Correspondence

Primary Open-Angle Glaucoma

N Engl J Med 2009; 360:2679-2680June 18, 2009

Article

To the Editor:

With regard to the review article on primary open-angle glaucoma by Kwon et al. (March 12 issue),1 we believe that some discussion of the possible role of vascular factors in the pathophysiology of glaucomatous optic neuropathy is necessary.

Investigators in the Barbados Eye Studies reported that baseline vascular risk factors, including decreased systolic blood pressure and decreased systolic, diastolic, and mean ocular perfusion pressure, can influence the risk of open-angle glaucoma. Specifically, low ocular perfusion pressure doubled the risk of glaucoma in that population.2 Investigators in the Early Manifest Glaucoma Trial reported that baseline predictors of progression of open-angle glaucoma include decreased ocular systolic perfusion pressure, a history of cardiovascular disease, and decreased systolic blood pressure.3 Another study showed that a diastolic blood pressure of less than 90 mm Hg due to antihypertensive treatment is associated with increased optic-nerve cupping and a decreased rim area of the optic disk in subjects without glaucoma.4

Andrzej Grzybowski, M.D.
Karol Marcinkowski University Medical School, 61-701 Poznan, Poland

Alon Harris, Ph.D.
Indiana University School of Medicine, Indianapolis, IN 46202
alharris@indiana.edu

4 References

1. 1

   Kwon YH, Fingert JH, Kuehn MH, Alward WLM. Primary open-angle glaucoma. N Engl J Med 2009;360:1113-1124
   Full Text | Web of Science | Medline

2. 2

   Leske MC, Wu SY, Hennis A, Honkanen R, Nemesure B. Risk factors for incident open-angle glaucoma: the Barbados eye studies. Ophthalmology 2008;115:85-93
   CrossRef | Web of Science | Medline

3. 3

   Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z. Predictors of long-term progression in the Early Manifest Glaucoma Trial. Ophthalmology 2007;114:1965-1972
   CrossRef | Web of Science | Medline

4. 4

   Topouzis F, Coleman AL, Harris A, et al. Association of blood pressure status with the optic disk structure in non-glaucoma subjects: the Thessaloniki Eye Study. Am J Ophthalmol 2006;142:60-67
   CrossRef | Web of Science | Medline

To the Editor:

Regarding the review article by Kwon et al.: it appears that Helicobacter pylori infection is associated with various risk factors for primary open-angle glaucoma.1,2 Moreover, an association between H. pylori infection and primary open-angle glaucoma has been found in a Greek cohort, and levels of H. pylori infection–specific IgG antibodies are increased in the aqueous humor in patients with primary open-angle glaucoma; the concentration of this antibody correlates with the degree of vertical cupping, possibly indicating the severity of glaucomatous damage.3 Similar observations4,5 have been made in China, India, Turkey, and Iran.

Jannis Kountouras, M.D., Ph.D.
Christos Zavos, M.D.
Georgia Deretzi, M.D., Ph.D.
Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
jannis@med.auth.gr

5 References

1. 1

   Kountouras J, Mylopoulos N, Boura P, et al. Relationship between Helicobacter pylori infection and glaucoma. Ophthalmology 2001;108:599-604
   CrossRef | Web of Science | Medline

2. 2

   Kountouras J, Mylopoulos N, Chatzopoulos D, et al. Eradication of Helicobacter pylori may be beneficial in the management of chronic open-angle glaucoma. Arch Intern Med 2002;162:1237-1244
   CrossRef | Web of Science | Medline

3. 3

   Kountouras J, Mylopoulos N, Konstas AG, Zavos C, Chatzopoulos D, Boukla A. Increased levels of Helicobacter pylori IgG antibodies in aqueous humor of patients with primary open-angle and exfoliation glaucoma. Graefes Arch Clin Exp Ophthalmol 2003;241:884-890
   CrossRef | Web of Science | Medline

4. 4

   Hong Y, Zhang C, Duan L, Wang W. Relationship between Helicobacter pylori infection and open angle glaucoma in China. Asian J Ophthalmol 2007;9:205-208
   

5. 5

   Deshpande N, Lalitha P, Krishna das SR, et al. Helicobacter pylori IgG antibodies in aqueous humor and serum of subjects with primary open-angle and pseudo-exfoliation glaucoma in a South Indian population. J Glaucoma 2008;17:605-610
   CrossRef | Web of Science | Medline

Author/Editor Response

We agree with Grzybowski and Harris that systemic and local vascular factors play an important role in the pathogenesis of primary open-angle glaucoma, as shown by several large epidemiologic studies, both cross-sectional and longitudinal. In a study involving clinic populations, an author of our review article and others reported that patients with normal-tension glaucoma and patients with anterior ischemic optic neuropathy who showed progressive visual-field deterioration were more likely to have nocturnal, systemic hypotension than patients with stable visual fields.1 Because of space constraints, we confined the discussion in our review article to the mechanisms of elevated intraocular pressure and resultant changes to the cells and structures of the optic-nerve head (or optic disk).

