Editors Selection IGR 21-4

Clinical Forms of Glaucoma: Perfusion and Microvascular Changes in NTG I

Min Hee Suh

Comment by Min Hee Suh on:

90999 Global assessment of arteriolar, venular and capillary changes in normal tension glaucoma, Lin TPH; Lin TPH; Wang YM; Ho K et al., Scientific reports, 2020; 10: 19222

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It has long been a debate whether vascular mechanism plays a role in the pathogenesis of glaucoma. As OCT angiography (OCTA) has facilitated the in-vivo assessment of the ocular perfusion, the interest in the compromise of the retinal vasculature in glaucoma has been boosted. A recent study by Lin TPH et al. adds to the literature that generalized microvascular attenuations were observed in normal-tension glaucoma (NTG) patients by using both fundus photography and OCTA. Moreover, OCTA-derived retinal capillary metrics attenuations were more strongly associated with NTG than fundus photography.

Degeneration of the retinal capillary vasculature is a potential surrogate marker of RGC axonal loss in glaucoma

These findings support the notion that compromised retinal perfusion may play a role in the pathogenic process of NTG. Also, this study highlights the clinical utility of OCTA in assessing retinal vasculature.

Meanwhile, it is still unclear whether vascular compromise is the result or cause of the glaucomatous damage. Theoretically, optic nerve head degeneration can be derived from reduced ocular perfusion.1 On the other hand, there is an increasing number of studies utilizing OCTA that support the hypothesis that reduced retinal perfusion is rather a consequence of retinal ganglion cell (RGC) degeneration.2,3 Given that an area of retinal capillary attenuation coincides with that of RNFL defect, microcirculatory insufficiency is rather a consequence of metabolic demand driven by the loss of RGC axon. If vascular compromise is a primary change, it should have followed the retinal arterial territory.2 Also, OCTAderived macula vessel density percent loss was significantly less than that for ganglion cell complex (GCC) thickness in early glaucoma eyes.3

Either way, degeneration of the retinal capillary vasculature is a potential surrogate marker of RGC axonal loss in glaucoma.

Further work is needed to elucidate the pathogenic role of the optic disc vascular perfusion on the pathogenesis of glaucomatous optic neuropathy.


  1. Flammer J, Orgul S, Costa VP, et al. The impact of ocular blood flow in glaucoma. Prog Retin Eye Res. 2002;21(4):359-393.
  2. Lee EJ, Lee KM, Lee SH, Kim TW. OCT Angiography of the Peripapillary Retina in Primary Open-Angle Glaucoma. Invest Ophthalmol Vis Sci. 2016;1;57(14):6265-6270.
  3. Hou H, Moghimi S, Zangwill LM, et al. Macula Vessel Density and Thickness in Early Primary Open-Angle Glaucoma. Am J Ophthalmol. 2019;199:120-132.

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