The Evolving Role of the Relationship between Optic Nerve Structure and Function in Glaucoma

The relationship between functional vision loss and structural changes of the optic nerve head and retinal ganglion cells is the hallmark of glaucoma diagnosis. Understanding and measuring this relationship has been the focus of numerous studies, the goal of which have been to improve glaucoma diagnosis and detection of glaucoma worsening. In this review, a historical perspective is used to understand structure–function relationships in glaucoma and their application to improve glaucoma diagnosis and monitoring. Initially, histologic studies that link visual field sensitivity to retinal ganglion cell count are discussed. Additionally, those studies that determined the mathematical relationship between visual field sensitivity and ganglion cell number are reviewed. Next, those studies that attempt to create a map of the structure–function relationship using fundus photography and visual field sensitivity are examined. Subsequently, studies that use more recent imaging technology, such as optical coherence tomography, confocal scanning laser ophthalmoscopy, or scanning laser perimetry, to measure structure quantitatively in vivo and to correlate these measures with automated perimetry are explored. Among these studies that use advanced imaging, those that use cross-sectional data to explore structure–function relationships to improve glaucoma diagnosis first are discussed. Second, those studies that use longitudinal data to improve detection of worsening are reviewed. Finally, areas of further research and steps needed to implement structure–function relationships clinically are explored.