World Journal of

WJ C C Clinical Cases
Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2023 May 16; 11(14): 3187-3194

DOI: 10.12998/wjcc.v11.i14.3187 ISSN 2307-8960 (online)

ORIGINAL ARTICLE
Retrospective Study
Value of optical coherence tomography measurement of macular
thickness and optic disc parameters for glaucoma screening in
patients with high myopia

Hua Mu, Rui-Shu Li, Zhen Yin, Zhuo-Lei Feng

Specialty type: Ophthalmology Hua Mu, Rui-Shu Li, Zhen Yin, Zhuo-Lei Feng, Department of Ophthalmology, The First
Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province,
Provenance and peer review: China
Unsolicited article; Externally peer
reviewed. Corresponding author: Hua Mu, Doctor, Department of Ophthalmology, The First Affiliated
Hospital of Harbin Medical University, No. 23 Youzheng Street, Nangang District, Harbin
Peer-review model: Single blind 150001, Heilongjiang Province, China. [email protected]

Peer-review report’s scientific

quality classification Abstract
Grade A (Excellent): 0
BACKGROUND
Grade B (Very good): 0
The basic method of glaucoma diagnosis is visual field examination, however, in
Grade C (Good): C, C
patients with high myopia, the diagnosis of glaucoma is difficult.
Grade D (Fair): 0
Grade E (Poor): 0 AIM
To explore the value of optical coherence tomography (OCT) for measuring optic
P-Reviewer: Baird PN, Australia;
disc parameters and macular thickness as a screening tool for glaucoma in
Laude MC
patients with high myopia.
Received: February 24, 2023 METHODS
Peer-review started: February 24, Visual values (contrast sensitivity, color vision, and best-corrected visual acuity)
2023 in three groups, patients with high myopia in Group A, patients with high
First decision: March 10, 2023 myopia and glaucoma in Group B, and patients with high myopia suspicious for
Revised: March 12, 2023 glaucoma in Group C, were compared. Optic disc parameters, retinal nerve fiber
Accepted: April 12, 2023 layer (RNFL) thickness, and ganglion cell layer (GCC) thickness were measured
Article in press: April 12, 2023 using OCT technology and used to compare the peri-optic disc vascular density of
Published online: May 16, 2023 the patients and generate receiver operator characteristic (ROC) test performance
curves of the RNFL and GCC for high myopia and glaucoma.

RESULTS
Of a total of 98 patients admitted to our hospital from May 2018 to March 2022,
totaling 196 eyes in the study, 30 patients with 60 eyes were included in Group A,
33 patients with 66 eyes were included in Group B, and 35 patients with 70 eyes
were included in Group C. Data were processed for Groups A and B to analyze
the efficacy of RNFL and GCC measures in distinguishing high myopia from high
myopia with glaucoma. The area under the ROC curve was greater than 0.7,
indicating an acceptable diagnostic value.

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Mu H et al. OCT in screening suspicious glaucoma

CONCLUSION
The value of OCT measurement of RNFL and GCC thickness in diagnosing glaucoma in patients
with high myopia and suspected glaucoma is worthy of development for clinical use.

Key Words: High myopia suspected glaucoma; Optical coherence tomography; Retinal nerve fiber layer
thickness; Ganglion cell layer thickness; Diagnostic efficacy

©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.

Core Tip: Glaucoma is an irreversible, blinding eye disease with a high clinical incidence that is charac-
terized by loss of visual acuity, optic disc atrophy, and visual field defects. The basic method of glaucoma
diagnosis is visual field examination, however, in patients with high myopia, the diagnosis of glaucoma is
difficult. optical coherence tomography (OCT) is a high-resolution technique that uses low-coherence light
interference to reflect light from biological tissues, allowing visualization of internal structures of the
living body via tomographic imaging. The value of OCT measurement of retinal nerve fiber layer and
ganglion cell layer thickness in diagnosing glaucoma in patients with high myopia and suspected
glaucoma is worthy of development for clinical use.

