RU2508043C1 - Method of predicting open-angle glaucoma in patients with eye manifestations of pseudoexfoliation syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. To predict development of open-angle glaucoma (OAG), eye parameters are assessed in patients with eye manifestations of pseudoexfoliation syndrome (PES). PES stage on eye is determined; thickness of crystalline lens is measured, patient's age and presence or absence of artherosclerosis, ischemic heart disease, chronic failure of brain vessels, hypertension disease are registered. After that, index of risk of open-angle glaucoma development (IRD) is calculated by formula: IRD=0.0035*AGE+0.173*PES+0.094*CR+0.528*AT+0.377*IHD+0.276*CFBV+. 0.388*HT-0.322, where AGE is patient's age, years, PES is stage of PES (from 1 to 3), CR is crystalline lens thickness in mm, presence - 1, absence - 0 of accompanying cardiovascular diseases: AT - artherosclerosis, IHD - ischemic heart disease, CFBV - chronic failure of brain vessels, HD - hypertension disease, 0,322 is an independent constant If IRD>2, development of open-angle glaucoma on eyes with PES manifestations is predicted.

EFFECT: method makes it possible to predict risk of OAG development on eyes with clinical PES signs, taking into account PES stage, crystalline lens thickness, age and presence of cardiovascular diseases.

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Description

The invention relates to medicine, namely to ophthalmology, and is intended to predict the risk of developing open-angle glaucoma (OSH) in patients over the age of 45 years with ocular manifestations of pseudoexfoliation syndrome (PES).

Primary open-angle glaucoma (POAG) is considered a polyetiological disease due to the influence of several factors, which are considered: the size of the anteroposterior axis of the eye, the thickness of the cornea, the anatomical features and degree of pigmentation of the trabecula, the presence of systemic cardiovascular pathology, the nature of nutrition, smoking, age , gender (Miglior S., Pfeiffer N., Torri V. et al. Predictive factors for open-angle glaucoma among patients with ocular hypertension in the European Glaucoma Prevention Study // Ophthalmology. - 2007.- Vol. 114. -No. 1. - P. 3-9). Extensive studies have been conducted on the role of vascular and metabolic factors in the development of POAG, including: atherosclerosis, dyslipidemia, hypertension, coronary heart disease, cerebrovascular insufficiency, etc. (Bonomi L., Marchini G., Vascular risk factors for primary open angle glaucoma : the Egna-Neumarkt Study. - 2012.- vol.-26.-p.-283-91; Leske M, Wu S., et al. Risk factors for incident open-angle glaucoma: the Barbados Eye Studies. // Ophthalmology 2008; 115: 85-93).

The closest analogue is a method for predicting the risk of development and progression of OAG, taking into account the elastic properties of the cornea, determining the corneal hysteresis and the thickness of its central zone, and then calculating the biomechanical coefficient of the cornea (RF patent No. 2354287 from 05.10.09).

However, the proposed formula does not take into account the role of other local and systemic factors in the development of OAG, which may lead to insufficient accuracy and reliability of the forecast. Another significant drawback of this method is that during the examination of patients, no signs of PES in the eyes were diagnosed, and the role of this syndrome in the pathogenesis of OAG was not evaluated.

Currently, there is no doubt the significant role of PES as a trigger for the development of OAG. It is known that the risk of developing glaucoma in the eyes with PES is very high and exceeds 55%. However, at present, the fact of the development of CVD only in a certain proportion of patients with ocular manifestations of PES remains unclear, which suggests the presence in some cases of both local and systemic risk factors that cause its more rapid progression.

The objective of the invention is to develop an effective, easily feasible method for predicting the risk of developing open-angle glaucoma in patients with ocular manifestations of PES.

The technical result of the proposed method is to increase the accuracy and reliability of predicting the risk of developing OAG in the eyes with clinical signs of PES, taking into account the stage of PES, the thickness of the lens, age and the presence of cardiovascular diseases.

