C L I N I C A L T R I A L S
Correlation between Local Glaucomatous Visual Field
Defects and Loss of Nerve Fiber Layer Thickness
Measured with Polarimetry and Spectral Domain OCT
Folkert K. Horn, Christian Y. Mardin, Robert Laemmer, Delia Baleanu,
Anselm M. Juenemann, Friedrich E. Kruse, and Ralf P. Tornow
PURPOSE. To study the correlation between local perimetric field
defects and glaucoma-induced thickness reduction of the nerve
layer measured in the peripapillary area with scanning laser pola-
rimetry (SLP) and spectral domain optical coherence tomography
(SOCT) and to compare the results with those of a theoretical model.
METHODS. The thickness of the retinal nerve fiber layer was
determined in 32 sectors (11.25 each) by using SLP with variable
cornea compensation (GDxVCC; Laser Diagnostics, San Diego,
CA) and the newly introduced high-resolution SOCT (Spectralis;
Heidelberg Engineering, Heidelberg, Germany). Eighty-eight
healthy subjects served as control subjects, to determine the
thickness deviation in patients with glaucoma. The relationship
between glaucomatous nerve fiber reduction and visual field
losses was calculated in six nerve fiber bundlerelated areas.
Sixty-four patients at different stages of open-angle glaucoma and
26 patients with ocular hypertension underwent perimetry (Oc-
topus G1; Haag-Streit, Koniz, Switzerland) and measurements
with the two morphometric techniques.
RESULTS. Sector-shaped analyses between local perimetric
losses and reduction of the retinal nerve fiber layer thickness
showed a significant association for corresponding areas ex-
cept for the central visual field in SLP. Correlation coefficients
were highest in the area of the nasal inferior visual field (SOCT,
0.81; SLP, 0.57). A linear model describes the association
between structural and functional damage.
CONCLUSIONS. Localized perimetric defects can be explained by
reduced nerve fiber layer thickness. The data indicate that the
present SOCT is useful for determining the functional-struc-
tural relationship in peripapillary areas and that association
between perimetric defects and corresponding nerve fiber
losses is stronger for SOCT than for the present SLP. (Clinical-
Trials.gov number, NCT00494923.) (Invest Ophthalmol Vis
Sci. 2009;50:19711977) DOI:10.1167/iovs.08-2405
K nowledge of the relationship between structural and func-
tional damage in glaucoma may be helpful in understand-
ing the pathogenesis of the disease and in observing the
From the Universitatsklinikum, Augenklinik, Erlangen, Germany.
Supported by Deutsche Forschungsgemeinschaft Grant SFB 539.
Submitted for publication June 9, 2008; revised September 23,
November 13, and December 22, 2008; accepted March 23, 2009.
Disclosure: F.K. Horn, None; C.Y. Mardin, None; R. Laemmer,
None; D. Baleanu, None; A.M. Juenemann, None; F.E. Kruse, None;
R.P. Tornow, None
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked advertise-
ment in accordance with 18 U.S.C. 1734 solely to indicate this fact.
Corresponding author: Folkert K. Horn, Universitatsklinikum, Au-
genklinik, Schwabachanlage 6, D-91054 Erlangen, Germany;
folkert.horn@uk-erlangen.de.
Investigative Ophthalmology & Visual Science, May 2009, Vol. 50, No. 5
Copyright Association for Research in Vision and Ophthalmology
Downloaded From: http://jov.arvojournals.org/ on 05/26/2016
progress of the disease over a period. This relationship has
been measured with sensory tests and various imaging tech-
niques.1 4 Significant correlations have been described be-
tween perimetric tests and optic disc parameters, such as the
area of the neuroretinal rim or the nerve fiber layer thickness.
Despite the local information of computerized white-on-white
perimetry, the perimetric mean defect of the whole visual field
has been used as a quantitative measure of functional ability.57
However, local correspondence may be important to judge
progression, and therefore several studies have compared local
visual field defects and corresponding local change in retinal
structure. Photographic methods as well as modern scanning
laser devices have been used to measure retinal structures and
to investigate the association between focal structural damages
and possible losses in the corresponding visual field area (Gar-
way-Heath DF, et al. IOVS 2003;44:ARVO E-Abstract 980).1,2,8
A matter of particular interest is the topographic association
between glaucomatous scotomas and losses in the course of
the nerve fiber layer bundles.9,10 Retinal nerve fiber layer
(RNFL) thickness can be measured with optical coherence
tomography (OCT) and scanning laser polarimetry (SLP). Re-
cently, spectral domain optical coherence tomography (SOCT)
has been introduced in glaucoma diagnosis as a more accurate
measurement technique for the study of retinal layers.
Diagnostic values in glaucoma detection of SLP and OCT
technique have been documented, but only a few studies have
been conducted to investigate the association between local
RNFL and corresponding perimetric losses by using both meth-
ods in the same individuals. In the present study, RNFL thick-
ness was measured in three subject groups with SLP and a
newly introduced SOCT. In earlier statistical evaluations, sig-
nificant correlations between local RNFL reduction and local
sensitivity loss were found by using linear and nonlinear re-
gression analysis. Recently, a linear model based on a few
simple assumptions was proposed to describe this relationship,
and it was shown that local perimetric losses and data from the
time domain OCT fit the model.9 So far, results of SLP and
SOCT have not been shown to fit this model.
The purpose of this study was to quantify local field loss of
conventional computerized white-on-white perimetry and local
RNFL reduction measured with SOCT and SLP in the same indi-
viduals and to compare the results with the recently published
linear model for the relation between field loss and RNFL reduc-
tion.
METHODS
Procedures
All patients who participated in this study were thoroughly examined
by slit lamp inspection, applanation tonometry, funduscopy, gonios-
copy, perimetry, and papillometry. In addition, a 24-hour intraocular
1971
 1972 Horn et al.
pressure profile (six determinations) was obtained for all patients.
Papillometric evaluations of patients were based on 15 color photo-
graphs (telecentric fundus camera; Carl Zeiss Meditec, Dublin, CA) and
subsequent planimetry (Summasketch III; Summagraphics, Seymour,
CT) of the area of the optic disc and the neuroretinal rim area.11 To
reduce the possible influence12,13 of the optic disc size, we did not
include eyes with disc areas larger than 4 mm2 in the study. Criteria for
glaucoma diagnosis were an open anterior chamber angle and glauco-
matous appearance of the optic nerve head, including an unusually
small neuroretinal rim area in relation to the optic disc size and
cup-to-disc ratios that were larger vertically than horizontally.14 These
analyses were independently performed ophthalmoscopically and
planimetrically by three glaucoma specialists (CYM, RL, AMJ). All
individuals included in the study had clear optic media and visual
acuity of 0.7 or better. On the day of examination, intraocular pressure
was equal to or less than 23 mm Hg in all individuals. Exclusion criteria
were all eye diseases other than glaucoma, the presence of diabetes
mellitus, and a myopic refractive error exceeding 6 D. All patients
were members of the Erlangen Glaucoma Registry, with yearly visits to
our glaucoma service. The patients were referred by ophthalmologists
for further diagnosis and follow-up of glaucoma. The inclusion/exclusion
criteria and the type of examinations are defined in a protocol that was
approved by the local ethics committee. The study protocol adhered to
the tenets of the Declaration of Helsinki for research involving human
subjects. Informed consent was obtained from all participants.
Subjects
Glaucoma Group. All 64 patients in this group had glaucoma-
tous optic disc damage. The heterogeneous cohort of patients with
glaucoma (34 women, 30 men; age, 62.5 9.2 years) included 31
patients with primary open-angle glaucoma characterized by elevated
intraocular pressure measurements higher than 21 mm Hg; 11 patients
with secondary open-angle glaucoma with elevated intraocular pres-
sure measurements due to pigmentary glaucoma (5 patients); pseudo-
exfoliation (5 patients); or traumatic anterior chamber angle recession
(1 patient); and 22 patients with normal-pressure glaucoma. For the
diagnosis of normal-pressure glaucoma, all intraocular pressure mea-
surements had to be less than 21 mm Hg without medication. In these
latter patients, ophthalmoscopy, medical history, and neuroradiologic,
neurologic, and medical examinations did not reveal any other reason
than glaucoma for the optic nerve damage. As we were interested in
the correlation between nerve fiber loss and possible functional de-
fects, we included patients with early and those with advanced glau-
coma: 14 patients had diffuse, 34 had local, and 16 had no visual field
losses in conventional white-on-white perimetry. The mean (SD) of
perimetric mean defects (MD) in the glaucoma cohort was 6.9 6.0
dB, and corrected loss variance (CLV) in this group was 40.1 43.4
dB2 (standard indices of the Octopus G1 program; Haag-Streit). The
local visual field losses were: 2.8 4.3 dB (central), 6.5 8.4 dB (nasal
inferior), and 5.9 7.3 dB (nasal superior). In this patient group, one
eye of each patient was selectedalways the eye with more advanced
perimetric loss.
Ocular Hypertension Group. Patients in this group (26 pa-
tients: 14 men, 12 women; age, 57.8 9.8 years) had intraocular
pressures above 21 mm Hg in repeated measurements. All of them had
normal results in white-on-white perimetry and normal optic discs. The
perimetric MD was 0.9 1.0 dB, and corrected loss variance was
2.1 1.5 dB2. One randomly selected eye of each patient was used in
the study.
Control Group. The study included 88 normal eyes of 88
healthy subjects (32 women, 56 men; age. 58.1 9.9 years). RNFL data
of these subjects were necessary to determine sector-specific normal
data for SLP and SOCT measurements. Findings in slit lamp inspection,
white-on-white perimetry and/or FDT perimetry, tonometry, and fun-
duscopy were normal. Optic discs were inspected and classified as
normal by at least two experienced ophthalmologists. One randomly
selected eye of each patient was used in the study.
Downloaded From: http://jov.arvojournals.org/ on 05/26/2016
IOVS, May 2009, Vol. 50, No. 5
26
20
12
vertical position [deg]
8
4
0
-4
-8
-12
-20
-26
-20 -12 -8 -4 0 4 8 12 20
horizontal position [deg]
FIGURE 1. Location of test points using Octopus perimetry (Haag-
Streit, Koniz, Switzerland) and superposition of an upside down nerve
fiber photograph. The 59 test positions were arranged according to the
course of the nerve fibers. Dotted lines: borders between visual field
areas, delineated to study the correlation between localized perimetric
losses and RNFL reduction.
Perimetry
All patients underwent visual field tests with standard white-on-white
perimetry with a computerized static projection perimeter (Octopus
500; Haag-Streit). All patients had experience in sensory tests and had
at least one earlier determination with the present perimeter. Those
tests with more than 12% false-positive or -negative responses were
excluded. The present measurement algorithm (Octopus program G1,
three phases) includes 59 test positions arranged according to the
course of the nerve fibers (Fig. 1). Two commercial software programs
(PeriData perimetry interpretation software, ver. 7.3.2; PeriData,
Hurth, Germany, and statistical software SPSS; SPSS, Chicago, IL) were
used to calculate local MDs based on a map of perimetric nerve fiber
bundles similar to the one presented in a study by Garway-Heath et
al.10 on the basis of test points of the perimeter (Humphrey; Carl Zeiss
Meditec). Thus, in the present study, we used mean values of six visual
field areas (Fig. 2). To calculate the mean visual field loss in these six
areas, we calculated the anti-log values at all single test positions and
averaged them.15 For presentation and statistical analysis, these aver-
aged values were converted back to the decibel scale.
Spectral Domain Optical Coherence Tomography
All normal subjects and patients were scanned using a commercially
available SOCT system (Spectralis HRAOCT; Heidelberg Engineer-
ing). This instrument uses a wavelength of 820 nm in the near-infrared
spectrum in the SLO mode. The light source of the SOCT is a super
luminescent diode with a wavelength of 870 nm. Infrared images and
OCT scans (40,000 A-Scans/second) of the dual laser scanning systems
are acquired simultaneously. Twenty to 25 consecutive circular B-scans
(3.4 mm diameter, 768 A-scans) centered at the optic disc were
automatically averaged to reduce speckle noise. An online tracking
system compensated for eye movements. The presently available man-
ufacturers software version allows measurements of the total retinal
thickness, but not of the RNFL thickness separately. To measure the
RNFL thickness, B-scan images were exported as TIF files (8 bit/pixel).
The upper and lower borders of the RNFL were manually segmented
 IOVS, May 2009, Vol. 50, No. 5 FunctionalStructural Relationship with SLP and SOCT 1973

