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Editors Selection IGR 20-1

Clinical Examination Methods: Blood perfusion pressure

Comment by Alon Harris on:

54284 Enhanced pressure in the central retinal vein decreases the perfusion pressure in the prelaminar region of the optic nerve head, Stodtmeister R; Ventzke S; Spoerl E et al., Investigative Ophthalmology and Visual Science, 2013; 54: 4698-4704

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Open-angle glaucoma (OAG) has evolved over the past several decades from an intraocular pressure (IOP) only-related disease to a multifactorial pathophysiology of retinal ganglion cell death and optic nerve degeneration. The pathophysiological events leading to glaucomatous vision loss remain elusive but are likely driven by multiple factors including pressure-related insult, lamina remodeling and vascular deficits. Stodtmeister and colleagues present a new paradigm in understanding these factors by examining perfusion pressure in the retina and prelaminar region of the optic nerve head (ONH) utilizing a contact lens dynamometer, calibrated in mmHg, to calculate the retinal perfusion pressure. The authors found perfusion pressure in the retina and prelaminar region of the ONH may be lower than expected because central retinal vein pressure (CRVP) may be elevated. The investigation is innovative in its approach and suggests that the influence of IOP, perfusion pressure and/or CRVP may need to be considered together, rather than as stand-alone parameters. One strength of their approach is to isolate CRVP in non-arbitrary units. Another benefit to the paper is the attempt to move beyond linear assessment models. Multi-factorial modeling of glaucomatous risk has indeed been emerging as a next step in understanding an individual's risk profile, and the authors contribute to this with interesting data. One weakness of the paper is the limited study population (n = 27 per cohort) and relative power to detect significance. Another limitation is a lack of direct hemodynamic assessment in the tissues supplying the retinal ganglion cells, which may have elucidated additional multi-factorial relationships. Stodtmeister and colleagues present advancement in CRVP evaluation and possible contributory factors in the OAG disease process. Advancements in parameter specificity and multifactorial modeling of OAG risk factors should be encouraged to shed further light on the mechanisms behind this debilitating disease.

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