Confocal Optical Coherence Research Articles

Detailed corneal and genetic characteristics of a pediatric patient with macular corneal dystrophy - case report

BackgroundCorneal dystrophies are a group of rare, inherited disorders that are usually bilateral, symmetric, slowly progressive, and not related to environmental or systemic factors. The majority of publications present the advanced form of the disease with a typical clinical demonstration. The initial signs and symptoms of different epithelial and stromal corneal dystrophies are not specific; therefore, it is very important to establish the early characteristic corneal features of these disorders that could guide the diagnostic process.Case presentationThe main purpose of this study was to report the differential diagnosis of a pediatric patient with bilateral anterior corneal involvement suspected of corneal dystrophy. An 8-year-old male patient presented with asymptomatic, persistent, superficial, bilateral, diffuse, anterior corneal opacities. Slit lamp examination results were not specific. Despite the lack of visible stromal involvement on the slit lamp examination, corneal analysis based on confocal microscopy and optical coherence tomography revealed characteristic features of macular corneal dystrophy (MCD). The diagnosis of MCD was confirmed by CHST6 gene sequencing. The early corneal characteristic features of MCD, established based on the findings of this case report, include corneal astigmatism (not specific), diffuse corneal thinning without a pattern of corneal ectasia (specific), and characteristic features on confocal microscopy (specific), including multiple, dark, oriented striae at different corneal depths.ConclusionsThe clinical examination should be complemented with corneal imaging techniques, such as confocal microscopy and optical coherence tomography. In patients suspected of corneal dystrophy, genetic testing plays an important role in establishing the final diagnosis.

Corneal hysteresis as a risk factor for optic nerve head surface depression and retinal nerve fiber layer thinning in glaucoma patients

To evaluate the role of corneal hysteresis (CH) as a risk factor for progressive ONH surface depression and RNFL thinning measured by confocal scanning laser ophthalmoscopy (CSLO) and spectral-domain optical coherence tomography (SD-OCT), respectively in glaucoma patients. Prospective study. A total of 146 eyes of 90 patients with glaucoma were recruited consecutively. The CH measurements were acquired at baseline and 4-months interval using the Ocular Response Analyzer (Reichert Instruments, Depew, NY). Eyes were imaged by CSLO (Heidelberg Retinal Tomograph [HRT]; Heidelberg Engineering, GmbH, Dossenheim, Germany) and SD-OCT (Cirrus HD-OCT; Carl Zeiss Meditec AG, Dublin, CA) at approximately 4-month intervals for measurement of ONH surface topography and RNFL thickness, respectively. Significant ONH surface depression and RNFL thinning were defined with reference to Topographic Change Analysis (TCA) with HRT and Guided Progression Analysis (GPA) with Cirrus HD-OCT, respectively. Multivariate cox proportional hazards models were used to investigate whether CH is a risk factor for ONH surface depression and RNFL progression after adjusting potential confounding factors. All patients with glaucoma were followed for an average of 6.76 years (range, 4.56–7.61 years). Sixty-five glaucomatous eyes (44.5%) of 49 patients showed ONH surface depression, 55 eyes (37.7%) of 43 patients had progressive RNFL thinning and 20 eyes (13.7%) of 17 patients had visual field progression. In the cox proportional hazards model, after adjusting baseline diastolic IOP, CCT, age, baseline disc area and baseline MD, baseline CH was significantly associated with ONH surface depression and visual field progression (HR = 0.71, P = 0.014 and HR = 0.54, P = 0.018, respectively), but not with RNFL thinning (HR = 1.03, P = 0.836). For each 1-mmHg decrease in baseline CH, the hazards for ONH surface depression increase by 29%, and the hazards for visual field progression increase by 46%. The CH measurements were significantly associated with risk of glaucoma progression. Eyes with a lower CH were significantly associated with an increased risk of ONH surface depression and visual field progression in glaucoma patients.