FIGURE 2. Correspondence of visual field areas and optic disc segmentation. Throughout this study we
used the following nomenclature: areas of visual field defects were based on local perimetric test positions
whereas peripapillary zones were based on thickness measurements in sectors. Left: visual field areas in
this study. Right: 32 peripapillary sectors in which the RNFL thickness was determined (numbers shown
in white on black). Six nerve fiber bundlerelated zones were formed similar to those introduced in a prior
study10 (numbers shown black on white). Black ring: the calculation area used in SLP measurements.
Dotted line: the position of the scan circle of the SOCT. Numbering and nomenclature for visual field areas
(corresponding optic disc zones are given in brackets, with 0 corresponding to clock hour 9): 1, central
(31534); 2, nasal-inferior (34 79); 3, inferior (79 124); 4, temporal (124 225); 5, superior (225
270); 6, nasal-superior (270 315).

by an experienced assistant using a purpose-written macro for ImageJ
(ver. 1.32; developed by Wayne Rasband, National Institutes of Health,
Bethesda, MD; available at http://rsb.info.nih.gov/ij/index.html). The
assistant was not informed about the disease classification. RNFL thick-
ness was calculated as the distance between these two borders with a
calibration factor of 3.87 m/pixel (provided by Heidelberg Engineer-
ing). Compared with time-domain B-scan images, the spectral domain
B-scans image showed less noise, higher resolution, and higher con-
trast for the RNFL, so that the borders could be clearly identified and
marked. The retinal vessels within the RNFL were considered to be
part of the RNFL. B-scans with unclear borders, as well as mean images
with insufficient alignment and focus were excluded. A parameter
describing the image quality is not available in the present Spectralis
software version (Heidelberg Engineering). To show the distribution of
RNFL thickness around the optic disc, we averaged the thickness data
of the circular scan to 32 sectors (11.25 each) and, to correlate the
data with results from visual field areas (Fig. 1), we grouped the 32
sectors in six zones (with 0 corresponding to clock hour 9): superior
retina from 34 to 79 and from 79 to 124, inferior retina from 225 The graphic presentations of thickness data show the mean and 95%
to 270 and from 270 to 315. Thus, the temporal optic disc sector
was from 315 to 34 and the nasal optic disc sector was from 124 to
225 (Fig. 2). This segmentation is very similar to that introduced
previously for RNFL analysis16,17 with respect to the present sector size
(11.25), which can be obtained in SOCT as in SLP.
Scanning Laser Polarimetry
All patients and control subjects included in the study underwent SLP
examination of the RNFL with the nerve fiber analyzer GDxVCC (Laser
Diagnostic Technologies, San Diego, CA), a confocal scanning-laser
ophthalmoscope for in vivo determination of the RNFL thickness
through the undilated pupil. The technique of the retinal nerve fiber
analyzer has been described in detail,7 and there are numerous dem-
onstrations of its diagnostic value.3,18 21 The examinations were per-
formed under photopic conditions. The RNFL thickness measurements
were performed in an annulus around the optic disc (inner diameter,
2.51; outer diameter, 3.26 mm). This diameter of the annulus was
recommended by the manufacturer. Because of this fixed analysis
circle, all subjects with large optic discs were excluded. The off-line
evaluation of the optic disc images and the assessment of the image
quality were accomplished by an experienced examiner (RL or CYM).
To be acceptable, the image needed a centered optic disc and a sharp
and evenly illuminated reflectance image as well as an overall quality
score greater than 7. If an atypical pattern of retardation or elevated
parapapillary atrophy was detected (6% of our original cohort), the
subject was not included in the study. The data were analyzed for 32
identical sectors and 6 zones, as in the SOCT measurements.
Statistical Methods
The RNFL thicknesses measured in the control subjects were used to
determine local thickness deviation in all 32 sectors. Description of the
results includes means and standard deviations. RNFL reduction was
calculated in absolute (micrometers) and in relative (percentage) val-
ues for the graphic comparison of data derived from SLP and SOCT.
confidence interval (CI). Comparisons between groups were made
with the unpaired Mann-Whitney U test. Correlations of RNFL thick-
nesses with corresponding visual field defects were examined by using
Spearman rank order correlations. Graphic correlation results are given
for the area of the papillomacular and nasal superior and nasal inferior
bundles (areas 1, 2, and 6), because these optic disc sectors fall
completely in the perimetric test field. To compare correlation coeffi-
cients, we calculated confidence intervals by bootstrap estimation,
using the free data analysis environment R (ver. 2.6.2, www.r-project.
org). Other analyses were performed in commercial software (SPSS-
WIN (ver. 15; SPSS Inc.). The level of significance was 0.05 in all
statistical tests. A Bonferroni correction for multiple testing was used
by multiplying the observed P with the number of comparisons within
each analysis.22
To show the association between local perimetric losses and rela-
tive RNFL thickness, we calculated a theoretical curve according to a