Citation: Mu H, Li RS, Yin Z, Feng ZL. Value of optical coherence tomography measurement of macular thickness
and optic disc parameters for glaucoma screening in patients with high myopia. World J Clin Cases 2023; 11(14):
3187-3194
URL: https://www.wjgnet.com/2307-8960/full/v11/i14/3187.htm
DOI: https://dx.doi.org/10.12998/wjcc.v11.i14.3187

INTRODUCTION
Glaucoma is an irreversible, blinding eye disease with a high clinical incidence that is characterized by
loss of visual acuity, optic disc atrophy, and visual field defects[1]. Studies have confirmed that
glaucoma pathogenesis involved reduced blood supply to the optic nerve and pathologically elevated
intraocular pressure[2,3].
Previously, a cup-to-disc ratio greater than 0.6 was considered to be a clinical characteristic of
glaucoma and a marker for its development. However, it was found that this ratio was also seen in high
myopia and was not specific to glaucoma[4]. Therefore, diagnosis of glaucoma in the setting of high
myopia is more difficult.
Recent studies have confirmed a correlation between glaucoma and high myopia, which has been
recognized as a risk factor for glaucoma[5]. In the early stages of glaucoma onset, abnormalities of the
fundus are similar with those of highly myopic individuals. For example, enlarged cup-to-disc ratio is
both a diagnostic clue for glaucoma and a clinical feature of high myopia[6,7]. Glaucoma can cause
irreversible damage to visual function, and clinics are constantly searching for sensitive diagnostic
indicators that can support the aim of early intervention[8].
Degenerative morphological changes in the fundus of highly myopic patients are the pathological
basis for abnormal visual function. When glaucoma is comorbid with myopia, the retinal photoreceptor
structure is significantly disturbed, and the patient’s regulatory response during visualization is
significantly worse than that of patients with pure myopia, resulting in a significant decrease in contrast
sensitivity (CS). Previous studies have confirmed that color vision (CV) and best-corrected visual acuity
(BCVA) are worse in patients with high myopia when it is combined with glaucoma[9]. It has been
noted that in high myopia, thinning of the superior and inferior, as opposed to nasal, retinal nerve fiber
layer (RNFL) thickness did not correlate well with myopic refraction; therefore, upon observation of
this, RNFL damage due to glaucoma must be watched out for[10].
The basic method of glaucoma diagnosis is visual field examination; however, studies have shown
that retinal ganglion cell damage may be present already before the development of visual field defects
in glaucoma patients[11]. optical coherence tomography (OCT) is a high-resolution technique that uses
low-coherence light interference to reflect light from biological tissues, allowing visualization of internal
structures of the living body via tomographic imaging[12]. It is commonly used to measure parameters
of the ocular RNFL and ganglion cell layer (GCC). The results of this method are in good agreement
with histological testing and have been widely used in the diagnosis and follow-up of glaucoma. It has
been clinically established[13] that the retinal plexiform layer, ganglion cell layer, and nerve fiber layer
collectively constitute the macular ganglion cell complex, and the measurement of GCC thickness can
assess ganglion cell loss. This technique accurately reflects retinal ganglion cell apoptosis and nerve
fiber loss in glaucoma[14]. Many studies have confirmed the high sensitivity and validity of OCT for

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 Mu H et al. OCT in screening suspicious glaucoma

glaucoma diagnosis[15,16].
This study applied OCT to the assessment of high myopia comorbid with glaucoma, evaluated its
diagnostic value for glaucoma, and assessed the screening value of parameters such as optic disc
parameters and macular thickness measured by OCT.

MATERIALS AND METHODS

Enrollment criteria
Patient who were enrolled into our hospital. Inclusion criteria were as follows: (1) All patients had
myopia with refractive error greater than -6.00 D, and the patient’s degree did not increase within 2
years, meeting the diagnostic criteria for high myopia; (2) Group B patients had elevated intraocular
pressure on clinical examination, characteristic changes in the optic disc, open atrial angle, and a certain
degree of visual field defect, meeting the diagnostic criteria for glaucoma in the Expert Consensus on
Glaucoma Diagnosis and Treatment in China[17]; and (3) Group C patients had one or more of the
following features in clinical examination: Open anterior chamber angle; persistent elevation of
intraocular pressure; structural changes in the optic nerve suggesting glaucoma; suspicious early
glaucomatous changes by visual field examination.
Exclusion criteria were as follows: (1) Optic nerve or retinal disease; (2) Family history of glaucoma;
(3) Resistance of a patient to the study; (4) Ocular disease; and (5) Other diseases that may cause ocular
pathology, such as intracranial pathology, hypertension, and diabetes.
All patients have given written informed consent.

