Nerve-Fiber Layer Assessment

[Optogal]

Hi folks

Anyone have any good resources they know that explain how to assess the nerve-fiber layer using fundus assessment techniques? (not imaging instruments)

My major proctor through school was an old-school OMD who felt NFL assessment was "smoke and mirrors" so I never actually learned.

Any help would be appreciated.

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[Meibomian SxN]

Hi folks

Anyone have any good resources they know that explain how to assess the nerve-fiber layer using fundus assessment techniques? (not imaging instruments)

My major proctor through school was an old-school OMD who felt NFL assessment was "smoke and mirrors" so I never actually learned.

Any help would be appreciated.

Many of the Review of Optometry, Review of Ophthalmology etc magazines have up to date articles and CE articles on assessing RNFL. You could also check some of the literature journals as well.

 

[Optogal]

Can you suggest any articles?

I googled "how to assess nerve fiber layer" before creating this thread and only found scientific articles. I'm kinda looking for the type of "professional" articles you describe.

Now when I google "how to assess nerve fiber layer", this thread is the first hit...

 

[PBEA]

don't waste your time, even the imaging devices for NFL are imperfect, and doing it by "eye" is only more so.

 

[hfpepperbean47]

I don't necessarily agree with the last post. The assessment of a patient's NFL can mean very much - especially when you work with a large population of glaucoma patients. You can detect NFL defects by eye, which is enhanced by the use of red-free filter. Of course it is imperfect - but technology changes pretty fast and I think it is a disservice to dismiss it as not being important just because its not perfect. Is a visual field perfect? Nothing is. I don't understand why the previous post stated that it is a waste of time.

 

[PBEA]

As a student, sure learn it, understand it, but don't expect it will add much. I would always just use a digital NFL analysis, why bother doing it by eye?. To me thats like performing a tangent screen vs HVF. No real point in doing the tangent screen, and I wouldnt trust it anyway. Just my 2 cents.

 

[Meibomian SxN]

don't waste your time, even the imaging devices for NFL are imperfect, and doing it by "eye" is only more so.

As a student, sure learn it, understand it, but don't expect it will add much. I would always just use a digital NFL analysis, why bother doing it by eye?. To me thats like performing a tangent screen vs HVF. No real point in doing the tangent screen, and I wouldnt trust it anyway. Just my 2 cents.

You ALWAYS should not just look at the nerve, but ANALYZE the nerve! This can not be emphasized enough. The digital NFL machines are just that, a machine. They are a help and can only tell you so much about the nerve. You are the doctor, you need to assess how the nerve looks and possibly functions.

You do not need a NFL machine to treat glaucoma, and if you believe different then that is a failure of your teachers!

Can you suggest any articles?

I googled "how to assess nerve fiber layer" before creating this thread and only found scientific articles. I'm kinda looking for the type of "professional" articles you describe.

Now when I google "how to assess nerve fiber layer", this thread is the first hit...

When I look at the nerve, instantly I am asking myself:

1) How big is the nerve itself and its description? (small, large, tilted, oblique, round, notched etc)
2) What color is the rim tissue? (pink, pale, optic nerve pits, PPA etc)
3) How large is the cupping and I compare that OD/OS?
4) What do the vessels look like?
4) ISN'T rule?

The list could go on and on...

One good source would be to look to see article by Murray Fingeret, OD. He gives excellent ways to analyze the ONH & RNFL. Ron Melton & Randall Thomas, OD are also excellent in their glaucoma series. Also check out http://www.optometricglaucomasociety.org

Its good to read how medical oriented ODs and glaucoma experts (not general ophthalmologists) analyze the ONH. You'll be surprised and amazed at how each person critically thinks about each case. And with time we'll all get to their seasoned level.

I'll keep my eye out for any articles etc and send them.

 

[Optogal]

1) How big is the nerve itself and its description? (small, large, tilted, oblique, round, notched etc)
2) What color is the rim tissue? (pink, pale, optic nerve pits, PPA etc)
3) How large is the cupping and I compare that OD/OS?
4) What do the vessels look like?
4) ISN'T rule?

I think most folks know this.

But I'm talking about the NFL, not assessing the optic disc.

 

[MR1]

Coming from a ophtho resident so may not be up to Meibomian's standards but as far as analyzing NFL with your eyes and not the OCT. The NFL is best seen with the red-free and you can tell if it is thinned (obviously we care most about superior and inferior bundle so look here). This mainly just helps you if you are trying to make the diagnosis of glaucoma b\c you can see thinned or not.

As far as tracking it for a change, if it is normal and then on fu it isn't, well that helps but to monitor a thinned NFL for worsening would be hard unless you take good red-free pics every visit. In that case I would just use OCT to monitor a thinned NFL for getting worse.

Here I actually agree with PBEA!!, but would take his HVF one step further, trying to monitor NFL for worsening with only your eyes is like following glaucoma with Confrontational VF not HVF

 

[Meibomian SxN]

Coming from a ophtho resident so may not be up to Meibomian's standards but as far as analyzing NFL with your eyes and not the OCT. The NFL is best seen with the red-free and you can tell if it is thinned (obviously we care most about superior and inferior bundle so look here). This mainly just helps you if you are trying to make the diagnosis of glaucoma b\c you can see thinned or not.

As far as tracking it for a change, if it is normal and then on fu it isn't, well that helps but to monitor a thinned NFL for worsening would be hard unless you take good red-free pics every visit. In that case I would just use OCT to monitor a thinned NFL for getting worse.

Here I actually agree with PBEA!!, but would take his HVF one step further, trying to monitor NFL for worsening with only your eyes is like following glaucoma with Confrontational VF not HVF

Sorry, I misread. In that case I agree with both, in that case there's nothing much to see at the NFL with the eye except if you see any wedge defects. In terms of thinning, the machines can see what we can not.