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Dave Hicks, OD, FAAOOptoWest 2018

San Diego – February 11

Santa Clara – March 4

Introduction

UC Berkeley School of Optometry 2008

San Francisco VA Residency 2009

VA Staff Optometrist – teaching

Regular lecturer at AAO and other meetings

No conflicts of interest

Today’s Goals

Visual field analysis and interpretation

OCT analysis and interpretation

Touch on research about HVF and OCT

for diagnosis and progression

Case examples with OCT and HVF to

help improve glaucoma care

Case #1 - 68 year old AA male

Ocular Findings:

BCVA: 20/30-2 OD, 20/20-2 OS

Pupils: ERRL, No APD OU

Slit Lamp: 1+ NS and cortical cataracts OU

IOP: 16/17 mmHg @ 0838

Pachy: 589 μm OD, 579 μm OS

Gonio: Ciliary Body 3600, 2+ Pig. OU

Family Ocular Hx: POAG – maternal aunt

Case #1: Optic Nerves

Glaucoma or not? IOP

Advanced age

Race

Family history

Pseudoexfoliation

Pigment dispersion

Disc hemorrhages

Diabetes

Glaucoma

syndromes

Corneal thickness

Gender: NTG, POAG

Migraines: NTG

History of Trauma

History of Steroid Use

Peripapillary atrophy

Myopia

Raynaud’s phenomenon

Ocular Biomechanics

Glaucoma: Risk Factors

Most cases detected

Technology

Glaucoma Continuum

Weinreb et al. Am J Ophth. 2004;138:458-467.

.

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HVF Glaucoma Questions

How does Humphrey VF work?

What defines a glaucomatous visual field?

What are the stages of glaucoma?

How fast does glaucoma progress?

How often are visual fields necessary?

Understanding the Humphrey

Visual Field Analyzer

Testing Strategies

Evaluating Reliability

Glaucoma Hemifield Test

Visual Field Indices (MD/PSD)

Total and Pattern Deviation

Testing

Strategies

Full Threshold

FastPAC

SITA Standard

SITA Fast

Decrease test time

Maintain sensitivity and specificity

Heijl and Patella. Essential Perimetry, 3rd Ed. 2002.

Test Patterns

Central 30-2

76 test points

30 degrees each quad

Central 24-2

54 test points

30 degrees nasal

24 degrees sup/inf/temp

Points 6 degrees apart

Pick one and stick with it


HVF: Reliability

Fixation Losses: <20-33%

False Positives: <15-33%

“Trigger Happy”

SITA Stnd may underestimate

Currently: >5% likely unreliable, reject >10%

False Negatives: <33%

Status of eye, not patient

84% of pts had FN in eye with more defects

Age, testing order had no effect

Bengtsson and Heijl. Invest Ophthalmol Vis Sci. 2000;41:2201-2204. Newkirk et al. Invest Ophthalmol Vis Sci. 2006; 47:4632–4637. Heijl and Patella. Essential Perimetry, 3rd Ed. 2002.

Chang, Ramulu, and Hodapp. Clinical

Decisions in Glaucoma, 2nd ed. 2016.

0% FP 28% FP

Newkirk et al. Invest Ophthalmol Vis Sci. 2006; 47: 4632-4637.

If Pattern > Total = Unreliable

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41-50 dB

Numerical and Probability Plots


Probability Plots

Total Deviation Corrects for age

Highlights abnormal areas

Pattern Deviation – Most important Corrects for general depressions (cataracts)

○ 7th most sensitive point on total = pattern baseline

Highlights localized loss (glaucoma)

Brusini and Johnson. Surv Ophthalmol, 2007;52(2):156-179. Heijl and Patella. Essential Perimetry, 3rd Ed. 2002.

8% FP

5% FP

7% FP

Case #2 - Consistently Elevated FP

16% FP

15% FP

6% FP

Switched to 24-2 Case #2

0% FP

More Rarely…

Glaucoma Hemifield Test (GHT)

Compares local defects in 5 distinct zones

“Outside Normal Limits” – p<0.01

“Borderline” – p<0.03

“Generalized Depression” – under 0.5%

“Abnormally High Sensitivity” – over 0.5%

“Within Normal Limits”

High sensitivity and specificity

Good for early loss

Heijl and Patella. Essential Perimetry, 3rd Ed. 2002. Brusini and Johnson. Surv Ophthalmol, 2007;52(2):156-179.

