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Dr.MAYUR ROKDEY, Dr.Ganesh Venkataraman,Dr. NITHYA R.

INTRODUCTION

In a glaucomatous eye, a disc haemorrhage is a sign of alarm, pointing to the fact that the disease is active and disease progression is very likely. Even without any clear glaucomatous visual field damage or  characteristic glaucomatous optic disc changes, finding a disc haemorrhage can be considered to be an indicator of glaucomatous optic nerve damage. Therefore, a DH is important for an early diagnosis of glaucoma. This cross sectional study incorporates multiple systemic factors which may bear an association with optic disc haemorrhages in glaucoma[1,2].

OBJECTIVE

To determine which systemic factors are contributory in the pathogenesis of optic disc haemorrhage in primary glaucoma.

MATERIALS AND METHODS

Subject Eye Inclusion Criteria Subject Eye Exclusion Criteria
1.        Patients older than 40 years.

2.        Patients with diagnosis of Primary Open Angle Glaucoma, Ocular hypertension, Normal tension Glaucoma Primary Angle Closure Glaucoma.

3.        Patients having glaucomatous optic disc change, such as notching or thinning of the neuroretinal rim, an acquired pit in the optic nerve, and/or an retinal nerve fibre layer (RNFL) defect.

4.        A correlated visual field defect, with mean deviation (MD) better than -30 dB, as measured by the central 24-2 program of the Humphrey Field Analyzer (Carl Zeiss Meditec Inc., Dublin, CA, USA).

5.        Pseudophakic patients can be included provided there was no documented evidence of glaucoma at the time of cataract surgery.

6.        He / She should be able to comprehend and sign a statement of informed               consent.

 

 1.        Age less than 40 years.

2.        All other types of  glaucoma other than included in the inclusion criteria.

3.        Concomitant ocular disease that might lead to non-glaucomatous optic   disc haemorrhage.

4.         High myopia (more than six diopters).

5.         Severe cataract(s) that might affect visual field mean deviation.

6.        Severe visual field defects with mean deviation worse than -30dB.

7.        Suspicion of glaucoma such as large disc cupping without obvious RNFL, or visual field defects.

8.        Patients with any other fundus abnormality.

9.         Patients who have undergone any ocular surgery other than cataract and glaucoma surgeries.

RESULTS AND DISCUSSION

34 eyes of 33 patients were included in the study.

On 24 hr ambulatory BP monitoring (ABPM), 9 patients exhibited a loss of nocturnal dip and another 5 patients had loss of both diurnal and nocturnal dip in BP, making a total of 14. The p value for Abnormal BP fluctuations was 0.005.

Sixteen (16) of the total 34 patients were on some kind of antihypertensive medication for control of BP.

Statistical analysis for comparison of these 2 variables, gave a significant p value (p value=0.000), indicating that the occurrence of  fluctuations in BP are probably independent of the maximal control of BP with antihypertensive medications.

To the best of our knowledge, no study has been conducted so far which has assessed the role of fluctuation of BP in patients with glaucoma on treatment who present with DH.

The prospective study conducted by Y-d Kim[3] et al on 281 eyes concluded that systemic hypertension is associated with DH in normal tension glaucoma (NTG) [p value=0.001].

On further analysing the results of ABPM by statistical analysis, the occurrence of loss of normal patterns of BP fluctuation were unrelated to SBP fluctuation, DBP fluctuation(p value=0.686), MABP fluctuation(p value=0.316).

Likewise, there were no significant associations found between BP fluctuation patterns and SOPP (p value= 0.062), DOPP (p value= 0.638),  MPP(p value= 0.129) on analysis.

The occurrence of abnormal BP fluctuation was also insignificantly related to  the diagnosis of the studied eyes (p value=0.976) on statistical analysis.

For maximal control of IOP, patients were either on Anti-glaucoma medications (AGM) or were stable post glaucoma surgery. The analysis of occurrence of abnormal BP fluctuation was again not significantly related to the number of AGM (p value=0.639), indicating that maximal IOP control or lack thereof may not be the basis for incidence of DH.

This observation in our study was similar to the study[3] conducted by  Y-d Kim et al which yielded a p value= 0.08 in relation to IOP range.

None of our 34 studied patients were found to have lower than normal left ventricular ejection fraction (LVEF), thus it can be safely concluded that LVEF has no correlation with occurrence of DH or that with presence of abnormal BP fluctuations.

Only 2 out of 34 patients had an abnormal carotid flow status on 2D echocardiography, ruling out the possibility of carotid flow causing DH or abnormal BP fluctuations. The abnormality was stenosis of Carotid artery on the side of the the DH. One of these patients had a drastically reduced DOPP.

