Cupping Reversal in Pediatric Glaucoma—Evaluation of the Retinal Nerve Fiber Layer and Visual Field

• Published in: American journal of ophthalmology 2014-11, Vol.158 (5), p.905-915.e1
• Main Authors: Ely, Amanda L, El-Dairi, Mays A, Freedman, Sharon F
• Format: Article
• Language: English
• Subjects: Adolescent; Child; Child, Preschool; Female; Follow-Up Studies; Glaucoma; Glaucoma, Open-Angle - pathology; Glaucoma, Open-Angle - physiopathology; Glaucoma, Open-Angle - surgery; Health Insurance Portability & Accountability Act 1996-US; Humans; Infant; Intraocular Pressure; Male; Nerve Fibers - pathology; Ophthalmologic Surgical Procedures - methods; Ophthalmology; Optic nerve; Optics; Pediatrics; Recovery of Function; Retinal Ganglion Cells - pathology; Retrospective Studies; Studies; Surgery; Tomography; Tomography, Optical Coherence - methods; Treatment Outcome; Visual Fields - physiology
• ISSN: 0002-9394; 1879-1891
• DOI: 10.1016/j.ajo.2014.07.030

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.