Glaucoma Hemifield Test (GHT)


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VF Indices (MD and PSD)

Mean Deviation (MD) Weighted average of dB values from total

deviation plot

Shows average amount of change from age matched normal subjects for entire VF

Can be affected by cataract

Pattern Standard Deviation (PSD) Low PSD = smooth hill of vision

High PSD = pt variability or irregular VF

Bengtsson et al. Arch Ophthalmol, 2009;127(12):1610-1615. Heijl and Patella. Essential Perimetry, 3rd Ed. 2002.

Variations in MD and PSD

Normal MD, higher PSD

= local defect

Low MD, normal PSD =

diffuse loss

MD -5.93dB

PSD 1.57dB

MD -0.06dB

PSD 5.41dB

Normal

Lower MD =

diffuse loss

Higher PSD =

irregularity

Using HVF for Glaucoma Basic Glaucoma VF Rules

1. Asymmetric across horizontal midline (early/mod)

2. Midperipheral (early/mod)

3. Clustered points

4. Reproducible 2x or more

5. Not explained by other diseases

6. Representative of pt’s functional status (FPs, FLs)

Foster et al. Br J Ophthalmol, 2002;86:238-242.

Common Glaucoma VF Patterns

Arcuate scotoma

Bjerrum/Seidel

Nasal step

Paracentral

Temporal wedge

Overall depression

Transient changes

Hiejl. Surv Ophthalmol, 1989;33:403-404.

Heijl and Patella. Essential Perimetry, 2002.

Paracentral Temporal Wedge

Partial Arcuate – Mild and Severe

https://vrcc.wustl.edu/vfrc/vfrc.html

Early Central Glaucoma Inferior Nasal Arcuate/Step


Superior Arcuate Scotoma Advanced Double Arcuate Scotoma


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Watch Out For…

Chang, Ramulu, and Hodapp. Clinical Decisions in Glaucoma, 2nd ed. 2016.

Glaucoma VF Definition (HAP)

GHT “Outside Normal” on at least 2 VFs

OR

Cluster of 3+ contiguous non-edge points

p< 5% on PD and 1+ points p< 1%

OR

Corrected PSD <5% on 2 VFs

(2 consecutive VFs for last 2 definitions)

Hodapp, Parrish, Anderson. Clinical Decisions in Glaucoma. 1993.

New Glaucoma VF Definition (HAP2)

Any of the following must be reproducible on two consecutive 24-2 VFs:

GHT “Outside Normal Limits”

A cluster of 3+ points in a location typical for glaucoma, all of which are depressed at a p<5% level on the pattern deviation plot and one of which is depressed at a p<1% level

PSD that occurs in <5% of normal VFs


New Glaucoma VF Definition (HAP2)


3 points <5%

1 points <1%

Case #3 - 62 year old Asian male

Ocular Findings:

BCVA: 20/25 OD and 20/30 OS

Pupils: ERRL, No APD OU

Slit Lamp: 1-2+ NS and cortical OU

IOP: 12/12 mmHg @ 0835

Fundus: Unremarkable OU

Family Ocular Hx: Unremarkable

Medical Hx: DM, hyperlipidemia, sleep apnea

Case #3 – Optic NervesCase #3

Baseline HVF

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Repeat HVF – 1 month later

a) 2 consecutive VFs with GHT

Outside Normal Limits

b) Cluster 3+ points in typical location

p< 5% on PD with 1+ points p< 1%

3rd HVF – 6 months laterStaging Glaucoma

Has evolved in last 25 years

Now part of ICD-10

Baseline = 2 HVFs

Hodapp, Parrish, Anderson. Clinical Decisions in Glaucoma. 1993.


