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Editors Selection IGR 24-3

Prognostic factors: IOP variability and RGC loss

Comment by Tony Realini on:

118083 Association of Long-Term Intraocular Pressure Variability and Rate of Ganglion Complex Thinning in Patients With Glaucoma, Mahmoudinezhad G; Moghimi S; Nishida T et al. et al., American Journal of Ophthalmology, 2024; 264: 104-119

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Mahmoudinezhad and colleagues have conducted a prospective cohort study in patients with glaucoma spanning the severity spectrum from early to advanced to explore the relationship between long-term intraocular pressure (IOP) variability and the rate of optical coherence tomography (OCT) ganglion cell complex (GCC) thinning over time. Study participants attended a minimum of four clinic visits with a minimum of two years of OCT follow-up. A linear mixed-effect model was utilized to investigate the association of IOP parameters (mean IOP, IOP fluctuation [the standard deviation of all IOP measurements], and IOP range [maximum minus minimum IOP]) with rates of GCC thinning. Analyses were conducted on early and moderate-advanced glaucoma subgroups. Overall, 369 eyes of 249 participants were included; 282 eyes had early glaucoma and 87 had moderate-advanced glaucoma. The mean duration of follow-up was 5.1 years. The overall mean rate of GCC change was -0.59 microns per year and was similar in both the early and moderate-advanced subgroups. In multivariable models, higher IOP fluctuation and higher IOP range were significantly associated with faster annual GCC thinning controlling for mean IOP and other cofounders. Most of what we know about the relationship between IOP variability and glaucoma progression comes from post hoc analyses of large clinical trials not designed to directly assess this important topic, and as a result, the findings of such analyses have been mixed. Also, many prior studies have utilized visual field change as the metric for disease progression, which has numerous limitations, including high test-retest variability and limited sensitivity in early disease. This study's strengths are that it was designed and conducted specifically to assess the relationship of interest, and that it relied on structural rather than functional assessment of glaucoma progression. OCT parameters are more objective than visual field parameters and are more sensitive to change early in the disease process. The clinical implications of this study are limited by a critical missing piece of the puzzle: does reducing IOP variability decrease the rate of structural glaucoma progression?

Does reducing IOP variability decrease the rate of structural glaucoma progression?

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