The technical result is achieved by the fact that in a method for predicting the development of open-angle glaucoma (OSH), including measuring eye parameters, according to the invention, in patients with ocular manifestations of pseudoexfoliation syndrome (PES), the stage of PES in the eye is determined, the thickness of the lens is measured, the patient’s age and the presence or the absence of atherosclerosis, coronary heart disease, chronic cerebrovascular insufficiency, hypertension, and then calculate the risk index for the development of open-angle laukomy (EMI) from the formula:

IRR = 0.0035 ∗ WHOR + 0.173 ∗ PES + 0.094 ∗ XP + 0.528 ∗ AT + 0.377 ∗ IHD + 0.276 ∗ CNSGM + 0.388 ∗ GB-0.322, where:

WHO - patient's age, years, PES - stage of PES from 1 to 3, XP - lens thickness in mm; presence - 1, absence - 0 concomitant cardiovascular diseases: AT - atherosclerosis, IHD - coronary heart disease, CNSHM - chronic cerebrovascular insufficiency, GB - hypertension, 0.322 - independent constant; and if the value of the IRR> 2, then the development of open-angle glaucoma in the eyes with manifestations of PES is predicted.

The method provides the possibility of predicting the risk of developing OAG in the eyes with clinical signs of PES, taking into account both local factors (PES stage, lens thickness) and the general somatic status of the patient, including age, as well as the presence and nature of concomitant cardiovascular pathology. This formula was obtained by examining 328 eyes of 185 patients (46 men and 139 women aged 48 to 87 years old) who had previously been diagnosed with primary open-angle glaucoma in one or both eyes. The stage of glaucoma was determined by the classification of A.P. Nesterov generally accepted in the Russian Federation (1975). All eyes were diagnosed with PES of varying severity. The control group consisted of 75 people (145 eyes) (44 women and 31 men aged 47-87 years) who were observed for complicated cataracts in the presence of PES. 4 experimental groups corresponding to the 1st, 2nd, 3rd, 4th stages of glaucoma were compared among themselves, as well as with the control group of patients. Each patient was considered as a separate clinical case. In the asymmetric course of the glaucoma process (76 patients), data analysis took into account the eye, which has a large stage of glaucoma.

For all patients, in addition to the standard ophthalmological examination, questionnaires were conducted with an analysis of outpatient medical records. Each clinical case was characterized by 18 signs, including the parameters of the eye (stage of PES (I-III), the size of the anteroposterior axis of the eye, the density of the nucleus of the lens (IV), the thickness of the lens (XP), the depth of the anterior chamber, pigmentation of the anterior angle chambers (CCP) (I-IV)), as well as the somatic status of the patient (age, gender, presence of atherosclerosis, hypertension, coronary heart disease, myocardial infarction and stroke in history, chronic cerebrovascular insufficiency, circulatory encephalopathy, crocosis failure of rotation, peripheral thrombosis, and diabetes mellitus. For each clinical case, numerical values of eye parameters, age were recorded, the stage of PES, the degree of pigmentation of the CPC, as well as the presence or absence of the studied somatic diseases were taken into account.

Data was processed using the SPSS 14.0 mathematical statistics software package. using the regression analysis method. The reliability of the results was determined by analysis of variance.

For each of the 18 parameters taken into account, the value of the regression coefficient (RC) was calculated, which is considered reliable at p <0.05 and reflects the specific contribution of each factor to the general regression equation that determines the risk of glaucoma. Then, a step-by-step regression analysis was used to rank the parameters by degree of significance. Of the 18 signs, seven were calculated as significantly affecting the development of glaucoma: AT, followed by coronary heart disease, PES, GB, XP, CNSGM, WHO (the order corresponds to the significance level, starting from the maximum). Given the values of the regression coefficients, a formula was derived for predicting the development of open-angle glaucoma depending on 7 signs, for each of which the coefficient values were determined as reliable:

IRR = 0.0035 ∗ WHOR + 0.173 ∗ PES + 0.094 ∗ XP + 0.528 ∗ AT + 0.377 ∗ IHD + 0.276 ∗ CNSGM + 0.388 ∗ GB-0.322, where:

IRR is the risk index for the development of glaucoma, WHO is age (years), PES is the stage of PES (1-3), XP is the thickness of the lens (mm), AT is atherosclerosis, ischemic heart disease ischemic heart disease, chronic heart failure, chronic vascular insufficiency, GB is hypertension, a value of 0.322 is an independent constant.