Multimodal imaging of Hurler syndrome-related keratopathy treated with deep anterior lamellar keratoplasty

BackgroundHurler syndrome-associated keratopathy is an exceedingly rare corneal disorder that requires corneal transplantation in advanced stages. Precise assessment of the corneal condition is necessary for deciding which type of keratoplasty (i.e., deep anterior lamellar or penetrating) should be proposed. We aimed to confront the results of multimodal imaging with those of histology in a case of Hurler syndrome-associated keratopathy.Case presentationA 16-year-old patient with Hurler’s syndrome treated with hematopoietic stem cell transplantation was referred for decreased vision related to advanced keratopathy. The patient was treated with deep anterior lamellar keratoplasty (DALK) in both eyes with uncomplicated outcome. Visual acuity improved from 0.1 (20/200) preoperatively to 0.32 (20/63) and 0.63 (20/32) after transplantation. The corneal endothelial cell density was 2400 cells/mm2 in both eyes 3 years after transplantation. In vivo confocal microscopy (IVCM) and spectral domain optical coherence tomography (SD-OCT) were performed preoperatively. The corneal buttons retrieved during keratoplasty were processed for histology. In SD-OCT scans, corneal opacities appeared as diffuse stromal hyperreflectivity associated with increased corneal thickness. IVCM showed diffuse cytoplasmic granular hyperreflectivity and rounded/ellipsoid aspects of keratocytes, presence of small intracellular vacuoles, and hyperreflective epithelial intercellular spaces. Bowman’s layer was thin and irregular. The corneal endothelium was poorly visualized but no endothelial damage was observed. Histology showed irregular orientation and organization of stromal lamellae, with the presence of macrophages whose cytoplasm appeared clear and granular. A perinuclear clear halo was visible within the epithelial basal cells. Bowman’s layer featured breaks and irregularities.ConclusionsThe observed corneal multimodal imaging features in mucopolysaccharidosis-related keratopathy were concordant with histology. Compared with standard histology, multimodal imaging allowed additional keratocyte features to be observed. It revealed both morphological and structural changes of all corneal layers but the endothelium. This information is essential for therapeutic management which should include DALK as the first-choice treatment in case of impaired visual acuity.

Influence of Inflammation in Uveitis on Confocal Scanning Laser Tomography and Optical Coherence Tomography Measurements

ABSTRACT Purpose: To evaluate the influence of active inflammation in uveitis on confocal scanning laser tomography (CSLT) and optical coherence tomography (OCT) measurements. Methods: Prospective enrollment of patients (64 eyes) with non-infectious uveitis. Retinal nerve fiber layer (RNFL), rim-area and -volume for CSLT and Bruch’s-membrane-opening minimum-rim-width (BMO-MRW) and retinal nerve fiber layer thickness (RNFL-O) for OCT were recorded. Results: No significant differences between eyes with active inflammation (31) vs no inflammation (33) were observed for all investigated CSLT parameters and BMO-MRW. The RNFL-O in OCT was significantly increased (1st p = .0439, 2nd p = .0327, 3rd p = .0313) while actively inflamed. CSLT did not show a significant difference between glaucomatous and non-glaucomatous eyes albeit all OCT derived parameters did. Conclusion: CSLT measurements were not affected by inflammation but unreliable in glaucomatous eyes. RNFL-O was significantly influenced by inflammation while BMO-MRW was not. BMO-MRW seems to be the best approach in uveitic eyes.

Non-invasive Imaging for Skin Cancers—the European Experience

The aim of this work is to review the role of advanced non-invasive imaging, such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT), in malignant melanomas and non-melanoma skin cancers (NMSCs) using data coming from the most recent literature, with a particular highlight on the results of the European experience. Examination with RCM and OCT increases the accuracy of diagnosis. The most recent diagnostic clues for melanoma and NMSCs are revised. In addition, the application of these techniques in presurgical margin definition and in monitoring the efficacy of topical therapies is discussed. Skin cancer incidence is continuously increasing. While melanoma and squamous cell carcinoma are high-risk skin cancers, basal cell carcinoma can progressively infiltrate and damage the surrounding tissues. Physicians should consider that advanced non-invasive techniques may be employed for an early and accurate diagnosis and an improved management of skin cancers.

Amniotic Membrane Transplant for Bullous Keratopathy: Confocal Microscopy & Anterior Segment Optical Coherence Tomography

ABSTRACTPurpose: To assess amniotic membrane retention after amniotic membrane transplant in bullous keratopathy patients and whether there were any corneal structural changes that may hinder further penetrating keratoplastyMethods: A retrospective study including 22 patients who have undergone amniotic membrane transplant from 1 Jan 1998 till 30 Jun 2016. Confocal microscopy and anterior segment optical coherence tomography (ASOCT) were performed to assess the retention of amniotic membrane and to detect any corneal structural changes. The comparison was made with 5 controls who had bullous keratopathy awaiting endothelial keratoplasty.Results: Patients had a mean follow-up of 61 ± 33.7 months. Pain reduction was significant (p < .001) although it did not significantly correlate with the regularity of the superficial, intermediate or basal epithelial layers, nor with the retention of the amniotic membrane. No long-term structural changes that may hinder future penetrating keratoplasty were detected.Conclusion: This procedure is a safe and effective long-term treatment for symptomatic bullous keratopathy patients.

