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      Preperimetric Glaucoma Prospective Observational Study (PPGPS): Design, baseline characteristics, and therapeutic effect of tafluprost in preperimetric glaucoma eye

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          Abstract

          Purpose

          There is no consensus on the diagnosis or treatment policy for Preperimetric Glaucoma (PPG) because the pathogenesis of PPG is not clear at this time. Preperimetric Glaucoma Prospective Observational Study (PPGPS) is a first multicenter, prospective, observational study to clarify the pathogenesis of PPG. This article indicates study design, patient baseline characteristics, and analysis focused on optic nerve head (ONH) blood flow in PPG, as well as the intraocular pressure (IOP) -lowering effect and ONH blood flow-improving effects of Tafluprost.

          Method

          In this study, 122 eyes from 122 subjects (mean age: 53.1 ± 14.3) newly diagnosed as PPG were enrolled. The circumpapillary retinal nerve fiber layer thickness (cpRNFLT) was evaluated with optical coherence tomography (OCT). The ONH blood flow was measured with laser speckle flowgraphy. The therapeutic effect of Tafluprost was evaluated at Month 0 (ONH blood flow-improving effect) and Month 4 (IOP-lowering effect).

          Results

          The untreated IOP, cpRNFLT, and baseline Mean deviation (MD) value was 16.4 ± 2.5 mmHg, 80.4 ± 8.2 μm, and -0.48 ± 1.29 dB, respectively. In the site-specific visual field evaluation using the sector map, there was no appreciable site-specific visual field defect in the eye with PPG. The inferior region of cpRNFLT in 4-quadrant OCT sector analysis and 6 o’clock region in 12-o’clock OCT sector analysis was the highest rate of abnormality in PPG eyes. Topical administration of Tafluprost significantly reduced IOP from 16.4 ± 2.5 mmHg at baseline to 14.5 ± 2.3 mmHg at Month 4 ( P < 0.001, paired t-test). In the linear regression analysis, there was a significant relationship between the increase of ONH blood flow and baseline value.

          Conclusion

          PPGPS is a first prospective study focusing on the pathology of PPG. This study is expected to elucidate the pathology of PPG, with evidence useful for determining a treatment strategy for PPG.

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          Most cited references30

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          The impact of ocular blood flow in glaucoma.

          Two principal theories for the pathogenesis of glaucomatous optic neuropathy (GON) have been described--a mechanical and a vascular theory. Both have been defended by various research groups over the past 150 years. According to the mechanical theory, increased intraocular pressure (IOP) causes stretching of the laminar beams and damage to retinal ganglion cell axons. The vascular theory of glaucoma considers GON as a consequence of insufficient blood supply due to either increased IOP or other risk factors reducing ocular blood flow (OBF). A number of conditions such as congenital glaucoma, angle-closure glaucoma or secondary glaucomas clearly show that increased IOP is sufficient to lead to GON. However, a number of observations such as the existence of normal-tension glaucoma cannot be satisfactorily explained by a pressure theory alone. Indeed, the vast majority of published studies dealing with blood flow report a reduced ocular perfusion in glaucoma patients compared with normal subjects. The fact that the reduction of OBF often precedes the damage and blood flow can also be reduced in other parts of the body of glaucoma patients, indicate that the hemodynamic alterations may at least partially be primary. The major cause of this reduction is not atherosclerosis, but rather a vascular dysregulation, leading to both low perfusion pressure and insufficient autoregulation. This in turn may lead to unstable ocular perfusion and thereby to ischemia and reperfusion damage. This review discusses the potential role of OBF in glaucoma and how a disturbance of OBF could increase the optic nerve's sensitivity to IOP.
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            Mapping the visual field to the optic disc in normal tension glaucoma eyes.

            To establish the anatomical relationship between visual field test points in the Humphrey 24-2 test pattern and regions of the optic nerve head (ONH) DESIGN: Cross-sectional study. Glaucoma patients and suspects from the Normal Tension Glaucoma Clinic at Moorfields Eye Hospital. Sixty-nine retinal nerve fiber layer (RNFL) photographs with well-defined RNFL defects and/or prominent bundles were digitized. An appropriately scaled Humphrey 24-2 visual field grid and an ONH reference circle, divided into 30 degrees sectors, were generated digitally. These were superimposed onto the RNFL images. The relationship of visual field test points to the circumference of the ONH was estimated by noting the proximity of test points to RNFL defects and/or prominent bundles. The position of the ONH in relation to the fovea was also noted. The sector at the ONH corresponding to each visual field test point, the position of the ONH in relation to the fovea, and the effect of the latter on the former. A median 22 (range, 4-58), of a possible 69, ONH positions were assigned to each visual field test point. The standard deviation of estimations was 7.2 degrees. The position of the ONH was 15.5 degrees (standard deviation 0.9 degrees ) nasal and 1.9 degrees (standard deviation 1.0 degrees ) above the fovea. The location of the ONH had a significant effect on the corresponding position at the ONH for 28 of 52 visual field test points. A clinically useful map that relates visual field test points to regions of the ONH has been produced. The map will aid clinical evaluation of glaucoma patients and suspects, as well as form the basis for investigations of the relationship between retinal light sensitivity and ONH structure.
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              Mapping of macular substructures with optical coherence tomography for glaucoma diagnosis.