Methods
OCT examination: The patient was instructed to sit with the lower jaw in the jaw frame and the pupil in
its natural state without dialation. Spectralis OCT (Heidelberg, German was used for the examination.
The scan was started with the central macular recess as the center, the scan diameter was set at 7 mm,
and the depth was 5 μm. The thickness of the upper and lower macula and the average GCC and the
general loss of volume (GLV) and focal loss of volume (FLV) were recorded. The thickness of the retinal
nerve fiber layer (RNFL) of quadrant measurements (whole circumference, upper and lower quadrants,
temporal side, and nasal side) in the Group A, B, and C was automatically measured and recorded by
the instrument system, with the optic papilla as the center, and the scanning depth was set at 5 μm and
the diameter was 3.45 mm.

Observation indicators
General ophthalmologic examination was performed on all patients, and their visual values, including
CS, CV, and BCVA, were recorded. OCT was performed on all patients to record peripapillary
parameters including optic cup area, optic disc area, cup/disc area ratio, and cup/disc diameter ratio.

Statistical methods
SPSS 23.0 (IBM, Amonk, New York, United States) was used to process the data. The F-test was
performed for each patient measure (clinical examination data, RNFL thickness, optic disc parameters,
mean GCC thickness, and peripapillary vascular density of patients), and the receiver operator charac-
teristic (ROC) curve was used to determine the diagnostic value for high myopia accompanied by
glaucoma at the level of α = 0.05.
Patients in the three groups were compared for each retinal quadrant and the superior, inferior, and
mean GCC thicknesses were compared to record the patients’ GLV and FLV. The ROC curve for the
diagnostic value of RNFL and mean GCC for high myopia comorbid with glaucoma was constructed
after comparing the patients’ peripapillary vascular density.

RESULTS
Ninety-eight patients (196 eyes) who were admitted to our hospital from May 2018 to March 2022 were
included in the study, including 30 patients with 60 eyes with high myopia (Group A), 33 patients with
66 eyes with high myopia accompanied by glaucoma (Group B), and 35 patients with 70 eyes with high
myopia suspected of glaucoma (Group C). There was no statistically significant difference in the
baseline information of the three groups (Table 1), with high comparability (P > 0.05).
The visual value levels (of CS, CV, and BCVA) of the three groups were compared, and significant
differences were observed (P < 0.05). Compared to Group A, the CS, CV, and BCVA levels of Groups B
and C were lower, but the values in Group C were higher than those in Group B, and the differences
were statistically significant (P < 0.05) (Table 2).

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Mu H et al. OCT in screening suspicious glaucoma

Table 1 Comparison of baseline data between the three patient groups (mean ± SD, n)

Group Age (yr) Gender (male/female) Equivalent sphere diameter (D) Mean refraction (D)
Group A (n = 60) 36.45 ± 3.78 22/38 -1.78 ± 2.21 -0.44 ± 1.56

Group B (n = 66) 35.48 ± 3.24 30/36 -2.16 ± 2.15 0.65 ± 2.45

Group C (n = 70) 36.15 ± 3.12 36/34 -2.57 ± 2.45 -1.05 ± 2.15

2
F/χ value 1.384 2.858 1.949 1.430

P value 0.253 0.240 0.145 0.242

Table 2 Comparison of contrast sensitivity, color vision, and best-corrected visual acuity levels among three groups (mean ± SD, n)

Group CS CV BCVA
Group A (n = 60) 96.45 ± 1.78 0.94 ± 0.08 0.97 ± 0.08

Group B (n = 66) 87.48 ± 1.24a 0.81 ± 0.05a 0.87 ± 0.15a

Group C (n = 70) 89.15 ± 1.12a,b 0.87 ± 0.02a,b 0.91 ± 0.11a,b

F value 32.163 90.314 11.430

P value 0.000 0.000 0.000

a
P < 0.05 vs group A.
b
P < 0.05 vs group B.
CS: Contrast sensitivity; CV: Color vision; BCVA: Best-corrected visual acuity.

