Cupping reversal in pediatric glaucoma--evaluation of the retinal nerve fiber layer and visual field

Am J Ophthalmol. 2014 Nov;158(5):905-15. doi: 10.1016/j.ajo.2014.07.030. Epub 2014 Jul 25.

Abstract

Purpose: To identify optic nerve head (ONH) cupping reversal and associated optical coherence tomography (OCT) and Humphrey visual field changes in pediatric glaucoma.

Design: Retrospective observational case series.

Methods: Sequential surgical cases of juvenile open-angle glaucoma (OAG) or primary congenital glaucoma (PCG) with sustained postoperative intraocular pressure (IOP) reduction. Group 1 had preoperative and postoperative ONH photographs and OCT; Group 2 had preoperative clinical ONH assessment and postoperative imaging. Cupping evaluation was confirmed by masked glaucoma and neuro-ophthalmology specialists.

Results: Of 80 cases, 9 eyes (9 children) met criteria for Group 1; 24 eyes (19 children) met criteria for Group 2. Group 1: Five of 9 eyes (56%) demonstrated cupping reversal, with preoperative vs postoperative mean IOP 34.2 ± 6.6 mm Hg vs 10.6 ± 4.1 mm Hg (P < .00001) and mean average retinal nerve fiber layer (RNFL) 71.0 ± 30 μm vs 62.8 ± 24 μm (P = .4), respectively. RNFL was stable in 4 of 5 eyes (all juvenile OAG), but thinned (Δ = -41 μm) in 1 eye with PCG. Humphrey visual fields (reliable in 2 of 3 eyes) showed no significant change. Group 2: Fourteen of 24 PCG eyes (58%) demonstrated cupping reversal, with preoperative vs postoperative mean IOP 36.1 ± 8.9 mm Hg vs 13.3 ± 2.1 mm Hg (P < .00001). Two eyes had thin RNFL postoperatively despite healthy-appearing ONH. Postoperative RNFL showed statistically significant linear correlation with preoperative (but not postoperative) cup-to-disc ratio. Limitations include small numbers, few reliable Humphrey visual fields, and absent preoperative imaging (Group 2).

Conclusion: Some eyes with IOP reduction and ONH cupping reversal show continued RNFL thinning postoperatively. The preoperative ONH cup-to-disc ratio predicted the postoperative RNFL better than the postoperative "reversed and smaller" cup-to-disc ratio. Cupping reversal in pediatric glaucoma may not predict improved ONH health and deserves further study.

Publication types

  • Observational Study

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Female
  • Follow-Up Studies
  • Glaucoma, Open-Angle / pathology
  • Glaucoma, Open-Angle / physiopathology
  • Glaucoma, Open-Angle / surgery*
  • Humans
  • Infant
  • Intraocular Pressure
  • Male
  • Nerve Fibers / pathology*
  • Ophthalmologic Surgical Procedures / methods*
  • Recovery of Function*
  • Retinal Ganglion Cells / pathology*
  • Retrospective Studies
  • Tomography, Optical Coherence / methods*
  • Treatment Outcome
  • Visual Fields / physiology*