Retinal Ganglion Cell Count Estimates Associated with Early Development of Visual Field Defects in Glaucoma

Purpose: To estimate retinal ganglion cell (RGC) losses associated with the earliest development of visual field defects in glaucoma. Design: Observational cohort study. Participants: The study group included 53 eyes of 53 patients with suspected glaucoma who were followed as part of the Diagnostic Innovations in Glaucoma (DIGS) study. These eyes had normal standard automated perimetry (SAP) visual fields at baseline and developed repeatable (3 consecutive) abnormal test results during a median follow-up of 6.7 years. An age-matched control group of 124 eyes of 124 healthy subjects recruited from the general population was included. Methods: Estimates of RGC counts were obtained using a previously published model that combines estimates of RGC numbers from SAP sensitivity thresholds and retinal nerve fiber layer (RNFL) thickness measurements with spectral domain optical coherence tomography (SD-OCT). For eyes converting to glaucoma, estimates of RGC counts were obtained at the time (within +/- 3 months) of the first abnormal visual field, representing the time of earliest detection of visual field losses. Main Outcome Measures: Estimates of RGC counts in eyes converting to glaucoma versus healthy eyes. Results: The average RGC count estimate in the eyes with early visual field defects was 652 057 +/- 115 829 cells, which was significantly lower than the average of 910 584 +/- 142 412 cells found in healthy eyes (P < 0.001). Compared with the average number of RGCs in the healthy group, glaucomatous eyes had an average RGC loss of 28.4%, ranging from 6% to 57%, at the time of the earliest visual field defect on SAP. Retinal ganglion cell counts performed significantly better than the SD-OCT average RNFL thickness parameter in discriminating glaucomatous from healthy eyes with receiver operating characteristic curve areas of 0.95 +/- 0.02 versus 0.88 +/- 0.03, respectively (P = 0.001). Conclusions: Glaucomatous eyes with the earliest detectable visual field loss on automated perimetry may already show substantial loss of RGCs. Empirical estimates of RGC counts combining structural and functional tests agreed closely with previous histologic reports on the number of RGCs associated with early visual fields defects on SAP. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. Ophthalmology 2013;120:736-744 (C) 2013 by the American Academy of Ophthalmology.