Abstract WP94: Association of Corneal and Retinal Nerves With Cerebral Small Vessel Disease in Patients With Acute Ischemic Stroke

Introduction: Cerebral small vessel disease (SVD) confers an increased risk of stroke, dementia and death. Corneal confocal microscopy (CCM) and Optical Coherence Tomography (OCT) are ophthalmic instruments which can detect neuronal loss non-invasively and may be useful surrogate markers for white matter disease (WMD). Hypothesis: To determine whether corneal and retinal nerve pathology identified using CCM and OCT, respectively, are associated with cerebral SVD in patients with acute ischemic stroke. Methods: 248 patients admitted with acute ischemic stroke underwent CCM to quantify corneal nerve fiber density (CNFD), corneal nerve fiber length (CNFL), corneal nerve branch density (CNBD) and OCT to quantify central foveal ganglion cell complex (CF-GCC). SVD was graded in periventricular (PV) and deep white matter (DWM) regions according to the Fazekas scale and white matter hyperintensities (WMH) were quantified. Statistical analysis was performed using ANOVA and multiple regression. Results: DWMSVD and PVSVD were absent (50%,40%) or present with mild (37%,37%), moderate (9%,16%) and severe (4%,7%) severity in patients with acute ischemic stroke. CNFD was significantly lower in patients with mild PVSVD (P=0.02) and severe PVSVD (P=0.004) and DWMSVD (P=0.026) compared to no SVD. CNBD was significantly lower in patients with severe PVSVD (P=0.020) compared to no PVSVD. CF-GCC was significantly lower in patients with moderate PVSVD (P=0.012) and DWMSVD (P=0.044) and severe PVSVD (P=0.012) compared to no SVD. Comparing patients with and without WMH, CF-GCC was significantly lower (P=0.045), but there was no difference for CCM. Multiple regression analysis showed an association between CNFD and PVSVD severity (β= –1.416, P=0.014) and triglyerides (β=1.146, P=0.016). There was no correlation between DWSVD and PVSVD with age, cholestrol, HbA 1c or blood pressure. Conclusions: Corneal confocal microscopy and optical coherence tomography allow rapid non-invasive identification of corneal and retinal nerve pathology in patients with moderate and severe SVD. Furthermore, corneal nerve fibre density correlates with the severity of PVSVD and triglycerides.

Pseudo‐Kaposi sarcoma: report of a case investigated by dermoscopy, reflectance confocal microscopy and optical coherence tomography

Pseudo‐Kaposi sarcoma: report of a case investigated by dermoscopy, reflectance confocal microscopy and optical coherence tomography

Optical and Cross-Sectional Imaging Technologies for Bladder Cancer.

Optical and cross-sectional imaging plays critical roles in bladder cancer diagnostics. White light cystoscopy remains the cornerstone for the management of non-muscle-invasive bladder cancer. In the last decade, significant technological improvements have been introduced for optical imaging to address the known shortcomings of white light cystoscopy. Enhanced cystoscopy modalities such as blue light cystoscopy and narrowband imaging survey a large area of the urothelium and provide contrast enhancement to detect additional lesions and decrease cancer recurrence. However, higher false-positive rates accompany the gain of sensitivity. Optical biopsy technologies, including confocal laser endomicroscopy and optical coherence tomography, provide cellular resolutions combined with subsurface imaging, thereby enabling optical-based cancer characterization, and may lead to real-time cancer grading and staging. Coupling of fluorescently labeled binding agents with optical imaging devices may translate into high molecular specificity, thus enabling visualization and characterization of biological processes at the molecular level. For cross-sectional imaging, upper urinary tract evaluation and assessment potential extravesical tumor extension and metastases are currently the primary roles, particularly for management of muscle-invasive bladder cancer. Multi-parametric MRI, including dynamic gadolinium-enhanced and diffusion-weighted sequences, has been investigated for primary bladder tumor detection. Ultrasmall superparamagnetic particles of iron oxide (USPIO) are a new class of contrast agents that increased the accuracy of lymph node imaging. Combination of multi-parametric MRI with positron emission tomography is on the horizon to improve accuracy rates for primary tumor diagnostics as well as lymph node evaluation. As these high-resolution optical and cross-sectional technologies emerge and develop, judicious assessment and validation await for their clinical integration toward improving the overall management of bladder cancer.

