Imaging is a valuable tool in the assessment of glaucoma and glaucoma progression. Although glaucoma is a clinical diagnosis—there is no blood test or definitive genetic test, for example, for the disease—the diagnosis has traditionally been subjective albeit based on certain physical characteristics of the patient. Over the years, the diagnosis has gone from a hard, blind, painful eye; to palpation indicating a hard eye associated with sudden pain or slow, painless visual loss; to a specifically described progressive optic neuropathy with characteristic neural damage and visual loss, sometimes associated with elevated intraocular pressure (IOP). In the mid-19th century, Helmholtz and Von Graefe enabled clinical assessment of the optic nerve head (ONH); later, fundus photography permitted objective recording of this physical parameter.1,2 Nevertheless, despite objective photographs of the ONH, subjective interpretation on the part of the clinician was necessary for identification of glaucomatous damage or progression. Different clinicians would provide discrepant interpretations of the optic nerve, and even the same observer would frequently characterize the disc differently on separate viewings of the same photograph.3 Measurement of ocular function is and has been similarly crude and subjective. From discriminating finger movement in different quadrants to discerning white objects on a black background to map the visual field in tangent screen perimetry, the patient must tell the examiner when a light or object is seen. The same is true of kinetic and static perimetry, both manual and automated. The patient must detect the object (or light) on the retina, realize that a light or object has been seen, and then inform the examiner of this fact. The evaluation is difficult as best, often tedious, and fraught with problems in reproducibility of findings. For these reasons, clinicians, scientists, and engineers have sought to objectively measure optic nerve structure and function both quantitatively and reproducibly, preferably without the requirement for patient input. In the assessment of optic nerve function, this has meant multifocal electroretinography,4 pattern electroretinography,5,6 multifocal visual evoked potential, and pattern visual evoked potential,7,8 among other tests.9 Unfortunately, none of these objective functional tests has been validated to the level of perimetry, which remains the clinical gold standard, despite its shortcomings. Automated objective, quantitative characterization of the optic nerve has been more successful. As mentioned above, the first step in this direction was optic nerve photography, particularly stereoscopic disc photography. This method enables objective recording, but still requires subjective interpretation. More sophisticated techniques, invented and/or developed in the past quarter century, include confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT). These systems capture, in different ways, objective, accurate, and precise quantitative information about optic nerve and retinal structure that does not require subjective input for measurement. Although there is objective image and segmentation algorithm quality evaluation, subjective quality assessment is still necessary to ensure that the image acquired is adequate for evaluation and that the analysis algorithm has functioned properly.