Downloaded From: http://jov.arvojournals.org/ on 05/26/2016

 1974 Horn et al.
linear model given by Hood et al.9 Briefly, this model assumes that the
measured RNFL thickness TM consists of two components: TM TA
TR, where TA is the thickness of the RGC axons, and TR is the residual
or base thickness including glia cells and blood vessels.
As the visual field sensitivity decreases, the thickness TA decreases
also, whereas the residual thickness TR, does not change. The axons
thickness TA is linearly related to the relative linear sensitivity S: TA
TA0 S, where TA0 is the axonal thickness of a normal subject, and S
10D/10. The expression converts the measured defect value D (in
decibels) to the relative linear sensitivity S. A normal subject is char-
acterized by D 0, S 1, and TA TA0. The resulting expression for
the relation between the measured RNFL thickness TM and the relative
sensitivity S is TM TA0 S TR, and the relation between the
measured RNFL thickness TM and D is TM TA0 10D/10 TR.
In this article (Fig. 3), the measured values TM and D are presented
in a loglinear plot. For better comparability of SLP and OCT results,
which show different thicknesses, the thickness in Figure 3 is given in
relative values: Trel TM/Tavg, where Tavg is the average RNFL thickness
in our control subjects (Trel in percents, D in decibels). The solid line
Downloaded From: http://jov.arvojournals.org/ on 05/26/2016
IOVS, May 2009, Vol. 50, No. 5
FIGURE 3. Correlation between local
RNFL loss and corresponding perimet-
ric defects in all subjects and areas
where optic disc zones fall completely
within the Octopus test field (Haag-
Streit, Koniz, Switzerland). Sector-
shaped analyses illustrate the decrease
in RNFL thickness in glaucoma and the
association with progression of the dis-
ease (Spearman correlation coeffi-
cients, ***P 0.001). A theoretical
function is included in all scatterplots,
starting at 100% RNFL thickness and
assuming a residual RNFL thickness if
defects are worse than 10 dB. (F) Pa-
tients with glaucoma. (
) Patients with
secondary glaucoma with melanin dis-
persion or pseudoexfoliation. () Pa-
tients with ocular hypertension. ()
Normal control group. Error bars, SD.
in Figure 3 represents the linear relation between Trel and S, according
to the linear model. The residual thickness was calculated for each
zone as the median of the RNFL data when local visual field losses were
greater than 10 dB.
RESULTS
To study the relationship between nerve fiber damage and
perimetric defects in nerve fiber bundlerelated areas, we
calculated the deviations from measurements in normal sub-
ject. Figure 4 shows the distribution of the RNFL thickness
around the optic disc in 32 sectors in the different study
groups. Mean sectoral thicknesses, as measured with SOCT,
ranged from 60 to 144 m in the control eyes and from 49 to
87 m in the glaucomatous eyes (Fig. 4A). When the SLP
technique was used for determination of the RNFL thickness,
the range was from 29 to 86 m in the control eyes and from
28 to 64 m in the glaucomatous eyes. Figure 4B gives an
 IOVS, May 2009, Vol. 50, No. 5
control group oht
Thickness of RNFL [m]
1 9 17 25 32 1 9 17 25 32
Deviation from normal thickness [m]
1 9 17 25 32 1 9 17 25 32
Distance around optic disc [sector number]
FIGURE 4. (A) Mean values (95% CI) of retinal thickness as deter-
mined with the SLP and SOCT in 32 peripapillary sectors in normal
subjects, patients with ocular hypertension or glaucoma (t, temporal;
s, superior; i inferior; n, nasal). Absolute RNFL thickness data are
higher in SOCT than in SLP measurements. (B) Deviation from normal
RNFL thickness for all subjects. In patients with glaucoma, losses of
nerve fiber thickness were more pronounced in the inferior and supe-
rior sectors than in the nasal or temporal ones.
impression of the glaucomatous reduction of nerve fiber thick-
ness in all sectors. Both devices showed nerve fiber losses in
glaucomatous eyes to be more pronounced in the inferior and
superior sectors than nasally or temporally. Differences be-
tween SLP and SOCT can be seen in the temporal sectors,
where a reduction was found with SOCT but not with SLP. In
the OHT eyes, none of the sectors showed significantly altered
RNFL results for SOCT measurements. A reduction trend was
observed for several sectors in the SLP measurements. How-
ever, this finding is not significant if an adjustment according to
Bonferroni is used. RNFL thickness values in perimetry-associ-
ated zones in all study groups are given in Table 1.
There are significant correlations (Table 2) between local
mean visual defects and relative RNFL loss for both devices,
with the exception of the papillomacular bundle in the SLP
