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Section 3 – Structure and function

1. Both optic nerve structure and function should be evaluated for detection of glaucomatous progression.
2. Currently, no specific test can be regarded as the perfect reference standard for detection of glaucomatous structural and/or functional progression.
3. Progression detected by functional means will not always be corroborated using structural tests, and vice-versa.
   Comment: This is due to the imperfect nature of testing analysis, individual variability, and the structure-function relationship.
4. The use of standard automated perimetry as the sole method for detection of change may result in failure to detect or underestimate progression in eyes with early glaucomatous damage.
   Comment: In glaucoma suspect or ocular hypertensive eyes with initially normal achromatic perimetry, a change in optic nerve structure (e.g., optic topography, retinal nerve fiber layer, optic disc hemorrhage, or parapapillary atrophy) may occur before perimetric change.
5. In general, detection of progression is more difficult in eyes with advanced disease.
   Comment: In eyes with advanced visual field damage, alternative perimetric strategies (i.e., larger stimulus, macular strategies, kinetic perimetry, etc.) may need to be employed.
6. A statistically significant change in structure and/or function (which takes age and variability into account) is not always clinically relevant.
   Comment: Its clinical relevance for patient management must take into account other risk factors and lifetime risk of visual disability.
7. Progressive structural changes are often but not always predictive of future development or progression of functional deficits in glaucoma.
   Comment: The predictive strength depends on the method used to assess structural/functional change.
8. Corroboration of glaucomatous progression through the use of more than one test may provide more effective and more rapid detection of glaucomatous progression than repeated confirmation of change using a single modality.
   Comment: Examples of corroborative change include structure-function (e.g., a structural change of the optic nerve and a spatially consistent functional change).
9. In order to increase the likelihood of detecting progression, test results should be of sufficient quality and appropriate quantity to provide meaningful information.
   Comment: While adjunctive testing can help clinical decision making, the use of multiple modalities of testing, at the expense of quality and appropriate frequency and quantity, should be avoided.
10. Life expectancy should be considered when evaluating the clinical relevance of a structural and/or functional change in glaucoma.
11. Structural and/or functional testing should be conducted throughout the duration of the disease.

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