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Retinal Vessels Change in Primary Angle-Closure Glaucoma: the Handan Eye Study

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Retinal Vessels Change in Primary Angle-Closure Glaucoma: the Handan Eye Study OPEN Retinal Vessels Change in Primary SUBJECT AREAS: Angle-Closure Glaucoma: The Handan EYE ABNORMALITIES GLAUCOMA Eye Study Jianlu Gao1,2, Yuanbo Liang1, Fenghua Wang1, Ran Shen3, Tienyin Wong4,5, Yi Peng1, Received David S. Friedman6,7 & Ningli Wang1 2 December 2014 Accepted 1Beijing Tongren Eye Center, Capital University of Medical Sciences, Beijing, China, 2Liaocheng Clinical Hospital, Taishan Medical 2 March 2015 College, Shandong Province, China, 3Handan Eye Hospital, Hebei Province, People’s Republic of China, 4Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia, 5Singapore Eye Research Institute, National University of Singapore, Published Singapore, Republic of Singapore, 6Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, 30 April 2015Baltimore, Maryland, 7Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland. Correspondence and Glaucoma is the second leading cause of blindness worldwide. To examine the relationship between angle requests for materials closure and the retinal vessel diameter in Chinese adults, we conducted Handan Eye Study (HES), a large should be addressed to population-based cross-sectional study, which enrolled 6830 participants .30 year-old living in 13 N.W. (wningli@vip. randomly selected villages of Yongnian County. After adjusting for age, gender, spherical equivalent (SE), 163.com) diabetes, and hypertension, the mean central retinal artery equivalent (CRAE, mm) was 127.1 6 7.0 and 145.6 6 4.4 in primary open-angle glaucoma (POAG) and primary angle closure glaucoma (PACG), respectively; narrower than that in normal control (156.1 6 0.4), primary angle-closure suspect (PACS) (156.3 6 1.1) or primary angle closure (PAC) (156.0 6 3.4) (P 5 0.001). The mean central retinal vein equivalent (CRVE, mm) was 229.0 6 5.9 and 215.8 6 9.5 in POAG and PACG, respectively; narrower than that in normal control (238.3 6 0.5), PACS (241.2 6 1.4) or PAC (242.2 6 4.6) (P 5 0.001). There was no significant difference in the mean CRAE or CRVE between PACG and POAG. Compared to the normal control (0.66), the mean arterio-venous ratio (AVR) was smaller in POAG (0.64) and PACG (0.59), whereas larger in PACS (0.65) and PAC (0.67) (P 5 0.003). To conclude, PACG and POAG individuals have narrower retinal arteries and veins. laucoma is a critical public health problem and the second (after cataracts) leading cause of blindness worldwide. Primary open-angle glaucoma (POAG) is the major reason for incurable visual impairment1. G It is characterized by progressive loss of retinal ganglion cells, resulting in glaucomatous optic neuro- pathy (GON). The etiology of POAG is not well established. Potential risk factors include intraocular pressure (IOP), age2, race, family history, genetic3, myopia4, intraocular pressure5, and poor perfusion of optic nerve head or ganglion cell layer6–9. The common consequence for potential etiologies is optic nerve head damage, which is secondary to primarily ganglion cell axon loss; however, loss of blood vessels and glial cells has also been observed. There are many postulated mechanisms of ganglion cell damage. It has been reported that eyes with glaucomatous damage had narrower retinal arteriolar diameters (183 6 2.6 mm) than normal eyes (194 6 0.4 mm) or ocular hypertension (195 6 1.6 mm)8. A prospective cross-sectional study observed significant reduction in the speed and flow of retinal blood in POAG patients compared to normal controls. It is unclear whether an ischemic process can lead to GON or whether the narrowing of retinal blood vessel is secondary to glaucoma10. In primary angle closure (PAC), an eye has a primary anatomic narrow angle and trabecular obstruction in the peripheral iris, caused by peripheral anterior synechiae (PAS), elevated IOP, iris whorling or sectoral atrophy, and excessive pigment deposition on the trabecular surface. The eye does not have glaucomatous damage of the optic nerve. In primary angle-closure suspect (PACS) or anatomic narrow angle, the anterior chamber angle recess has an abnormally narrow angular width. The peripheral iris is located close to, but not touching, the posterior pig- mented trabecular meshwork (TM). No PAS are present. IOP, optic nerve, and visual field are normal. Primary angle closure glaucoma (PACG) is diagnosed when iridotrabecular contact is present in three or more quadrants of the drainage angle in the presence of documented optic nerve damage and visual field loss. It has SCIENTIFIC REPORTS | 5 : 9585 | DOI: 10.1038/srep09585 1 www.nature.com/scientificreports been proposed that the GON in PACG is caused by high IOP and nasal and temporal quadrants. Small movements of the lens were allowed to visualize reduced circulation5,11. We hypothesize that the retinal vessel dia- the drainage angle, but large movements were avoided because of the possibility of indentation. Dynamic examinations with Goldmann lens were performed after the