Study of correlation between stereopsis and retinal nerve fiber layer thickness in cases of glaucoma

Sanjay Kumar Dhar; K Raji; Shankar Sandeep; Abhijit

doi:10.1016/j.mjafi.2020.01.004

. 2020 Apr 29;77(1):63–69. doi: 10.1016/j.mjafi.2020.01.004

Study of correlation between stereopsis and retinal nerve fiber layer thickness in cases of glaucoma

Sanjay Kumar Dhar ^a,^∗, K Raji ^b, Shankar Sandeep ^c, Abhijit ^d

PMCID: PMC7809574 PMID: 33487868

Abstract

Background

Glaucoma is an important and common optic neuropathy characterized by progressive loss of retinal ganglion cells and associated morphological changes to the optic nerve and retinal nerve fiber layer (RNFL). The most common assessment of visual function in glaucoma uses perimetric measurements of visual sensitivity. Only few studies have evaluated the binocular function in patients with glaucoma. This study was taken up to establish the correlation of RNFL thickness, in glaucoma, with near and distance stereopsis.

Methods

This pilot, cross-sectional observational study included 100 diagnosed cases of glaucoma and 100 normal participants as controls, studied over a period of one year. The records of all the participants were checked, and only established cases of glaucoma after fulfilling the inclusion and exclusion criteria were included. Analysis of the RNFL using spectral-domain optical coherence tomography was carried out. All the participants were thereafter evaluated for stereoacuity by near (at 40 inches) and distance (at 3 meter) Randot stereoacuity charts.

Results

There was a negative correlation between the RNFL thickness and the absolute value of streoacuity (-0.303 for distance versus -0.101 for near in cases and -0.308 for distance and -0.416 for near in control group), decreasing the actual functional stereoacuity, therefore the cases with lower RNFL thickness had lower stereoacuity both for distance and near, however it was statistically significant only for distance (p=0.002).

Conclusion

Functional aspects, such as stereoacuity, may also be affected in the glaucoma because of decrease in RNFL thickness. Therefore, binocular status should also be evaluated in cases of glaucoma.

Keywords: Retinal nerve fibre layer thickness, Stereoacuity (near & distance), Optical coherence tomography, Glaucoma

Introduction

Glaucomatous optic neuropathy results from loss of retinal ganglion cells (RGCs) and is associated with damage to the optic nerve and retinal nerve fiber layer (RNFL).¹ The visual loss seen in glaucoma is not reversible and can result in blindness.¹ Visual field assessment is the commonly performed investigation for visual function in glaucoma.

There are only limited studies, which have evaluated binocular function or stereoacuity in cases of glaucoma. The reasons for binocular function to get affected in glaucoma are (i) the two types of ganglion cells – large and small – that project separately in the nucleus of the lateral geniculate body: parvocellular layer (small ganglion cell) and magnocellular layer (large ganglion cell). There is some evidence to believe that stereoscopic function is mediated through the large ganglion cell pathway²^,³(ii) The damage in two eyes is generally unequal. This disparity in damage can manifest as an afferent pupillary defect⁴^,⁵^,⁶ or asymmetry in visual field loss⁷^,⁸ or this asymmetric damage may result in subnormal stereopsis or impaired binocular function. (iii) Thirdly stereopsis may be affected because of the resulting abnormalities in the optics.⁹

As per our knowledge, there is no study which correlates the RNFL thickness measured by optical coherence tomography (OCT) with near and distance stereopsis on the Randot test in patients with glaucoma. The study provides an insight into the effect of the RNFL thickness on glaucoma and stereopsis.

