Update

25

Glaucoma

Objective evaluation of the lens density in 3D

Further research needed to unlock perfusion pressure secrets in glaucoma

by Dermot McGrath in Paris
hile there is growing evidence of the role of low ocular perfusion pressure in the development and progression of open-angle glaucoma (OAG), there are still too many unanswered questions to justify its inclusion as a standard part of glaucoma management regimens, said Fotis Topouzis MD. In theory, ocular perfusion pressure could be incorporated in glaucoma management by checking or treating perfusion pressure. However, based on the current state of knowledge we are not there yet. We have a limited understanding of the complexity of ocular perfusion pressure and its interaction with potential risk factors for glaucoma, he told delegates attending the World Glaucoma Congress. Dr Topouzis, associate professor of ophthalmology, Aristotle University of Thessaloniki, Greece, said that recent studies have described the potential effects of low ocular perfusion pressure in the development and progression of glaucoma and shown that prevalence rates decrease progressively with increased diastolic perfusion pressure. Based on current glaucoma management guidelines, Dr Topouzis said that treating the ocular perfusion pressure is not a straightforward matter. We can treat perfusion pressure either by increasing blood pressure or by lowering IOP. However, there is no evidence to date that increasing perfusion pressure by increasing blood pressure would be of benefit in glaucoma patients, he said. Safety concerns should also be to the fore of any discussion involving treatment of perfusion pressure, added Dr Topouzis. The role of blood pressure in glaucoma remains controversial and there are serious cardiovascular safety concerns to be borne in mind. Studies have shown a doubling of mortality for every 20 mmHg increase in systolic blood pressure or 10 mmHg increase in diastolic blood pressure. In addition, we should consider that 66 per cent of hypertensive patients are not being controlled to target blood pressure levels, he said. Dr Topouzis said that the prevalence of white coat hypertension up to 30 per cent in the general population and more common in the elderly could lead to overtreatment of hypertension. Furthermore, in extreme dippers very low blood pressure could potentially lead to end-organ damage
EUROTIMES | Volume 16 | Issue 10

PERFUSION PRESSURE

including the optic nerve. In these patients, adjustment of antihypertensive treatment by the cardiologist may be justified, but there is no evidence of potential benefit to glaucoma. Turning to IOP, Dr Topouzis said that the difference in a new treatment scenario would be that lowering IOP would also aim to achieve a target perfusion pressure, involving a re-evaluation of the target IOP beyond the established algorithm. We need to bear in mind that perfusion pressure is a tricky variable. Of the two players in ocular perfusion pressure, we do not know for sure who is really playing the game: IOP alone, blood pressure alone or, more likely a combination of both? In the combination scenario, we need to ask what is the weight of each variable? Is it the same for the whole IOP spectrum? he asked. Dr Topouzis noted that the EgnaNeumarkt study found no association between low diastolic perfusion pressure and increased glaucoma prevalence in normal tension glaucoma. Furthermore, the Rotterdam study found that low diastolic blood pressure actually decreased the risk for individuals with low-tension glaucoma, which makes the data difficult to interpret. In the Early Manifest Glaucoma Trial (EMGT) subgroup analyses with regards to IOP, systolic blood pressure less than 60 mmHg was associated with progression in patients with baseline IOP less than 21 mmHg, while in patients with higher baseline IOP, systolic perfusion pressure less than 125 mmHg was associated with progression, but not systolic BP less than 160 mmHg. Furthermore, while perfusion pressure involves blood pressure level, it does not take account of blood pressure status, meaning normal, hypertension, treated hypertension, lowered blood pressure secondary to antihypertensive treatment, and high blood pressure despite antihypertensive treatment. In the Rotterdam Study, low diastolic perfusion pressure was associated with glaucoma prevalence only in subjects under antihypertensive treatment. With this in mind, we think it might be a good idea to introduce perfusion pressure status into the equation, taking account of the use of antihypertensive treatment, rather than the traditional method of using only perfusion pressure level, he concluded.

OCULUS Pentacam HR The indispensable tool for anterior segment analysis

PNS, objective Pentacam Nucleoues Staging (unique) 3D lens densitometry in selectable zones Corneal density evaluation Total Corneal Refractive Power for improved toric IOL placement Detailed Pre-op Cataract display (NEW!) Auto-release for user independent results iMAC & iPAD compatible

www.oculus.de

contact

Fotis Topouzis ftopouzis@otenet.gr