Staging: ICD-10

Mild or early: pre-perimetric (normal VF)

Moderate: ONH abnormalities c/w

glaucoma and VF abnormalities in 1

hemifield, but not within 50 of fixation


Staging: ICD-10

Severe: ONH abnormalities c/w

glaucoma and VF abnormalities in both

hemifields and/or loss within 50 of

fixation in 1 hemifield

Indeterminate: ONH abnormalities c/w

glaucoma without VF data


HAP2 Staging Criteria

Early defect – neither extensive

nor near fixation

Must meet all 3 criteria:

1. MD > -6 dB

2. No point in central 50 can be <15dB

3. Less than 25% (1-12 points) are <5% level and <10% (1-4 points) are <1% level on pattern deviation (PD)


Mild (need all 3)

MD: >-6dB

No central pts

<15db

PD: 1-12 pts <5%

and 1-4 pts <1%

Moderate (need 1)

MD: -6 to -12dB

No central pts 0db

PD: 13-26 pts <5%

PD: 5-13 pts <1%

MD -1.04

9 points <5%

2 points <1%

O central points <15db

Early or Mild Defect HAP2 Staging Criteria

Severe defect – Only 1 necessary:

1. MD < -12 dB

2. More than 50% (27+ points) are <5% level and

more than 25% (14+ points) are <1% on PD

3. Any point in central 50 is 0 dB

4. Both hemifields have points <15dB within

central 50


MD: -19.69dB

35 points <5%

31 points <1%


Severe Defect Moderate (need 1)

MD: -6 to -12dB

No central pts 0db

PD: 13-26 pts <5%

PD: 5-13 pts <1%

Severe (need 1)

MD: < -12dB

Any central pts 0db

PD: 27+ pts <5%

PD: 14+ pts <1%

Both hemifields

central pts <15dB

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HAP2 Staging Criteria

Moderate defect – any VF defect that is

neither early nor severe

At least one of the following is present:

1. MD is between -6 dB and -12 dB

2. 25-50% (13-26 points) are <5% level and

10-25% (5-13 points) are <1% level on PD

3. No point in central 50 is 0 dB

4. Only 1 hemifield has a point of <15dB within

central 50


MD: -5.07dB

17 points <5%

10 points <1%


Moderate Defect Mild (need all 3)

MD: >-6dB

No central pts

<15db

PD: 1-12 pts <5%

and 1-4 pts <1%

Moderate (need 1)

MD: -6 to -12dB

No central pts 0db

PD: 13-26 pts <5%

PD: 5-13 pts <1%

VF Progression

NO WIDELY ACCEPTED STANDARD!

Most authors agree:

Deepening or expansion of an existing scotoma

New defect in a previously normal area

Risk factor analysis

Spry and Johnson. Surv Ophthalmol, 2002;47(2):158-173.

Giangiacomo et al. Curr Op in Ophthalmol, 2006;17:153-162.

Drance et al. Am J Ophthalmol, 2001;131:699-708.

Sample. Surv Ophthalmol, 2001;45(S3):S319-S324.

Major Challenges

Every clinical trial has different criteria

Large differences in testing analyses

Methods for determination only agree about 50-

60% of the time

Suspected changes have to be confirmed

Variability is huge amongst populations

Rates of VF change are not constant

No consensus among major investigators

Brusini and Johnson. Surv Ophthalmol, 2007;52(2):156-179.

CNTGS 20% progress even with 30% in IOP

50% have no VF progression without tx

EMGT Untreated controls had a median time to

progression of 4 years

60% progress in 6 yearsOliver et al. Am J Ophthalmol, 2002;133(6):764-772.

Clinical judgment

Defect classification systems

HAP, HAP2, AGIS, CIGTS

Event analysis

Greater change than expected (GPA)

Trend analysis

Rate over time (MD, VFI, etc)

All have pros and cons

Be consistent and evidence-

based in your decisions

Spry and Johnson. Surv Ophthalmol, 2002;47(2):158-173.

Determining ProgressionVF Progression: HAP2

Requires at least 2 consecutive VFs

New defects in previously normal area:

1 point >10dB

Within central 100 – 2+ points >5dB

Outside central 100 – 3+ points >5dB


VF Progression: HAP2

Within preexisting defects:

1 point >15dB

Within central 100 – any point >10dB

Outside central 100 – 3+ points >10dB on 2 consecutive VFs or >5dB on 3 consecutive

Either of these on GPA:

Slope of p<1% on VFI or “Likely Progression” on GPA


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Classic

Progression

Heijl, Patella, Bengtsson. Effective Perimetry, 4th Ed. 2012.

