, had an increased risk of developing pri- to or interdependent on one another, ex- Mailman School of Public Health (Dr Graff Zivin), mary open-angle glaucoma (for every cept at gross extremes. Furthermore, varia- Columbia University, New 40-µm decrease in CCT, the relative risk tions in mean CCT have been observed in York, NY. The authors have no was 1.71). Moreover, individuals with patients with different types of glau- relevant financial interest in CCTs of 555 µm or less hada3times coma.11-13 Altogether, these studies sug- this article. greater risk of developing glaucoma com- gest that IOP measurements are affected (REPRINTED) ARCH OPHTHALMOL / VOL 122, SEP 2004 WWW.ARCHOPHTHALMOL.COM 1270 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 by CCT values. In fact, misdiagnosis often occurs when 544±34 µm). The IOP data were corrected using a linear al- CCT is not considered, because generally patients with gorithm and a mathematical model. The linear correction scale normal-tension glaucoma have thinner corneas and those (based on extensive literature review) added or subtracted 2.5 with glaucoma suspect have thicker corneas.11 Accord- mm Hg for every 50-µm difference in CCT from the reference ing to manometric data from Ehlers and colleagues,14 44% value of 545 µm (ie, a 1.0-mm Hg change for every 20-µm dif- ference in CCT from the reference value of 545 µm). A cor- of patients with normal-tension glaucoma would be re- rection factor (CF) of 2.5 mm Hg (for every 50-µm deviation classified as having primary open-angle glaucoma, and from the reference CCT value) was used, because various CFs 35% of patients with ocular hypertension would be re- in the literature have ranged from approximately 1.00 to 3.57 classified as having normal IOPs. Furthermore, Hern- mm Hg for every 50-µm deviation. In fact, in the study by Ehlers don et al15 found that as many as 65% of patients with and Hansen,2 the CF reported was 3.57 mm Hg per 50-µm de- ocular hypertension could be reclassified as having nor- viation (ie, about 5 mm Hg for every 70 µm), and the meta- mal IOPs. analysis of 134 studies by Doughty and Zaman1 found that the Believing corneal pachymetry to be essential to the slope of the regression line created by the data resulted in 3.33 care of patients, Tanaka stated that mm Hg per 50-µm deviation. Furthermore, in a cannulation study of 125 patients undergoing phacoemulsification cata- . performing pachymetry may influence the management of ract surgery with corresponding manometric water column and all patients by allowing clinicians to (1) observe or pursue less Perkins tonometry measurements, Pillunat and colleagues17 cal- aggressive treatment of patients with pseudo-ocular hyperten- culated an approximate 2.5-mm Hg change in IOP for every sion; (2) modify the target intraocular pressure in patients with 50-µm difference in corneal thickness. glaucoma; and (3) detect an elevated intraocular pressure in Adjustments of IOP were made according to the follow- otherwise normal patients with thin corneas and “normal” ap- 16(p544) ing linear formula: Corrected IOP = Measured IOP – (CCT – planation readings. 545)/50ϫ2.5 mm Hg. There is growing consensus that routine measurement of Sensitivity analyses of the linear model were performed, CCT may be critical for the proper management of pa- substituting 2.0 and 3.0 mm Hg as the CFs (for every 50-µm tients with glaucoma and glaucoma suspect not only for deviation from the reference CCT of 545 µm). To provide a comparison, a mathematical formula de- cost reasons, but most important, for effective quality care. 18 Therefore, we hypothesized that CCT has a significant effect rived by Orssengo and Pye was used, because the formula ac- counts for factors such as the anterior radius of curvature, thick- on the clinical management of patients with the diag- ness, and Poisson ratio of the cornea. The formula is as follows: noses of glaucoma and glaucoma suspect. To evaluate the True IOP = Goldmann applanation IOP ÷ K, where K is a com- effect of incorporating CCT measurements into daily clini- plex CF dependent on applanted area, radius of curvature of cal practice, we performed a cross-sectional retrospective the anterior cornea, center thickness of the cornea, and Pois- study of consecutive patients seen for glaucoma care. son’s ratio of the cornea. A standard radius of curvature of the anterior cornea (7.74 mm) was used for the purpose of this study METHODS as it was not calculated for individual patients. In regard to CCT-adjusted IOP values, measurement- A cross-sectional retrospective study was performed on 188 con- significant adjustments were defined as IOP corrections of 1.5 secutive patients seen at an academic medical center glau- mm Hg or greater (in either direction). Although there may be coma practice between June 20, 2002, and August 20, 2002. differences in opinion regarding the value of key CFs, our analy- Patients with known corneal pathologic conditions (eg, with sis suggests that 1.5 and 3.0 mm Hg are appropriate cutoff val- corneal edema or those who had undergone penetrating kera- ues for determining potential outcome effects. Although re- toplasty) were excluded from the study. However, patients who sults of the Early Manifest Glaucoma Trial19 and the Ocular had undergone refractive surgery were not excluded from the Hypertension Treatment Study4 suggest a 10% difference in out- study. Three consecutive ultrasound pachymetry (Sonomed, come for each millimeter of mercury, this figure was derived Inc, Lake Success, NY) measurements of CCT were obtained from extrapolated data. As a conservative measure, we opted from each eye, and a mean value was then computed. Mea- to set our first cutoff slightly higher at 1.5 mm Hg. surements were performed under topical anesthesia. The cor- The 1.5-mm Hg figure was arrived at because a change as responding Goldmann applanation tonometry (GAT) measure- small as 1.0 mm Hg is noted to be measurement significant in ments were obtained at each of these visits with the use of clinical trials; the Early Manifest Glaucoma Trial reported that fluorescein solution (in most cases, only one measurement was “each higher (or lower) millimeter of mercury of IOP on fol- taken).
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