Glaucoma Diagnosis Ophthalmology Glaucoma Rachel L. Anderson, BA, Maria de los Angeles Ramos Cadena, MD, Joel S. Schuman, MD  Ophthalmology Glaucoma  Volume 1, Issue 1, Pages 3-14 (July 2018) DOI: 10.1016/j.ogla.2018.06.002 Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 1 An early iteration of the Helmholtz ophthalmoscope, 1852. Courtesy of the “Joint Library of Ophthalmology Moorfields Eye Hospital & UCL Institute of Ophthalmology.” (Reprinted with permission.) Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 2 An 1854 illustration of a glaucomatous optic disc by Eduard Jaeger, drawn to depict protrusion and swelling, Jaeger’s interpretation of glaucomatous disc change. The image was originally published in his text Ueber Staar und Staaroperationen (Wien) (Reprinted with permission.) Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 3 Areas under the receiver operating characteristic (AUROCs) for the best parameters obtained using 3 objective, quantitative methods of structural assessment demonstrate the superiority of OCT (inferior average thickness, AUROC = 0.91) over scanning laser polarimetry with enhanced (TSNIT, AUROC = 0.87) or variable (TSNIT, AUROC = 0.81) corneal compensation. Originally published in Sehi M, Ume S, Greenfield DS. Scanning laser polarimetry with enhanced corneal compensation and optical coherence tomography in normal and glaucomatous eyes. Invest Ophthalmol Vis Sci. 2007;48:2099-2014. (Reprinted with permission.) ECC = enhanced corneal compensation; RNFL = retinal nerve fiber layer; TSNIT = temporal, superior, nasal, inferior, temporal; VCC = variable corneal compensation. Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 4 Visual field (VF) results (A) and OCT retinal nerve fiber layer (RNFL)–guided progression analysis reports (B) for a representative patient. These studies illustrate that even when early abnormalities on VF or OCT are not statistically significant, one can be reasonably certain that real progression is occurring when changes are occurring in corresponding areas for both tests. GPA = Guided Progression Analysis; VFI = visual field index. Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 5 Data from a representative eye with glaucoma detectable on perimetric testing. The first and second columns display 6×6 mm en face angiograms from nonprojection-resolved OCT angiography (OCTA) and projection-resolved OCTA, respectively. The white arrows highlight the focal decrease in vessel density in a superior arcuate pattern in the superficial vascular complex (SVC) and all-plexus projection-resolved OCTA images. The ganglion cell complex (GCC) map (second image in third column) and VF pattern deviation (third image in third column) demonstrate defects in corresponding locations. Of note, as might be expected, a corresponding decrease in vessel density was not found in the projection-resolved OCTA for the intermediate capillary plexus or deep capillary plexus. Originally published in Takusagawa HL, Liu L, Ma KN, et al. Projection-resolved optical coherence tomography angiography of macular retinal circulation in glaucoma. Ophthalmology. 2017;124:1589-1599. (Reprinted with permission.) DCP = deep capillary plexus; GCC = ganglion cell complex; ICP = intermediate capillary plexus; PR-OCTA = projection-resolved optical coherence tomography angiography; SVC = superficial vascular complex; VF = visual field. Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 6 Assessment of the relationships between perimetric visual function and (A) structural measures of the of retina and optic nerve head (ONH) (B) visual cortex activity as measured by magnetic resonance imaging (MRI) blood-oxygenation-level-dependent (BOLD) signal revealed that each of these relationships can be described by broken-stick (segmented) models. That is, this study demonstrated that functional impairment in terms of visual field (VF) progression occurs only after a “tipping point” in terms of other measurements of glaucoma damage, and this finding holds true not only for measures of ocular structure (tipping points were 76.9 μm for retinal nerve fiber layer. (RNFL) (95% confidence interval [CI], 67.9–86.0 μm), 59.6 μm for GCIPL (95% CI, 54.5–64.7 μm), and 0.81 for cup-to-disc ratio (95% CI, 0.79–0.83), but also for measures of brain function (topping point was BOLD = 0.58% for upper VF stimulation [95% CI, 0.34–0.82] and BOLD = 0.61% for lower VF stimulation [95% CI, 0.30–0.92]). Red line represents the spline fit, and the black line represents the broken stick fit model (*P < 0.05, **P < 0.01, ***P < 0.001: Davies’ test for statistically significant difference in slope between segments). Originally published in Murphy MC, Conner IP, Teng CY, et al. Retinal structures and visual cortex activity are impaired prior to clinical vision loss in glaucoma. Sci Rep. 2016;6:31464. (Reprinted with permission.) dB = decibels; GCIPL = ganglion cell inner plexiform layer. Ophthalmology Glaucoma 2018 1, 3-14DOI: (10.1016/j.ogla.2018.06.002) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions