Objective: In previous decades, glaucoma has been primarily attributed to elevated intraocular pressure (IOP), but this has gradually been replaced by the development of optic neuropathy as the central concept of glaucoma in developed countries. However, there still remain strong controversies in the definition of glaucoma in China. In this current review, we are going to discuss these controversies and elaborate on the historical transitions of the definition of glaucoma both in China and developed countries. Furthermore, we will briefly describe the "ocular-cranial pressure gradient" theory and discuss the relationship between glaucoma and degenerative diseases of the central nervous system (CNS) in order to show the complex pathogenesis of glaucoma and the importance for the modification to the definition of glaucoma. Data Sources: We performed a comprehensive search in both PubMed and SinoMed using the following keywords: (a) "primary glaucoma" and "guideline," (b) "ocular-cranial pressure gradient," and (c) "glaucoma," "Alzheimer's disease," and "Parkinson's disease." The literature search included the related articles with no restrictions on publication date. Study Selection: The primary references were Chinese and English articles including (a) original guidelines and expert consensuses of primary glaucoma, (b) reviews focusing on the differences between various versions of these guidelines and consensuses, and (c) papers about ocular-cranial pressure gradient theory and the relationship between glaucoma and CNS degenerative diseases. Results: The definitions and classifications of both primary open-angle glaucoma and primary angle-closure glaucoma differ between Chinese glaucoma consensuses and international primary glaucoma guidelines. Chinese definitions and classifications put more emphasis on the IOP, while international guidelines put more emphasis on the presence of optic neuropathy. The ocular-cranial pressure gradient theory and the research on the relationship between glaucoma and CNS degenerative diseases have provided new directions for exploring the pathogenesis of glaucoma. Conclusions As regards the definition and classification of primary glaucoma, we find that there are still some discrepancies between Chinese expert consensuses and international guidelines. Glaucoma is a disease with complex etiologies, while its common characteristic is a specific optic neuropathy. The current definition and understanding of glaucoma is an ongoing and evolving process, reflecting our latest available evidence on its pathogenesis. Chinese ophthalmology community may need to update our guidelines, accommodating these latest developments.
China ; Glaucoma ; diagnosis ; physiopathology ; Glaucoma, Angle-Closure ; diagnosis ; physiopathology ; Glaucoma, Open-Angle ; diagnosis ; physiopathology ; Humans ; Intraocular Pressure ; physiology ; Ophthalmology ; methods

BACKGROUNDMany studies indicated that short-term and long-term intraocular pressure (IOP) fluctuations in primary open angle glaucoma patients might lead to glaucomatous progression. However, seldom study has evaluated the long-term fluctuation of IOP in primary chronic angle closure diseases. The objective of this study was to investigate the long-term IOP fluctuation of primary angle closure diseases and its associations following laser peripheral iridotomy (LPI) with or without laser peripheral iridoplasty.

METHODSA total of 158 patients with primary angle closure suspect (PACS, n = 21), primary angle closure (PAC, n = 81) and primary angle closure glaucoma (PACG, n = 55) had been treated by LPI with or without laser peripheral iridoplasty and followed up for more than 12 months. IOP was measured with Goldman applanation tonometer. Multivariate linear regression with generalized estimating equation (GEE) regression models was used to evaluate the association of long-term IOP fluctuation (maximum IOP minus minimum IOP) with gender, age, baseline IOP, baseline peripheral anterior synechia (PAS), baseline vertical cup/disc ratio (VCDR), baseline mean deviation (MD), need for IOP-lowering medications.

RESULTSIOP fluctuation during follow-up in PACS, PAC and PACG groups were (4.83 ± 2.90), (5.67 ± 3.35), and (9.40 ± 7.14) mmHg, respectively. IOP fluctuation was strongly correlated with baseline IOP (r = 0.356, P < 0.001), PAS (r = 0.374, P < 0.001). IOP fluctuation was higher in patients with higher baseline IOP (0.18 mmHg per unit increase, 95%CI: 0.05 - 0.31 mmHg).

CONCLUSIONSLong-term IOP fluctuation in PACG group was larger than that in PACS or PAC group. Eyes with higher baseline IOP were observed to have larger long-term IOP fluctuation.