(visual field area 1). The analyses with SOCT revealed the
strongest correlation between local RNFL losses and perimetri-
cally defined stages of glaucoma to be in the arcuate bundles of
the visual field. As the normal thickness data differed consid-
erably between SLP and SOCT measurements, we used relative
data (percentages) to achieve comparison of the SLP and SOCT
Downloaded From: http://jov.arvojournals.org/ on 05/26/2016
FunctionalStructural Relationship with SLP and SOCT 1975
glaucomas results. Figure 3 shows the thickness loss (linear scale) as a
function of local perimetric defects (decibel scale) in all pa-
A. tients and the theoretical curve according to the linear model.
The data of patients with pseudoexfoliation and dispersion
glaucoma were within the range of that for the patients with
primary open-angle glaucoma. The earlier described model fits
the data comparing RNFL thickness to visual field loss well. In
our data, the model describes the data obtained with SOCT
SOCT slightly better than those obtained with SLP. Highest Spearman
correlation coefficients for the total glaucoma cohort were
0.81 for the SOCT and 0.57 for the SLP. In all visual field
areas the remaining residuum of relative RNFL thickness at
advanced perimetric losses was lower in SOCT than in SLP. The
residual thickness in zones 1, 2, and 6 were 43%, 30%, and 31%
for the SOCT and 92%, 48%, and 53% for the SLP, respectively.
t s n i t SLP
1 9 17 25 32
DISCUSSION
To investigate the relationship with bundle-related visual field
B. defects, we used the deviation of the RNFL thickness from
normal subjects, as absolute values differ between the SLP and
OCT techniques.23 In the past, the correlation between local-
ized perimetric losses and measurements of the optic nerve
was studied in corresponding sectors using parameters of the
neuroretinal rim4,8,24 and the thickness of the nerve fiber
layer.2,5,15,25,26 When comparing results of these studies, it
SOCT should be considered that analyses with HRT and planimetry
are based on optic disc data, whereas the results of SLP and
SOCT, as used in the present study, are measured in the
peripapillary region, not on the border of the optic disc. When
comparing results of peripapillary zones, one has to keep in
t s n i t
mind that test grids of the present perimetric test routines
cover only a part of the temporal visual field (maximum verti-
cal eccentricity of the Octopus G1: 26). Therefore correlation
SLP results may be biased in these areas and the main focus should
1 9 17 25 32 be on nasal areas (numbers 1, 2, and 6 in Fig. 1).
In our correlations between optic disc zones and corre-
sponding field areas, the structurefunction relationship is
more obvious with SOCT than with SLP, as can be seen in
Table 2 and Figure 3. In agreement with earlier reports,25,27
SLP data correlated significantly with visual field defects in all
arcuate superior and inferior visual field areas, but not in the
central visual field. This lack of correlation is in concordance
with the observation that SLP-derived RNFL thickness loss is
generally low in this area, despite considerable perimetric
losses. This result indicates that the diagnostic value of the
present polarimeter depends on the localization of the pa-
tients functional defects. However, this does not mean that the
diagnostic value of SLP is generally lower than that of the SOCT
technique; one should keep in mind that only a small part of
the total information from the SLP (namely, the thickness
under the measurement ring) are included in this study,
whereas other contributions to the devices nerve fiber index
(i.e., the number) were not considered. In addition, new
methods used in SLP such as the ECC (enhanced corneal
compensation) acquisition technique and a more advanced
quality assessment28 (TSS [typical scan score] quality score)
may lead to higher diagnostic accuracy. It has been reported
that 15%29 to 44%30 of examined subjects have an atypical
birefringence pattern that can influence the SLP measure-
ments. Therefore, the present differences between SOCT and
SLP may be smaller if all subjects with atypical birefringence
pattern are excluded. Choi et al.31 and Mai et al.32 showed that
the structurefunction relationship an be improved by using
the ECC technique. The ECC technique and the TSS quality
score were not available in our GDx software, and atypical
retardation patterns were only assessed qualitatively. Further-
 1976 Horn et al. IOVS, May 2009, Vol. 50, No. 5

TABLE 1. RNFL Thickness in the Three Study Groups in Zones Corresponding to Six Visual Field Areas (see Figure 2)

Optic Disc Zone (Visual Field Area)