Chang, Ramulu, and Hodapp.

Clinical Decisions in

Glaucoma, 2nd ed. 2016.

Long Term Fluctuations (LTF)

Giangiacomo et al. Curr Opinion in Ophthalmol, 2006;17:153-162.

2006

2013

2013

2015

Progression - OHTS

At 5 years, 90.5% of untreated patients showed no ONH or VF progression 9.5% in the observation group progressed

4.4% in the treatment group progressed

85.9% of eyes with initial VF defects had normal repeat VF

Change in MD of -0.08 dB/yr

Keltner et al. Arch Ophthalmol, 2005;123:1201-1206.Kass MA, et al. Arch Ophthalmol, 2002; 120:701-713.

Demirel S, et al. IOVS, 2002; 53:224-227.

Keltner et al. Arch Ophthalmol, 2000;118:1187-1194.

Confirming Progression

AGIS – 12,746 VFs over 10-13 years

Sustained decreased VFs (SDVF)

Can temporarily recover

55% with SDVF on 2 visits, 40% on 3 visits

showed recovery

Repeat VF at least once!

AGIS Investigators. Ophthalmology, 2004;111:2109-2116.

Visual Field Index (VFI)

Summary index on 24-2 and 30-2 tests

Calculated by all test points in pattern dev’n

Normal points (p>5%) = 100%, 0 dB points = 0%

Eccentricity-weighted mean of scores

Gives visual function as % of normal age VF

Resistant to cataract

Used to judge rate of progression

Bengtsson et al. Arch Ophthalmol, 2009;127(12):1610-1615.

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Guided Progression Analysis (GPA)

Calculates rate of progression from VFI

1-2 page summary report

Baseline exams at top

VFI trends in middle

Current exam at bottom

Uses oldest 2 exams as baseline Can and should be changed*

Zeiss. HFA II-i Manual. 2008.Nouri-Mahdavi et al. Graefes Arch Ophthalmol, 2011;249:1593-1616.

How many VFs are needed?

OHTS: 3 consecutive, abnormal, reliable

Originally 2 VFs, but 66% then were WNL

HAP and HAP2: 2 reliable for baseline

WGA: 2 reliable baseline in 6 months, then 2

more within 18 months

CIGTS: 2+ for confirmation

CNTGS: 2-3 in 1st month & 2-3 at 3 months

HVF algorithms: 2 to 6 for analysis

Giangiacomo et al. Curr Opinion in Ophthalmol, 2006;17:153-162.

Hodapp,Parrish, Anderson. Clinical Decisions in Glaucoma. 1993.

Keltner et al. Arch Ophthalmol, 2005;123:1201-1206.

Jampel et al. Ophthalmol, 2011;118:986-1002.

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No single definition of progression exists Pick an evidence-based approach that works for

your patient population

Repeat VF when a change is suspected Set new baselines as needed

Use software to your advantage VFI and GPA are fast and easy to use

Rates of progression vary Determine an acceptable rate for each patient

VF Progression: Quick Review

Today’s Goals

Discuss analysis of optic nerve OCTs

Review strengths and weaknesses of OCT for glaucoma management

Review recent research about OCT for diagnosis and judging progression

Provide tips for improved use of OCT in clinical practice

Available OCTs

Zeiss Cirrus

Heidelberg Spectralis

Nidex 3000

Canon Copernicus

RTVue

Opko/OTI Spectral OCT/SLO

Topcon 3D-OCT

Zeiss Stratus (Time Domain)

Spectral vs. Time Domain

Similarities/differences in databases Color codes do not agree well

Progression between instruments?

SD-OCT advantages: Higher resolution, decreased scanning time

Better repeatability of RNFL measurements

More data – peripapillary scans with RNFL thickness maps, macular GC analysis, etc

Better for diagnosis and progression

Leung et al. Ophthalmol, 2010;117:1684–1691. Jeoung, Park. IOVS, 2010;51:938-945.

