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Editors Selection IGR 22-3

Clinical Examination Methods: Neuroretinal rim and loss of function

Comment by Harsha Rao on:

54578 Evaluation of Progressive Neuroretinal Rim Loss as a Surrogate End Point for Development of Visual Field Loss in Glaucoma, Medeiros FA; Lisboa R; Zangwill LM et al., Ophthalmology, 2014; 121: 100-109

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One of the major limitations in glaucoma is the lack of a good reference standard for its diagnosis. Traditionally, clinicians and researchers have used the presence of a visual field defect, structural change suggestive of glaucoma as diagnosed by experts on optic disc photographs or a combination of both as reference standard for glaucoma diagnosis. Therefore, subjects with suspicious but inconclusive findings for glaucoma are labelled as 'glaucoma suspects'. Although the 'glaucoma suspect' group forms a significant proportion of subjects seen in clinical glaucoma practice, most studies have excluded this group from analysis because of the reference standard issue. Previously, Medeiros et al. (Am J Ophthalmol 2005; 139: 1010-1018) used progressive structural change on photographs (a subjective evaluation) as reference standard for glaucoma diagnosis in this group of subjects. In this recent study, Medeiros et al. Demonstrate that progressive neuroretinal rim loss, measured on confocal scanning laser ophthalmoscopy (an objective evaluation) in glaucoma suspects, was highly predictive of the development of visual field loss in glaucoma.

This study strengthens the evidence for using progressive structural change as a reference standard for early diagnosis in glaucoma

Using a joint longitudinal survival model, they also demonstrate that the hazard ratio associated with progressive rim loss was independent of and higher than that of the IOP change that happen during the follow-up period in predicting the development of visual field loss. This study strengthens the evidence for using progressive structural change as a reference standard for early diagnosis in glaucoma. In addition to the neuroretinal rim changes, evaluating progressive change in peripapillary retinal nerve fiber layer and inner retinal layers at macula, all of which are now available with SDOCT imaging, is likely to increase the predictive ability of developing glaucomatous visual field defects in cases of suspects.

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