1 2 3 4 5 6
(Central) (Nasal-Inferior) (Inferior) (Temporal) (Superior) (Nasal-Superior)

SOCT
Control 75.1 11.8 122.7 16.6 107.3 22.2 80.2 14.2 103.9 23.3 134.9 16.7
Ocular hypertension 72.6 11.5 119.1 14.5 105.0 18.0 77.0 12.1 101.8 20.4 135.4 18.1
Glaucoma 54.9 17.7* 73.7 31.1* 74.7 27.0* 60.0 16.2* 70.0 22.9* 73.9 27.9*
SLP
Control 32.9 10.2 61.5 13.7 76.8 12.7 49.9 7.9 80.8 12.1 75.3 13.5
Ocular hypertension 29.3 5.9 57.5 10.4 76.7 10.7 47.1 5.8 78.9 12.5 70.6 13.4
Glaucomas 32.3 9.8 42.0 13.7* 59.6 15.3* 40.1 7.5* 61.7 15.1* 51.5 15.0*

Data are the mean SD of RNFL thicknesses (micrometers) in the six optic disc zones (visual field area). Control, n 88; ocular hypertension,
n 26; glaucoma, n 64.
* Significant (P 0.001) differences in comparison to the control group (analysis of variance, adjusted for multiple comparison).

more, SLP may be a sensitive technique to detect early changes
of the RNFL in glaucoma. The trend of reduction of SLP results
in our OHT patients (Fig. 4) is in line with a study in monkeys
by Fortune et al. (IOVS 2008;49:ARVO E-Abstract 3761) show-
ing that birefringence of RNFL possibly declines before thick-
ness in glaucomatous optic disc atrophy.
In the past, relationships between RNFL losses and visual field
defects have been studied using different theoretical curves to fit
the data (e.g., linear, logarithmic) (Garway-Heath DF, et al. IOVS
2003;44:ARVO E-Abstract 980).1,2,4,33 The present plots (Fig. 3),
including data points from patients with OHT and those with all
glaucomas, may give an impression of glaucoma development
starting in normal subjects, where neither functional nor struc-
tural losses are present. We used a semilogarithmic plot, with
RNFL losses in percentages on the linear y-axis and field defects in
decibels on the x-axis, to show a theoretical function, as proposed
earlier. These curves always start at visual field loss and RNFL
thickness corresponding to 0 dB and 100%, respectively. The
curve shows an asymptotic approach to the residual thickness
when all axons are lost. Thus, our data are in agreement with the
predictive model by Hood and Kardon.15 Their model indicates
that even complete loss of ganglion cells leaves a residual thick-
ness. The authors stated that residual thickness from nonaxonal
elements might be 33% in arcuate nerve fiber bundles and higher
in the region of the papillomacular bundle. The same is true in our
SOCT results as can be seen in Figure 3: The residual thickness is
31% and 30% in optic disc zones 2 and 6, respectively, and 43% in
the papillomacular bundle.
Earlier it was shown that thickness measurements can be
considerably influenced by the position of the circular scan line
around the optic disc.15 A shortcoming of the present investiga-
tion is that images, obtained with SLP and SOCT, do not stem
from identical retinal regions and that measurement circles are
generated independently for both devices. Future comparisons of
both techniques should be performed with aligned SLP and SOCT
images and applying the same measurement circle for both de-
vices. In addition, these future investigations should exclude the
positions of retinal vessels from analyses to reduce the contribu-
tion of blood vessels to residual thickness. Beside blood vessels,
other anatomic features (size and tilt of the optic disc, splitting in
the nerve fiber bundles, polarization of anterior segments) can
affect images of the peripapillary fundus.13,34 36 In addition, trans-
mission properties,37 corneal thickness,38 age, and myopic refrac-
tion12,39,40 may play a role. In the present study, several arrange-
ments were made to reduce the influence of side effects: Younger
subjects, as well as eyes revealing high refractive error, media
opacities, or large discs were excluded.
We studied a heterogeneous group of patients with glaucoma,
including some with secondary glaucomas due to melanin disper-
sion and pseudoexfoliation. There is no published evidence that a
laser beam deviation might be caused by exfoliation deposits or
pigment dispersion. In our measurements a possible influence of
pigment dispersion on the images was minimized, as all tests were
performed with undilated pupils avoiding liberation of additional
free melanin material in the anterior chamber.41 In our study, the
data from the secondary glaucomas fit the model as well as those
from the primary glaucomas.
In conclusion, this study shows correspondence between lo-
cal visual field defects and reductions of the RNFL thickness by
using two different methods: SLP and SOCT. We showed that a
theoretical model can be used to describe this relationship. Re-
sidual thickness was always higher in SLP measurements than in
those obtained with SOCT. Local correlation analyses indicate that
focal perimetric defects can be identified best by measurements
of the nerve fiber losses if they occur in the arcuate bundles
(visual field areas 2 and 6) of the visual field. For the SLP with

TABLE 2. Correlations between Peripapillary Optic Disc Zones and Defects in Visual Field Areas Determined in Glaucomatous Eyes

Optic Disc Zone vs. Visual Field Area

1 2 3 4 5 6
Central Nasal-Inferior Inferior Temporal Superior Nasal-Superior

SOCT
Spearman R, significance P 0.75, 0.001 0.81, 0.001 0.68, 0.001 0.47, 0.001 0.57, 0.001 0.77, 0.001
Confidence interval 0.61 to 0.85 0.68 to 0.88 0.46 to 0.79 0.22 to 0.68 0.37 to 0.72 0.64 to 0.85
SLP
Spearman R, significance P 0.05, no sign 0.57, 0.001 0.57, 0.001 0.33, 0.05 0.49, 0.001 0.49, 0.001
Confidence interval 0.27 to 0.18 0.33 to 0.72 0.36 to 0.76 0.07 to 0.54 0.26 to 0.67 0.28 to 0.63

Data are Spearman correlation coefficients with 95% CI for the six optic disc zones versus visual field area.