Follow-Up Studies ; Glaucoma, Angle-Closure ; physiopathology ; therapy ; Humans ; Intraocular Pressure ; Iridectomy ; Iris ; surgery ; Laser Therapy ; Middle Aged

PURPOSE: To compare the glaucomatous optic nerve damage in primary angle-closure glaucoma (PACG) with acute attack (acute PACG; AACG) and PACG without acute attack (chronic PACG; CACG). METHODS: The study subjects were 84 normal individuals, 130 AACG patients, and 86 CACG patients. Color optic disc photographs were evaluated for the presence or absence of 10 qualitative signs to differentiate between normal and glaucomatous optic discs. RESULTS: Abnormally shaped rim width (alteration of ISN'T rule), bared circumlinear vessel, vessel bayonetting, rim width narrower than the temporal sector, and zone beta (nasal and superotemporal sectors) were detected more frequently in the CACG group than in the AACG group (P< 0.05). The most accurate qualitative sign was abnormally shaped rim width in both groups. The specificity and sensitivity of abnormally shaped rim width were 71.4% and 60.8% for AACG, and 71.4% and 81.4% for CACG, respectively. CONCLUSIONS: The optic disc damage is greater in CACG than in AACG.
Optic Nerve/*pathology ; Middle Aged ; Male ; Intraocular Pressure ; Humans ; Glaucoma, Angle-Closure/*pathology/physiopathology ; Female ; Chronic Disease ; Aged ; Acute Disease

We investigated the relationship between the circumferential extent of peripheral anterior synechiae (PAS) and the severity of visual field defects in primary angle-closure glaucoma (PACG). Correlations between visual field defects and the extent of PAS were analyzed in 73 eyes; 28 with and 45 without acute attacks. Spearman's correlation coefficient between the severity of visual field defects and the extent of PAS was 0.348 (P = 0.003) in all subjects (n = 73), 0.377 (P = 0.012) in the PACG eyes without acute attacks (n = 45), and 0.338 (P = 0.079) in the eyes with acute attacks (n = 28). Our results showed a statistically significant correlation between the extent of PAS and the severity of visual field damage in PACGoverall, and especially in PACG patients without a history of acute attacks.
Aged ; Comparative Study ; Female ; Glaucoma, Angle-Closure/*etiology/physiopathology ; Humans ; Intraocular Pressure ; Iris Diseases/*complications/physiopathology ; Male ; Middle Aged ; Perimetry ; Scotoma/*etiology/physiopathology ; *Visual Fields

OBJECTIVETo investigate the progression of visual field loss and to explore the prognosis of glaucomatous optic neuropathy in patients with chronic angle-closure glaucoma (CACG) after their intraocular pressures were well controlled under 21 mmHg.

METHODSForty-seven eyes of 29 patients in the Department of Ophthalmology in PUMC Hospital were included. All the patients had at least two separate tests of visual fields using the 24-2 program of the Humphery Visual Field Analyzer after their intraocular pressure were well controlled under 21 mmHg after sugery. The visual fields of patients were followed routinely for at least 1 year. In addition, all patients were divided into 2 groups according to follow-up period: 1-2 years group and over 2 years group. Visual field scores were calculated with the Advanced Glaucoma Intervention Study (AGIS) method. The visual fields were divided 5 sections and the sensitivity and defect depth of each section were calculated.

RESULTNo statistically significant differences were found in terms of AGIS scores, localized sensitivities and localized defects within the time interval of the observation.

CONCLUSIONGlaucomatous optic neuropathy is not likely to progressively deteriorate in CACG cases once their intraocular pressure are well controlled under 21 mmHg.