In reply to the comments by Kountouras et al.: the association between H. pylori infection and glaucoma remains controversial. Since the initial reports of the association observed in a Greek cohort involving 41 study subjects and 30 control subjects, a larger independent study in Canada (involving 97 study subjects and 94 control subjects)2 and another study in Israel (involving 51 study subjects and 36 control subjects)3 showed that H. pylori seropositivity in the study cohort was not significantly greater than that of controls. A study from South India involving 50 study subjects and 50 control subjects showed that the level of anti–H. pylori IgG antibodies in the serum, but not in the aqueous humor, was significantly elevated in patients with primary open-angle glaucoma as compared with that of controls.4 The negative finding in the aqueous humor is in contrast to the significantly elevated level of IgG detected in the aqueous humor in patients with primary open-angle glaucoma in an earlier study from Greece involving 26 study subjects and 31 control subjects.5 We acknowledge that the hypothesis concerning the contribution of H. pylori infection to the pathogenesis of glaucoma through a cellular or humoral immune response remains an intriguing possibility. However, to date, independent studies involving larger cohorts have not corroborated the conclusions of the initial reports.

Young H. Kwon, M.D., Ph.D.
John H. Fingert, M.D., Ph.D.
Markus H. Kuehn, Ph.D.
University of Iowa, Iowa City, IA 52242

5 References

1. 1

   Hayreh SS, Zimmerman MB, Podhajsky P, Alward WL. Nocturnal arterial hypotension and its role in optic nerve head and ocular ischemic disorders. Am J Ophthalmol 1994;117:603-624
   Web of Science | Medline

2. 2

   Galloway PH, Warner SJ, Morshed MG, Mikelberg FS. Helicobacter pylori infection and the risk for open-angle glaucoma. Ophthalmology 2003;110:922-925
   CrossRef | Web of Science | Medline

3. 3

   Kurtz S, Regenbogen M, Goldiner I, Horowitz N, Moshkowitz M. No association between Helicobacter pylori infection or CagA-bearing strains and glaucoma. J Glaucoma 2008;17:223-226
   CrossRef | Web of Science | Medline

4. 4

   Deshpande N, Lalitha P, Krishna das SR, et al. Helicobacter pylori IgG antibodies in aqueous humor and serum of subjects with primary open angle and pseudo-exfoliation glaucoma in a South Indian population. J Glaucoma 2008;17:605-610
   CrossRef | Web of Science | Medline

5. 5

   Kountouras J, Mylopoulos N, Konstas AG, Zavos C, Chatzopoulos D, Boukla A. Increased levels of Helicobacter pylori IgG antibodies in aqueous humor of patients with primary open-angle and exfoliation glaucoma. Graefes Arch Clin Exp Ophthalmol 2003;241:884-890
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Jannis Kountouras, Christos Zavos, Georgios Sakkias, Georgia Deretzi, Ioannis Venizelos, Stergios Arapoglou, Stergios A. Polyzos. (2011) Helicobacter pylori Infection as a Risk Factor for Both Primary Open-Angle Glaucoma and Pseudoexfoliative Glaucoma in Thessaloniki Eye Study. American Journal of Ophthalmology 152:6, 1079-1080
   CrossRef

2. 2

   Jannis Kountouras, Christos Zavos, Georgia Deretzi, Stergios A. Polyzos, Emmanuel Gavalas, Elena Tsiaousi, Evaggelia Giartza-Taxidou, Dimitrios Chatzopoulos, Stavros Michael, George Tsarouchas. (2011) Neuroprotection in glaucoma: Is there a future role of Helicobacter pylori eradication?. Experimental Eye Research 92:5, 436-438
   CrossRef

3. 3

   Jannis Kountouras, Christos Zavos, Georgia Deretzi, Emmanouel Gavalas, Stergios Polyzos, Panagiotis Katsinelos, Nikolaos Grigoriadis, Evangelos Koutlas, Jobst Rudolf, Iakovos Tsiptsios. (2011) Impact of Helicobacter pylori on chronic hepatitis C-related cognitive dysfunction. Journal of Neuroimmunology 233:1-2, 254-256
   CrossRef