Using this formula, you can calculate the risk of developing OAG in patients with ocular manifestations of PES. For this, the numerical value of age (years), thickness of the lens (mm), and stage of TES (from 1 to 3) are substituted into the formula. If a patient has any of 4 cardiovascular diseases (AT, IHD, CNSHF, GB), 1 is substituted in the formula, and in the absence - 0. After arithmetic, it was found that for the control group patients, the risk indicator value is 95 % of cases did not exceed 2, on average ranged from 0.35 to 1.6. Thus, with a value of IRR> 2, it is possible to predict the probable development of OAG in patients with ocular manifestations of PES.

The proposed method is as follows: a comprehensive ophthalmic examination of the patient. The clinical signs of PES in the eye are determined using a slit lamp by biomicroscopic examination of the anterior segment of the eye, then examination is carried out under conditions of drug mydriasis, the degree of CPC pigmentation is determined by gonioscopy (I-IV). Stage PES from 1 to 3 is determined in accordance with the classification of Broshevskaya EB (1997).

With the exception in accordance with existing standards for the diagnosis of OAG in front of eyes with PES, a further calculation of the risk of its development is made according to the obtained formula. The diagnosis of OAG is excluded with normal boundaries of the peripheral field of vision, the absence of ophthalmoscopic signs of glaucoma optical neuropathy and significant changes in the photosensitivity of the retina, as well as with values of perimetric indices mean deviation (MD)> - 2 and pattern standart deviation (PSD) <2 no Humphrey Field Analyzer 11 (if possible).

The thickness of the lens is determined by A-scan (mm). The patient's age (years) is fixed. The patient is questioned, anamnestic data are collected, outpatient medical records, the conclusions of the therapist, neurologist, cardiologist are analyzed to determine the presence of any of the following diseases or their combination: atherosclerosis, hypertension, coronary heart disease, chronic cerebrovascular insufficiency.

Calculation of the risk of developing glaucoma is performed according to the formula, which substitutes the numerical value of age (years), lens thickness (mm), stage of PES (1-3), "1" - if the patient has any of 4 vascular diseases, "0" - in the absence.

IRR = 0.0035 ∗ WHOR + 0.173 ∗ PES + 0.094 ∗ XP + 0.528 ∗ AT + 0.377 ∗ IHD + 0.276 ∗ CNSGM + 0.388 ∗ GB-0.322

The obtained index value (IRR) characterizes the risk of developing OAG in patients with clinical signs of ocular PES. The developed simple and safe method for assessing the degree of risk of developing open-angle glaucoma against a background of PES allows it to be used on an outpatient basis, as a screening method for the timely identification of patients falling into a high-risk group for developing CVD. The diagnostic value of this method is confirmed by a high percentage of confirmed results for patients with signs of PES, in which, upon further examination, characteristic manifestations of glaucoma optical neuropathy were revealed.

The proposed method is characterized by the following clinical examples.

Example 1. Patient K., 78 years old, was diagnosed with OU - complicated cataracts, PES, mild hyperopia. Complaints of decreased vision, a veil before the eyes. Visual acuity with correction OD = 0.4, OS = 0.6.

Intraocular pressure (IOP) - OD = 21, OS = 22 mmHg Lens thickness OD - 5.3 mm, OS - 5.0 mm. According to the kinetic perimetry, no visual field defects were detected. The results of computer static perimetry revealed single paracentral scotomas (4 on OD, 3 on OS), on OD: MD - 5.8 dB and PSD 4.5 dB, on OS MD - 2.2 dB and PSD - 3.5 dB, the percentage of errors - false positive - 12% and false negative - 8%.

OU: Pseudoexfoliation deposits were determined biomicroscopically on the anterior lens capsule and on the pupil edge of the iris (on OD more pronounced than on OS), the pigment border is broken, on the OD it looks like a cellophane film. A scattering of pigment on the surface of the iris. Mydriasis OD - 3.5 mm, OS - 4.5 mm. OU - Pigmentation of the CPC III degree. Diagnosed stage III of PES on OD and stage II on OS.

Ophthalmoscopically: OU - DZN is pale pink, the borders are clear, the amount of excavation is 0.5, the macular zone is beyond the fleur.

When analyzing medical documentation and collecting an anamnesis, information was found on concomitant diseases: atherosclerosis, stage 11 hypertension, risk 2, coronary heart disease, functional class 2 angina, stage I circulatory failure.