Aged ; Female ; Follow-Up Studies ; Glaucoma, Angle-Closure ; physiopathology ; surgery ; Humans ; Intraocular Pressure ; Male ; Middle Aged ; Optic Disk ; physiopathology ; Optic Nerve Diseases ; physiopathology ; Retrospective Studies ; Visual Fields

To estimate the rate of visual field progression in primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG), we reviewed the medical records of POAG and PACG patients who had a minimum of 5-year longitudinal Goldmann visual field data. I4e and I2e isopters were quantified using grid systems. The rate of change was calculated from the slope of a linear fit to a series of average visual field scores. Twenty-three eyes of POAG patients and 25 of PACG patients were studied. The rate of visual field score change was -2.00 +/- 2.0% per year in the PACG group, and -0.81 +/- 1.0% per year inthe POAG group. In these two patient groups, who were on conventional treatment at two referral hospitals, better visual field on initial presentation yielded faster progression in the POAG group, while the higher average of highest intraocular pressure in each year during follow-up was related to faster progression in the PACG group.
Adult ; Aged ; Comparative Study ; Disease Progression ; Female ; Glaucoma, Angle-Closure/*physiopathology ; Glaucoma, Open-Angle/*physiopathology ; Humans ; Intraocular Pressure ; Male ; Middle Aged ; Perimetry/methods ; Retrospective Studies ; Vision Disorders/etiology/*physiopathology ; *Visual Fields

OBJECTIVE: To investigate the difference in color pattern reversal visual evoked potential (CPR-VEP)between primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG) patients. METHODS: Vision Monitor visual electrophysiograph made by Metro Vision Inc. in France was used to record CPR-VEP in 17 eyes of 12 POAG patients, 56 eyes of 41 PACG patients, and 26 eyes of 13 age-equivalent normal persons at an ascending series of temporal frequency (1, 2, 4, 8, 16, and 32 Hz) and color stimulation (black/white, red/green, and blue/yellow). P(100) wave amplitudes and latencies of these patients were compared respectively with those of the normal group. RESULTS: With black/white stimulation, the P(100) wave amplitudes were reduced with the increase of temporal frequency in the 3 groups. The P(100) wave latencies were extended with the increase of temporal frequency with different color stimulations. The P(100) amplitudes were PACG group > NC group > POAG group and black/white > blue/yellow > red/green. The P(100) wave latencies in the POAG group and the PACG group were extended compared with the NC group, but there was no significant difference between PACG group and POAG group. CONCLUSION CPR-VEP P(100) amplitudes in the PACG group and POAG group have their own characteristics. The P(100) amplitude of PACG is higher, and POAG is lower than normal. The P(100) wave latencies of PACG and POAG are extended.
Adult ; Aged ; Aged, 80 and over ; Color Vision ; Evoked Potentials, Visual ; physiology ; Female ; Glaucoma, Angle-Closure ; physiopathology ; Glaucoma, Open-Angle ; physiopathology ; Humans ; Male ; Middle Aged ; Photic Stimulation ; methods ; Young Adult

INTRODUCTIONPrimary angle-closure glaucoma (PACG) is a major cause of blindness among Asians. A better understanding of the disease will improve the treatment and outcome of this condition.

METHODSA literature review of all recent publications on PACG was carried out. Articles were retrieved using a key word search of MEDLINE, PubMed and Science Citation Index databases.

RESULTSFollowing laser peripheral iritodomy for acute angle-closure, Asians were found to have a higher tendency to develop a subsequent rise in intraocular pressure compared to Caucasians. Furthermore, the extent and severity of visual field damage was more severe in Asians than Caucasians, particularly in eyes that presented insidiously with chronic PACG. Prophylactic laser iridotomy in the contralateral eye was found to be highly effective in preventing acute angle-closure attacks.

CONCLUSIONPACG is more difficult to manage and is associated with more severe long-term visual morbidity in Asians than Caucasians. Regular follow-up of patients with PACG is important for the early detection of progression of the disease and visual field deterioration.

Asian Continental Ancestry Group ; European Continental Ancestry Group ; Glaucoma, Angle-Closure ; complications ; physiopathology ; surgery ; Humans ; Intraocular Pressure ; Iridectomy ; adverse effects ; Ocular Hypertension ; etiology ; Visual Fields

BACKGROUNDArgon laser peripheral iridoplasty (ALPI) is proved to be effective in lowering intraocular pressure (IOP) of patients with mild acute primary angle closure (APAC). It is unclear whether this laser treatment is equally efficient in managing patients with severe APAC. This study aimed to evaluate the IOP-lowering efficacy of ALPI and laser peripheral iridotomy (LPI) on patients with refractory APAC, who have previously responded poorly to intensive medical therapy.

