March 2009 Vijay Pai et al.

- Comparison of visual field defects in NTG and POAG 47

Comparison of Visual Field Defects in
Normal-Tension Glaucoma (NTG) and
Primary Open Angle Glaucoma (POAG)
Dr.Vijaya Pai H. MS, Dr.Himabindu Veluri MS
Department of Ophthalmology, Kasturba Medical College, Manipal - 576104
Purpose: Comparison of visual field defects in patients with Normal tension glaucoma (NTG) and
Primary open angle glaucoma (POAG) may reveal a difference in the pathogenesis of the two
conditions.
Methods: We compared closely matched visual fields of 37 eyes with NTG and 22 eyes with POAG
which were performed using the 30-2 program of Humphrey perimeter.
Period of study- January 2003 to March 2006.
Results: In the mild defects 46.2 % of the NTG group showed defects close to fixation compared
to 33.3 % of the POAG group (P = .687). The NTG group had a PSD of 6.78 dB compared to
5.87 dB in the POAG group (P = .648). 53.9% of eyes in the NTG group had vascular risk factors
compared to 33.3% in the POAG group (P = .5).
Conclusion: Results suggest that field defects of NTG and POAG are similar and should thus not
be used to hypothesize different pathogenic mechanisms.
The association between increased intraocular pressure
and glaucoma is well known
1, 2, 3
. However, the exact
role of intraocular pressure in the pathogenesis of
glaucoma remains obscure. Since the description of a
patient with glaucomatous optic nerve damage and
visual field loss in the absence of increased intraocular
pressure by Von Graefe, the relationship between
intraocular pressure, optic nerve damage, and visual
field loss has aroused controversy. However, there has
been little agreement in published reports as to the
similarities and differences of these characteristics in
patients with normal-tension glaucoma and patients
with high-tension glaucoma
2, 3,4
. Some investigators
have shown that visual field defects in patients with
normal-tension glaucoma as compared to patients with
high-tension glaucoma tend to be of sudden onset
2
,
closer to fixation
2-4,6
, deeper and steeper
2,-4
, more
localized or less diffuse
7-9
, more common in the superior
hemifield
10,11
have a greater amount of localized visual
field loss in the inferior hemifield
5
. The studies of
Caprioli and Spaeth
4
,

which suggested that normal-
tension glaucomatous visual field defects were closer
to fixation and had steeper slopes, were challenged by
Phelps, Harry
1
, and Montague
1
who pointed out the
inappropriateness of the method used in making these
quantitative assessments. Similarly, other investigators
have found no differences between the visual field
defects in patients with normal tension glaucoma and
patients with high-tension glaucoma
12-15
. The reasons
for such controversial reports seem to be caused by
O R I G I NA L
A R T I C L E
48 Kerala Journal of Ophthalmology Vol. XXI, No. 1
differences in study designs, including different types
of perimetry, various definitions of normal-tension
glaucoma regarding the highest recorded intraocular
pressure, different stages of optic nerve damage and
visual field loss, and different methods used in statistical
analysis of the data. This study was designed to compare
the visual field defects of patients with normal-tension
glaucoma and patients with high-tension glaucoma by
using strict criteria for defining both types of glaucoma
and closely matching both groups with respect to the
amount of visual field loss.
Patients and Methods
This study was conducted at Kasturba Medical College,
Manipal. Patients seen from January 2003 to
February 2006 in the Out Patient Department of
Ophthalmology were selected. We used 37 eyes of
24 patients with Normal-Tension Glaucoma (NTG) and
22 eyes of 16 patients with Primary Open Angle
Glaucoma (POAG) for comparison in this non-
randomized comparative trial. Criteria for inclusion in
the NTG group included a maximum recorded
intraocular pressure (IOP) of <21mm Hg before the
initiation of therapy and for the POAG group, a
maximum recorded IOP of >21mm Hg by Goldmann
applanation tonometry. CCT was measured with
Ocuscan [Alcon] and the IOP was adjusted accordingly.
All patients had glaucomatous optic nerve damage,
open anterior chamber angles on gonioscopy, a diurnal
IOP curve done without therapy with a minimum of
6 measurements, a visual acuity of 20/60 or better,
a pupil diameter of at least 3 mm, at least two reliable
visual field tests (fixation loss <20 %, and false positive
and false negative errors <33 %) using C 30-2 program
of Humphrey perimeter, and glaucomatous visual field
loss (according to Andersons criteria). Cup/disc ratio
was determined by binocular examination of the dilated
fundus using slit lamp biomicroscopy with a 90 Dioptre
double aspheric lens. When binocular examination was
not possible due to a poorly dilated pupil, direct
ophthalmoscopy with monocular clues such as disc
vessel bending was used to determine the cup/disc
ratio.
Patients were excluded if they had history of trauma or
any ocular disease known to affect the visual field such
as diabetic retinopathy, macular degeneration and
vascular occlusions. Also, patients with a visual acuity
< 20/60, pupil diameter of <3mm, unreliable visual
field tests, optic neuropathy other than glaucoma, local
disc malformations or neurologic abnormalities were
also excluded. The visual field defects were classified
into mild, moderate, severe and end-stage based on
Advanced Glaucoma Intervention Study (AGIS)
16
scoring system. Visual field defects of the NTG group
were matched with those of the POAG group for the
severity of damage, for comparison. All visual field
examinations were performed by trained technicians.
Mild defects in the NTG group were compared with
mild defects in the POAG group, moderate with
moderate, and so on and so forth. A whole group
analysis was also done in which all the visual fields
defects in the NTG group were compared with all the
field defects in the POAG group, irrespective of the
severity of the defect.
To determine if there was a difference in the frequency
of visual field defects close to fixation between patients
with NTG and patients with POAG, the number of
patients in each group with scotomas extending to
within 6 of central fixation were counted. Patients were
counted if any of one of the central 4 threshold values
in the pattern standard deviation plot decreased to
10 dB or more below the age-corrected normal values,
or if any of the central 4 threshold values along with
contiguous values decreased 5 dB or more below age-
corrected normal values
5
.
To determine if there was a difference between the two
groups with respect to localized visual field loss, pattern
standard deviation was compared
5
as the NTG group
and the POAG group were matched for the severity of
the defect. The number of eyes in each group with a
more severe involvement of either the superior or the
inferior hemifield was also noted in order to determine
which hemifield is more commonly involved in each
group and also to determine if there are any
differences in the frequency of involvement of a
hemifield between the two groups. A hemifield was
considered to be more involved if the PSD plot showed
at least 3 or more contiguous locations with p = 0.005
in that half of the visual field
17
.

