The Optic Disc In

Glaucoma
Primary Open Angle Glaucoma

• Chronic progressive optic neuropathy

• Typical changes in optic disc, (NFL) &

visual field

• IOP is a causal risk factor

Glaucoma Damage

GLAUCOMA

Optic Nerve Damage

 Why Optic Disc ?

• Because !!!

• Optic disc & RNFL changes usually occur first

• Field defects occur later

• IOP & visual field lack diagnostic sensitivity

Disc With Minimal Field Defect

30 - 50% nerve fibers already lost

 Careful Examination of the
Optic Disc Allows Us to Detect
Early & (Pre Perimetric)
Glaucoma
Optic Disc for Diagnosis
Which One is Normal ?
 Objective

• Examination Technique
of Disc

• Normal appearance of
the Disc and NFL

• Changes in glaucoma
• Early & Pre perimetric

Differential Diagnosis
 Methods of Examination
• Indirect ophthalmoscope

• Direct ophthalmoscope

• Slit lamp : stereoscopic view

• Hruby or el Bayadi lens

• 60, 78, 90 d

• Contact lens
 Stereo Biomicroscopy
• Slit lamp

• 60 D lens

• Contact lens

• Red free light for RNFL

 Why Stereo Disc Examination ?
• Cup is a description of topography

• Estimate by contour change

• Best seen stereoscopic

• Dilated pupil

• Thin slit beam

 Stereo Disc Examination

• See the contour of the rim

• Infer from indirect clues

• Blood vessels
• Color
 Disc Examination : Variation

• High inter individual variation

• Less intra individual

• Improved agreement with stereo

 Disc and RNFL

• Stereoscopic
examination of the
optic disc and NFL
should be made a
routine
The Normal Optic Disc is
Highly Variable
 Optic Disc Variability
• Size
• Shape
• Angle of insertion of ON
• Refractive error
• Patient factors : ethnic
 Normal Disc Size
• Highly variable
• Area : 0.8 mm2 to 6.0 mm2
• Area 1 : 7, diameter 1 : 3
• Independent of + 5 D
• > With high myopia
• < With high hypermetropia
 Normal Disc Size : Race

• Whites < Asians < Africans

• Varies with method used

• Whites : 2.1 to 2.8 mm2

• Indians : 3.4 to 3.5 mm2

 Clinical Importance of Disc Size

• Small discs :
• Drusen, papilledema, NAION

• Large discs :
• Pits, morning glory syndrome

• Normal size :
• Arteritic AION, CRVO
 Disc Size in Glaucoma

• Normal in :
• POAG, JOAG, SOAG, PXE ?

• Abnormally large :
• Glaucoma in high myopia
 Optic Disc Changes in Glaucoma
• Loss of ISNT pattern
• Localized notch in the rim
• Acquired Pit
• Disc Hemorrhage
• Wedge / diffuse loss of retinal
nerve fibers
• Absent rim inferiorly, superiorly,
temporally & or nasally
• Increase in cupping over time
• Over pass phenomenon
Many Just Use The Cup : Disc Ratio
• Cup large for disc size
• Vertically oval cup
• Baring of CL vessels
• Large CDR
• CDR of > 0.7
• Deep cup
• Laminar dot sign
• Assymetry in CDR of > 0.2
• Thinned retinal arterioles
 Definition of Cup Disc Ratio

• Disc margin defined by

inner edge of white
scleral ring
• Cup is the level at which
NRR steepens
 Definition of Cup Disc Ratio

• Disc Diameter

• Cup Diameter
c d
• CDR = c / d

• Horizontal > Vertical

 Cup Disc Ratio

• Normals : 0.0 to 0.87

• More than 0.65 in < 5 % normals

• > 0. 2 asymmetry in < 5% normal

• Larger horizontally in 93 %
 Implications of Disc Size
in Cup Disc Ratio

• 1.2 million axons pass through each disc

• Disc size varies
• Think of the space “left over” : the cup
• “Left over” space has to vary with size of
the disc
 1.2 Million Axons Pass
Through The Optic Disc
 Cup Disc Ratio
• Is a surrogate for NR rim

• Varies with disc size

• Large cup normal for large disc

• Small cup abnormal for small disc

 Measure Disc Size

• Measure disc
• Slit lamp
• 60 D or others
• Contact lens

• Spill over of fundus

color
 Lens Type & Magnification
• 60 D : X 1

• 78 D : X 1.15

• 90 D : X 1.41

• Goldmann : X 1.13

Multiply reading by correction

Disc Size : Direct Ophthalmoscope
 Value of CDR

Documented increase in CDR over time is a sign of glaucoma

Increase in CDR Over Time

Courtesy Ivan Goldberg

CDR Asymmetry
CDR Asymmetry
CDR Asymmetry
 CDR Asymmetry

> Vertical CDR

 Value of CDR
• Relate to disc size
• Larger vertical CDR is suspicious

• Progression

• Asymmetry
• Important clue

• Relate to size of disc

• Size may be different

 Cup Disc Ratio
“We have found that assessment of the CDR is
practically useless in mangement”