Kim et al. IOVS, 2012;53:3193-3200.Savini et al. Curr Opin Ophthalmol, 2011;22:115-123.

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http://www.optovue.com/pdf/RT

Vue-FD-OCT-Brochure.pdf

Influential Factors?

Normative

databases

Media

ONH size

ONH distance to

foveola

PPA

Retina

Axial length

Interocular

symmetry

Refractive error

Age

Sex

Race

Stratus Database

328 subjects

48% male, 52% female

Mean age 47.4 +/- 15.8 yrs, range 18-85

Rx: -11.75 to +6.75, mean -0.54

63% Caucasian, 24% Hispanic,

8% African American, 11% Asian

No eye surgery except cataract (9 pts), no ocular disease, IOP <22, normal and reliable VF, normal ONH, BCVA >20/32

Budenz et al. Ophthalmol, 2007;114:1046-1052.

Cirrus Database

284 subjects


Age range 19-84

Only 3 pts >80 and 28 pts between 70-79

Rx: -12 to +8

43% Caucasian, 18% African American, 12% Hispanic, 1% Indian, 6% mixed

All normal subjects

Cirrus HD-OCT 510(k) Summary. FDA. Jan 2012.Chong, Lee. Curr Op Ophthal, 2012; 23:79-88.

Spectralis Database

201 subjects, all Caucasian


Mean age 48.2 +/- 14.5 yrs, Range 18-78

Only 1 pt <20 and only 13 pts >70

Rx: -7 to +5

No glaucoma, normal IOP, normal VF,

normal optic nerve, etc

Spectralis HRT+OCT 510(k) Summary. FDA. Oct 2010

RTVue Database

861 subjects, various ethnicities

Largest available database

Mean age 50 +/- 15.5 yrs, Range 19-82

Rx: -8 to +8 sphere, -2 to +2 cylinder

No glaucoma, normal IOP, normal VF,

normal optic nerve, etc

Average RNFL Thickness

Stratus: 99-100um in Caucasian/Japanese

132.7um in Hispanics

Spectralis: 89-97.3um +/- 9.6 to 15.87um

African American 99.2um, Caucasian 96um

Cirrus: 84-94um +/- 13.68um

Superior quad up to 122um, inferior quad up to 127um

RTVue: 107.9 +/- 10um

African American 107um, Caucasian 102um

Topcon: 102um

Alasil et al. J Glaucoma, 2013 Sep;22(7):532-41.Budenz et al. Ophthalmol, 2007;114:1046-1052.

84-108um

Red-Green Disease

Color code determined by the database

of the instrument

Based on probability of that population only

15-36% of OCTs for glaucoma may

contain artifacts that influence red-

green analysis

Asrani, et al. JAMA Ophthalmol, 2014; 132(4):396-402.

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Media and Eye Mvmts

Aref AA, Budenz DL. Ophthal Surg Lasers Imaging, 2010;41:S15-S27.

ONH Size/Disc Area

Larger ONH means OCT scan is closer to ONH RNFL decreases as measurement diameter increases

Overestimates RNFL in some studies but not others

Thicker RNFL measurements in larger ONH 3.3um per 1mm2 (Budenz 2007)

RNFL thickness correlates with disc area (Hirasawa 2010, Japanese)

No association between ONH size and RNFL thickness (AIGS 2012)

Budenz et al. Ophthalmol, 2007;114:1046-1052.

Hirasawa et al. Arch Ophthalmol, 2010;128(11):1420-1426. Huang et al for AIGS. IOVS, 2012;53:4990-4997.

Cirrus

Small: <1.66mm2

Medium: 1.66-1.97mm2

Large: >1.97mm2

Only 5% of eyes in normal database were

<1.33mm2 or >2.5mm2 with Cirrus

Stratus: 2.26mm2 mean disc area

RTVue: Range 1.86-2.1mm2

Disc Area Measurements

Budenz et al. Ophthalmol, 2007;114:1046-1052.Knight et al. Arch Ophthalmol, 2012 Mar;130(3):312-8.