There was no significant difference in the cup-to-disc area ratio among the three groups (P > 0.05);
however, there were statistically significant differences in cup area, optic disc area, and cup/disc
diameter ratio among all groups. The values of Groups B and C were significantly higher than those of
Group A, and the area of the optic disc and cup/disc diameter ratio of Group C were significantly
smaller than those of Group B (P < 0.05) (Table 3).
RNFL thicknesses in all quadrants (whole circumference, upper and lower quadrant, temporal side,
and nasal side) were statistically different among the three groups. Compared with Group A, RNFL
thickness in the whole circumference, upper and lower quadrants, and nasal side decreased in Groups B
and C, and Group C was greater than that in Group B. The temporal RNFL thickness in Groups B and C
was significantly higher than that in Group A, and the temporal RNFL thickness in Group C was
significantly lower than that in Group B (P < 0.05) (Table 4).
The upper, lower, and mean GCC thickness and GLV and FLV values between the three groups
decreased in Groups B and C, and each GCC thickness in Group C was greater than that in Group B;
GLV and FLV in Groups B and C were higher than those in Group A, and Group C was lower than
Group B, with statistical significance (P < 0.05). The comparison of capillary density around the optic
disc among the three groups showed statistically significant differences in other regions but not in the
comparison of capillary density in the optic disc (P < 0.05). The hologram, vascular density beside and
within the optic disc, and capillary density beside the optic disc of Groups B and C were reduced to
varying degrees, and the values of Group C were higher than those of Group B, and the difference was
statistically significant (P < 0.05) (Table 5).

DISCUSSION
This study investigated the value of OCT measurement of peripapillary parameters and macular
thickness as a screening test for patients with high myopia and suspected glaucoma.
There was no significant difference in the cup-to-disc area ratio between the groups when
peripapillary parameters were compared. With the increase in the ocular axis of the eye that occur in
high myopia, the myopic arcs gradually atrophied, some dimensions correlated with the those of disc
defect, and the cup-disc area ratio also changed. Therefore, the change in cup-to-disc area ratio can only
be used as an auxiliary indicator.
When combined with the measurements used in this study, the optic cup area, optic disc area, and
cup/disc diameter ratio were significantly different among the three groups. Therefore, the above
indicators can be applied in combination with a view to improve the effectiveness of screening for
glaucoma suspected of high myopia. In this study, the CS, CV, and BCVA levels in the three groups

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 Mu H et al. OCT in screening suspicious glaucoma

Table 3 Comparison of weekly parameters in the three groups (mean ± SD, n)

Group Optic cup area (mm) Optic disc area (mm) Cup/disc area ratio Cup/disc diameter ratio
Group A (n = 60) 1.02 ± 0.81 2.82 ± 0.88 0.34 ± 0.21 0.56 ± 0.05

Group B (n = 66) 1.31 ± 0.75a 3.87 ± 0.87a 0.37 ± 0.22 0.61 ± 0.06a

Group C (n = 70) 1.42 ± 0.65a 3.45 ± 0.75a,b 0.35 ± 0.18 0.59 ± 0.04a,b

F value 4.890 25.691 0.369 15.672

P value 0.009 0.000 0.692 0.000

a
P < 0.05 vs group A.
b
P < 0.05 vs group B.

Table 4 Retinal nerve fiber layer thickness in each of the three groups (mean ± SD, n)

Group Complete cycle (μm) Upper quadrant (μm) Lower quadrant (μm) Temporal side (μm) nasal side (μm)
Group A (n = 60) 109.12 ± 10.54 133.23 ± 7.87 130.23 ±5.54 111.23 ± 5.36 60.45 ± 3.45
a a a a
Group B (n = 66) 102.78 ± 9.23 125.65 ± 7.54 121.32 ± 5.45 123.45 ± 5.21 56.45 ± 2.98a

Group C (n = 70) 106.45 ± 10.21a,b 129.87 ± 8.56a,b 127.63 ± 5.78a,b 115.46 ± 5.14a,b 58.45 ± 2.12a,b

F value 4.212 14.177 42.888 89.611 30.552

P value 0.016 0 0 0 0

a
P < 0.05 vs group A.
b
P < 0.05 vs group B.

