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Editors Selection IGR 9-3

Clinical Glaucoma: PPA after AACG

Comment by Martin Wax on:

19519 Peripapillary atrophy after acute primary angle closure, Lee KY; Rensch F; Aung T et al., British Journal of Ophthalmology, 2007; 91: 1059-1061

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Lee et al. (858) studied the changes in peripapallary atrophy (PPA) after episodes of acute angle-closure glaucoma in 40 eyes of 38 patients of predominantly Chinese descent. In this prospective study, the attacks were broken with laser iridotomy and medical treatment. Stereo disc photos were taken at 2 and 16 weeks following the attack and the photos were then subjected to morphometric analysis to quantitate changes in both the zone a and zone b areas of the peripapillary atrophy. In general the size of the PPA areas did not change during the follow-up period although the cup to disc area increased minimally but significantly (from 0.56 to 0.62, p < 0.0001). The authors suggest there may be two reasons for their negative result. They believe that the elevated IOP that occurred during the acute attack may simply not result in a change of the PPA, or the change in PPA was not noted because the longest follow-up period was only 16 weeks. This reviewer is inclined to believe that the latter is the more likely explanation. As beautifully described in the Jackson Memorial; Lecture in 1995 (Am J Ophthalmol 1996; 121: 473), Brubaker noted delayed functional glaucomatous loss in three patients who had normalized IOP after their initial presentation with markedly elevated IOP as occurs in angle-closure glaucoma. Although the author's cite their previous work to suggest that non AION episodes do not result in an alteration of PPA (IOVS1993; 34: 2260), the cited work comprises a retrospective study in which 20 eyes of 17 patients were studied retrospectively from two weeks to three years after the acute attack. Thus, a far longer period of follow-up may have been necessary to observe these changes, as exemplified by the appearance of disc and field damage occurring decades after the initial events cited by Brubaker. Finer resolution of retina and disc changes of the NFL in glaucoma are now possible due to OCT as well as other technologies such as confocal microscopy.

The change in peripapillary atrophy may not have been noted because of the relatively short follow-up period (16 weeks)

A recent study by Tsai et al. (IOVS 2007; 48: 1659). Showed that OCT was able to detect NFL decreases following acute angle-closure glaucoma at 12 weeks following the attack. This is consistent with the slight change in optic disc cupping seen by Lee et al. in the same approximate period of time following acute angle closure attacks. Since Tezel observed that PPA appears to progress with glaucomatous progression in either NPG, POAG and OHT (Ophthalmology 1996; 103: 2105) and since both NLF damage and cupping was noted by independent observers to occur about 12 weeks after acute angle closure, it is certainly reasonable to think that PPA changes may eventually be observed following acute angle-closure glaucoma if the follow-up period is long enough.

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