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DDLS to Evaluate the Optic Disc
George L. Spaeth, M.D.Esposito Research Professor
Wills Eye Institute/Jefferson Medical CollegeSpaeth/Katz/Myers/Fudemberg/Mantravadi
American Optometric Association, 2014
The hallmark of glaucoma is:
a visual field?
• Page 100
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• No, the hallmark of glaucoma is not loss of visual field.
• The hallmark of glaucoma is certainly not intraocular pressure
• Even though intraocular pressure is in every case, in some way, responsible for the optic nerve damage
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• The hallmark of glaucoma is disc change.
• What is glaucoma?
–Glaucoma is the visible manifestation of the glaucomatous process (structural change and functional loss (“blindness”)
• c/d = a great step ahead when it was developed, but. . .
• 2 fatal flaws with c/d
–Does not measure eccentricity (rim width locally)
–Does not consider disc size
• Are the following discs glaucomatous? All are illustrations shown on the net as examples of glaucomatous optic nerves. What do you think?
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This disc is probably not glaucomatous.
This disc is probably not glaucomatous,
but rather the sign of ischemic optic
neuropathy
• The disc on the left is probably not glaucomatous, but asymmetrical due to it being a larger disc than the disc on the right.
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• Not the way glaucomatous disc changes occur. Cup never enlarges in glaucoma without a change in the blood vessels occurring.
Which of these discs is most likely associated with a person who will go blind from glaucoma?
A B C
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• A is almost certainly due to glaucoma
• B could be glaucoma
• C is least likely to be glaucoma
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The Disc Damage Likelihood Scale (DDLS)
Based on width of neuroretinal rim
adjusted for disc size, or circumferential
extent of loss of neuroretinal rim
• Henderer, et al, Reliability of the Disk Damage Likelihood Scale, Am J Ophthalmol. 2003 Jan;135(1):44-8
• Bayer, et al, Validity of a New Disk Grading Scale for Estimating Glaucomatous Damage: Correlation with Visual Field Damage, Am J Ophthalmol.2002 June;133(6):758-63
• Spaeth, et al, The Disc Damage Likelihood Scale: Reproducibility of a New Method of Estimating the Amount of Optic Nerve Damage Caused by Glaucoma, Trans Am Ophthalmol Soc. 2002;100:181-5
• Spaeth, et al, The Disc Damage Likelihood Scale (DDLS): Its Use in the Diagnosis and Management of Glaucoma, Highlights of Ophthalmology, 2003; 31:4-19
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• Danesh-Meyer HV, Ku JY, PapchenkoTL, Jayasundera T, Hsiang JC, Gamble GD. Regional correlation of structure and function in glaucoma, using the Disc Damage Likelihood Scale, Heidelberg Retina Tomograph, and visual fields. Ophthalmology. 2006 Apr;113(4):603-11.
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Peter Gross (Philadelphia) with Stephen Drance, proved the validity of using a 5 degree spot to measure disc size. Using planimetry and ray trace modeling, they showed that for eyes within ±8 diopters of emmetropia, a 5 degree spot cast a light beam of constant size on the retina.
Gross P. and Drance S. Comparison of a Simple Ophthalmoscopic and PlanimetricMeasurement of Glaucomatous NeuroretinalRim Areas J Glaucoma 1995 Oct;4(5):314-6.
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THE DISC DAMAGE LIKELIHOOD SCALE
Narrowest width of rim (rim/disc ratio) Examples
DDLS Stage
For Small Disc <1.50 mm
For Average Size Disc 1.50-
2.00 mm
For Large Disc >2.00 mm
DDLS Stage
1.25 mm optic nerve
1.75 mm optic nerve
2.25 mm optic nerve
1 .5 or more .4 or more .3 or more 0a
2 .4 to .49 .3 to .39 .2 to .29 0b
3 .3 to .39 .2 to .29 .1 to .19 1
4 .2 to .29 .1 to .19 less than .1 2
5 .1 to .19 less than .10 for less than
45°3
6 less than .10 for less than
45°0 for 46° to
90°4
7 0 for less than 45º0 for 46° to
90°0 for 91° to
180°5
8 0 for 46º to 90º0 for 91° to
180°0 for 181° to
270°6
9 0 for 91º to 180º0 for 181° to
270°0 for more than 270°
7a
100 for more than
180º0 for more than 270°
7b
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DDLS 1 (Average)
DDLS 2 (Average)
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DDLS 3 (Average)
DDLS 3 (if large); DDLS 4 (if average); DDLS 5 (if small)
DDLS 5 (Average)
DDLS 5 or 6 (Average)
DDLS 6 (Average)
DDLS 7 (Average)
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DDLS 6 (Small)
DDLS 6 (Large)
DDLS 7
DDLS 9
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
What goes on Y axis?
