Effect of Cataract Extraction and Intraocular Lens Implantation on Nerve Fibre Layer Thickness Measurements by Scanning Laser Po
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Eye (2004) 18, 163–168 & 2004 Nature Publishing Group All rights reserved 0950-222X/04 $25.00 www.nature.com/eye 1;2;3 1;2;3 1;2 Effect of cataract G Gazzard , PJ Foster , JG Devereux , CLINICAL STUDY F Oen1, PTK Chew1, PT Khaw2;3 and SKL Seah1 extraction and intraocular lens implantation on nerve fibre layer thickness measurements by scanning laser polarimeter (GDx) in glaucoma patients Abstract superior and inferior averages, superior integral) were significantly greater than Purpose To assess the influence of visually preoperative values (all Po0.01), whereas significant cataract on the measurement of ratios and measures of symmetry (symmetry, 1Singapore National Eye nerve fibre layer thickness by scanning laser superior/nasal) were unchanged (all P40.1) Centre, Singapore polarimetry (GDx) in glaucoma patients and ‘the number’ was smaller (P ¼ 0.04). undergoing phacoemulsification cataract Differences in measured NFLT were most 2Institute of Ophthalmology extraction. strongly correlated with posterior subcapsular and Moorfields Eye Hospital Method and Subjects All subjects with cataract (average thickness, P ¼ 0.01). London, England, UK primary glaucoma participating in a Conclusions Removal of cataract resulted in 3 prospective trial of glaucoma surgery who greater absolute measurements of NFLT but Singapore Eye Research Institute, Singapore subsequently underwent cataract extraction ratio values were unchanged. Scanning laser were eligible. A single trained observer using polarimetry measurements can change Correspondence: the GDx nerve fibre layer analyser (LDT) significantly after cataract extraction. New G Gazzard performed pre- and post-operative baseline measurements may be required. Department of Wound measurements of nerve fibre layer thickness Eye (2004) 18, 163–168. doi:10.1038/ Healing Institute of (NFLT). NFLT parameters, best-corrected sj.eye.6700600 Ophthalmology LogMAR visual acuity, and automated visual Bath Street London EC1V 29EL, UK fields were assessed before and after Keywords: glaucoma; GDX; scanning laser Tel: þ 44 207 608 6906 phacoemulsification cataract extraction with polarimetry; cataract Fax: þ 44 207 250 3207 implantation of an acrylic intraocular lens. E-mail: gus@ gazzard. Results A total of 49 subjects were assessed: demon.com 22 (45%) had POAG and 29 (55%) PACG; all Introduction were Asian (36 (73%) were Chinese), with Received: 1 November 2002 mean age 67.1 (77.6 SD) and mean ‘LOCS III’ Glaucomatous optic neuropathy is characterised Accepted: 26 March 2003 lens opacity grading 11.4 (73.1 SD). Visual by the progressive loss of ganglion cells and Funding and support by acuity significantly improved (mean LogMAR accompanying optic disc and retinal nerve fibre Singapore National Medical 0.5 vs 0.15, Po0.0001). Corrected pattern layer (NFL) changes. Alterations in visual field Research Council NMRC/ standard deviation (6.1 vs 6.4, P ¼ 0.2) and sensitivity are the corresponding functional 0044/1994, Singapore mean deviation (À17.7 dB vs -17.0 P ¼ 0.91) measure of ganglion cell function but there may National Eye Centre, and were little changed after cataract removal. be a substantial loss of axons before visual field Medical Research Council 1 (UK) G9330070 (Professor Pseudo-phakic measurements of NFLT were changes develop. Khaw) significantly different from pre-op values. The detection of changes over time in visual Measures of absolute thickness (including the function or in anatomy is the mainstay of the Commercial relationships or average thickness, ellipse, ellipse average, follow-up and treatment of glaucoma. However, conflict of interest: None Cataract and GDx G Gazzard et al 164 the inherent test–retest variability of a psychophysical trained glaucoma specialist on clinical disc assessment, measure such as visual field testing makes the reliable and a visual field defect consisting of at least two points detection of change in even established scotomata2,3 reduced by 45 dB or one point reduced by 410 dB difficult and is highly patient dependent.4 Examination below age-specific threshold. of the optic disc and NFL by careful stereoscopic Exclusion criteria were: age less than 30 years, biomicroscopy permits the detection of morphological previous intraocular or conjunctival surgery, any changes in anatomy before perimetry shows changes in nonlenticular axial media opacity, corneal oedema, and visual function.5,6 Quantification of objective other ocular or systemic pathology, which might result in measurements of these structural alterations may allow a visual field defect (including diabetic retinopathy or even greater sensitivity in the detection of progressive age-related macular degeneration). glaucomatous loss.7,8 Scanning laser polarimetry (SLP) Data were collected regarding one eye only of each gives a reproducible,9–11 objective in vivo measurement of subject. During preoperative work-up, a full ophthalmic the thickness of the NFL, based on the alteration it causes examination was carried out. The degree