Structure and Function In Glaucoma

What do we know,  and how can we apply it?

Paul H Artes, PhD 
Ophthalmology and Visual Sciences,  Dalhousie University, Halifax, Canada
EUPO Course 2011 European Glaucoma Society / EUPO Geneva, June 3, 2011

CR: Research support, Heidelberg Engineering

Message of this talk

1. Perform both elds and imaging, in all stages
2. Complementary - do not expect agreement.

Myths & Half-Truths

1. Structure changes rst, function later.
2. Visual elds are more variable than imaging.
3. Imaging is more useful in early disease,  and less useful in advanced disease.

200 m
OCT ART (16) Q: 22 [HR] OCT ART (16) Q: 22 [HR]

Asymmetry OD - OS
ILM ILM RNFL RNFL

200 m 200 m

Thickness [m] Thickness [m]

300 300 240 240 180

Withi Within

180 120 12060 60 0 0

0 45 0 TMP 45 TMP ILM 90 SUP 90 135 180 225 NAS 225 180 Position [ ] NAS 270 INF 270 315 360 TMP 360

Bord Borde

Q: 22 [HR]

Outsi Outsi

135

315

SUP

INF

TMP

Position [ ]

RNFL

S 110 S

Mean Deviation, dB

-5

-10

-15

controls
glaucoma

40 60 80 100 120

-20

Retinal Nerve Fibre Layer Thickness, um

Normal range VF

Normal range RNFLt

Normal range VF

Normal range RNFLt

Normal range VF
Test Variability

Structure & Function: Diagnosis

Imaging tests have large normal ranges, but excellent precision.
More powerful for measuring change over time in serial exams than for interpreting a single exam.

Structure/Function: Prediction



-5
-10 0

Mean Deviation, dB

-15

-20

Retinal Nerve Fibre Layer Thickness, um

40

60

80

100

120

Structure/Function: Prediction



-5
-10 0

Mean Deviation, dB

-15

-20

Retinal Nerve Fibre Layer Thickness, um

40

60

80

100

120

Structure & Function: Prediction

Relationship is curved as predicted from theory
large scatter makes it difcult to predict function from structure, or structure from function.
Imaging cannot replace visual eld assessment,  or vice versa.

Structure & Function: Progression

0

Mean Deviation, dB

Mean Deviation, dB

?

Retinal Nerve Fibre Layer Thickness, um
40 60 80 100 120

-5

-5

-10

-10

-15

-15

-20

-20

Retinal Nerve Fibre Layer Thickness, um

40

60

80

100

120

Structure & Function: Progression

least stringent criteria
all
84 eyes
most stringent criteria
all 84 eyes
VF change
15
HRT change
3
14

VF change
35

20

HRT
change
35

Artes & Chauhan, Prog Ret Eye Res 2005

 Do not expect agreement between structure and function, either in diagnosis or progression. Imaging and visual elds are complementary they do not replace each other.

Structure and function are equally important in all stages, but either S or F can be most useful in individual patients.
Perform only those tests that can change your management, and be wary of average rules that may not apply to individual patients

Thank you!

 Do not expect agreement between structure and function, either in diagnosis or progression.
S and F equally important in all stages, either S or F most useful in individuals.
Perform only those tests that can change your management.
Be wary about applying general rules of thumb to individual patients

Take-Home Messages

Use structure and function, (almost) always.
Look at the data, carefully
Weigh up the evidence
Take structural changes seriously.