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Retinal Perfusion 6 Months After Trabeculectomy As Measured by Optical Coherence Tomography Angiography

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Retinal Perfusion 6 Months After Trabeculectomy As Measured by Optical Coherence Tomography Angiography Int Ophthalmol (2019) 39:2583–2594 https://doi.org/10.1007/s10792-019-01107-7 (0123456789().,-volV)( 0123456789().,-volV) ORIGINAL PAPER Retinal perfusion 6 months after trabeculectomy as measured by optical coherence tomography angiography C. Lommatzsch . K. Rothaus . J. M. Koch . C. Heinz . S. Grisanti Received: 17 March 2019 / Accepted: 29 April 2019 / Published online: 9 May 2019 Ó Springer Nature B.V. 2019 Abstract Results Nineteen eyes, one each from 19 patients (11 Purpose To investigate potential changes of vessel females; 8 males) with a mean age of 66.0 (58.07, density (VD) at the optic nerve head (ONH) and the 70.94) years and a mean intraocular pressure (IOP) of macula 6 months after trabeculectomy (TE). 21.0 mmHg (17.07, 23.87), were included in the Methods In a prospective monocentric study, 19 study. All showed a significant reduction in IOP at eyes with open-angle glaucoma were treated with each follow-up after TE (p \ 0.0001). There was no TE ? MMC (mitomycin C). At four different time significant change in the peripapillary retinal nerve points multiple morphological papillary parameters fiber layer thickness (p = 0.88), the ganglion cell were measured by OCT, and the ONH VD in the radial complex (p = 0.97), the cup–disk ratio (p = 0.63), the peripapillary capillary layer and the superficial and rim area (p = 0.78), or the mean visual field defect deep plexuses of the macula was determined by OCTA (p = 0.82). With regard to VD, no significant differ- (optical coherence tomography angiography, RTVue- ence could be determined in either the ONH or the XR, Optovue). The mean defect was determined by macular area. visual field examination (mode 30-2, Humphrey Field Conclusions After significant surgical reduction of Analyzer). The duration of follow-up was 6 months. IOP by TE, there are no significant detectable mor- phological changes in the ONH or the ganglion cell complex as measured by OCT, nor does the papillary The contents of this paper were presented as a lecture at the or macular OCTA-determined VD change signifi- Congress of the German Ophthalmological Society (DOG) on cantly. September 30, 2018, in Bonn. Trial registration 2016-409-f-S Avanti-OCT-A. Registered December 1, 2016. C. Lommatzsch (&) Á K. Rothaus Á J. M. Koch Á C. Heinz Department of Ophthalmology, St. Franziskus Hospital, Keywords OCT angiography Á Glaucoma Á Hohenzollernring 74, 48145 Muenster, Germany Intraocular pressure Á Trabeculectomy Á Blood flow Á e-mail: [email protected] Vessel density C. Heinz Department of Ophthalmology, University of Essen, Duisburg, Germany S. Grisanti Department of Ophthalmology, University of Luebeck, Luebeck, Germany 123 2584 Int Ophthalmol (2019) 39:2583–2594 Introduction Inclusion criteria: It is estimated that approximately 80 million people • Glaucomatous optic neuropathy, defined as the worldwide will suffer from glaucoma in the year 2020 presence of at least two of the following charac- [1]. The question of whether structural and functional teristics: changes occur during and after the surgical reduction of intraocular pressure (IOP) has often been raised. To • Vertical cup-to-disk ratio (VCDR) C 0.5 answer this question, it is important to first consider (based on HD-OCT measurements) with cor- the morphological consequences of glaucoma. This responding reduced RNFL thickness and gan- disease is characterized by damage to the retinal glion cell complex (GCC) defects on OCT ganglion cell axons, thinning of the peripapillary analysis consistent with glaucoma retinal nerve fiber layer (RNFL) thickness and intra- • VCDR asymmetry C 0.2 papillary nerve fiber loss (‘‘cupping’’). Furthermore, • IOP B 21 mmHg on the day of examination, there is accompanying posterior displacement of the with or without antiglaucomatous eye drop. lamina cribrosa. This anatomical change is thought to affect the circulation, resulting in ischemic insults [2]. Exclusion criteria: The aim of therapy is to reduce the IOP at the earliest possible stage of the disease and thus avoid the • Significant media opacity preventing high-quality occurrence of morphological and functional changes imaging in the form of visual field defects. If drug therapy fails, • Age \ 18 years or in the event of drug intolerance, surgery can be used • Refractive error [ ± 6 D sphere and ± 2 to achieve the target IOP. There are many surgical D cylinder techniques to reduce IOP. Trabeculectomy is still • Previous intraocular surgery except for uncompli- considered the gold standard. This filtering technique cated cataract extraction with IOL implantation in provides good results in IOP reduction and is also a the bag cost-effective procedure. In the study reported here we • Any ocular disease other than glaucoma or cataract set out to evaluate the morphological and functional • Arterial hypertension, hypotension, diabetes or any consequences of this surgical