Downloaded From: http://jov.arvojournals.org/ on 05/26/2016

 IOVS, May 2009, Vol. 50, No. 5 FunctionalStructural Relationship with SLP and SOCT
VCC, a lack of correspondence was seen in the area of the
papillomacular bundle where SOCT indicated a loss of more than
50% of the normal RNFL thickness in the advanced glaucomas
(Fig. 3, visual field area 1). Ongoing long-term studies in patients
with progressive glaucoma should reveal whether the present
relationships can be confirmed intraindividually.
References
1. Reus NJ, Lemij HG. The relationship between standard automated
perimetry and GDx VCC measurements. Invest Ophthalmol Vis
Sci. 2004;45:840 845.
2. Bowd C, Zangwill LM, Weinreb RN. Association between scanning
laser polarimetry measurements using variable corneal polarization
compensation and visual field sensitivity in glaucomatous eyes.
Arch Ophthalmol. 2003;121:961966.
3. Chen YY, Chen PP, Xu L, Ernst PK, Wang L, Mills RP. Correlation
of peripapillary nerve fiber layer thickness by scanning laser pola-
rimetry with visual field defects in patients with glaucoma. J
Glaucoma. 1998;7(5):312316.
4. Garway-Heath DF, Holder GE, Fitzke FW, Hitchings RA. Relation-
ship between electrophysiological, psychophysical, and anatomi-
cal measurements in glaucoma. Invest Ophthalmol Vis Sci. 2002;
43:22132220.
5. Bagga H, Greenfield DS, Knighton RW. Scanning laser polarimetry
with variable corneal compensation and optical coherence tomog-
raphy in normal and glaucomatous eyes. Am J Ophthalmol. 2003;
135:512529.
6. Horn F, Jonas JB, Martus P, Mardin CY, Budde WM. Polarimetric
measurements of retinal nerve fiber layer thickness in glaucoma
diagnosis. J Glaucoma. 1999;8:353362.
7. Weinreb RN, Shakiba S, Sample PA, et al. Association between
quantitative nerve fiber layer measurement and visual field loss in
glaucoma. Am J Ophthalmol. 1995;120:732738.
8. Junemann AG, Martus P, Wisse M, Jonas J. Quantitative analysis of
visual field and optic disc in glaucoma: retinal nerve fiber bundle-
associated analysis. Graefes Arch Clin Exp Ophthalmol. 2000;238:
306 314.
9. Hood DC, Anderson SC, Wall M, Kardon RH. Structure versus
function in glaucoma: an application of a linear model. Invest
Ophthalmol Vis Sci. 2007;48:36623668.
10. Garway-Heath DF, Poinoosawmy D, Fitzke FW, Hitchings RA. Map-
ping the visual field to the optic disc in normal tension glaucoma
eyes. Ophthalmology. 2000;107:1809 1815.
11. Jonas JB, Gusek GC, Naumann GOH. Optic disc morphometry in
chronic primary open angle glaucoma. II. Correlation of the intra-
papillary morphometric data to visual field indices. Graefes Arch
Clin Exp Ophthalmol. 1988;226:531538.
12. Bowd C, Zangwill LM, Blumenthal EZ, et al. Imaging of the optic
disc and retinal nerve fiber layer: the effects of age, optic disc area,
refractive error, and gender. J Opt Soc Am A Opt Image Sci Vis.
2002;19:197207.
13. Laemmer R, Horn FK, Viestenz A, Juenemann AG, Mardin CY.
Influence of optic disc size on parameters of retinal nerve fiber
analysis with laser scanning polarimetry. Graefes Arch Clin Exp
Ophthalmol. 2006;244:603 608.
14. Jonas JB, Budde WM, Panda-Jonas S. Ophthalmoscopic evaluation
of the optic nerve head. Surv Ophthalmol. 1999;43:293320.
15. Hood DC, Kardon RH. A framework for comparing structural and
functional measures of glaucomatous damage (review). Prog Retin
Eye Res. 2007;26:688 710.
16. Bowd C, Zangwill LM, Medeiros FA, et al. Structure-function rela-
tionships using confocal scanning laser ophthalmoscopy, optical
coherence tomography, and scanning laser polarimetry. Invest
Ophthalmol Vis Sci. 2006;47:2889 2895.
17. Miglior S, Riva I, Guareschi M, et al. Retinal sensitivity and retinal
nerve fiber layer thickness measured by optical coherence tomog-
raphy in glaucoma. Am J Ophthalmol. 2007;144:733740.
18. Bowd C, Zangwill L, Berry CC, et al. Detecting early glaucoma by
assessment of retinal nerve fiber layer thickness and visual func-
tion. Invest Ophthalmol Vis Sci. 2001;42:19932003.
19. Colen TP, Tang NE, Mulder PG, Lemij HG. Sensitivity and speci-
ficity of new GDx parameters. J Glaucoma. 2004;13:28 33.
Downloaded From: http://jov.arvojournals.org/ on 05/26/2016