ERM

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Date of download: 7/11/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: Artifacts in Spectral-Domain Optical Coherence Tomography Measurements in Glaucoma

JAMA Ophthalmol. 2014;132(4):396-402. doi:10.1001/jamaophthalmol.2013.7974 ERM

Liu et al. AJO, 2015;159:565-576.

PPA

Present in 15% of normals but 62-84%

of glaucoma patients

Stratus overestimates disc size in

glaucoma patients and controls

Cirrus performs well compared to

clinical disc evaluation

Kim C, Radcliffe N. APJ Ophthal, Nov/Dec 2012;1(6):364-373.Kim et al. IOVS, 2012;53:3193-3200.

Axial Length

Variable relationship in the literature No correlation of axial length and RNFL (Hirasawa 2010)

RNFL thickness with axial length (Ueda 2015)

If temporal quadrant is thick, superior and

inferior thinning could be due to refractive error (Alasil 2012, Ueda 2015)

Be cautious of thinning in myopic

Caucasians

Hirasawa et al. Arch Ophthalmol, 2010;128(11):1420-1426.Vernon et al. Br J Ophthalmol, 2008;92:1076-1080.

Alasil et al. J Glaucoma, 2013 Sep;22(7):532-41.Leung et al. IOVS, 2012 Oct 17;53(11):7194-7200.

Budenz et al. Ophthalmol, 2007;114:1046-1052.Ueda et al. J Glaucoma, 2015 Jan 12. Epub.

Hong, Anh, Kand. IOVS, July 2010;51(7):3515-3523.

Leung, et al. IOVS, 2012 Oct 17;53(11):7194-7200.

34 y/o

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34 y/oOther Factors

Rx:

RNFL thinner by 1.2um/diopter of myopia

Race:

RNFL decreases from Hispanics>Asians> African Americans>Caucasians

Differences in ONH area, ave C/D, vert C/D, cup volume also

FOHx:

Patients with FOHx of glaucoma have thinner RNFL and GCC than normals

Knight et al. Arch Ophthalmol, 2012 Mar;130(3):312-8.Alasil et al. J Glaucoma, 2013 Sep;22(7):532-41.

Rolle et al. BJO, 2014; in press

Utility of OCT in glaucoma

RNFL loss precedes VF loss by 6 years in 60% of eyes

In OHTS, HRT showed glaucomatous change 8 years before VF defects

17% RNFL loss before VF detection

Progressive optic disc changes may not correspond to RNFL thinning in the same eyes with glaucoma progression

Wollstein et al. BJO, 2012;96:47-52. Sommer, Katz, Quigley. Arch Ophthalmol, 1991;111:485-490.

Glaucoma Detection

Both TD and SD have high sensitivity and specificity for glaucoma when >1 clock hour is <5% level (yellow)

Both TD and SD may be inadequate in detecting preperimetric RNFL defects

Worse when defects <10 degrees

Cirrus can discriminate mild glaucoma from normal using ONH parameters Vertical rim thickness (VRT), Rim area, Vertical C/D

Leung et al. Ophthalmol, 2010;117:1684–1691. Jeoung, Park. IOVS, 2010;51:938-945.

Mwanza et al. Ophthalmol, 2011;118:241-248.

Glaucoma Detection

RNFL parameters:

Average/global RNFL thickness*

RNFL thickness at infero-temporal*

○ (3,4,9 o’clock are most variable)

RNFL thickness inferior quadrant

Additional useful information:

Cirrus – RNFL deviation-from-normal map

Stratus – TSNIT

Asymmetry

Jeoung, Park. IOVS, 2010;51:938-945.

Mwanza et al. Ophthalmol, 2011;118:241-248.Lisboa et al. Ophthalmol, 2012;119 (11):2261-2269.

