Imaging Studies

Advances in computerized ocular imaging technology provide useful measures that can assist in glaucoma diagnosis and monitoring.

Imaging technologies such as confocal scanning laser ophthalmoscopy (eg, Heidelberg retina tomogram-HRT), scanning laser polarimetry (GDx), and optical coherence tomography (OCT) provide objective and quantitative measurements of retinal nerve fiber layer (RNFL) that are highly reproducible and show very good agreement with clinical estimates of optic nerve head structure and visual function. As with other technologies, imaging may produce false identification of glaucoma and its progression, thus management decisions should not be based solely on the results of one single test or technology.^{[49, 50]}

In one prospective study of 24 matched eyes, Stratus OCT was found to detect significant differences in RNFL thickness between normal, ocular hypertensive, and glaucomatous eyes.^[51]

In a longitudinal study of 857 eyes, the OHTS found HRT imaging to be as effective as stereophotographs for estimating risk of POAG development in ocular hypertensive patients.^[52]

Current sensitivities and specificities in these modalities are continuing to improve.

Ultrasonographic Biomicroscopy

Ultrasonographic biomicroscopy (UBM) may prove helpful for obtaining a better view of the angle, iris, and ciliary body structures to rule out anatomic pathology and secondary causes of elevated IOP.^[49]

Other Studies

Tonography, used to help determine trabecular outflow facility, is primarily a research tool used in testing pharmacologic agents. Fluorescein angiography, ocular blood flow analysis via laser Doppler flowmetry, color vision measurements, contrast sensitivity testing, and electrophysiologic tests (eg, pattern electroretinograms) currently are used as research tools in the management of ocular hypertension. Routine clinical use is not advocated at this time.^[53]

Treatment & Management

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Media Gallery

Diagram of intraocular pressure distribution. Used with permission from Survey of Ophthalmology.
Flowchart for evaluation of a patient with suspected glaucoma. Used by permission of the American Academy of Ophthalmology.
Diagram showing the relative proportion of people in the general population who have elevated pressure (horizontally shaded lines) and/or damage from glaucoma (vertically shaded lines). Notice that most have elevated pressure but no sign of damage (ie, ocular hypertensives), but there are those with normal pressures who still have damage from glaucoma (ie, normal tension glaucoma). (Diagram used by permission of M. Bruce Shields.) OHT = horizontal lines only NTG = vertical lines only POAG and other glaucomas with both elevated intraocular pressure and damage = overlapping horizontal and vertical lines
Humphrey visual field, right eye, showing patient with advanced glaucomatous field loss. Notice both the arcuate extension from the blind spot (Bjerrum scotoma), as well as the loss nasally (nasal step), which often occurs early in the disease process. Courtesy of M. Bruce Shields.
Illustration of progressive optic nerve damage. Notice the deepening (saucerization) along the neural rim, along with notching and increased excavation/sloping of the optic nerve and circumlinear vessel inferiorly. Courtesy of M. Bruce Shields.
Example of progressive visual field loss over time (from top to bottom) in a patient with glaucoma. Notice the early appearance of an inferior nasal step and arcuate loss, with progressive enlargement and increasing density of the scotomata over time. Humphrey visual field courtesy of M. Bruce Shields.
Example of optic nerve asymmetry in a patient with glaucomatous damage, left eye, showing optic nerve excavation inferiorly similar to Image 5. Used by permission of M. Bruce Shields.
Glaucomatous optic nerve damage, with sloping and nerve fiber layer rim hemorrhage at the 7-o'clock position. Hemorrhage is indicative of progressive damage, usually due to inadequate pressure control. Further notching and pallor corresponding to the area of hemorrhage usually is seen several weeks after resorption of the blood. Courtesy of M. Bruce Shields.
Advanced glaucomatous damage with increased cupping and substantial pallor of the optic nerve head. Courtesy of M. Bruce Shields.
Correction values according to corneal thickness.
Ocular hypertension study (OHTS). Percentage of patients who developed glaucoma during this study, stratified by baseline intraocular pressure (IOP) and central corneal thickness (CCT).

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Ocular Hypertension Workup

Imaging Studies

Ultrasonographic Biomicroscopy

Other Studies

References

Tables

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