              To use optical coherence tomography (OCT) to identify the specific retinal layers and macular regions damaged in glaucoma. Observational cross-sectional study. One hundred forty-nine participants in the Advanced Imaging for Glaucoma Study, divided into 3 groups: normal (N) perimetric glaucoma (PG), and glaucoma suspect and preperimetric glaucoma (GSPPG) with 44, 73, and 29 persons, respectively. The Zeiss Stratus OCT system (Carl Zeiss Meditec, Inc., Dublin, CA) was used to map the macula over a 6-mm diameter and to scan the circumpapillary nerve fiber layer (cpNFL). The macular OCT images were exported for automatic segmentation using software developed by the authors. The thickness of the macular nerve fiber layer (mNFL), ganglion cell layer (mGCL), inner plexiform layer (mIPL), inner nuclear layer (mINL), outer retinal layer (mORL), and total retinal thickness were measured. Thickness measurements of GSPPG and PG eyes were compared with those of N eyes. The ability to differentiate between GSPPG and PG eyes against N eyes was assessed by fractional loss, standardized deviation, and the area under the receiver operating characteristic curve. Area-weighted average thicknesses of retinal sublayers in the macula. The mNFL, mGCL, mIPL, and mINL were significantly (P<0.001) thinner in both the GSPPG and PG eyes than in the N eyes. In PG eyes, mNFL, mGCL, and mIPL thinning was most severe (approximately 20%), mINL thinning was intermediate (7%), and mORL thinning was minimal (3%). The repeatability (coefficient of variation and intraclass correlation) of thickness measurements was improved by combining the mNFL, mGCL, and mIPL measurements as the inner retinal layer (mIRL). The mIRL was the best macular parameter for glaucoma diagnosis and had discriminant power comparable with that of the cpNFL. The fractional loss of mIRL thickness was most severe in the inferior perifoveal region for both the PG and GSPPG groups. Glaucoma leads to thinning of the mNFL, mGCL, mIPL, and mINL, even before detectable visual field changes occur. A combination of the 3 innermost layers seems to provide optimal glaucoma detection. Increasing the sampling of peripheral macula with a new OCT scan pattern may improve glaucoma diagnosis further.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: ResourcesRole: Writing – original draft
                Role: SupervisionRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: Investigation
                Role: Data curationRole: Formal analysisRole: Investigation
                Role: Data curationRole: Formal analysisRole: Investigation
                Role: Data curationRole: Formal analysisRole: Investigation
                Role: Data curationRole: Funding acquisition
                Role: Data curationRole: Funding acquisition
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 December 2017
                2017
                : 12
                : 12
                : e0188692
                Affiliations
                [1 ] Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
                [2 ] Department of Retinal Disease Control, Tohoku University Graduate School of Medicine, Sendai, Japan
                [3 ] Department of Ophthalmic Imaging and Information Analytics, Tohoku University Graduate School of Medicine, Sendai, Japan
                [4 ] Yasui Eye Clinic, Rifu, Japan
                [5 ] Kato Eye Center, Taiwa, Japan
                [6 ] Japan Medical Affairs, Global R&D, Santen Pharmaceutical Co. Ltd., Osaka, Japan
                [7 ] Department of Advanced Ophthalmic Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
                Universita degli Studi di Firenze, ITALY
                Author notes

                Competing Interests: We have the following interests: The corresponding author, Toru Nakazawa, will be in charge of implementing the proposed clinical study, with funding from Santen Pharmaceutical Co. Ltd. In addition, Toru Nakazawa is conducting two other collaborative studies, with funding from Santen Pharmaceutical Co. Ltd. Toru Nakazawa also serves as a research consultant to Santen Pharmaceutical Co. Ltd. and is paid by the company. Furthermore, Tohoku University has received research donations from Santen Pharmaceutical Co. Ltd. The clinical study was fairly conducted by a study group at Tohoku University. With regard to conflict of interest with the sponsor companies or other funding sources, a Committee for Management of Conflict of Interest in Tohoku University has already reviewed and approved the study. If any additional condition or change in conflict of interest occurs, the study group reported it to the Committee for Management of Conflict of Interest in Tohoku University and applied for a review to ensure fairness regarding conflict of interest with the sponsor companies or other funding sources. Hiroaki Kurashima, Etsuyo Miyamoto, and Masayo Hashimoto are employees of Santen Pharmaceutical Co. Ltd. Tomoki Yasui is an employee of Yasui Eye Clinic, and Keiichi Kato is an employee of Kato Eye Center. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-5591-4155
                Article
                PONE-D-17-07455
                10.1371/journal.pone.0188692
                5728557
                29236784
                c6227e9f-1b21-43d4-aa0e-a31b59a14373
                © 2017 Aizawa et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 12 May 2017
                : 10 November 2017
                Page count
                Figures: 3, Tables: 4, Pages: 15
                Funding
                Funded by: Santen Pharmaceutical Co. Ltd.
                This study was performed under collaborative research agreement between Tohoku University Graduate School of Medicine and Santen Pharmaceutical Co. Ltd. and funded by Santen Pharmaceutical Co., Ltd. Santen Pharmaceutical Co., Ltd. contributed towards study design and preparation of the manuscript but did not participate in data management, statistical analysis, or audit which was conducted by Contract Research Organizations. Hiroaki Kurashima, Etsuyo Miyamoto, and Masayo Hashimoto are employees of Santen Pharmaceutical Co. Ltd. Tomoki Yasui is an employee of Yasui Eye Clinic, and Keiichi Kato is an employee of Kato Eye Center. Yasui Eye Clinic and Kato Eye Center provided support in the form of salaries for authors (TS, KK), but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.
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