Material and methods

This pilot, cross-sectional observational study that included 100 diagnosed cases of glaucoma and 100 normal individuals without glaucoma as the comparison group carried out over a period of one year. The study was carried out in a tertiary eye care center after taking permission from the institutional ethical committee. The records of all the participants were checked, and only established cases of glaucoma with a best corrected visual acuity (BCVA) of or more than 6 of 18 in the worse eye were included. The diagnosis of glaucoma was established after a detailed ocular examination including BCVA, anterior segment examination for anterior chamber depth, optic nerve head changes using slit lamp biomicroscopy with 90D lens, gonioscopy, corneal pachymetry, OCT–RNFL, visual field analysis, and measuring IOP (intraocular pressure) on Goldman applanation tonometry. Only after the patient had undergone all the aforementioned investigations, a diagnosis of glaucoma was made after taking into consideration the optic nerve head and visual field changes for glaucoma and corrected IOP. Individuals with normal ocular examination after performing detailed ocular examination were included as the comparison group. Participants with any kind of strabismus (manifest or latent), amblyopia, optic nerve pathway disease, or with dense media opacities were excluded from the study. A detailed medical and surgical history was taken and all the relevant positive family/drug/past history was noted. The RNFL thickness in both the eyes was measured using spectral-domain (SD)-OCT (Cirrus 500 SD-OCT, for analysis the average RNFL values of the two eyes was taken. All the participants were thereafter evaluated for stereoacuity for near (at 40 cms) and distance (at 3 m) by using near and distance Randot stereoacuity charts, Stereo Optical Co. Inc. The data recorded were subjected to statistical analysis using SPSS, version 25:00.

Results

A total of 100 participants were included in the study. In addition, 100 normal participants were taken as the comparison group.

The result was compiled and analyzed after collecting the data at the end of the study.

In the group with cases, the total number of men and women was 63 (63%) and 37 (37%), respectively. The minimum age was 11 years, and the maximum age was 86 years (average age: 61.7 ± 11.3 years).

In the control group, the total number of men and women was 48 (48%) and 52 (52%), respectively. The minimum age was 37 years, and maximum age was 78 years (average age: 57.9 ± 9.2 years).

The age and sex difference between the two groups was significant (P-value: 0.009 [age]; 0.046 [sex]).

The average RNFL thickness was 69.1μ (±19.8 SD) in the case group and 95.3μ (±17.8 SD) in the control group.

The average stereoacuity for near in the case group was 74.8 s of arc (±37.7 SD). The maximum stereoacuity for near was 20 s of arc and the minimum was 200 s of arc.

The average stereoacuity for distance in the case group was 196.6 s of arc. The maximum stereoacuity for distance was 60 s of arc and the minimum was 400 s of arc.

The average stereoacuity for near in the control group was 59.3 s of arc. The maximum stereoacuity for near was 40 s of arc and the minimum was 100 s of arc.

The average stereoacuity for distance in the control group was 178.6 s of arc, maximum stereoacuity for distance was 60 s of arc and the minimum was 400 s of arc.

The correlation between the average RNFL and absolute values of stereoacuity for near and distance was found by Spearman's correlation.

There was a significant difference between the RNFL thickness (p value = 0.001) and near stereoacuity of the case and comparison group (p value = 0.002), but there was no statistically significant difference between the absolute values for distance stereoacuity in the two groups (p = 0.140).

There was a negative correlation for the average RNFL value with the absolute values of distance and near stereoacuity in both the groups; the negative correlation in the case group was found to be more for distance stereoacuity (−0.303) than for near (−0.101) than in the comparison group which had negative correlation less for distance (−0.308) and more for near (-0.416). The correlation was significant for distance stereoacuity in both the groups (p value = 0.002) and for near stereoacuity in the comparison group only.

The negative correlation was significant for average RNFL and distance stereoacuity. However, the lower the absolute value of stereoacuity, the better is the stereoacuity functionally, therefore it can be interpreted that if the RNFL thickness decreases the absolute value of stereoacuity both for distance and near increases (negative correlation), decreasing the actual functional stereoacuity. In our study, we found that the cases with lower RNFL thickness have lower stereoacuity both for distance and near; however, it was statistically significant only for distance. However, in the comparison group, it was significant both for near and distance (Table 1, Table 2, Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6).

Table 1.

Correlation of average RNFL thickness with near and distance stereoacuity in cases.

Correlation Cases:
			Stereoacuity near	Stereoacuity distance
Spearman's rho	Average RNFL	Correlation coefficient	−0.101	−0.303
		Sig.(2-tailed)	0.318	0.002
		N	100	100

Open in a new tab

RNFL, retinal nerve fiber layer.