• IOP – No
• Hx – insensitive early, but best in late disease
• VF – non-specific; not sensitive in early disease
• c/d – not as stage; okay for change
• DDLS – works for one eye
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For Y Axis
• HRT – what aspect? Poor relation to disc size
• OCT – questionably used for staging, may be excellent for follow
• GDx – questionable relationship to staging, may be excellent for follow
• GGL cell – feasible?
DDLS
1) Measure disc size with 66D (or other)
2) Direct ophthalmoscopy
identify narrowest rim in terms of rim/disc ratio or
.1.2
0
.3
(500)
Extent in degrees of rim absence
Healthy discs
Healthy discs with large cup/disc ratios, from patients that have been followed for more than 30 years with no disc change or any other sign of glaucoma.
On X Axis
Estimated Years Remaining
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• Development and validation of a prognostic indicator for four-year mortality in older adults
Lee, et al.
JAMA 2006; 295:801-808
• General health (BMI, cardiac, respiratory, etc.)
• Lifestyle (good or poor at self-care, smoker, etc.)
• Family history
• Age
• A 92-year-old healthy woman has a 3 percent chance of dying within four years
• A 50-year-old overweight male, who is a smoker, post myocardial infarction with high blood pressure has a 50 percent chance of dying in less than four years.
• A healthy 96-year-old woman has a 97 percent chance of living to be 100.
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• A 50-year-old overweight male smoker has no chance of living to be 100 years old.
Age 74 yo banker
EYR 20
Hx yes
Reliable? yes
IOP 13
DDLS 9
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
?
Age 64 yo beautician
EYR 10
Hx Worse
Reliable? No
IOP 26/22
DDLS 4/4
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
?
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Age 71 yo homemaker
LE 20
Hx Old attack
Reliable? Yes
IOP 14
DDLS ?
Rx None
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
Age – 71 yo homemaker
LE 20
Hx Worse
Reliable? Yes
IOP 14
DDLS 6
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
?
Age 72 yo engineer
LE 20
Hx No symptoms
Reliable? Yes
IOP 19/18
DDLS 4/4
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The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
Age 56 yo chemist
EYR 30
Hx No change
Reliable? No
IOP 14/15
DDLS 6/7
The Glaucoma Graph1
2
3
4
5
6
7
8
9
10
AsymptomaticGlaucoma Damage
GlaucomatousDisease/Disability
Disc StageDamage Likelihood Scale
Birth Death
Not DefinitelyDamaged
?
• “When I was a child, I talked like a child, I thought like a child, I reasoned like a child. When I became a man, I put the ways of childhood behind me.”
First Corinthians 13:11
St. Paul, The Bible
• c/d’s don’t work
• Poor correlation with:
–Visual field
–RNFLT
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Cost Availability Ease Inconvenience Obsolescence % good
images
Value Dx Value
follow
OCT High Poor 1+ 3+ 3+ 50% ? Good
HRT High Moderate 2+ 3+ 3+ 65% Poor Good
Ophthal Low Excellent 2+ 1+ 0 96% Excellent Fair
• DDLS works
–Correlates better with VF than
• OCT
• HRT
–Inexpensive
–No special equipment needed
–Quick
–Convenient for doctor and patient
Valid evaluation of the optic disc, staging the amount of damage,
provides the basis for the diagnosis and continuing care of patients
with glaucoma
or suspected of having glaucoma
• DDLS is valid, relevant, easy
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