Abnormal RNFL Thickness

Average RNFL <5th percentile

Yellow or red

Any quadrant <5th percentile

Yellow or red

Any clock hour <1st percentile

Red


Abnormal RNFL Contour (TSNIT)

Any focal thinning superior or inferior

Especially if yellow or red

Any significant asymmetry between

contour of OD and OS, especially

superior or inferior


Case #4 - 45 year old Caucasian male

Ocular Findings:

BCVA: 20/20 OD, 20/25+2 OS

Pupils: ERRL, no APD

Slit Lamp: trace NS, no PXF OU

IOP: 22/23 mmHg @ 0841

C/D: 0.35 OD and OS

Fundus: normal OU

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2/1/13 5/13/13 6/18/132/1/13 8/20/13

4/21/14 1/5/15Interocular symmetry

Increasing age is not associated with

increased RNFL asymmetry

Spectralis: 6.6x greater asymmetry in

glaucoma vs. normal

Difference of 6um for RNFL global average had

high sensitivity and specificity to detect POAG

Macular asymmetry has also proven

sensitive and specific (Sullivan-Mee)

Sullivan-Mee et al. Am J Ophthalmol, 2013; 156:567-577.Field et al. J Glaucoma, 2014; in press.

Mwanza et al.

Ophthalmol, 2011;118:241-248.

>9 um difference may be indicative

of early glaucoma OCT is a validated technology for

glaucoma detection

Variations exists between instruments

Average RNFL thickness = ~84-108um

Use caution when interpreting OCTs

Normal eyes can appear glaucomatous

Detection: Quick Review

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Progression: Considerations

Variable nature of glaucoma

Event-based vs. trend-based analyses

Changing technology – longitudinal f/u

Instrument variability

No consensus on limit of RNFL thinning that equals progression; no reference standard

Eyes without VF loss?

Mwanza et al. IOVS, 2010;51:5724-5730.Grewal et al. Curr Opin Ophthalmol, 2013;24:150-161.

Reliability and Reproducibility

Inter-visit repeatability is good for

most SD-OCT

Signal strength: 7 or greater desired

Dilation: may not effect repeatability

Variability vs. progression?

Progressive RNFL thinning occurs with increased glaucoma severity

Abnormal (thinner) RNFL may show less inter-visit variability than normal (thicker) RNFL

Severe glaucoma can potentially have more functional loss with smaller RNFL changes

Assumptions To Remember


Variability vs. Progression

Stratus

Test-retest variability of ~4-10um per quadrant

Be suspicious of changes over 10um

Cirrus

Ave RNFL thinning of >4-6um between visits is suspicious

Spectralis

Clinically appears to have very low fluctuation

Global 5-14um intra- and inter-visit variation

Roh et al. Ophthalmol, 2013;120(5):969-977.Mwanza et al. IOVS, 2010;51:5724-5730.

Toscano et al. Arq Bras Oftalmol, 2012;75(5):320-3.Hong et al. Korean J Ophthalmol, 2012;26(1):32-38.

Leung et al. IOVS, 2008;49:4886-4892.

Suspected Progression

Variability: Average RNFL: ~5um

By quadrant: ~8um

By clock hour: ~10-12um

Thinning of >10um (or maybe 20um) are more concerning, especially I/T and S/T

Suspicious OCTs should be repeated

Ghasia et al. J Glaucoma, 2013; May 29 [E-pub].Mwanza et al. IOVS, 2010;51:5724-5730.

8/201112/2012

Case #5 - 68 year old male1/9/15 Case #5 7/24/15

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Case #5 4/12/17

Repeat OCTs before making treatment

decisions

41-56% of abnormal scans were not

duplicated on f/u exams

Consider abnormal if 2 of 3 RNFL or

GCIPL scans are borderline or ONL

Some suggest up to 5 tests (linear regression)

Recommendations

Iverson, et al. Br J Ophthalmol, 2014;98:920-925.

Serial, good quality OCTs can help detect

progression

For patients who can NOT do VFs:

Early glaucoma: average RNFL 8um

Mod/severe glaucoma: ave RNFL 4um

HAP2 Recommendations


For patients who can do reliable VFs

No VF defect: average RNFL 10um

New VF defect or disc heme: RNFL 5um

If severe glaucoma with RNFL <60um, a

stable OCT does NOT rule out progression

HAP2 Recommendations


Types of RNFL Change

Inferotemporal is most common in glaucoma

Widening of RNFL defect (85.7%)

Development of new RNFL defect (17.9%)

Other optic neuropathies can cause RNFL

thinning, but patterns are different

Age related thinning is most common

superior and inferior

Alasil et al. J Glaucoma, 2013 Sep;22(7):532-41.Leung et al. Ophthalmol, 2012;119(9):1858-1866.

