Retinal Nerve Fiber Layer Imaging with Spectral-Domain Optical Coherence Tomography Pattern of RNFL Defects in Glaucoma

Objective: To characterize the distribution pattern, angular width, and area of retinal nerve fiber layer (RNFL) defects in glaucoma using spectral-domain optical coherence tomography (OCT). Design: Prospective, cross-sectional study. Participants: We included 113 normal subjects and 116 glaucoma patients. Methods: One eye from each individual was randomly selected for Cirrus HD-OCT (Carl Zeiss Meditec Inc., Dublin, CA) RNFL imaging of the 6 x 6-mm(2) parapapillary region. The RNFL defects were identified in the RNFL thickness deviation map as superpixels coded in red. The angular location and the angular width of RNFL defects were measured. The proportion of area with RNFL measurements within the normal ranges in the RNFL thickness deviation map was expressed as the RNFL area index (RAI): 1 - [area of superpixels coded in red/(6 x 6 - optic disc and parapapillary atrophic area)]. The diagnostic performance between RAI and average RNFL thickness was compared with the area under the receiver operating characteristic curve after adjusting refraction, signal strength, optic disc, and parapapillary atrophic areas. Main Outcome Measures: Frequency distribution profiles and distribution patterns of RNFL defects, diagnostic sensitivity and specificity of RAI, and average RNFL thickness. Results: The RNFL defects in glaucoma were most frequently found at the inferotemporal meridian at 284 (80.4%), followed by the superotemporal meridians at 73 degrees (54.2%). The respective proportions of localized (angular width <= 30 degrees) and diffuse (angular width >30 degrees) RNFL defects were 11.4% and 70.5% in mild glaucoma (MD >= 6 dB), and 4.2% and 94.5% in moderate to advanced glaucoma (MD<-6 dB). The RAI was 90.2 +/- 6.4% and 83.6 +/- 7.4% in the mild and moderate to advanced glaucoma groups, respectively. At a specificity of 90.0%, the respective diagnostic sensitivity of RAI and average RNFL thickness was 95.7% (95% confidence interval, 92.2-99.1%) and 94.0% (90.1-99.1%). Conclusions: Analysis of the pattern of RNFL defects with spectral domain OCT imaging offers important insights in understanding the characteristics of RNFL damage. As RNFL defects expand in size as the disease progresses, measurement of the angular width and area of RNFL defects can provide an additional dimension for evaluation of glaucoma.