meter of PACG patients may confer the changes in circulation and static gonioscopy of the four quadrants was completed. If a satisfactory examination correlate with the subsequent GON. In China, 1.0–1.5% of people could not be achieved with Goldmann lens, 4-mirror Sussman lens (Ocular $40 year-old have PACG6–9, which is much higher than that in Instruments, Bellevue, Washington, USA) were used. The Spaeth Gonioscopic 17 Caucasian (0.1%–0.6%)12,13. This high prevalence has enabled the Grading System was used to record the results . The vertical cup-to-disc ratio (VCDR) was calculated to exclude the presence of Handan Eye Study (HES), a large population-based study on eye peripapillary atrophy and the scleral ring of Elschnig. The margin of the cup was diseases in northern China, obtained a larger group of PACG defined by stereoscopic view as the point of the maximum inflection of the vessels patients. Here, we analyzed the differences in retinal vessel diameters crossing the neuroretinal rim. Standard photographs for VCDR from 0.1 to 1.0 in 0.1 among PACS, PAC, PACG, POAG and normal participants, after increment were used for the grading process. Every 10th participate was systematically sampled with a visual field test using 24-2 adjusting for age, gender, refraction, and other possible confounders. Swedish Interactive Threshold Algorithm (SITA) fast program. In addition, all par- ticipants with angle closure disease or suspected glaucoma had SITA standard visual Methods field test. Tests were repeated twenty minutes later if the glaucoma hemifield test (GHT) was outside the normal limits, on the borderline, or if the test was unreliable (i. Study population and design. The HES is a population-based study on vision, e., fixation loses .20%, false positives .33%, or false negatives .33%). common eye diseases, and other outcomes of health problems. The study was GON was diagnosed based on the consensus opinion of three glaucoma specialists conducted according to the Declaration of Helsinki, and was approved by Ethical after review of all relevant information including patient history, VA, and optic nerve Committee of Beijing Tongren Hospital. Written informed consent was obtained stereo photographs. POAG was diagnosed if 1) GON was present without identifiable from each of the participants. Details of the study design, sampling plan, and baseline secondary causes; and 2) angle closure was excluded on gonioscopy18. PACS was data have been described previously14,15. In brief, 7557 eligible individuals older than diagnosed if the posterior trabecular meshwork was not visible for 180u or more on 30 years living in Yongnian County, Handan City, Hebei Province, China, were gonioscopy. PAC was defined as PACS with IOP $21 mmHg or the presence of identified from 13 randomly selected villages using a stratified, clustered, and multi- peripheral anterior synechiae (PAS) without GON. PACG was defined as PAC with staged sampling technique, with probabilities proportionate to the size of the GON13. The eyes without PACS, PAC, PACG, POAG, or non-glaucomatous population in each cluster. Among the population in Yongnian County, 90% are neuropathy were defined as the normal. farmers, and 98% are Han Chinese. Certified nurses measured height, weight, pulse rate, and blood pressure according All eligible subjects were invited to visit Yongnian County Hospital for a serial to standardized protocols. Total cholesterol, total triglycerides, low density lipopro- examination. Those who declined to visit the hospital were offered a simplified tein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and glucose level evaluation at a temporary field site established in the village; those who declined to in fasting blood were analyzed using certified protocols. Diabetes mellitus (DM) and visit the temporary site were offered a limited examination conducted at home. All hypertension were defined as previously reported14. Migraine and angina were fieldwork was conducted from October 2006 to October 2007. Finally, 6830 subjects diagnosed using interviewer-administrated questionnaires. completed the examination, and 6656 of 6830 (97.45%) participates with detailed demographic and clinical information were included in final data analysis. Statistics. Patients diagnosed with ocular hypertension without GON were assigned to the ‘‘normal’’ group(control), and patients diagnosed with normal-tension Procedures and definitions. For the baseline evaluation, 5909 of 6830 participants glaucoma were assigned to the POAG group, because previous studies have found no were examined in the county hospital, 807 in a temporary study site at the village, and difference in retinal vessel diameter among these groups8. 114 at home. At the county hospital and the village temporary site, fundus All statistical analysis was performed using SAS software9,13. Data from the right photographs of two fields (optic disc and macula) were taken from both eyes of each eyes of all participants in the normal controls and binocular glaucoma participants participant after pupil dilation using a digital retinal camera.
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