Shin et al. Ophthalmology 2014;121:1990-1997.

Age-Related RNFL Loss

Average rate: -0.10 to -0.52um/yr or

1.5-2um/decade

Greater baseline thickness = faster

rate of change

No significant change in nasal and

temporal quadrants with age

Rate in glaucoma is faster

> -2.54 um/yr is significant

Leung et al. Ophthalmol, 2012;119:731-737.Budenz et al. Ophthalmol, 2007;114:1046-1052.

Alasil et al. J Glaucoma, 2013 Sep;22(7):532-41.Ueda et al. J Glaucoma, 2015 Jan 12. Epub.

84 y/oGPA

Cirrus: GPA available for OCT or HVF or combined analysis for both

Pros: OCT GPA on Cirrus is useful to judge

progression when VF defect is mild

Cons: Agreement between OCT GPA and disc

photos or VF analysis can be poor

Subject to artifacts in scans

Leung et al. IOVS, 2010;51:217-222. Tenkumo et al. Jpn J Ophthalmol, 2013 Jun 25. [Epub]

Na et al. Curr Eye Res, 2013 Mar;38(3):386-95.

4/2011 6/2013

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Case #4

1/5/15

Macular OCT

Useful in advanced

glaucoma

Papillomacular bundle

preservation

Early glaucoma

detection

High discriminating

power

High reproducibility

Sung et al. Ophthalmol, 2012;119: 308-313. Grewal et al. Curr Opin Ophthalmol, 2013;24:150-161.

Nakatani et al. J Glaucoma, 2011;20:252-259.

Hood et al. IOVS, 2014: 55: 632-649.Jeong et al. J Glaucoma, 2015: in press

Hood et al. Prog Retin Eye Res,

2013: Jan; 32C:1-21.

Ganglion Cell Analysis (GCA)

Macular RGC complex is 1-7 cells thick: RNFL, GCL and IPL Contains 50% of retinal RGCs

Average RGC count is lower in eyes with early VF defects: 652K vs 911K RGC loss of 7877 per year

RGC counts were better than average RNFL thickness for detecting glaucoma with early/minimal VF loss

Medeiros et al. Ophthalmol, 2013;120:736-744.Medeiros et al. Am J Ophthalmol, 2012;154:814-824.

Shin et al. Ophthalmol, 2013; in press.

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Ganglion Cell Analysis

Macular RGC counts can be affected by drusenand AMD

GCIPL thinning with thinner RNFL, older age, longer axial length, and males

GCIPL and total macular thickness (TMT) have similar sensitivity in detecting glaucoma progression Average RNFL was better in diagnosis

Minimum GCIPL is best parameter for early perimetric glaucoma detection and is similar to best RNFL or ONH parameters (Mwanza, Jeoung)

Na et al. IOVS, 2012;53:3817-3826. Mwanza et al. Ophthalmol, 2014;121:849-854.

Mwanza et al. IOVS, 2011;52:7872-7879.Jeoung JW et al. IOVS, 2013;54:4422-9.

http://www.heidelbergengineering.com/us/wp-content/uploads/2134_Info-Sheet_Posterior-Pole_Final-Low-Res.pdf

Glaucoma is likely when:

Intereye macular thickness asymmetry >5 um Intraeye macular thickness asymmetry >9 um Intereye RNFL thickness asymmetry >9 um Global RNFL thickness <78 um

*Spectralis

Sullivan-Mee et al. Am J Ophthalmol, 2013; 156:567-577. Hwang YH, Anh SI, Ko SJ. Clin Exp Ophth, 2015; in press.

Ganglion cell asymmetry shows good

diagnostic ability in early glaucoma

Image courtesy of John Hammer

at Carl Zeiss

OCT: Conclusions

OCT is great technology but it isn’t perfect

Correlate HVF and OCT findings

Evaluate scan data and not just colors

Remember artifacts, instrument capabilities, etc

No set standard for OCT progression

Research studies vs. clinical care

Repeat OCTs and correlate with other

findings before making treatment decisions

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Thank you!

[email protected]

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