Chi-square analysis,
t-test and Mann-Whitney tests were used for statistical
analysis.
March 2009 Vijay Pai et al. - Comparison of visual field defects in NTG and POAG 49
Results
The total number of eyes in the NTG group were 37,
and in the POAG group, 22. The demographic data for
the two groups were analyzed. In the mild defects, as
reported by other investigators, the NTG group had a
younger mean age
2
and a larger mean cup/disc
ratio
2, 3,18
. However, the differences were not statistically
significant [Table 1]. 46.2 % of the NTG group showed
defects close to fixation compared to 33.3 % of the
POAG group. We found no statistically significant
difference in the number of patients with scotomas
falling within 6 of central fixation (p = 0.687).
Although the NTG group had a larger PSD than the
POAG group, (6.78 3.25 vs. 5.866 1.55), this
difference was not statistically significant (p = 0.648).
53.83 % of the NTG group had vascular risk factors
compared to 33.3 % of the POAG group. Once again,
the difference was not statistically significant. The
superior hemifield was more involved in both groups,
although there was no statistically significant difference
in the frequency of involvement between the two groups
[Table 2]. A similar comparison was carried out
between the two groups for each category of the field
defect that is, moderate, severe, and end-stage. However,
the comparison done between mild defects is given
more significance as the defects tend to look similar in
both groups, as they progress in severity. It is during
the mild stage that any true differences can be
established with more certainty.
Discussion
Since the description of an entity called normal-tension
glaucoma, in which glaucomatous optic disc changes
with visual field defects occur in the presence of a
normal intraocular pressure, various hypotheses such
as vascular ischemia have been put forward in an
attempt to discover if differences exist in the pathogenic
mechanisms of NTG as compared to those of POAG.
Differences in the pattern of visual field loss in the two
groups may lead towards such a difference.
Unfortunately, due to various differences in the way
previous studies were conducted, there has been little
agreement between investigators, as to the similarities
or differences in the visual field defects between the
two groups. Some investigators found that visual field
defects were closer to fixation in patients with NTG
than in patients with POAG
2-4
. However, others have
found no significant differences in the two groups with
respect to involvement of fixation
5, 6,11,12,
. In our study,
in the mild defects, we found no significant differences
in the number of patients with NTG and patients with
POAG with scotomas extending to within 6 of central
fixation.
Studies have also shown that patients with NTG have
more localized defects and those with POAG have
more generalized defects
6, 9
. We investigated these
findings by comparing the PSD values (localized visual
field loss) between the two groups. Although the NTG
group had a greater amount of localized visual field
loss than the POAG group, this difference was not
statistically significant. This finding is similar to that
of Zeiter, Shin et al
5
, who found no significant difference
in the PSD values between patients with NTG and
POAG.
In our study we also found a tendency toward
involvement of the superior hemifield in both groups.
The finding that patients with early to moderate POAG
have visual field defects that involve the superior
hemifield more than the inferior hemifield has been
documented
19, 20
. In addition, many investigators have
studied whether there is any difference in the
distribution of visual field defects over the superior and
inferior hemifields between patients with NTG and
POAG
10-13
. Although many have found no differences
between the two groups
10,12,13
, some have found a
greater involvement of the superior hemifield in the
NTG group as compared to the POAG group
11
. We
found no statistically significant difference in the
distribution of field loss over the superior and inferior
hemifields between the two groups.
Many authors have hypothesized that vascular factors
in addition to IOP have an important role in the
pathogenesis of normal tension-glaucoma. However,
our results showed no significant differences in the
vascular risk factors between the two groups.
In conclusion, although this study does not imply that
there are no different pathogenic mechanisms between
NTG and POAG, it does show that there are no
differences in the visual field defects between the two
groups and hence visual field defects may not point
towards differences in pathogenic mechanisms.
50 Kerala Journal of Ophthalmology Vol. XXI, No. 1
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