As we consider various personal goals for 2021 in our “new normal,” are there ways in which we can also progress professionally? More specifically, and related to glaucoma, how can we make (more) progress on detecting glaucomatous progression? What clinical and diagnostic signs should we look for in our glaucoma patients that might suggest progression?

Here, I provide a diagnostic triad to accomplish this:

1 STUDY THE NERVE

All structural (OCT) and functional (VF) testing, as well as all clinical findings (especially IOP measurements), must be considered in the context of the optic nerve appearance. Therefore, systematically evaluating the optic nerve with your high-magnification fundus lens through a dilated pupil — and then carefully evaluating associated fundus photos if available — is the first step in monitoring for glaucomatous progression. When examining the optic nerve, consider these questions, all of which a “yes” answer suggests disease progression:

• Is the neuroretinal rim thinner and/or showing a wider area of loss?
• Are there associated glaucomatous disc hemorrhages, specifically in areas of previous damage?
• Are the focal retinal nerve fiber layer (RNFL) defects deeper/wider?
• If present, is there increased vessel clarity in areas of diffuse RNFL defects?
• Is the extent of the peripapillary area showing enlargement, specifically with more beta-zone atrophy?
• Does the cupping appear deeper, with increased laminar pores visible?
• Does the central retinal vessel trunk show increased eccentricity/nasalization within the disc?

2 STUDY THE OCT

After ensuring that the device’s signal strength is similar to previous scans and that the current scan shows good centration and is free of artifacts, consider the OCT RNFL analysis in the context of the optic nerve appearance. With respect to the optic nerve appearance, and when evaluating the OCT analysis, ask yourself these questions. If the answer is “yes,” except the last question, this indicates disease progression.

• Are the RNFL defects getting deeper (decreased RNFL thickness values)?
• Are the RNFL defects getting larger (increased sectoral thinning)?
• Are there any new glaucomatous RNFL defects?
• Is there anything else that could cause the potential progression?

3 STUDY THE VISUAL FIELD

After making sure that the test results are reliable and similar to previous scans and that the current test results are relatively free of artifacts, consider the VF analysis in the context of the optic nerve appearance. When evaluating the VF printout, consider these questions. If the answer is “yes,” except for the last question, this indicates disease progression.

• Are the VF defects getting deeper (worse pattern standard deviation)?
• Are the VF defects getting larger (worse mean deviation)?
• Are there any new VF defects?
• Could anything else cause potential progression?

A FRESH START

Hopefully, we can make this diagnostic triad approach a part of our “new normal” when evaluating our patients for progression of glaucoma. OM

DR. LIFFERTH practices at Grossnickle Eye Center as a consultative optometrist with an emphasis in glaucoma management, and he is a member of the Optometric Glaucoma Society. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at austinlifferth@yahoo.com.