Similar was the case with analysis of patients on cardiac medications which included patients on aspirin or anticoagulants. These findings were contradictory to the findings in the study by Adael soares et al[4] who had found a p value= 0.019 for DH occurring in presence of aspirin use. These values need to be further evaluated in view of a smaller sample size in our study and the probability of occurrence of a chance phenomenon cannot be ruled out.

SBP fluctuation in all 34 patients was below the normal range of fluctuation and thus could not be statistically analysed.

22 patients were seen to show a DBP fluctuation less than the normal range  on ABPM. As well 25 patients had a DOPP fluctuation that was below normal range. Statistical analysis of DBP fluctuation and DOPP fluctuation showed that DOPP fluctuation was affected significantly by DBP fluctuation, giving us a p value= 0.009.

Lower SOPP, DOPP were associated with increased incidence of glaucoma as seen in the Barbados Eye Study, may influence DH pathogenesis.[5]

Although the cut off for DOPP is 53 mmHg, majority of the patients have  a DOPP of less than 40 mmHg

The MPP fluctuation cut off was 44 mmHg, a large chunk of patients were found to have MPP less than 30 mmHg.

Even after a thorough search of literature we could find no similar studies on this topic. Thus we are unable to compare our results with any pre- existing study.

Another 31 patients had an MABP fluctuation that was below normal value on ABPM. 28 patients had a subnormal MPP fluctuation. Statistical analysis of these variables revealed a p value =0.000, which is suggestive of an association between MABP fluctuation and MPP fluctuation. In a prospective study by Rafal L. Furlanetto et al[6] on 253 eyes of 127 patients, a positive association was found between DH and low mean arterial ocular perfusion pressure (MPP) [p value= 0.02]. In view of these observations it can be safely concluded that pathogenesis and incidence of DH has a positive association with low MABP fluctuation.

Mean deviation on HFA 24-2 in studied patients was not associated with occurrence of abnormal BP fluctuation. (p value =0.586)

None of our 34 patients were on any kind of oral antioxidants, leaving that factor unavailable for analysis.

Similarly none of our 34 patients at the time of enrolment in the study showed any derangement in their glycemic status on the day of examination, hence this aspect also remains unexplored. One similar cohort study was done in 2004 by Adael soares et al[4] where they found a significant association of DH with diabetes with a p value =0.001.

CONCLUSIONS

  • Our study demonstrated that there was a statistically significant association of DH in primary glaucoma with the presence of abnormal BP fluctuation patterns and lower MPP, despite maximal control of
  • Daily DBP fluctuation was also significantly associated with daily fluctuation of DOPP, which could be contributing to DH.
  • Maximum daily MABP fluctuation showed a statistically significant association with maximum daily MPP.
  • Mean IOP fluctuations, Cardiac status, carotid blood flow analysis showed no significant statistical association with the development of DH in primary glaucoma.

REFERENCES

  1. Jost B. Jonas, Vinay Nangia, Anshu Khare, Maithili Kulkarni, Arshia Matin, Ajit Sinha, Krishna Bhojwani,  Prabhat  Nangia, Songhomitra Panda-Jonas . Prevalence of Optic Disc Haemorrhages in Rural Central India. The Central India Eye and Medical Study. PLoS One. Sep 30 2013; 8-9 : e76154.
  2. Drance SM, Fairclough M, Butler DM, Kottler MS. The importance of disc haemorrhage in the prognosis of chronic open angle glaucoma. Arch Ophthalmol  95; 226-228.
  3. Y-d Kim, SB Han, KH Park, SH Kim, SJ Kim, M Seong, TW Kim and DM Kim. Risk factors associated with optic disc haemorrhage in patients with normal tension glaucoma. Eye. 2010 ; 24: 567–572.
  4. Adael S. Soares, Paul H. Artes, Pantelis Andreou,  Raymond P. Leblanc,  Balwantray C. Chauhan, Marcelo T. Nicolela.  Factors Associated with  Optic Disc Haemorrhages in Glaucoma. Ophthalmology. 2004; 111: 1653–1657.
  5. Leske MC, Connell AM, Wu SY, et al. Risk factors for open-angle glaucoma. The Barbados Eye Study. Arch Ophthalmol. 1995;113: 918–24.
  6. Rafael l. Furlanetto, Carlos Gustavo de Moraes, Christopher C. Teng, Jeffrey m. Liebmann,David S. Greenfield, Stuart K. Gardiner, Robert Ritch, and Theodore Krupin. Low-Pressure Glaucoma Treatment Study. AmJ Ophthalmol. 2014; 157: 945–952.

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