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David S. Greenfield,MD, holds the Douglas R. Anderson Chair in Ophthalmology and serves asVice-Chair for Academic Affairs and Co-Director of the Glaucoma Service at theBascom Palmer Eye Institute of the University of Miami Miller School ofMedicine. He notes that there is frequently a discrepancy between measurementsof structure and function in glaucoma. "Our group looked at informationfrom 147 glaucomatous eyes that had been observed monthly for six years using serialvisual field testing and OCT examinations of the retinal nerve fiber layer andmacula. 1 Only 7% of these eyes demonstrated consistent improvement in each ofthe three metrics.


Undoubtedly one of themost typical explanations for a difference between OCT and visual fields isalso the best-known: Not all measurable changes in function are followed bydetectable changes in structure. "Ganglion cell axons die and eventuallybecome atrophic when physiologic changes connected to glaucoma progressionoccur," claims Dr. Greenfield. "Longitudinal changes in macularganglion cell thickness and retinal nerve fiber layer thickness should [intheory] agree with serial changes in visual function using standard automatedperimetry, but many patients with glaucoma progression develop isolated changesin structural tests without detectable changes in visual function, and viceversa."


There are instanceswhen one measurement reveals symptoms of deteriorating while the other appearsconstant, according to Philip P. Chen, MD, professor and Grace Hill Chair inthe University of Washington's department of ophthalmology and head of the UWMedicine Eye Institute. In the case of early glaucoma, the visual fieldfrequently appears normal, but OCT may show that structural change is takingplace. Many years ago, Harry Quigley's group made the case that a 5-dB lossseen on automated perimetry required a 20% loss of ganglion cells.

He goes on to say,"Though the OCT suggests a structural change in early disease, I'd obtaina confirmatory OCT and then explain to the patient that starting therapy isprudent even if we can't yet identify any symptoms."


According to Joel S.Schuman, MD, FACS, director of the NYU Langone Eye Center and Elaine LangoneProfessor and chief of ophthalmology at NYU Langone Health, NYU Grossman Schoolof Medicine, the same gap occurs as the disease advances, but in the reverseway. If a more advanced glaucoma patient has a very thin nerve fiber layer,let's say below 55 m, "you'll typically have both an aberrant vision fieldand abnormal OCT," he notes. If you're searching for progression, the meanOCT nerve fiber layer thickness might not be moving even though the patient isactually becoming worse. The OCT floor effect is to blame for that. Progress isstill apparent there because the visual field still has a higher dynamic rangeat the low end.


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The OCT RNFLassessment may become obsolete earlier than visual field testing, according toDr. Chen, who agrees.


The retinal nervefiber layer contains glial scar tissue or other nonfunctional structuraltissue, which causes the quantitative thinning to cease even while the damageis still occurring. Therefore, OCT RNFL thickness may approach a measurementfloor while parts of the visual field are still followable, particularly ifyou're performing a 10-degree test rather than a 24- or 30-degree test.


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