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Glaucoma Dialogue IGR 10-2

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Comment by William Morgan on:

20979 Cerebrospinal fluid pressure is decreased in primary open-angle glaucoma, Berdahl JP; Allingham RR; Johnson DH, Ophthalmology, 2008; 115: 763-768

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This is a landmark study, since it is the first clinical investigation which strongly underlines the importance to examine the role the cerebrospinal fluid pressure may play for the physiology and pathophysiology of the optic nerve. The issue has been raised in several previous presentations including those by Myron Yablonski and others, examining the anatomy of the lamina cribrosa and ophthalmodyna-mometric aspects of the central retinal vein blood pressure.

Issues of the present study to be discussed are: There was a marked selection of patients: out of 31,786 subjects who underwent a lumbar puncture, only 77 subjects or 0.2% were included into the statistical analysis of the present study. Although the inclusion criteria and exclusion criteria were very well described, there is the possibility of a bias in the inclusion of the patients. It also includes the possibility that the reason why the lumbar puncture was performed led to a selection of patients in both study groups.

The diagnosis of glaucoma based on the retrospective analysis of charts can markedly vary depending on the clinical criteria and the experience of the clinician. Instead of the intraocular pressure under anti-glaucomatous treatment, it would even be more interesting to have the intraocular pressure untreated.

Since the systemic blood pressure is positively correlated with the intraocular pressure and probably with the cerebrospinal fluid pressure, it could be interesting to include the arterial blood pressure into a multivariate analysis.

The number of subjects included in the study may be too small for a large multivariate analysis including the issues of an association between the intake of systemic blood pressure medication and CSF pressure.

Were highly myopic eyes included in the study? If yes, they may be excluded from the statistical analysis, since the cup/ disc diameter ratio is abnormally large due to the large optic disc, and since the anatomy of the optic nerve head is markedly different from the anatomy of non-highly myopic eyes.

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