Association Between Nocturnal Blood Pressure Dips and Optic Disc Hemorrhage in Patients With Normal-Tension Glaucoma

doi:10.1016/j.ajo.2017.01.002

American Journal of Ophthalmology

Volume 176, April 2017, Pages 87-101

https://doi.org/10.1016/j.ajo.2017.01.002 Get rights and content

Purpose

To investigate the effect of nocturnal blood pressure (BP) dips on the occurrence of optic disc hemorrhage (ODH) in normal-tension glaucoma (NTG) patients and determine whether ODH is associated with greater likelihood of visual field progression (VFP).

Design

Prospective case-control study.

Methods

This study enrolled 698 eyes of 349 consecutive NTG patients who were ≥40 years old, underwent 24-hour intraocular pressure and ambulatory BP monitoring in the habitual position, were examined for ODH every 4–6 months with optic disc photography, and had ≥5 reliable visual field tests with minimum follow-up of 3 years. NTG patients were classified into 2 groups: “nonphysiologic” dippers, including nondippers and overdippers, and “physiologic” dippers. Odds ratios for the association between the “nonphysiologic” group and ODH were calculated using logistic regression models. Kaplan-Meier analyses were performed to compare outcomes with reference to the presence of ODH for VFP.

Results

Overall, ODH and VFP were detected in 107 (15.3%) eyes and 60 (8.6%) eyes among total 698 eyes, respectively. Overdippers showed a significantly greater frequency of ODH than nondippers or dippers. Being an overdipper was a significant and an independent risk factor for ODH occurrence during follow-up. The rates of VFP were 6%, 7%, and 24% for dippers, nondippers, and overdippers, respectively. Eyes with ODH were associated with greater likelihoods of subsequent VFP than those without. VFP occurred only in eyes with ODH.

Conclusions

Being an overdipper is a significant risk factor for ODH in NTG eyes. The detection of ODH during follow-up is a potent predictor of future VFP.

Section snippets

Patients

This was a prospective case-control study in which the subjects consisted of NTG patients from the Normal Tension Glaucoma Study, an ongoing prospective study to evaluate the relationship between NTG and systemic BP, which began recruitment from March 2010 at the glaucoma clinic of Asan Medical Center, Seoul, Korea. This study was approved by the institutional review board of Asan Medical Center and adhered to the tenets of the Declaration of Helsinki. All patients provided written informed

Clinical Demographics

A total of 377 consecutive NTG patients who met a minimum follow-up of 3 years since the recruitment on March 2010 were included. Of these, 12 patients were excluded owing to poor quality of stereoscopic disc photography, and 16 patients were excluded owing to insufficient and/or unreliable VF results during follow-up in both eyes. There were no unilateral NTG patients, and all enrolled subjects had bilateral NTG. Therefore, there were a total of 698 eyes of 349 subjects analyzed in the current

Discussion

NTG is a progressive optic neuropathy with a component of structural vascular abnormality and/or VD.13, 16, 25, 28 Nailfold capillaroscopy has been useful to evaluate VD in patients with glaucoma.13, 16, 53 Nail bed hemorrhage and the loss of nail capillaries during capillaroscopy are strongly associated with ODH detection in NTG patients, suggesting that ODH may be linked to VD in NTG patients.⁵³ Therefore, it is plausible to hypothesize that “nonphysiologic” BP dippers such as overdipper or

