Editorial
Multidisciplinary approach on the management of glaucoma: the role of corneal biomechanics
Abordaje multidisciplinar para el manejo del glaucoma: papel de la biomecánica corneal
R. Bouchikh-El Jarroudia,b,c,
, P. Romera-Romeroa, J. Botella-Garciaa, J. Loscos-Arenasa
Corresponding author
a Servicio de Oftalmología, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain
b Departamento de Cirugía, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
c Unidad de Oftalmología Basada en Evidencias (Oftalmoevidencia), Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru
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The choroidal thinning (white arrow) at nasal level could be physiological and attributable to the patient’s myopia. Subfoveal hyperreflectivity resolved at two weeks (B) leaving a minimal sequel of subfoveal RPE thickening at 1.5 months (C). The outer nasal layers progressively recovered (B and C). In A-OCT 8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8 <span class="elsevierStyleItalic">en-face,</span> at ellipsoid layer level, hyperreflective points were observed surrounding the papilla (green arrow) at debut (D). After two weeks (E), these peripapillary hyperreflective points decreased but hyporeflective spots were observed (white arrow), which correlate with the disruption of the outer retina in autofluorescence. After 1.5 months (F), hyporeflective spots decreased and white peripapillary spots disappeared. The A-OCT 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 showed at choriocapillary level two apparent hypoperfusion spots in the debut of the disease (G), which correlate with the shadow of the subfoveal column hyperreflectivity.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Moll-Udina, I. Hernanz, M. Dotti, V. Llorenç, A. Adán" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Moll-Udina" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Hernanz" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Dotti" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Llorenç" ] 4 => array:2 [ "nombre" => "A." 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Bouchikh-El Jarroudi, P. Romera-Romero, J. Botella-Garcia, J. Loscos-Arenas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Bouchikh-El Jarroudi" "email" => array:1 [ 0 => "rachid.bascara@gmail.com" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Romera-Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." 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"apellidos" => "Loscos-Arenas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Oftalmología Basada en Evidencias (Oftalmoevidencia), Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Abordaje multidisciplinar para el manejo del glaucoma: papel de la biomecánica corneal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Glaucoma is defined as a progressive, irreversible optic neuropathy of multifactorial origin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among the associated risk factors, increased intraocular pressure (IOP) is the most recognized, as it is the only modifiable risk factor, making it the main therapeutic target for the management of glaucoma.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Other known risk factors include advanced age, a family history of glaucoma, myopia, optic nerve abnormalities, central corneal thickness, and corneal stiffness.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Among these factors, corneal stiffness is a reflection of corneal biomechanics, indicating a decrease in corneal hysteresis, or in other words, a reduced viscoelastic capacity of the cornea.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is well known that patients with stiffer corneas have a higher risk of developing glaucoma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> One explanation for this is that in eyes with stiffer corneas, small variations in volume cause a greater increase in IOP and, consequently, greater IOP fluctuations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, corneal biomechanics is not only a risk factor for the development of glaucoma but is also related to its progression. Reduced corneal hysteresis has been associated with a higher rate of glaucoma progression in several studies, which show that eyes with stiffer corneas exhibit greater glaucoma progression.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6–8</span></a> This greater progression has been confirmed through perimetry, showing a greater loss of the visual field<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7,8</span></a> and, topographically, with greater thinning of the nerve fiber layers<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> over time.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, in the most recent clinical practice guidelines (CPG) for open-angle glaucoma (OAG), corneal biomechanics is either not mentioned at all or simply listed as a risk factor,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> without considering its prognostic implications, as demonstrated by several authors.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6–8</span></a> In fact, if we base ourselves on the CPGs for monitoring and following up on glaucoma, the approach relies on routine patient control through ophthalmological examination, including IOP measurement and fundoscopy to evaluate the optic nerve head and its cupping. Additionally, visual field testing and optical coherence tomography are included as supporting tools to determine if there is glaucoma progression, but at no point is corneal hysteresis mentioned or its potential applicability.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However, evaluating corneal biomechanics in patients diagnosed with OAG would be relevant, given the prognostic value of this factor according to the current available evidence.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6–8</span></a> This evaluation would allow for individualized follow-up and the selection of the most appropriate therapeutic option based on corneal hysteresis. In patients with stiffer corneas, knowing that they are associated with a higher risk of glaucoma progression, it would be advisable to consider stricter IOP control with closer follow-up or even more aggressive treatment. Conversely, patients with corneal biomechanics consistent with less rigid corneas,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> in whom the rate of progression is lower, might be considered for a more flexible approach to IOP control and a more conservative treatment. These evidence-based recommendations could be added or, at least, considered in future CPGs on the management of OAG.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since corneal hysteresis is a risk factor for developing glaucoma and a predictive factor for its progression, we believe it is essential to include this parameter in the management of glaucoma patients. This would allow for a more precise approach based on the most updated evidence, which should be reflected in the CPGs.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Indeed, the involvement of corneal biomechanics in glaucoma not only improves our understanding of the disease but also facilitates a multidisciplinary approach beyond IOP and the anatomical and functional changes of the optic nerve. Thus, a more comprehensive evaluation of the patient with OAG can be achieved, enabling more personalized decisions aligned with scientific evidence and considering the prognostic implications of corneal stiffness.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, corneal biomechanics is not only an associated risk factor for glaucoma but also seems to have prognostic implications of vital importance. Considering it as such would allow for greater individualization of patient treatment, identifying those at greater risk of progression and, therefore, needing stricter IOP control and possibly earlier intervention. We believe that the prognostic implication of corneal biomechanics would be of interest for discussion in future CPGs on the management of OAG and that the baseline determination of corneal hysteresis could be very useful in patients attending a first glaucoma visit.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">CRediT authorship contribution statement</span><p id="par0035" class="elsevierStylePara elsevierViewall">The manuscript is the original work of the authors and has not been submitted to another scientific journal. The original idea was from the lead author, and the remaining 4<span class="elsevierStyleSup">th</span> authors developed and approved the manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "CRediT authorship contribution statement" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary open-angle glaucoma preferred practice pattern®" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.J. 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