Combining structural and functional testing for detection of glaucoma

Purpose: To assess whether the combined use of both structural and functional tests improves discrimination between healthy and glaucomatous eyes over either type of testing alone. Design: Observational cross-sectional study. Participants: One hundred twenty-three eyes of 123 participants enrolled in the Diagnostic Innovations in Glaucoma Study. Methods. Because both structural and functional tests were evaluated, 2 definitions of glaucoma were used: glaucomatous visual field (VF) damage based on repeatable abnormal standard automated perimetry results (n = 43) and glaucomatous optic disc (glaucomatous optic neuropathy [GON]) based on masked assessment of optic disc stereophotographs (n = 65). Participants had scanning laser polarimetry, optical coherence tomography (OCT), and confocal scanning laser ophthalmoscopy imaging in addition to frequency-doubling technology (FDT) perimetry and short-wave length automated perimetry (SWAP) testing completed within a 6-month interval. Main Outcome Measures: For each glaucoma definition, sensitivities and specificities were calculated for the best structural parameters, FDT perimetry pattern standard deviation (PSD), and SWAP PSD/glaucoma hemifield test, and then for each possible pairwise combination of one structural and one functional parameter. Results: The best structural parameters for discriminating between glaucoma and control eyes were nerve fiber indicator for scanning laser. polarimetry, inferior average retinal nerve fiber layer thickness for OCT, and Moorfields regression classification for confocal scanning laser ophthalmoscopy. Sensitivities and specificities for detecting glaucomatous VF damage for scanning laser polarimetry, OCT, confocal scanning laser ophthalmoscopy, FDT perimetry, and SWAP were 41.9% and 98.3%, 58.1% and 98.3%, 58.1% and 84.5%, 44.2% and 98.3%, and 65.1% and 86.2%, respectively. Adding FDT perimetry to each of the best structural parameters led to a significant (P < 0.05) increase in sensitivity without a significant change in specificity compared with structural parameters alone. Adding SWAP to each of the best structural parameters led to a significant increase in sensitivity and also a significant decrease in specificity compared with each structural parameter alone. Conclusions: A combination of parameters from structural tests and functional tests can improve the sensitivity of glaucoma detection. The sensitivity and specificity desired for a particular clinical application will determine the selection of the particular diagnostic tests.