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Ординатура / Офтальмология / Английские материалы / Glaucoma An Open Window to Neurodegeneration and Neuroprotection_Nucci, Cerulli, Osborne_2008.pdf
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Fig. 6. Disk photos of an NTG patient that show tilted disks with inferior and temporal peripapillary atrophy and corresponding visual fields. (A) Note the inferior notch on the right nerve. (B) Note the superior notch on the left nerve. (See Colour Plate 14.6 in the colour plate section.)

determining which patients will progress rapidly and hence appropriate follow-up and treatment must be given to all NTG patients.

Risk factors

Intraocular pressure

The relationship between NTG and IOP has been examined and debated by many researchers and

clinicians. Two studies have demonstrated that NTG patients with asymmetric IOPs have worse visual field loss in the eye with higher IOP (Cartwright and Anderson, 1988; Crichton et al., 1989). The LowPressure Glaucoma Treatment Study, however, did not find such a relationship between IOP asymmetry and visual field asymmetry (Greenfield et al., 2007). Another small study found the IOP to rise in a subset of NTG patients after initial diagnosis and demonstrated that the rising IOP correlated with a

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Fig. 7. (A) Disk photo showing the infratemporal thinning of neuroretinal rim of the right nerve in an NTG patient. The corresponding visual field shows a focal nasal defect. (B) Disk photo and visual field of the patient’s left eye. (C) HRT also shows the larger cup and thinner neruoretinal rim of the right nerve head. (D) Both OCT and GDx show thinning in the nerve fiber layer inferiorly in the right eye.

higher maximum IOP over 24 h and development of disk hemorrhage (Oguri et al., 1998). The most influential of studies regarding the relationship between IOP and NTG is the CNTGS. The CNTGS showed that IOP reduction of 30% resulted in lowering the rate of visual field progression from 35 to 12%. This demonstrated a definite role of IOP as a risk factor for progressive visual field loss in NTG. Some patients (12%), however, had progression in spite of aggressive IOP reduction, illustrating, as in POAG, that other factors may also be important in

disease progression. Within NTG, therefore, there may exist IOP-independent and IOP-dependent mechanisms of damage (Fig. 8). Further research is needed to identify potential IOP-independent mechanisms in order to develop more effective therapies to protect the optic nerve. Though it is now widely accepted that IOP reduction has a direct effect on the progression of NTG, the extent of the influence of IOP on disease progression versus IOPindependent mechanisms is variable, and unpredictable, among patients.

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Fig. 7. (Continued)

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Fig. 7. (Continued)

Fig. 8. A hypothetical scheme of the relative roles of pressure-dependent and pressure-independent mechanisms of optic nerve damage in glaucoma. In patients who develop optic nerve damage only at high IOPs, pressure-dependent mechanisms likely predominate. In patients who develop optic nerve damage at relatively low IOPs, pressure-independent mechanisms may be relatively more important. In this scheme, pressure-independent factors are operative across the range of IOPs, and pressure-dependent factors may still be operative to some extent at low pressures. The latter hypothesis is supported by the CNTGS at least in some people. Adapted with permission from Caprioli (1998).