Modern endoscopic imaging tools for urothelial carcinoma of the urinary bladder

Cystoscopy is the gold standard for the initial diagnosis of urothelial carcinoma in the urinary bladder (UCB). White light exhibits significant limitations in its ability to detect flat lesions or carcinoma in situ. Photodynamic Diagnosis (PDD) and Narrow Band Imaging (NBI) are established techniques which may improve the detection rates of UCB and reduce the risk of recurrence. Multiple novel tools have been developed in order to improve the diagnostic accuracy of endoscopic procedures, including Digital Contrast Enhancement Technology, Confocal Laser Endomicroscopy (CLE) and Optical Coherence Tomography (OCT). In future, spectral analysis of urothelial lesions may be achieved by Raman spectroscopy, thus providing information about biological alterations in the tissue. Furthermore, molecular imaging may allow specific targeting by fluorescent antibodies or small molecule agents, thus enabling differential diagnosis of suspicious lesions. Software-based approaches have been developed to incorporate computer-aided diagnosis and improve digital documentation of endoscopic findings. This study reviews current and future developments in the field of modern endoscopy of the urinary bladder and discusses the different approaches.

Comparative investigation of stimulus-evoked rod outer segment movement and retinal electrophysiological activity.

Transient retinal phototropism (TRP) has been observed in rod photoreceptors activated by oblique visible light flashes. Time-lapse confocal microscopy and optical coherence tomography (OCT) revealed rod outer segment (ROS) movements as the physical source of TRP. However, the physiological source of TRP is still not well understood. In this study, concurrent TRP and electroretinogram (ERG) measurements disclosed a remarkably earlier onset time of the ROS movements (≤10 ms) than that (∼38 ms) of the ERG a-wave. Furthermore, low sodium treatment reversibly blocked the photoreceptor ERG a-wave, which is known to reflect hyperpolarization of retinal photoreceptors, but preserved the TRP associated rod OS movements well. Our experimental results and theoretical analysis suggested that the physiological source of TRP might be attributed to early stages of phototransduction, before the hyperpolarization of retinal photoreceptors.

Abstract 4226: The rodent eye as a non-invasive window for understanding cancer nanotherapeutics

Abstract We have successfully used the mouse eye as a non-surgical window for highly efficient, optical investigation of xenograft models, using a state-of-the-art ocular imaging facility, the UC Davis “EyePod”. The EyePod employs single-cell resolution intravital confocal microscopy and optical coherence tomography, performed completely non-invasively through the natural optics of the eye (1). This technology enables repeatable in vivo imaging over days, weeks and even months, quantitative tracking of tumor development and delivery of theranostic nanoparticles, and the measurement of tumor and tumor microenvironment responses. Moreover, the retina is a highly “approachable part of the brain”, so that non-invasive study of ocular tumors provides a platform for examining such critical issues as drug delivery across the blood retinal barrier (BRB) and blood brain barrier (BBB). Clinical metastasis of solid tumor to the uvea is not uncommon. Therefore, uvea/subretinal xenograft implant, even though not orthotopic, is clinically relevant. To visualize and photo-manipulate nanoparticle delivery to intraocular xenograft, we have used our recently reported nanoporphyrin (2) as the model system. This novel multifunctional porphyrin-based micellar nanoplatform allows (i) efficient encapsulation of hydrophobic chemotherapeutic drugs or fluorescent dyes, (ii) near-infra red fluorescent (NIRF) detection of the tumor via the intrinsic fluorescence of porphyrins, (iii) photodynamic therapy (PDT) and photothermal therapy (PTT) via efficient free radical and heat generation at the tumor site, respectively. Thorough understanding of how this nanocarrier distributes within the tumor microenvironment, and how it responds to controlled optical stimulation will enable us to maximize its therapeutic potential as a nano-theranostic agent. Preliminary FRET study with doxorubicin-loaded nanoporphyrin has allowed us to visualize in vivo and in real time the release of doxorubicin at the tumor site upon illumination with 680nm laser. In addition, the EyePod has enabled us to follow the tumor response over a period of 35 days. Work is currently underway to (i) develop patient-derived xenograft (PDX) model in the eye of NSG mice, and (ii) use EyePod to study the effect of tumor targeting and brain endothelial cell targeting peptides, recently developed in our laboratory, for nanodelivery into the tumor cells and across the BRB. Citation Format: Xinlei Wang, Wenwu Xiao, Yuanpei Li, Pengfei Zhang, Mayank Goswami, Robert J. Zawadzki, Edward N. Pugh, Kit S. Lam. The rodent eye as a non-invasive window for understanding cancer nanotherapeutics. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4226.