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Retrospective cross-sectional study.
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The worse mean deviation of SITA 24-2, thinner GCIPL thickness, and lower deep peripapillary VD were associated with the presence of central VF damage in glaucoma patients with myopia. Thinner GCIPL thickness, lower deep peripapillary VD, and longer disc-fovea distance were associated with decreased VA in logistic regression analysis. Thinner GCIPL thickness, lower deep peripapillary VD, and larger β-zone PPA area were associated with lower VA in linear regression analysis. Deep peripapillary VD showed a positive correlation with GCIPL thickness, whereas there was no relationship between deep peripapillary VD and RNFL thickness.
Decreased VA in glaucoma patients with myopia was associated with lower deep peripapillary VD and papillomacular bundle damage. Lower deep peripapillary VD was independently associated with decreased VA along with thinner GCIPL thickness. Therefore, it could be stated that decreased VA in glaucoma patients is related to the damage location and the status of blood flow in the optic nerve head.
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Citation Excerpt :
The average values from the measurements of the β-PPA area by the 2 independent observers were used in the final analysis to minimize the effect of interobserver variation. The glaucomatous ODH was identified from stereoscopic optic disc photographs as an isolated splinter- or flame-shaped hemorrhage on the optic disc or peripapillary area, extending to the disc border as defined before.33 All ODHs occurring during the follow-up period were counted and recorded in the present study.
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This study enrolled 208 eyes from 208 consecutive patients with OAG with CVF damage at baseline and with a minimum 2 years of follow-up. Optical coherence tomography (OCT) angiography was used to measure circumpapillary and macular VDs in the retina and parapapillary VD in the choroid (pCVD) at the baseline. The circumpapillary retinal nerve fiber layer (cpRNFL) and macular ganglion cell–inner plexiform layer (mGCIPL) thicknesses were also measured as reference standards. Cox proportional hazard analysis was performed to identify the baseline clinical factors associated with VF progression according to the glaucoma stage. The relationships between the CVF mean sensitivity reduction rate during follow-up and the baseline clinical factors were evaluated.
VF progression was detected in 54 eyes (26.0%) during 2.78 years of mean follow-up. A lower pCVD (hazard ratio = 0.916, P = .014) at baseline in early-stage OAG eyes and a reduced baseline average mGCIPL thickness (hazard ratio = 0.896, P = .001) in eyes with moderate to advanced glaucoma were independent predictors of VF progression. The baseline pCVD (β = 0.018, P = .028) in eyes with early-stage glaucoma and the baseline average mGCIPL thickness (β = 0.035, P = .013) in eyes with moderate to advanced glaucoma were significantly correlated with the rate (dB/y) of CVF mean sensitivity reduction.
In eyes with OAG with CVF damage, a lower baseline pCVD in early-stage glaucoma and a reduced mGCIPL thickness at baseline in moderate to advanced glaucoma are significantly associated with subsequent VF progression.
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To investigate the structural characteristics of the posterior sclera around the optic nerve head (ONH) in patients with normal-tension glaucoma (NTG) and myopia with central visual field (VF) defect.
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Ninety-seven eyes of 97 NTG patients with myopia were included in this study. Swedish interactive thresholding algorithm (SITA) 24-2 and 10-2 were both performed to compare the central VF with peripheral VF. Optic disc torsion, tilt, and peripapillary atrophy area were calculated in 2-dimensional disc photographs. The most posterior point—that is, the deepest point of the eye (DPE)—was identified in 3-dimensional en face optical coherence tomography results and related measurements were calculated using built-in software.
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Original articleAssociation Between Nocturnal Blood Pressure Dips and Optic Disc Hemorrhage in Patients With Normal-Tension Glaucoma

Purpose

Design

Methods

Results

Conclusions

Section snippets

Patients

Clinical Demographics

Discussion

Ophthalmology

Am J Ophthalmol

Ophthalmology

Prog Retin Eye Res

Ophthalmology

Ophthalmology

Am J Ophthalmol

Prog Retin Eye Res

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Surv Ophthalmol

Ophthalmology

Lancet

Ophthalmology

Am J Ophthalmol

Surv Ophthalmol

Ophthalmology

Am J Hypertens

Lancet

Ophthalmology

Am J Ophthalmol

Pharmacol Ther

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

The importance of disc hemorrhage in the prognosis of chronic open angle glaucoma

Arch Ophthalmol

Prevalence and significance of optic disc hemorrhage in a longitudinal study of glaucoma

Arch Ophthalmol

Spatially consistent, localized visual field loss before and after disc hemorrhage

Invest Ophthalmol Vis Sci

Optic disc haemorrhages preceding manifest glaucoma

Acta Ophthalmol (Copenh)

Prevalence of migraine in low-tension glaucoma and primary open-angle glaucoma in Japanese

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Original article
Association Between Nocturnal Blood Pressure Dips and Optic Disc Hemorrhage in Patients With Normal-Tension Glaucoma