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Discussion on NTG Risk Factors丨WOC 2022

Posting time:2022-12-02 07:49:08

Discussion on NTG Risk Factors丨WOC 2022

Editor's Note The current clinical diagnosis and treatment of normal tension glaucoma (NTG) is difficult, and understanding the risk factors of NTG may help to better provide treatment for NTG patients. At this World Ophthalmology Congress (WOC 2022), Dr. Ki Ho Park from Seoul National University, South Korea, summarized the ocular and systemic risk factors associated with the pathogenesis of NTG based on evidence-based evidence. The incidence of NTG is higher in eastern countries. It has been reported that the incidence of normal tension glaucoma (NTG) in open-angle glaucoma (OAG) is higher in eastern countries, about 80% to 90%, while it is higher in western countries. low, about 30% to 39% (Figure 1). Figure 1. Incidence of NTG in OAG by country The currently known risk factors for NTG include general risk factors, ocular risk factors, and systemic factors. General risk factors include age, family history, and race; ocular risk factors include intraocular pressure, disc hemorrhage, parapapillary choroidal atrophy (PPA), myopia, central corneal thickness (CCT), and biomechanical properties; systemic risk factors include high Blood pressure, hypotension, ocular perfusion pressure (OPP), migraine, Raynaud's phenomenon, cardiovascular disease, diabetes, immune disorders, sleep apnea. Evidence that intraocular pressure and myopia are associated with NTG The Japanese Tajimi study showed that intraocular pressure, myopia, and age were risk factors for OAG, of which 92% of OAG were NTG (Figure 2). Figure 2. The results of the Japanese Tajimi study. The Korean National Health and Nutrition Survey found that 95% of primary open-angle glaucoma (POAG) were NTG, and old age, male sex, high intraocular pressure, myopia, and hypertension were risk factors for the incidence of POAG ( image 3). Figure 3. Results of the National Health and Nutrition Examination Survey in Korea Another epidemiological study in Korea, the Namil study, showed that the mean IOP was 13.3 mmHg in the non-glaucoma group and 14.6 mmHg in the NTG group, with visible NTG The mean intraocular pressure of patients in the group was higher than that of patients in the non-glaucoma group (Fig. 4). Age, thyroid disease, and intraocular pressure were risk factors for NTG in the Namil study, similar to the Tajimi study (Figure 5). Figure 4. Overview of the Namil study. Figure 5. Risk factors for NTG development in the Namil study. A 2013 study examined the effect of lateral decubitus on intraocular pressure in glaucoma patients with asymmetric visual field loss. It was found that eyes with poor visual field showed higher intraocular pressure in the supine position and higher intraocular pressure in the lateral decubitus position compared with eyes with better visual field (Figure 6). And in normal eyes, the pressure in the eye increases when the eyeball is pressed against the pillow, so if someone with NTG sleeps in this position, the pressure in their dependent eye can be very high at night. Figure 6. The effect of lateral decubitus position on intraocular pressure in glaucoma patients with asymmetric visual field loss. The study also found that the intraocular pressure fluctuation of patients at night was higher than that in the daytime. Using the contact lens sensor, it was found that the intraocular pressure of NTG was higher than that of the non-glaucoma group at night, and the peak intraocular pressure was Appears at night (Figure 7). The 24-hour intraocular pressure of NTG and healthy eyes was monitored using a contact lens sensor, and it was found that compared with healthy eyes, NTG 24-hour intraocular pressure fluctuated more, and NTG had higher intraocular pressure during sleep (Fig. 8). Figure 7. NTG nighttime intraocular pressure is higher than non-glaucoma eye Figure 8. NTG has higher intraocular pressure during sleep. Another study monitored long-term NTG patients receiving medication for up to 18 years and found that mean intraocular pressure fluctuations were significantly associated with NTG of visual field progression (Figure 9). Figure 9. Study Finds Mean IOP Fluctuation Associated with Visual Field Progression of NTG Evidence for Intervertebral Hemorrhage Associated with NTG Blue Mountains Eye Study shows that NTG patients have a higher prevalence of intervertebral hemorrhage compared to POAG or ocular hypertension (OHT). high (Figure 10). The study by Dr. Ki Ho Park's team also showed that if the patients were followed up for a longer time, the cumulative probability of intervertebral disc hemorrhage in NTG patients was about 50%, which was higher than the 23% probability in POAG patients (Figure 11). Figure 10. Results from the Blue Mountains Ophthalmology Study Figure 11. Findings from Dr. Ki Ho Park's team A 2014 study examined the topographical features of NTG optic disc hemorrhages, which were greater in NTG patients than in patients with high-tension glaucoma , longer in length (Fig. 12). Figure 12. Evidence of larger and longer disc hemorrhage in patients with NTG. Evidence that systemic vascular abnormalities are associated with NTG. A study in Hong Kong, China showed that asymptomatic cerebral infarction was one of the risk factors for progression of the NTG visual field (Figure 13). Figure 13. Asymptomatic cerebral infarction is a risk factor for NTG visual field progression. Studies have shown that retinal nerve fiber layer (RNFL) defects are associated with cerebral small vessel disease (Figure 14). Many large epidemiological studies have also found an association between hypertension and OAG, but there are also some studies that show no significant association between hypertension and OAG. Figure 14. RNFL deficiency is associated with cerebral small vessel disease. Another study has shown that nocturnal hypotension is a risk factor for the development of NTG. The Los Angeles Latino Eye Study found that both hypotension and hypertension were risk factors for OAG (Figure 15). Figure 15. Both hypotension and hypertension are risk factors for OAG. Most studies show a higher incidence of OAG with low OPP (Figure 16). One study found that lower systolic OPP, lower systolic blood pressure, and history of cardiovascular disease were new predictors of NTG progression (Figure 17). In a 5-year prospective study, disc hemorrhage, long-term intraocular pressure fluctuations, and greater vertical C/D ratio were risk factors for disease progression in the absence of treatment in patients with NTG. Another study showed that disc hemorrhage and migraine were risk factors for NTG progression (Figure 18). Figure 16. Higher OAG incidence with low OPP Figure 17. Lower systolic OPP, lower systolic blood pressure, and history of cardiovascular disease are new predictors of NTG progression Summary of risk factors Intervertebral disc hemorrhage is one of the most important risk factors for NTG. High intraocular pressure, intraocular pressure fluctuation, myopia, asymptomatic cerebral infarction or small vessel disease are all associated with NTG. Hypertension and hypotension may be associated with NTG and ocular perfusion pressure with POAG.

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