1977
20. Nguyen NX, Horn FK, Hayler J, Wakili N, Junemann A, Mardin CY.
Retinal nerve fiber layer measurements using laser scanning pola-
rimetry in different stages of glaucomatous optic nerve damage.
Graefes Arch Clin Exp Ophthalmol. 2002;240:608 614.
21. Trible JR, Schultz RO, James CR, Robinson JC, Rothe TL. Accuracy
of scanning laser polarimetry in the diagnosis of glaucoma. Arch
Ophthalmol. 1999;117:1298 1304.
22. Armitage P, Berry G. Statistical Methods of Medical Research. 3rd
ed. Boston: Blackwell Oxford Scientific Publications; 1994.
23. Leung CK, Chan WM, Chong KK, et al. Comparative study of
retinal nerve fiber layer measurement by StratusOCT and GDx
VCC, I: correlation analysis in glaucoma. Invest Ophthalmol Vis
Sci. 2005;46:3214 3220.
24. Gulati V, Agarwal HC, Sihota R, Saxena R. Correlation analysis of
visual field thresholds and scanning laser ophthalmoscopic optic
nerve head measurements in glaucoma. Ophthalmic Physiol Opt.
2003;23:233242.
25. Horn FK, Mardin CY, Viestenz A, Junemann AG. Association be-
tween localized visual field losses and thickness deviation of the
nerve fiber layer in glaucoma. J Glaucoma. 2005;14:419 425.
26. El Beltagi TA, Bowd C, Boden C, et al. Retinal nerve fiber layer
thickness measured with optical coherence tomography is related
to visual function in glaucomatous eyes. Ophthalmology. 2003;
110:21852191.
27. Schlottmann PG, De Cilla S, Greenfield DS et al. Relationship
between visual field sensitivity and retinal nerve fiber layer thick-
ness as measured by scanning laser polarimetry. Invest Ophthal-
mol Vis Sci. 2004;45:18231829.
28. Bagga H, Greenfield DS, Feuer WJ. Quantitative assessment of
atypical birefringence images using scanning laser polarimetry
with variable corneal compensation. Am J Ophthalmol. 2005 Mar;
139(3):437 446.
29. Toth M, Hollo G. Enhanced corneal compensation for scanning
laser polarimetry on eyes with atypical polarisation pattern. Br J
Ophthalmol. 2005;89:1139 1142.
30. Orlev A, Horani A, Rapson Y, Cohen MJ, Blumenthal EZ. Clinical
characteristics of eyes demonstrating atypical patterns in scanning
laser polarimetry. Eye. 2008;22(11):1378 1383.
31. Choi J, Kim KH, Lee CH, et al. Relationship between retinal nerve
fibre layer measurements and retinal sensitivity by scanning laser
polarimetry with variable and enhanced corneal compensation.
Br J Ophthalmol. 2008;92:906 911.
32. Mai TA, Reus NJ, Lemij HG. Structure-function relationship is
stronger with enhanced corneal compensation than with variable
corneal compensation in scanning laser polarimetry. Invest Oph-
thalmol Vis Sci. 2007;48:16511658.
33. Leung CK, Chong KK, Chan WM, et al. Comparative study of
retinal nerve fiber layer measurement by StratusOCT and GDx
VCC, II: structure/function regression analysis in glaucoma. Invest
Ophthalmol Vis Sci. 2005;46:37023711.
34. Greenfield DS, Knighton RW, Huang XR. Effect of corneal polar-
ization axis on assessment of retinal nerve fiber layer thickness by
scanning laser polarimetry. Am J Ophthalmol. 2000;129:1522.
35. Colen TP, Lemij. Prevalence of split nerve fiber layer bundles in
healthy eyes imaged with scanning laser polarimetry. Ophthalmol-
ogy. 2001;108:151156.
36. Essock EA, Sinai MJ, Fechtner RD. Interocular symmetry in nerve
fiber layer thickness of normal eyes as determined by polarimetry.
J Glaucoma. 1999;8:90 98.
37. Hoh ST, Greenfield DS, Liebmann JM, et al. Factors affecting image
acquisition during scanning laser polarimetry. Ophthalmic Surg
Lasers. 1998;29:545551.
38. Iester M, Mermoud A. Normal retinal nerve fiber layer thickness in
the peripapillary region measured by scanning laser polarimetry. J
Glaucoma. 2001;10:170 176.
39. Funaki S, Shirakashi M, Funaki H, Yaoeda K, Abe H. Relationship
between age and the thickness of the retinal nerve fiber layer in
normal subjects. Jpn J Ophthalmol. 1999;43:180 185.
40. Kanamori A, Escano MFT, Eno A, et al. Evaluation of the effect of
aging on retinal nerve fiber layer thickness measured by optical
coherence tomography. Ophthalmology. 2003;217:273278.
41. Vesti E, Kivelae T. Exfoliation syndrome and exfoliation glaucoma.
Prog Retin Eye Res. 2000;19:345368.