pressure relief. Our other vascular diseases such as status post-heart primary goal was to assess by means of optical failure, apoplexy or thrombosis coherence tomography angiography (OCTA) the • Systemic drugs with an effect on vascular diameter change in the circulatory status (vessel density, VD) either dilation or construction. in the area of the optic nerve and the macula after surgical pressure relief using. The duration of follow- Subjects up was 6 months. The patients’ characteristics are shown in Table 1. The study population was recruited from among patients Methods with open-angle glaucoma (OAG) scheduled for trabeculectomy at the Department of Ophthalmology, Study design St. Franziskus Hospital Muenster. OAG was defined as the presence of at least two of the following This was a prospective monocentric study conducted characteristics: at the Department of Ophthalmology, St. Franziskus Hospital Muenster (Germany). The study followed the • Vertical cup-to-disk ratio (VCDR) C 0.5 (based on tenets of the Declaration of Helsinki and was approved HD-OCT measurements) with corresponding by the Ethics Committee of the Medical Association of reduced RNFL thickness and ganglion cell com- Westfalen-Lippe, Germany. All patients gave their plex (GCC) defects on OCT analysis consistent informed consent before study entry. with glaucoma 123 Int Ophthalmol (2019) 39:2583–2594 2585 Table 1 Demographic and Age, years 66.0 (58.07, 70.94) ocular characteristics of the study population Female/male, n 11/8 preoperatively Glaucoma entity POAG, high-tension 12 SOAG, XFG 7 First diagnosis of glaucoma, months 84.16 ± 80.76 Refractive error 0.07 ± 1.78 D IOP, mmHg 21.0 (17.07, 23.87) MAP, mmHg 98.87 ± 10.18 Visual acuity, logMAR 0.14 ± 0.09 Values expressed as Visual field mean deviation, dB - 10.70 ± 8.26 mean ± standard deviation or as median and Topical medications, n 3.21 ± 0.92 interquartile range Type of topical medication, number of active ingredients POAG primary open-angle Prostaglandins 1.0 (1.0, 1.0) glaucoma, SOAG secondary Beta blockers 0.74 ± 0.45 open-angle glaucoma, XFG CAI 1.0 (1.0, 1.0) exfoliation glaucoma, IOP intraocular pressure, MAP Alpha-adrenergics 0.68 ± 0.48 mean arterial pressure, CAI Pretreatment surgery, n Cataract surgery 2 carbonic anhydrase Argon laser trabeculoplasty, 4 inhibitor • VCDR asymmetry C 0.2 Examination • IOP B 21 mmHg on the day of examination, with or without antiglaucomatous eye drop. The measurements detailed below were carried out at four different times: before operation and 3 weeks, The indication for surgery was progressive glaucoma 3 months, and 6 months thereafter. An additional (OCT, visual field and/or optic disk) with insufficient assessment within the first 3 days after surgery was IOP reduction under a topical medication or topical excluded from consideration due to insufficient image incompatibility of the topical antiglaucomatous ther- quality. At all examination times the relevant medical apy. All patients used exclusively topical IOP-lower- history and the current glaucoma medication were ing medication, with no systemic glaucoma treatment. documented. Prior to OCTA measurement all patients The inclusion criteria were diagnosis of OAG with underwent detailed ophthalmic examination including spherical refraction of \ ± 6 D sphere and ± 2 best-corrected visual acuity (BCVA), slit-lamp biomi- D cylinder, no significant media opacity to hinder croscopy with indirect ophthalmoscopy, Goldmann high-quality imaging, and age over 18 years. The applanation tonometry, and visual field examination exclusion criteria were the presence of any ocular (mode 30-2, Humphrey Field Analyzer; Zeiss, Jena, disease other than glaucoma and cataract or systemic Germany). Visual field examination was not per- diseases such as arterial hypertension or hypotension, formed 3 weeks postoperatively. The thickness of the diabetes, or any other vascular diseases such as status peripapillary (RNFL and ganglion cell complex post-heart failure, apoplexy, or thrombosis. Persons (GCC), the focal loss volume (FLV), the cup–disk taking systemic drugs with an effect on vascular ratio and the rim area were measured with spectral- diameter (dilation or constriction) were also excluded. domain optical coherence tomography (SD-OCT, Postoperative IOP \ 6 mmHg and hypotensive mac- RTVue-XR; Optovue, Inc., Fremont, California, ulopathy were reasons to exclude patients from USA; software version 2016.2.035). At each visit the follow-up. blood pressure was measured (Riva-Rocci method) and the mean arterial pressure (MAP) was calculated. MAP is the average blood pressure during a single cardiac cycle, and it is considered a better indicator of 123 2586 Int Ophthalmol (2019) 39:2583–2594 perfusion to vital organs than systolic blood pressure measurement according to Riva-Rocci was carried (SBP). MAP was calculated as follows: out. All scans were performed on non-drug-dilated pupils except for a few 3 weeks postoperatively, as 2 Â DBP MAP ¼ SBP þ or MAP some patients were still using atropine drops. At all 3 SBP þ 2 Â DBP other postoperative measurement times the pupil was ¼ 3 not dilated.
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