MR Diffusion Tensor Imaging (DTI) enables visualisation of the visual system in glaucoma; it has been shown that the atrophy of the optic radiation is more pronounced in glaucoma than in age-matched controls. The atrophy of the optic radiation thereby correlates with OCT and visual field measures. Diffusion tensor imaging permits quantification of the axonal integrity of the optic radiation by calculation of fractional anisotropy (FA) and radial diffusivity (RD). Both within and also outside the visual system, there are substantial changes in FA and RD, changes suggesting a complex neurodegenerative disease. Metabolic MRI by specific Na-coils and by the CEST-technique (CEST: chemical exchange saturation transfer) will enable visualisation of neuronal cell death and pathological protein accumulation in the visual system. It is proposed that glaucomatous atrophy of the visual system may be induced by antero- and retrograde axonal degeneration. In normal tension glaucoma and PEX glaucoma, retrograde degeneration is induced by ischemic lesions or pathological protein accumulation within the cerebral portion of the visual system. Magnetic resonance imaging of the visual system with DTI and metabolic imaging will potentially improve therapeutic monitoring and diagnosis of glaucoma.
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