Table 5 Comparison of mean ganglion cell layer thickness and general loss of volume and focal loss of volume in the three groups
(mean ± SD, n)

Group Upper GCC (μm) Bottom GCC (μm) Mean GCC (μm) GLV (%) FLV (%)
Group A (n = 60) 94.15 ± 6.78 92.45 ± 7.45 92.56 ± 7.45 5.16 ± 4.12 1.36 ± 1.12
a a a a
Group B (n = 66) 71.45 ± 6.56 78.26 ± 11.65 73.66 ± 8.12 23.15 ± 8.97 7.54 ± 4.85a

Group C (n = 70) 83.54 ± 5.54a,b 82.64 ± 8.78a,b 82.43 ± 8.26a,b 15.05 ± 8.78a,b 3.88 ± 2.56a,b

F value 205.836 36.474 88.326 85.061 57.448

P value 0 0 0 0 0

a
P < 0.05 vs group A.
b
P < 0.05 vs group B.
GCC: Ganglion cell layer; GLV: General loss of volume; FLV: Focal loss of volume.

were also compared, and statistically significant differences were found between the groups. We also
found that these values decreased sequentially in Groups A, C, and B. These facts suggest that the above
indices are more likely to be affected in patients with high myopia and glaucoma. Therefore, an effective
method for the early assessment of retinal ganglion cell abnormalities is more meaningful when
screening for glaucoma in the setting of high myopia. When RNFL thickness in the outer macular ring
region was measured in the three groups in this study, the temporal side was found to be the thinnest
and the other quadrants to be thicker, which were consistent with clinically-recognized anatomical
features.
In this study, we further compared the differences between the three groups and found statistical
differences in RNFL thickness in each orbital quadrant (whole circumference, upper and lower
quadrants, temporal side, and nasal side), with thicker RNFL in the upper and lower quadrants next to
the optic disc in each group, followed by the temporal and nasal side. The full circumferential, upper
and lower quadrant, and nasal RNFL thickness in patients with high myopia accompanied by glaucoma
were the smallest among the three groups, while the temporal side was the largest. Previous studies
have confirmed that CV and BCVA were worse in patients with high myopia combined with glaucoma

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Mu H et al. OCT in screening suspicious glaucoma

[14], and the present study yielded consistent results.

It is suggested that the above index characteristics can be used to screen for glaucoma with suspected
high myopia. The analysis was as follows: The high myopia-suspect glaucoma population may already
have nerve fiber layer loss and ganglion cell damage, with the phenomenon more pronounced in
patients with comorbid glaucoma. In high myopia with glaucoma, the temporal optic disc undergoes
significant tilting and anticlockwise transposition, resulting in an overlap of retinal temporal fiber
bundles and a significant increase in temporal RNFL thickness[18].
The efficacy of the GCC thickness parameter has been found to be better than that of the RNFL
thickness parameter for the diagnosis of glaucoma[19]. In this study, GCC thickness was found to be
minimal in Group B—significantly lower than those in the other two groups—and significantly lower in
that in Group C than that in Group A. It has been suggested that the GCC can be used to screen people
with high myopia and glaucoma. Structural changes in the macular optic ganglion cell complex can
affect the function of this layer of the retina, which may account for the different sensitivities of the GCC
and RNFL. Retinal ganglion cell apoptosis and axonal damage are among the pathological changes in
glaucoma; therefore, GCC thickness testing is more commonly used and more effective.
Indicators, such as GLV and FLV, can assess optic nerve atrophy and changes in visual function, such
as visual acuity and visual field. In the present study, the highest values of these indices were found in
patients with high myopia comorbid with glaucoma, and GLV and FLV measured the average amount
of loss in the whole and local GCC. The results confirmed that the GCC was significantly thinner in
patients with high myopia accompanied by glaucoma. The altered GLV and FLV values are consistent
with the pathological basis of glaucoma.
The results of this study showed that whole-image vascular density, intra- and near-optic disc
density, and peri-optic capillary density were significantly lower in Groups A, C, and B, with statistical
significance between the groups. It has been clinically established that the above indices were reduced
to a greater extent in high myopia accompanied by glaucoma than in high myopia alone[20], and the
AUC values for pars plana vascular density analyzed in that study were higher than those for the intra-
optic disc. The results of the present study are similar to those of the previous studies.
Numerous studies have used OCT as the primary method for examining glaucoma. The present
study showed that changes in RNFL thickness and each GCC parameter were more obvious in the
population with high myopia comorbid with glaucoma, and the efficacy of diagnosing high myopia
with glaucoma was higher. In highly myopic eyes with significant tilted degeneration of the optic disc,
segmentation of the optic nerve fiber stratification measured by OCT occurs with a large error, and the
combined analysis of OCT parameters was a meaningful method. The sample size of each group in this
study was small and did not consider the effect of other relevant factors on the results. Further studies
are required to improve the screening of high myopia with glaucoma.

