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Editors Selection IGR 17-4

Clinical examination methods: Progression of structural and functional damage

Comment by Ki Ho Park on:

67229 Risk of Visual Field Progression in Glaucoma Patients with Progressive Retinal Nerve Fiber Layer Thinning: A 5-Year Prospective Study, Yu M; Lin C; Weinreb RN et al., Ophthalmology, 2016; 123: 1201-1210

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By analysis of the serial retinal nerve fiber layer (RNFL) thickness values for 139 primary open-angle glaucoma patients followed up on for at least five years, the authors prospectively investigated whether progressive RNFL thinning can be considered to be predictive of progressive visual field (VF) loss.

Progressive RNFL thinning was determined by event analysis (Guided Progression Analysis [GPA]) and trend analysis (Trend-based Progression Analysis [TPA]) of serial registered RNFL thickness maps. VF progression was detected according to the Early Manifest Glaucoma Trial (EMGT) ('likely progression') and pointwise linear regression (PLR) criteria ( three contiguous locations with sensitivity change < 0 decibels [dB]/year at P < 0.01).

Progressive RNFL thinning can predict future VF progression and, therefore, can be considered to be an outcome measure in clinical trials evaluating glaucoma treatments

In the results, a total of 65 (27.1%) and 117 eyes (48.8%) showed progressive RNFL thinning based on the GPA and TPA, respectively, and 30 (12.5%) and 39 eyes (16.3%) showed VF progression per the EMGT and PLR criteria, respectively. Progressive RNFL thinning predicted the development of VF progression: the hazard ratios (HRs) after controlling for baseline covariates were 8.44 (EMGT criteria) and 5.11 (PLR criteria) for TPA and 3.95 (EMGT criteria) and 3.81 (PLR criteria) for GPA. This is the first paper reporting, based on a prospective study, that progressive RNFL thinning indicates increased risk of subsequent VF progression. Another strength of this paper is the fact that the progression analysis for RNFL thickness change was both event- and trend-based. The trend analysis, furthermore, detected more cases with progression and also showed higher HRs for prediction of the development of VF progression than did the event analysis.

The limitations of the study are: (1) the relatively large proportion of excluded subjects (84 patients) due to poor VF performance; (2) the shorter follow-up for normal healthy eyes (eight weeks).

Notwithstanding these limitations, the paper provides important evidence that OCT-based progression analysis of RNFL thickness ‒ which is to say, progressive RNFL thinning ‒ can predict future VF progression and, therefore, can be considered to be an outcome measure in clinical trials evaluating glaucoma treatments.

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