Table 2.

Correlation of average RNFL thickness with near and distance stereoacuity in controls.

Correlation Controls:
			Stereoacuity Near	Stereoacuity Distance
Spearman's rho	Average RNFL	Correlation coefficient	−0.416	−0.308
		Sig.(2-tailed)	0.000	0.002
		N	100	100

Open in a new tab

RNFL, retinal nerve fiber layer.

Fig. 1 — Distribution of average RNFL thickness and near stereoacuity for all cases. RNFL, retinal nerve fiber layer.

Fig. 2 — Distribution of average RNFL thickness and distance stereoacuity for cases. RNFL, retinal nerve fiber layer.

Fig. 3 — Distribution of average RNFL thickness and near stereoacuity for controls. RNFL, retinal nerve fiber layer.

Fig. 4 — Distribution of average RNFL thickness and distance stereoacuity for controls. RNFL, retinal nerve fiber layer.

Fig. 5 — Whisker graph for near stereoacuity (sec of arc) in cases and controls. RNFL, retinal nerve fiber layer.

Fig. 6 — Whisker graph for distance stereoacuity (sec of arc) in cases and controls. RNFL, retinal nerve fiber layer.

Discussion

Visual impairment associated with glaucoma is not reversible and can lead to visual disability and blindness,¹⁰ without proper treatment. Stereopsis is the ability for depth perception, and only few studies have evaluated the binocular functions in patients with glaucoma. The small ganglion cell (parvocellular) system is involved in high spatial resolution and slow temporal resolution, whereas the large ganglion cell (magnocellular) system is involved in low spatial resolution and fast temporal resolution^. There is literature to indicate that stereoscopic depth may be a function of the magnocellular pathway.²^,³ It is also hypothesized that the unequal damage due to glaucoma between two eyes may also give rise to decreased stereoacuity.

Earlier, available OCT used a time-domain technique and was known as time-domain OCT (TD-OCT). The RNFL thickness measurements performed using TD-OCT differentiated normal eyes from those with glaucoma¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷ and detected change over time,¹¹^,¹⁸^,¹⁹ but this technology had a drawback of lower resolution and slow scan speed. With the introduction of SD-OCT, the resolution and the scan speed improved, resulting in improved quantification of structural damage in glaucoma.²⁰^,²¹^,²²

Lisboa et al²³ took into consideration the RNFL, Optic Nerve Head (ONH), and macular parameters to diagnose preperimetric glaucoma and found that RNFL thickness had higher chances in detecting preperimetric glaucoma.

The diagnosis and follow-up of progression of glaucoma are based on an investigation to see the visual field defects, which shows the structural aspects.²⁴^,²⁵ More importantly, the functional and structural defects are to be correlated with the loss of RGCs²⁶^,²⁷; there are several methods proposed to quantify loss of RGCs, based on axonal loss or visual sensitivity changes but without consensus.²⁸^,²⁹

There are very few studies, which have evaluated stereoacuity as a part of functional impairment in glaucoma. One of the study carried out by Mumcuoglu et al.³⁰ has compared far and near stereoacuity by using the Mentor Binocular Visual Acuity Tester(BVAT) system and Randot test circles and concluded that patients with glaucoma have decreased distance and near stereoacuity. Their results suggested that binocular function might be impaired in cases of glaucoma.

Another study carried out by Lakshmanan³¹ compared mild., moderate, and severe glaucoma with stereoacuity and found that stereoacuity was decreased in cases having moderate visual field loss and significantly decreased in cases having involvement of fixation.

Our study also correlated well with the aforementioned studies, as we also found that in cases of glaucoma, decreased RNFL thickness is associated with the decreased levels of near and distance stereoacuity, which was statistically significant for distance stereoacuity. In the comparison group, it was significant for near and distance stereoacuity.

According to Park et al. ³² patients having glaucoma have subnormal stereoacuity which becomes worse as glaucoma progresses. They have even suggested stereoacuity assessment to identify glaucoma at an early stage.