• The neuro retinal rim and the contour of this

tissue is the key parameter being assessed

Chandler and Grant

 Obvious Structural Progression

Courtesy Ivan Goldberg

 Increase in CDR Over Time

Courtesy Ivan Goldberg

What is important is the Neuro Retinal Rim

 Neuro Retinal Rim : Size
• Variable

• > With large disc

• < With smaller disc

• > Reserve in large disc

 Neuro Retinal Rim : Shape

• ISNT rule
S

T N
• Inferior > Superior >
Nasal > Temporal
I

• 83% of Eyes

Temporal rim is the smallest

 Neuro Retinal Rim : Shape

Ratio
• Inf to Temp
2:1

• Sup to Temp
1.5 : 1

Temporal rim is the smallest

Neuro Retinal Rim : ISNT Rule
• Less marked in large
discs S

• Rim more evenly T N

distributed
• Punched out well defined I
cup in large discs
 Neuro Retinal Rim : Shape

• Sloping rim in small and intermediate discs

• Steep or over hanging with oblique insertion

• Supero nasal tilt in normal

• Nasal tilt in myopes

 Neuro Retinal Rim in Glaucoma

• Loss of physiological shape

• ISNT rule is broken

• Vertical cup enlarges

 Neuro Retinal Rim in Glaucoma

• Loss of physiological shape

• ISNT rule is broken

• Vertical CDR
 Neuro Retinal Rim : I S N T

• Also compare Inferior &

Superior to temporal rim S

• Inferior to Temporal 2 : 1 T N

• Superior to Temporal 1.5 : 1 I

 ISNT Broken

• Compare

• Superior to temporal

• Inferior to temporal

Temporal rim should be the smallest

ISNT Broken : Notch or Pseudo Pit
 Temporal Portion of Rim

• Papillo macular bundle

• Preferential cupping temporally with field loss near

fixation

• POAG with Myopia and NTG

 Neuro Retinal Rim : I S N T
• Partially depends on exit of central
retinal vessels

• Rim furthest away is more affected

• May explain unusual configuration of

rim
 Glaucoma & Contour of Rim

• May cause a backward bowing of the rim tissue

• Deep extension of the cup in one meridian

• Gentler sloping backward : Saucerization

Rim Contour (Normal)
 Saucerization

• Slight backward
bowing : like saucer

• Periphery or a portion

• Or whole disc

• May be first change

Shelving : ? No Field Defect
Excavation : Field Defect
Excavation : Field Defect
Excavation : Superior and Inferior
 Disc Hemorrhage
• Rare in normals (1%)

• 4 -7 % in glaucoma

• > In “NTG”

• Lasts 10 weeks (10-35)

 Disc Hemorrhage

• Splinter or flame
shaped
• Border of disc
• Inf or Sup temporal
region
• NFL defects, notch,
focal perimetric loss
 Disc Hemorrhages

• Specific for Gl

• Low sensitivity

• Jost’s Rule # 1

Until proved otherwise all glaucomas have an optic disc hemorrhage

 Cup Depth
• Not of much importance

• In normal : depends on disc area

• In glaucoma : type & level of IOP

• Deepest with high IOP

• Juvenile POAG
• Angle recession
 Circum Linear Vessels

•Vessel hugging the NRR

• Exits disc for macula

• Normally present in
50 % of eyes
Circum Linear Vessels
 Circum Linear Vessels “Bared” in Glaucoma

• Normal CLV

• As rim is lost : gap

between vessel and rim
• Implies loss of rim

• Fairly specific

• Superficial or deep

CLV normally present in 50 % of eyes

 Para Papillary Atrophy
• Central beta zone
• Peripheral alpha zone
• Rare nasally or
circumferential
• Correlate with myopia
and age
Para Papillary Atrophy In Normals

• Beta zone : 20 %

• Alpha zone : 95 + %
 Para Papillary Atrophy
Alpha Zone
• Peripheral to beta or disc margin

• Irregular Hyper and Hypo pigmentation

• Thinning of RPE

• Relative scotoma
 Para Papillary Atrophy
Beta Zone
• Central to alpha

• Peripheral to disc margin

• Marked atrophy of RPE

• Visible chr vessels & sclera

• Absolute scotoma
 P P A in Glaucoma

• Central beta zone

more important

• Peripheral alpha
zone
 Para Papillary Atrophy in POAG
• Beta larger in high
myopic POAG

• Next in age related

POAG

• Less in SOAG

• ? NTG and POAG

 Disc Hemorrhage &
Para Papillary Atrophy

• PPA assoc with Hge

• PPA ? marker for

old Hge
 Normal RNFL :
Axons Bundled by Mueller Cell Processes

•Bright fine striations

• Best seen Inf and sup

temporal (Inf > Sup)