IRR is calculated by the formula:

IRR (OD) = 0.0035 * 78 + 0.173 * 3 + 0.094 * 5.3 + 0.528 + 0.377 + 0.388-0.322 = 2.25

IRR (OS) = 0.0035 * 78 + 0.173 * 2 + 0.094 * 5.0 + 0.528 + 0.377 + 0.388-0.322 = 2.04

The value of the indicator allows us to predict the development of OAG in both eyes.

When examining the patient after 11 months, visual acuity did not change, IOP OD = 27, OS = 22 mm Hg The boundaries of the peripheral field of view did not change, and in the paracentral region on the OD non-edge scotomas were found in the amount of 11 pieces, of which 6 had p <1%, MD -7.5 dB, PSD - 8.7 dB; on OS, 5 non-edge cattle with p <5%, MD - 5.2 dB, PSD 3.2 dB, false-positive errors - 7%, false-negative 5% were detected. Ophthalmoscopically on OD revealed an increase in excavation to 0.6. Diagnosed with: OD - open-angle glaucoma in stage 1, treatment prescribed. OS - suspected glaucoma, repeated examination after 3 months.

Example 2. Patient T., 69 years old, was diagnosed with: OU - complicated cataract, PES. Complaints of periodic blurred vision. Visual acuity with correction: OD = 0.7, OS = 0.6.

Tonometry by pneumotonometer: IOP - OD = 20, OS = 20 mm Hg Lens thickness OD - 3.8 mm, OS - 4.0 mm. According to the kinetic perimetric indices, no visual field defects were detected. The results of computer perimetry did not reveal significant changes: on OD and OS, single paracentral scotomas, on OD: MD - 2.3 dB and PSD 3.4 dB, on OS: MD - 1.9 dB and PSD 3.2 dB, error percentage - false positive (4%) and false negative (5%).

OU: light pseudoexfoliation deposits along the pupil edge of the iris, partial destruction of the pigment rim, single pigment grains on the surface of the iris were determined biomicroscopically. Mydriasis 6 mm. Diagnosed with PES stage 1. Ophthalmoscopically: OU-DZN is pale pink, the borders are clear, the amount of excavation is 0.4, the macular zone is beyond the fleur.

Of the concomitant diseases - atherosclerosis, chronic cholecystitis. The risk of glaucoma is calculated by the formula:

IRR (OD) = 0.0035 * 69 + 0.173 * 1 + 0.094 * 3.8 + 0.528-0.322 = 0.86

IRR (OS) = 0.0035 * 69 + 0.173 * 1 + 0.094 * 4.0 + 0.528-0.322 = 0.88

Given the values of the indicators less than 2, the development of OAG is not predicted.

When viewed after 11 months: the visual acuity of the OU has not changed, IOP-OD = 21, OS = 19 mm Hg The results of kinetic and computer static perimetry did not reveal significant changes. Ophthalmoscopy OU - no change. The diagnosis of pseudoexfoliation glaucoma has not been confirmed. The proposed method for predicting the development of OSH in patients with PES is carried out taking into account a complex of factors that can be easily analyzed by ophthalmologists already at the stage of outpatient patients. Identification by targeted screening among all patients with PES of an increased risk group for developing CVD is necessary for the competent management of these patients and to prevent the development of severe clinical symptoms of glaucoma and, therefore, is clinically and economically feasible.

Claims (1)

A method for predicting the development of open-angle glaucoma (OAG), including an assessment of eye parameters, characterized in that in patients with ocular manifestations of pseudoexfoliation syndrome (PES), the stage of PES in the eye is determined, the thickness of the lens is measured, the patient’s age and the presence or absence of atherosclerosis, coronary heart disease , chronic cerebrovascular insufficiency, hypertension, and then calculate the risk index for the development of open-angle glaucoma (IRI) by the formula:
IRR = 0.0035 ∗ WHOR + 0.173 ∗ PES + 0.094 ∗ XP + 0.528 ∗ AT + 0.377 ∗ IHD + 0.276 ∗ CNSGM + 0.388 ∗ GB-0.322, where:
WHO - patient's age, years, PES - stage of PES (from 1 to 3), XP - lens thickness in mm, presence - 1, absence - 0 concomitant cardiovascular diseases: AT - atherosclerosis, CHD - coronary heart disease, CNSF - chronic insufficiency cerebral vessels, GB - hypertension, 0.322 - independent constant; and if the value of the IRR> 2, then the development of open-angle glaucoma in the eyes with manifestations of PES is predicted.