The clinical relevance of our study is that we should also perform the baseline stereoacuity test apart from RNFL thickness and other tests performed for glaucoma and follow it up as the disease progresses, for the reason that decreased stereoacuity may be responsible partially for difficulty in performing daily activities in patients with glaucoma such as driving, coordination for near work, or even while walking. By evaluating the level of stereocauity, we can make patients aware of existence of such problems and help them by educating them and modifying their daily activities to make life more comfortable for the patients and prevent events such as falls in elderly.

The limitation of our study is the wide range in age groups included in the study and the significant difference in age and gender in the case and comparison group.

Conclusion

The evaluation of glaucoma for diagnosis and progression is based upon the structural and functional evaluation. The detection of structural changes is commonly evaluated by assessment of RNFL and macular and optic nerve head damage with SD-OCT. The assessment of functional changes is commonly perimetry based, but it may not be the only functional change associated with glaucoma. Therefore, as we found in our study that stereoacuity is affected because of changes in RNFL thickness it should also be assessed in cases of glaucoma followed-up for progression.

Conflicts of interest

The authors have none to declare.

References

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[bib2] 2.Livingstone M. Hubal D, and Segregation of form, color, movement and depth: anatomy, physiology and perception. Science. 1988;240:740–749. doi: 10.1126/science.3283936. [DOI] [PubMed] [Google Scholar]

[bib3] 3.Livingstone M.S., Hubal D.H. Psychophysical evidence for separate channels for the perception of form, color movement and depth. Neuroscience. 1987;7:3416–3468. doi: 10.1523/JNEUROSCI.07-11-03416.1987. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib4] 4.Prywes A.S. Unilateral afferent pupillary defects in asymmetric glaucoma. Arch Ophthalmol. 1976;94:1286–1288. doi: 10.1001/archopht.1976.03910040158006. [DOI] [PubMed] [Google Scholar]

[bib5] 5.Kaback M.B., Burde R.M., Becker B. Relative afferent pupillary defect in glaucoma. Am J Ophthalmol. 1976;81:462–468. doi: 10.1016/0002-9394(76)90302-0. [DOI] [PubMed] [Google Scholar]

[bib6] 6.Kohn A.N., Moss A.P., Podos S.M. Relative afferent pupillary defect in glaucoma without characteristic field loss. ArchOphthalmol. 1979;97:294–296. doi: 10.1001/archopht.1979.01020010146010. [DOI] [PubMed] [Google Scholar]

[bib7] 7.Sponsel W.E. Tonometry in question: can visual screening tests play a more decisive role in glaucoma diagnosis and management ? Surv Ophthalmol. 1989;33(suppl l):291–300. [PubMed] [Google Scholar]

[bib8] 8.Feuer W.J., Anderson D.R. Static threshold asymmetry in early glaucomatous visual field loss. Ophthalmology. 1989;96:1285–1297. doi: 10.1016/s0161-6420(89)32724-2. [DOI] [PubMed] [Google Scholar]

[bib9] 9.Donzis P.B., Rappazzo J.A., Burde R.M., Gordon M. Effect of binocular variations of snellen's visual acuity on titmus stereoacuity. Arch Ophthalmol. 1983;101:930–932. doi: 10.1001/archopht.1983.01040010930016. [DOI] [PubMed] [Google Scholar]

[bib10] 10.Leske M.C. The Epidemiology of open-angle glaucoma: a review. Am J Epidemiol. 1983;118:166. doi: 10.1093/oxfordjournals.aje.a113626. [DOI] [PubMed] [Google Scholar]

[bib11] 11.G Schuman J.S., Price L.L., Aydin A. Optical coherence tomography longitudinal evaluation of retinal nerve fiber layer thickness in glaucoma. Arch Ophthalmol. 2005;123(4):464–470. doi: 10.1001/archopht.123.4.464. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib12] 12.Medeiros F.A., Zangwill L.M., Bowd C., Vessani R.M., Susanna R., Jr., Weinreb R.N. Evaluation of retinal nerve fiber layer, optic nerve head, and macular thickness measurements for glaucoma detection using optical coherence tomography. Am J Ophthalmol. 2005;139(1):44–55. doi: 10.1016/j.ajo.2004.08.069. [DOI] [PubMed] [Google Scholar]