• Bright Dark Bright

• Fans off the disc to

periphery
 RNFL Visibility
• Clear media

• Without yellowing of
lens

• Deeply pigmented RPE

• Decreases with age

• Loose 4000 - 5000 per
year
 Normal RNFL
• “Obscures” normal
vessels

• Slit like or groove

like defects

• Narrower than
retinal vessels
 Localized NFL Defects

• Dark wedge

• Larger than vessel

• Touching disc

• Fan out

• Broad at temporal raphe

 Localized NFL Defects
• Not seen in normals

• 20% of Glaucoma eyes

• Less with early glaucoma
• Touch the disc

• Other causes of atrophy

• Drusen, toxo, ischaemia,
papilledema, ON
 Localized NFL Defects & Disc Hge
• Disc hemorrhage

• Localized defect
• 6 - 8 weeks

• Localized type of disc

damage : notch
 Diffuse NFL Defects
• Inferior less visible than
Superior

• Bright, Dark, Bright

pattern lost

• Macula as bright as Sup

and Inf

• “Naked” vessels
 Frequency of NFLD in Glaucoma

• More with focal NTG

• Less with
• Age related POAG
• Highly myopic OAG
• Juvenile OAG
 Importance of Localized NFL
Defects in Early Diagnosis
• Eyes c normal IOP
and fields
• Show field loss on
follow up
• “Pre perimetric”
glaucoma
• Jost’s Rule # 2

Until proved otherwise, all glaucoma (suspects) have a NFL defect

Subtle Nerve Fiber Layer Defect
Not Convinced ?
 RNFL Examination
• Ophthalmoscope (red free light)

• Red Free Photographs

• HRT, OCT, GDX

Slit lamp (green light)

With Experience :
With More Experience :
Start Looking
Early or Pre Perimetric Glaucoma

• Shape of neuro retinal rim

• Size of cup (in relation to size of the disc)
• RNFL
• Disc hemorrhage
Early or Pre Perimetric Glaucoma

• ISNT Rule

• Equal rim width in all sectors is suspicious

• Account for exit of vessels

 Glaucoma in Small Discs
• Shape of rim (ISNT) is difficult to determine

 Cup in relation to disc size is an important factor

 Is this disc physiologically capable of having this cup ?

 Many Optic Disc Changes Have
Been Described in Glaucoma
 Loss of ISNT pattern
 Localized notch in the rim
 Acquired Pit
 Disc Hemorrhage
 Wedge / diffuse loss of retinal
nerve fibers
 Absent rim inferiorly,
superiorly, temporally & or
nasally
 Increase in cupping over time
 Asymmetry in CDR > 2
Don’t Just Use The Cup : Disc Ratio
 Cup large for disc size
 Vertically oval cup
 Baring of CL vessels
• Over pass phenomenon
• Large CDR
• CDR of > 0.7
• Deep cup
• Laminar dot sign
• Thinned retinal arterioles
 Diagnosis of Glaucomatous Disc
• Based on a combination
of signs

• Don’t forget a Field

Exam
• It may have to be a SWAP

• Could still be glaucoma

• ? Side step maneuver
• Unbiased opinion
• Follow up, look again
DD : Pseudo Glaucomatous Disc

• Congenital
• Pits or colobomas
• Temporal arteritis
• Intracranial neoplasm
• Methanol poisoning
• Luetic
• Kjers dominant optic atrophy
 DD : “Congenital” Disc

• Anomalous vessels
DD : Congenital Anomalies
 DD: Dysplastic Disc

• Anomalous vessels

• Funny shape
 DD : Myopia

• Difficult

• High index of
suspicion

• Jost’s Rule # 3

Until proved otherwise, all myopes have glaucoma

 Glaucomatous Versus
Non Glaucomatous Neuropathy

• Loss of rim
• Enlarged cup
• Beta zone para papillary atrophy
• Pallor not out of proportion

Typical “Glaucomatous” Field Defect

Pseudo Glaucomatous Atrophy

• Pale but no contour change

• Assess color of intact rim in other

quadrants of the disc

Color of intact rim pale

Typical “Neuro-Ophthalmic” Field Defect

Glaucomatous Disc ?

“Clinical” is fine : get a visual field

 Arteritic AION Can Progress
To Glaucomatous Like Cupping
Arteritic AION c Glaucomatous Cupping
Glaucomatous Disc ?
Glaucomatous Disc ?
Glaucomatous Disc ?
 Objectives ?
• Examination Technique
of Disc

• Normal appearance of
the Disc

• Changes in glaucoma

• Differential Diagnosis

Examine All Discs Critically

Which One is Normal ?
 Normal ?
• Small cup may be
abnormal for small
disc
• NFL, Rim, Vessels
• beta zone
• “Pseudo-normal”
glaucomatous mini
cup
 Glaucoma ?

• Large cup may be

normal for large disc
• ISNT
• Rim
• “Pseudo glaucomatous”
cup in large disc
 Jost’s Rules
Until Proved Otherwise :
• All discs have glaucomatous changes

• All glaucomas have RNFL defects

• All glaucomas have disc hemorrhage

• All myopes have glaucoma

Is This Disc Normal ?
Is This Disc Normal ?
How About This One ?
How About This One ?
Which is Normal ?
Neurofisiologi Nervus
Optikus
Muhammad Iqbal
Thank You