CONCLUSION
In conclusion, OCT measurement of RNFL and GCC thickness is of diagnostic value for glaucoma with
suspected high myopia and is worthy of clinical promotion.

ARTICLE HIGHLIGHTS
Research background
Glaucoma is an irreversible, blinding eye disease with a high clinical incidence that is characterized by
loss of visual acuity, optic disc atrophy, and visual field defects. The basic method of glaucoma
diagnosis is visual field examination, however, in patients with high myopia, the diagnosis of glaucoma
is difficult.

Research motivation
Optical coherence tomography (OCT) is a high-resolution technique that uses low-coherence light
interference to reflect light from biological tissues, allowing visualization of internal structures of the
living body via tomographic imaging. It is commonly used to measure parameters of the ocular retinal
nerve fiber layer and ganglion cell layer.

Research objectives
This study was to explore the value of OCT for measuring optic disc parameters and macular thickness
as a screening tool for glaucoma in patients with high myopia. The results could promote the
improvement of the diagnosis of glaucoma in patients with high myopia and suspected glaucoma.

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 Mu H et al. OCT in screening suspicious glaucoma

Research methods
Visual values in patients with high myopia in, patients with high myopia and glaucoma, and patients
with high myopia suspicious for glaucoma were compared. Optic disc parameters, retinal nerve fiber
layer thickness (RNFL), and ganglion cell layer (GCC) thickness were measured using OCT technology
and used to compare the peri-optic disc vascular density of the patients and generate receiver operator
characteristic test performance curves of the RNFL and GCC for high myopia and glaucoma.

Research results
The visual value levels of the three groups were significantly different. There were statistically
significant differences in cup area, optic disc area, and cup/disc diameter ratio among all groups. RNFL
thicknesses in all quadrants were statistically different among the three groups. The area under the ROC
curve was greater than 0.7, indicating an acceptable diagnostic value.

Research conclusions
The value of OCT measurement of RNFL and GCC thickness in diagnosing glaucoma in patients with
high myopia and suspected glaucoma is worthy of development for clinical use.

Research perspectives
Further studies with large sample and other relevant factors are required to improve the screening of
high myopia with glaucoma.

FOOTNOTES
Author contributions: Mu H designed the research study; Li RS performed the research; Mu H and Yin Z analyzed
the data and wrote the manuscript; all authors have read and approve the final manuscript.

Institutional review board statement: The study was reviewed and approved by the [The First Affiliated Hospital of
Harbin Medical University] Institutional Review Board.

Informed consent statement: The informed consent was obtained from every patient.

Conflict-of-interest statement: There is no conflict of interest.

Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at
[email protected].

Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by
external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-
NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is properly cited and the use is non-
commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Country/Territory of origin: China

ORCID number: Hua Mu 0000-0002-5224-3405; Rui-Shu Li 0000-0003-0463-672X; Zhen Yin 0000-0002-9095-518X; Zhuo-
Lei Feng 0000-0001-9383-5661.

S-Editor: Ma YJ
L-Editor: A
P-Editor: Zhao S

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