Relationship Between Nocturnal Dip, Carotid Artery Blood Flow, Brain Ischemic Change in Open Angle Glaucoma

Hong Ryung Seo; Sang Wook Jin; Sae Heun Rho

doi:10.3341/jkos.2013.54.9.1386

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Seo, Jin, and Rho: Relationship Between Nocturnal Dip, Carotid Artery Blood Flow, Brain Ischemic Change in Open Angle Glaucoma

Original Article

J Korean Ophthalmol Soc 2013;54(9):1386-1394.

Published online: 7 September 2013

DOI: https://doi.org/10.3341/jkos.2013.54.9.1386

Relationship Between Nocturnal Dip, Carotid Artery Blood Flow, Brain Ischemic Change in Open Angle Glaucoma

Hong Ryung Seo, MD, Sang Wook Jin, MD, Sae Heun Rho, MD, PhD

Department of Ophthalmology, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea

Address reprint requests to Sae Heun Rho, MD, PhD Department of Ophthalmology, Dong-A University Medical Center, #26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea Tel: 82-51-240-5227, Fax: 82-51-254-1987 E-mail: shrho@donga.ac.kr

∗ This study was presented as a poster at the 103th Annual Meeting of the Korean Ophthalmological Society 2010.

∗ This study has been supported by the Dong-A University Research Fund.

Received 15 February 201329 March 2013 Accepted 25 June 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the effect of nocturnal dip, carotid artery blood flow, and brain ischemic change on the progression of glaucomatous visual field defect in open-angle glaucoma (OAG) when IOP is less than the target pressure.

Methods

We classified OAG patients (74 patients, 148 eyes) who maintained IOP less than the target pressure as normal tension glaucoma (NTG; 52 patients, 104 eyes) or primary OAG (POAG; 22 patients, 44 eyes). Additionally, we performed 24-hr ambulatory blood pressure monitoring (24-hr ABPM), carotid artery color Doppler U/S (CAD), brain MRI, and visual field (V/F) tests on the patients. Nocturnal dips less than 10% were classified as non-dippers, and dips greater than 10% as dippers. The relationships among nocturnal dip, carotid artery blood flow, brain ischemic change, and progression of glaucomatous V/F defect were examined.

Results

In the case of dippers, glaucomatous V/F defects were aggravated, with a relative risk of approximately 1.74 (NTG) and 2.91 (POAG) times that of non-dippers. In NTG, decreased carotid artery blood flow and brain ischemic change furthered glaucomatous V/F defects, with a relative risk of approximately 2.40 and 2.54 times that of normal carotid artery blood flow and brain MRI findings, respectively. However, in POAG, decreased carotid artery blood flow and brain ische-mic change were not influenced by the progression of glaucomatous V/F defects.

Conclusions

In dippers, decreased carotid artery blood flow and brain ischemic change caused a progression of glaucom-atous V/F defects in NTG and POAG patients. Thus, performing 24-hr ABPM, CAD, and brain MRI should be helpful for glaucoma patients with progression of glaucomatous V/F defects even when the IOP is less than the target pressure. In addition, this analysis provides useful information regarding glaucoma diagnosis and treatment.

Keywords: Brain ischemia, Carotid artery blood flow, Dipper, Progression of visual field defect, 24-hour blood pressure monitoring

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Figure 1.

Abnormal findings of CAD. (A) Increased intima-media thickness in left common carotid artery (white arrow). (B) Multiple atheromas in left internal carotid artery (white arrows).

Figure 2.

Abnormal findings of brain MRI. (A) Chronic ischemic change deep white matter, basal ganglia. (B) Brain atrophy. widening of the sulci, thinning of the corpus callosum, enlargement of the lateral ventricles.

Table 1.

