Role of ocular Doppler ultrasonography in primary open angle glaucoma
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1 Role of ocular Doppler ultrasonography in primary open angle glaucoma Poster No.: C-0650 Congress: ECR 2012 Type: Scientific Exhibit Authors: A. Alconchel 1, L. Pablo 2, P. Seral Moral 2, J. Remírez 2, P. Calvo 2 ; 1 2 Zaragoza, 1/ES, Zaragoza/ES Keywords: DOI: Blood, Observer performance, Ultrasound-Spectral Doppler, Ultrasound-Colour Doppler, Eyes /ecr2012/C-0650 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13
2 Purpose Primary open-angle glaucoma is a prevalent chronic disease that has traditionally been related with increased intraocular pressure. Many studies have proved that an altered perfusion of the optic nerve head is an important patogenic factor in glaucoma. Ocular Colour and Pulsed Doppler US is a fast, low cost non invasive method that allows us to: Evaluate the optic nerve microcirculation qualitatively and quantitatively. Detect haemodynamic differences between patients having progressive versus stable glaucoma. Determine which of the assessed optic vessels are more useful to establish the differences. Methods and Materials 1. Study design and patients: We planned a 36-month longitudinal prospective study, that included patients with any risk factor for developing open-angle glaucoma, as altered appearance of the papilla, or ocular hypertension with normal or minimally abnormal visual field at the beginning of the study. Those patients who met the inclusion/exclusion criteria, and consented to participate, were selected and included in our study. The study was approved by the hospital ethics committee and was carried out in accordance with the Declaration of Helsinki. 2. Glaucoma progression: HRT A total of 59 patients were divided into two groups according to the presence of stable versus progressive disease, assessed by HRT (Heidelberg Retina Tomograph) scans. The HRT is a confocal laser tomograph for acquisition and analysis of three-dimensional images of the posterior segment of the eye,providing an objective and qualitative assessment of the anatomy of the optic nerve head (Fig. 1) Page 2 of 13
3 3. Doppler ocular US Perfusion of the retine depends on two vascular systems: externally, the choriocapillaris formed by the Short Posterior Ciliary Arteries (PCA), and internally by the Central Retinal Artery (CRA), both of them branches of the Ophtalmic Artery (OA). Protocol: The ocular US study is performed with the patient lying in supine position and closed eyes. We use a high frequency transducer (8-10MHz), avoiding excessive pressure on the ocular globe to prevent alteration of ocular hemodynamics. First, the ocular anatomical structures are assessed in B-mode ultrasonography, identifying anterior and posterior chambers, the lens, the Optic Nerve (ON) and retrobulbar fatty tissue (Fig.2) Afterwards, Colour and Pulsed Doppler imaging is performed to assess the principal ocular vessels: Ophtalmic Artery, Central Retinal Artery (CRA) and Vein (CRV) and Posterior Ciliary Arteries (Fig.3) Colour Doppler provides us a qualitative evaluation (presence/absece of flow) of microcirculation of the ON head. Pulsed Doppler measurements of hemodynamic parameters of each vessel are obtained, including Peak Systolic Velocity (PSV), End-diastolic Velocity (EDV) Mean Velocity (MV) Pourcelot Resistivity (RI) and Gosling Pulsativity (PI) indices are calculated, and spectral diagrams of blood velocity obtained. They provide us a quantitative evaluation of ocular blood flow. One eye randomly chosen of each patient was taken into account in the statystical analisis. Images for this section: Page 3 of 13
4 Fig. 1: Heidelberg Retina Tomograph image of the posterior segment of the eye. Page 4 of 13
5 Page 5 of 13
6 Fig. 2: Color Doppler US image of the retrobulbar vasculature. Central Retine Artry and Vein and Posterior Ciliary Arteries are shown. Fig. 3: Spectral graphic of OA hemodynamical parameters obtained with Pulsed Doppler US. Page 6 of 13
7 Fig. 4: Spectral graphic of CRA (positive) and CRV (negative) hemodynamical parameters obtained with Pulsed Doppler US. Page 7 of 13
8 Results During an average follow-up period of 36months, 22 of the 59 patients (37,3%) showed progression of glaucomatose retinal damage, and 37 patients (62,7%) were stable. Colour and Pulsed Doppler measurements in these patients were compared using the Mann-Whitney U test, and showed statistically significant differences (P-value >0,05) between both groups: Decreased RI and PI in the OA Decreased PSV and MV in CRA were found in patients with glaucoma progession. The parameters of the nasal and temporal PCA were not assessed, because of the limited number of data obtained due to poor reproducibility. No differences in flow velocities were found for the rest of the retrobulbar vasculature. Images for this section: Page 8 of 13
9 Fig. 5: Distribution of patients according to glaucomatose retinal damage: Progression vs. Non proegrssion. Page 9 of 13
10 Fig. 6: Decreased RI in the OA found in patiens with glaucomatous progression Page 10 of 13
11 Fig. 7: Decreased PI in the OA found in patiens with glaucomatous progression Page 11 of 13
12 Fig. 8: Decreased PSV in CRA found in patients with glaucomatous progression. Page 12 of 13
13 Conclusion Changes of ocular perfusion in patients with glaucoma have been associated by many past studies with progression of the desease. Colour and Pulsed Doppler US imaging is a fast, low cost, non invasive method for detecting ocular haemodinamic defects that might suppose a risk factor and imply the need for a more aggressive therapy in these patients. References 1. Friedman DS, Wolfs RC, O Colmain BJ et al. Prevalence of Open-Angle Glaucoma Among Adults in the United Sates. Arch. Ophthtalmol 2004; 122: Plange N, Kaup M, Weber A, Harris A, Arend KO, Remky A. Performance of color Doppler imaging discriminating normal tension glaucoma from healthy eyes. Eye 2007; Aug Akcar N, Yildirim N, Adapinar B, Kaya T, Ozkan IR. Duplex Sonography of retro-orbital and carotid arteries in patients with normal-tension glaucoma. J Clin Ultrasound 2005; 33(6): Harris A, Chung HS, Ciulla TA, Kagemann L. Progress in measurement of ocular blood flow and relevance to our understanding of glaucoma and aged related macular degeneration. Progress in retinal and eye research 1999; 18: Bedi DG, Gombos DS, et al. Sonography of the eye. AJR 2006; 187: Belden CJ, Abbitt PL, Beadles KA. Color doppler US of the orbit. Radiographics 1995; 15: Lieb WE, Cohen SM, Merton DA. Color doppler imaging of the eye and orbit. Arch Ophthalmol 1991; 109: Scoutt LM, Zawin ML, Taylor KJ. Doppler US. Part I: Basic principles, instrumentation, and pitfalls. Radiology 1990; 174: Personal Information Page 13 of 13
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