Pemphigus with features of both vulgaris and foliaceus variants localized to the nose

We report the case of a 74-year-old man affected by an unusual variant of pemphigus. He presented with a crusty and scaly lesion of the nose. We performed reflectance confocal microscopy and optical coherence tomography on the lesion, which suggested an unexpected diagnosis of pemphigus. Therefore, to confirm our diagnostic suspicions, we executed indirect immunofluorescence and two biopsies, one for histopathological examination and one for direct immunofluorescence. Histopathological evaluation showed acantholysis with formation of clefts in the granular and spinous layers of the epidermis. Direct immunofluorescence revealed immunoglobulin G and C3 deposit to the full thickness of the epidermis. Indirect immunofluorescence showed intercellular antibodies at a titer of 1:40 in the suprabasal epidermis. The immunoblot analysis using epidermal extract revealed the presence of circulating antibodies directed to 130- and 160-kDa antigens in the patient's serum. These two antigens were evidenced from nitrocellulose membrane with colorimetric AP systems, which highlighted the presence of autoantibodies against desmoglein (Dsg)1 and Dsg3 (sodium dodecylsulfate polyacrylamide gel electrophoresis). We also performed an enzyme-linked immunoassay. All these findings suggested that this patient's pemphigus had features of both vulgaris and foliaceus variants.

The influence of axial length on confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography size measurements: a pilot study

To investigate the influence of axial length on SD-OCT and cSLO size measurements from the Heidelberg Spectralis. In this pilot study, eight emmetropic pseudophakic eyes with subretinal visual implant were selected. The axial length was measured in three short (<22.5 mm), three medium (22.51-25.50 mm) and two long (>25.52 mm) eyes. The known size of subretinal implant sensor field (2800 × 2800 μm) was measured on 15 images per eye with cSLO and SD-OCT. The mean axial length was 20.8 ± 0.8 mm in short eyes, 23.3 ± 0.4 mm in medium eyes, and 26.3 ± 0.5 mm in long eyes respectively. We found in short eyes, in medium eyes and in long eyes a mean value of sensor field size measurements from cSLO of 3327 ± 9 μm, 2800 ± 9 μm and 2589 ± 12 μm and from SD-OCT of 3328 ± 9 μm, 2800 ± 12 μm and 2585 ± 19 μm respectively. The size measurements decreased in SD-OCT and cSLO measurements with longer axial lengths significantly (p < 0.0001). The present findings demonstrate accuracy of the scaling in cSLO and SD-OCT measurements of the Heidelberg Spectralis for emmetropic medium eyes. The size measurements from SD-OCT to those from cSLO were approximately equal. Caution is recommended when comparing the measured values of short and long eyes with the normative database of the instrument. Further studies with larger sample sizes are needed to confirm findings.

In-vivo-Bildgebung des Limbusepithels und der Vogt-Palisaden

Limbal disorders can lead to loss of stem cell population and deficiency in corneal integrity. The aim of this study is to describe the morphological features of this region by using confocal laser scanning microscopy (CLSM) and spectral domain optical coherence tomography (SD-OCT) in healthy subjects, contact lens wearers and in patients with surface disorders. On examination hyper- and hyporeflective finger-like structures were found with numerous basal epithelial cells within and in between crypts. In contrast, detailed imaging of limbal palisades of Vogt was not possible on SD-OCT, the corresponding hyperreflective line was identified. These typical crypts were less pronounced or absent in cases with corneal alterations as has been demonstrated. Additionally morphological changes at the level of intermediate and basal cell layers were discussed. A better understanding of the corneal limbus can provide valuable clues on understanding cell integrity and wound-healing processes. In future, quantitative analyses of limbal epithelium in different corneal disorders will be preferable.

