Cupping Reversal in Pediatric Glaucoma-Evaluation of the Retinal Nerve Fiber Layer and Visual Field

PURPOSE: To identify optic nerve head (ONH) cupping reversal and associated optical coherence tomography (OCT) and Humphrey visual field changes in pediatric glaucoma. DESIGN: Retrospective observational case series. METHODS: Sequential surgical cases of juvenile open-angle glaucoma (OAG) or primary congenital glaucoma (PCG) with sustained postoperative intraocular pressure (IOP) reduction. Group 1 had preoperative and postoperative ONH photographs and OCT; Group 2 had preoperative clinical ONH assessment and postoperative imaging. Cupping evaluation was confirmed by masked glaucoma and neuro-ophthalmology specialists. RESULTS: Of 80 cases, 9 eyes (9 children) met criteria for Group 1; 24 eyes (19 children) met criteria for Group 2. Group 1: Five of 9 eyes (56%) demonstrated cupping reversal, with preoperative vs postoperative mean TOP 34.2 +/- 6.6 mm Hg vs 10.6 +/- 4.1 mm Hg (P < .00001) and mean average retinal nerve fiber layer (RNFL) 71.0 30 mu m vs 62.8 24 mu m (P = .4), respectively. RNFL was stable in 4 of 5 eyes (all juvenile OAG), but thinned (Delta = -41 mu m) in 1 eye with PCG. Humphrey visual fields (reliable in 2 of 3 eyes) showed no significant change. Group 2: Fourteen of 24 PCG eyes (58%) demonstrated cupping reversal, with preoperative vs postoperative mean IOP 36.1 +/- 8.9 mm Hg vs 13.3 +/- 2.1 mm Hg (P < .00001). Two eyes had thin RNFL postoperatively despite healthy-appearing ONH. Postoperative RNFL showed statistically significant linear correlation with preoperative (but not postoperative) cup-to-disc ratio. Limitations include small numbers, few reliable Humphrey visual fields, and absent preoperative imaging (Group 2). CONCLUSION: Some eyes with TOP reduction and ONH cupping reversal show continued RNFL thinning postoperatively. The preoperative ONH cup-to-disc ratio predicted the postoperative RNFL better than the postoperative "reversed and smaller" cup-to-disc ratio. Cupping reversal in pediatric glaucoma may not predict improved ONH health and deserves further study. (C) 2014 by Elsevier Inc. All rights reserved.