Demographics of patients in NTG and POAG

	NTG	POAG	p-value
M:F (n)	23:29	10:12	0.571*
Mean age (years)	50.4 ± 10.87	53.6 ± 12.82	0.546^†
Mean IOP (mm Hg)	11.78 ± 1.97	16.35 ± 2.52	0.278^†
Mean deviation of visual field (dB)	-9.7 ± 5.9	-6.8 ± 5.2	0.194^†
Pattern standard deviation of visual field (dB)	-9.8 ± 4.3	-7.2 ± 4.3	0.214^†
Mean nocturnal dip of SBP (%)	7.26 ± 4.32	7.42 ± 5.16	0.328^†
Mean nocturnal dip of DBP (%)	8.68 ± 5.73	9.12 ± 6.14	0.274^†
Abnormal brain MRI (n)	16	11	0.348*
Abnormal CAD (n)	18	12	0.317*

Values are presented as mean ± SD.

NTG = normal tension glaucoma; POAG = primary open angle glaucoma; SBP = systolic blood pressure; DBP = diastolic blood pressur IOP = intraocular pressure; CAD = carotid artery color Doppler U/S.

^* Pearson chi-square test;

^† Student t-test.

Table 2.

Association of Nocturnal dip and V/F progression in OAG & NTG & POAG

	V/F progression		Chi-square test
	Yes	No	p-value*	Odd ratio	Relative risk
OAG			0.000
Dipper	38	22		3.701	1.990
Non-dipper	28	60		(CI^†: 1.855-7.384)	(CI^†: 1.387-2.857)
NTG			0.007
Dipper	28	16		3.023	1.736
Non-dipper	22	38		(CI^†: 1.347-6.782)	(CI^†: 1.163-2.591)
POAG			0.006
Dipper	10	6		6.111	2.917
Non-dipper	6	22		(CI^†: 1.574-23.719)	(CI^†: 1.305-6.520)

V/F = visual field; OAG = open angle glaucoma; NTG = normal tension glaucoma; POAG = primary open angle glaucoma.

^* Statistical significance: p<0.05;

^† Confidence interval, CI was calculated at 95 percentile.

Table 3.

Association of CAD findings and Nocturnal dip in NTG & POAG

	Abnormal CAD findings	Normal CAD findings	p-value*
The mean of nocturnal dip of SBP (%)	13.77 ± 4.73	14.19 ± 4.40	0.582
The mean of nocturnal dip of DBP (%)	16.16 ± 4.74	14.56 ± 4.21	0.224

Values are presented as mean ± SD.

NTG = normal tension glaucoma; POAG = primary open angle glaucoma; SBP = systolic blood pressure; DBP = diastolic blood pressure; CAD = carotid artery color Doppler U/S.

^* Student t-test, statistical significance: p < 0.05.

Table 4.

Association of CAD findings and V/F progression in OAG & NTG & POAG

	V/F progression		Chi-square test
	Yes	No	p-value	Odd ratio	Relative risk
OAG			0.000*
Abnormal CAD	24	16		4.500	2.400
Normal CAD	16	48		(CI^†: 1.926-10.515)	(CI^†: 1.464-3.933)
NTG			0.001*
Abnormal CAD	18	12		4.750	2.500
Normal CAD	12	38		(CI^†: 1.788-12.620)	(CI^†: 1.409-4.435)
POAG			0.211^‡
Abnormal CAD	6	4		3.750	2.100
Normal CAD	4	10		(CI^†: 0.674-20.861)	(CI^†: 0.796-5.543)

V/F = visual field; OAG = open angle glaucoma; NTG = normal tension glaucoma; POAG = primary open angle glaucoma; CAD = Carotid artery color Doppler U/S.

^* Statistical significance: p < 0.05;

^† Confidence interval, CI was calculated at 95 percentile;

^‡ Fisher's exact test, statistical significance: p < 0.05.

Table 5.

Association of brain MRI findings and Nocturnal dip in NTG & POAG

	Abnormal brain MRI findings	Normal brain MRI findings	p-value*
The mean of nocturnal dip of SBP (%)	14.50 ± 4.68	13.90 ± 4.36	0.627
The mean of nocturnal dip of DBP (%)	15.42 ± 4.49	15.48 ± 4.56	0.841
Values are presented as mean ± SD.

NTG = normal tension glaucoma; POAG = primary open angle glaucoma; SBP = systolic blood pressure; DBP = diastolic blood pressure.