New Endoscopic Diagnosis and Treatment Options for Early Esophageal Cancer

Recent advances in endoscopic technology have increased detection rates of early esophageal cancer. Novel imaging techniques, such as narrow band imaging, autofluorescence imaging, confocal laser endomicroscopy and optical coherence tomography, have been recently introduced that may be taking us closer to the “optical biopsy” for dignosis of esophageal lesions. Along with the increased endoscopic detection rates, more and more early esophageal lesions have been also treated by endoscopic options. There are now long-term randomized controlled data concerning the effectiveness of ablative approaches (photodynamic therapy, cryotherapy and radiofrequency ablation); however, the ablation does not provide a tissue specimen for histopathological assessment. Unlike ablative techniques, endoscopic resection permits histopathological assessment, similar to surgery. As a new resection technique, endoscopic submucosal dissection results in complete eradication of all diseases and may translate to a lower recurrence rate than conventional endoscopic mucosal resection procedure.

Visual Field Progression in Treated Glaucoma Patients.

As soon as the diagnosis of glaucoma has been made, the most important remaining question for all diagnostic efforts in glaucoma patients is whether the disease is stable or progressive. If the situation is stable, the therapy including the compliance of the patient has been sufficient, independent of the height of intraocular pressure, and if the disease is detected to be progressing, the therapy (which is lowering of intraocular pressure) has to be intensified independently of the present intraocular pressure. Paradoxically, it is clinically better if at that time the intraocular pressure is high instead of being low, because it is easier to lower the intraocular pressure from a high level than from an already low level. The question is how to detect a progression of glaucomatous optic neuropathy. For the primary diagnosis of glaucomatous optic nerve damage, morphological techniques and psychophysical methods have been scientifically tested and clinically applied. Studies have suggested that morphological tests may be better than functional tests for the detection of early glaucomatous optic nerve damage. These morphological tests include simple ophthalmoscopy, assessment of photographs of the optic nerve head and retinal nerve fiber layer, and confocal laser scanning tomography and optical coherence tomography of the optic nerve head and peripapillary retinal nerve fiber layer. 1,2 Functional tests are methods to measure the differential light threshold in a static or kinetic manner (perimetry). 3Y5 Other functional tests such as measurement of color vision and of critical flicker fusion frequency and electrophysiological methods have not been widely applied. In analogy to the superiority of morphological tests over functional tests in the early detection of glaucomatous abnormalities, one may infer that, for the detection of progression in an early stage of the disease, morphologic tests may be superior to functional methods. In an advanced stage of glaucoma, however, one may assume that functional tests such as perimetry are more useful, because in advanced glaucoma, only a relatively small part of the neuroretinal rim as the main morphological parameter remains and can show further, relatively small, change, whereas the visual field often can still be almost normal and can therefore show more marked changes. Analysis of changes in the visual field can be performed by an event analysis or a trend analysis. 3Y6 Event-based techniques compare a set of recent perimetric tests and define progression as a binary outcome of a difference (ie, progression) or no difference (ie, stable) between the baseline examination and the follow-up examination. Results of examinations performed in the interval between the baseline examination and the last follow-up examination are usually not taken into account. Trend analysis of changes in the visual field applies a pointwise linear regression analysis that provides an automated calculation of slopes of progression for individual perimetric test points (‘‘localized progression’’) and for the average of all test points (‘‘global progression’’). In this issue of the journal, Carlos Gustavo de Moraes and his colleagues from the New York Eye and Ear Infirmary examined the diagnostic capabilities of both approaches, with the new version of the Glaucoma Progression Analysis (GPA2) as event-based technique and PROGRESSOR analysis as trend-based method. 7 Including a relatively large group of well-examined patients with a large series of visual field examinations, they found that the PROGRESSOR analysis tended to detect more progressing eyes than GPA2, with both techniques showing a moderate agreement with respect to the progression criteria and a good spatial consistency regarding the location of the progressing points in the visual field. Although one has to take into account that there are different ways to define progression of glaucoma by using the GPA2 method and the PROGRESSOR technique, the results of the study indicate that, first, detection of glaucoma progression of course depends on the techniques applied; second, that also within the same type of examinations, in the study perimetry of Gustavo de Moraes et al, variations in the results of different technologies are common; third, that as anywhere in clinical medicine, a synopsis of all available clinical data should be performed to finally decide whether the patient was stable or progressive in his/her glaucoma; and fourth, that the PROGRESSOR analysis is without doubt an additional help or more in the detection of glaucoma progression.