[bib13] 13.Manassakorn A., Nouri-Mahdavi K., Caprioli J. Comparison of retinal nerve fiber layer thickness and optic disk algorithms with optical coherence tomography to detect glaucoma. Am J Ophthalmol. 2006;141(1):105–115. doi: 10.1016/j.ajo.2005.08.023. [DOI] [PubMed] [Google Scholar]

[bib14] 14.Hougaard J.L., Heijl A., Bengtsson B. Glaucoma detection by stratus OCT. J Glaucoma. 2007;16(3):302–306. doi: 10.1097/IJG.0b013e318032e4d4. [DOI] [PubMed] [Google Scholar]

[bib15] 15.Naithani P., Sihota R., Sony P. Evaluation of optical coherence tomography and heidelberg retinal tomography parameters in detecting early and moderate glaucoma. Invest Ophthalmol Vis Sci. 2007;48(7):3138–3145. doi: 10.1167/iovs.06-1407. [DOI] [PubMed] [Google Scholar]

[bib16] 16.Parikh R.S., Parikh S., Sekhar G.C. Diagnostic capability of optical coherence tomography (Stratus OCT 3) in early glaucoma. Ophthalmology. 2007;114(12):2238–2243. doi: 10.1016/j.ophtha.2007.03.005. [DOI] [PubMed] [Google Scholar]

[bib17] 17.Nouri-Mahdavi K., Nikkhou K., Hoffman D.C., Law S.K., Caprioli J. Detection of early glaucoma with optical coherence tomography (Stratus OCT) J Glaucoma. 2008;17(3):183–188. doi: 10.1097/IJG.0b013e31815768c4. [DOI] [PubMed] [Google Scholar]

[bib18] 18.Lee E.J., Kim T.W., Park K.H., Seong M., Kim H., Kim D.M. Ability of Stratus OCT to detect progressive retinal nerve fiber layer atrophy in glaucoma. Invest Ophthalmol Vis Sci. 2009;50(2):662–668. doi: 10.1167/iovs.08-1682. [DOI] [PubMed] [Google Scholar]

[bib19] 19.Medeiros F.A., Zangwill L.M., Alencar L.M. Detection of glaucoma progression with stratus OCT retinal nerve fiber layer, optic nerve head, and macular thickness measurements. Invest Ophthalmol Vis Sci. 2009;50(12):5741–5748. doi: 10.1167/iovs.09-3715. [DOI] [PMC free article] [PubMed] [Google Scholar]

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[bib21] 21.Gonzalez-Garcia A.O., Vizzeri G., Bowd C. 2009. Reproducibility of RTVue Retinal Nerve Fiber Layer Thickness and Optic Disc Measurements and Agreement with Stratus Optical Coherence Tomography Measurements. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib22] 22.Knight O.J., Chang R.T., Feuer W.J., Budenz D.L. Comparison of retinal nerve fiber layer measurements using time domain and spectral domain optical coherent tomography. Ophthalmology. 2009;116(7):1271–1277. doi: 10.1016/j.ophtha.2008.12.032. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib23] 23.Lisboa R., Paranhos A., Jr., Weinreb R.N., Zangwill L.M., Leite M.T., Medeiros F.A. Comparison of different spectral domain OCT scanning protocols for diagnosing preperimetric glaucoma. Invest Ophthalmol Vis Sci. 2013;54(5):3417–3425. doi: 10.1167/iovs.13-11676. [DOI] [PMC free article] [PubMed] [Google Scholar]

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[bib26] 26.Tate G.W. The physiological basis for perimetry. In: Drance S.M., Anderson D.R., editors. Automatic Perimetry in Glaucoma. A Practical Guide. Grune & Stratton, Inc; Orlando: 1985. pp. 1–28. [Google Scholar]

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PERMALINK

Study of correlation between stereopsis and retinal nerve fiber layer thickness in cases of glaucoma

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Abhijit