of lens opacity in the polarisation of light passed through it (nuclear opacity and colour, cortical and posterior (retardation).12 It is thought that neuronal microtubules subcapsular opacities) was graded by clinical act as naturally polarising, birefringent structures, and observation at a slit lamp using standard photographs of the degree of retardation is proportional to the NFL the LOCS III scheme.25 thickness (NFLT). NFL measurements were performed by scanning laser Longitudinal assessments of the stability of NFLT must polarimeter (‘‘GDx’’; Laser Diagnostic Technologies, San account for both age related ganglion cell loss12–15 and Diego, CA, USA; GDx software version 2.0.09) by a single the alteration of polarising structures in the path of the experienced individual under ambient room lighting. All SLP.16–18 The crystalline lens is a weakly polarising GDx measurements were taken within 8 weeks of structure and many patients with glaucoma will develop surgery on each occasion; specifically, postoperative cataract following glaucoma surgery or with increasing measurements were made at least 4 weeks after cataract age. Previous studies have looked at the effects of surgeryFafter any postoperative corneal oedema, if any, cataract extraction on the measurement of the NFL with had settled. The principles are well described conflicting results.19–23 Both Kremmer et al22 and Chiba elsewhere.26 Standard 151 Â 151 measurements, which et al19,20 found that dense cataract led to an passed the internal software quality control, were made underestimation of NFLT, whereas Park et al23 found at each visit through an undilated pupil and a mean unpredictable changes with intraocular lens (IOL) image used for analysis. The measurement ellipse was implantation and Collur et al24 suggested that there was positioned at the same position at the second no change after cataract extraction. examination by reference to the retinal landmarks in the The aim of this study was to evaluate the effects of initial image. Image analysis was carried out using the cataract extraction on the measurement of NFLT in a GDx software. We compared the pre- and post-operative population of moderate to severe glaucomatous subjects output values derived from the GDx software, as our aim using SLP (GDx, Laser Diagnostic Technologies, San was to establish the impact of cataract extraction on the Diego, CA, USA). use of GDx in a clinical setting. Phacoemulsification cataract extraction was performed by one of two senior consultant surgeons via a temporal Methods or superior clear corneal incision, as dictated by the Subjects enrolled in a prospective, randomised, placebo- orientation of existing astigmatism and/or the position controlled trial of the use of intraoperative 5-fluorouracil and extent of trabeculectomy bleb. All eyes underwent in glaucoma filtering surgery in South East Asia were in-the-bag implantation of a single type of foldable included. This study was granted ethical approval by acrylic lens (‘‘AcrySof’’, MA60 BD, Alcon). The Ethical Review Committee of Singapore National Visual field examination was carried out using a static Eye Centre, acting for The Ministry of Health of The automated perimeter (Model 750, Zeiss Humphrey, San Republic of Singapore. Written informed consent was Leandro, CA, USA). A minimum of two visual field tests obtained from all participants in their own language with were carried out on different days using the 24-2 an interpreter where necessary. program, requiring that the test was completed with The inclusion criteria were as follows: intraocular o33% false positives, o33% false negatives, and o20% pressure (IOP) greater than 21 mmHg on at least one fixation losses. If the mean defect in these tests differed occasion, reduction of the neuroretinal rim width to less by more than 2 dB, further tests were carried out until than or equal to 0.1 of the cup : disc ratio or a two test results with a mean deviation (MD) within 2 dB glaucomatous optic disc in the opinion of a fellowship- had been obtained. Eye Cataract and GDx G Gazzard et al 165 Differences in mean values of parametric data between posterior subcapsular cataract (Spearman correlation, rS), individuals before and after intervention were examined but not with nuclear colour, nuclear opalescence or using a paired sample t-test. For nonparametric data, a cortical cataract (eg for PSCLO LOCS score and average Mann–Whitney U-test was used to compare means and thickness, rS ¼ 0.35, P ¼ 0.006; superior average, rS ¼ 0.34, the Wilcoxon sign rank test for the distribution of two P ¼ 0.008; inferior average, rS ¼ 0.32, P ¼ 0.01; ellipse 2 related variables. w was used for the analysis of average, rS ¼ 0.38, P ¼ 0.004). This was true for ‘absolute categorical variables. A value of Po0.05 was taken as values’ of NFLT but not ratio measures (eg for PSCLO significant; where multiple tests were performed, a LOCS score and superior ratio, rS ¼ 0.14, P ¼ 0.16; inferior Bonferroni correction was applied. ratio, rS ¼ 0.14, P ¼ 0.16). There was a wide range of changes in the different parameters, and the change in one parameter did not necessarily predict the behaviour Results of another.