METHODSThirty-six patients (8 men and 28 women) were identified as medically refractory APAC, who still had ocular pain, red eye, hazy cornea, closed anterior chamber (AC) angle, and IOP of not less than 21 mmHg after two days or more of anti-glaucoma medication. All enrolled patients underwent ophthalmologic examinations including measurement of visual acuity (VA), best corrected VA (BCVA), IOP, biomicroscopy, and gonioscopy followed by ALPI immediately in the APAC eye and LPI in both eyes.

RESULTSAll patients were affected unilaterally, with average age of (54.6 ± 11.7) (range, 37.0 - 75.0) years old. The mean IOP value of the affected eyes dropped from (31.6 ± 7.7) (range, 21.0 - 39.0) mmHg at enrollment to (18.4 ± 8.7) (range, 10.0 - 27.0) mmHg 2 hours after ALPI. At follow-up day 7, the mean IOP value maintained at (14.8 ± 4.2) (range, 9.0 - 21.0) mmHg, which was significantly different (P = 0.000) compared with baseline. The average decrease of IOP in the APAC eyes was (16.8 ± 7.4) (range, 12.0 - 21.0) mmHg. At follow-up three years later, the mean IOP of the APAC eyes stabilized at (16.3 ± 3.2) (range, 9.0 - 20.0) mmHg with at least 180° of AC angle opened.

CONCLUSIONALPI and LPI lower the IOP of medically refractory cases of APAC though they have responded poorly to anti-glaucoma medication.

Adult ; Aged ; Female ; Glaucoma, Angle-Closure ; physiopathology ; surgery ; Humans ; Intraocular Pressure ; Iridectomy ; methods ; Iris ; surgery ; Laser Therapy ; Male ; Middle Aged ; Treatment Outcome

BACKGROUNDTrabeculectomy has become a mainstream treatment in intraocular pressure (IOP) reduction for primary angle-closure glaucoma (PACG); combined trabeculectomy and cataract surgery was reported to reduce IOP and simultaneously improve vision for patients with PACG and coexisting cataract. This study was specialized to compare the efficacy and safety of combined phacotrabeculectomy with that of trabeculectomy only in the treatment of PACG with coexisting cataract.

METHODSThis is a comparative case series study. Thirty-one patients (31 eyes) with PACG and coexisting cataract were enrolled. Of these, 17 underwent phacotrabeculectomy and 14 underwent trabeculectomy alone. IOP, filtering blebs, and complications were compared at the final follow-up. Complete success was defined as a final IOP less than 21 mmHg without IOP-lowering medication.

RESULTSAfter 10 months of postoperative follow-up, the phacotrabeculectomy and trabeculectomy groups showed no significant differences regarding IOP reduction ((20.59 ± 7.94) vs. (24.85 ± 14.39) mmHg, P = 0.614), complete success rate (88% vs. 71%, P = 0.370), formation rate of functioning blebs (65% (11/17) vs. 93% (13/14), P = 0.094), and complications (41% (7/17) vs. 57% (8/14), P = 0.380). IOP-lowering medication was not required for most of the patients in both groups. Additional surgery interventions, including anterior chamber reformation and phacoemulsification, were needed in the trabeculectomy group, whereas no surgery was needed postoperatively in the phacotrabeculectomy group.

CONCLUSIONPhacotrabeculectomy and trabeculectomy treatments exhibit similar IOP reduction, successful rates, and complications when it comes to treating PACG patients with coexisting cataract, although additional surgery intervention may be needed for a few cases with cataract and complications after trabeculectomy.

Aged ; Cataract Extraction ; Female ; Glaucoma, Angle-Closure ; physiopathology ; surgery ; Humans ; Intraocular Pressure ; Male ; Middle Aged ; Phacoemulsification ; adverse effects ; methods ; Postoperative Complications ; etiology ; Trabeculectomy ; adverse effects ; methods ; Visual Acuity