How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 1
How to Distinguish Physiologic Cupping
from Glaucoma
Michael Chaglasian, OD, FAAOIllinois College of Optometry
Illinois Eye Institute
Disclosures
Allergan - A/C/S
Aerie - A/S
Bausch+Lomb - A/S
Carl Zeiss - A/C
Equinox – R
Glaukos - A/S
Heidelberg – A/R
Optos - R
Novartis – S
Reichert - C
Sun - A
Topcon - C/R A ‐ Advisory BoardC ‐ ConsultantS ‐ Speaker BureauR ‐ Research
Learning Objectives:
1. Be able to distinguish key ophthalmoscopicfeatures of the glaucomatous optic nerve versus large physiological cupping
2. Be able to compare optic nerve photos to their OCT images.
3. Be able to compare optic nerve photos to their Visual Field results.
4. To review techniques for the determination of disease progression based upon optic nerve photos.
Physiological Optic Nerve
Optic Disc
7
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 2
What to look at?
More Useful:»Neural Retinal Rim
– Able to see most true glaucomatous changes here
»Asymmetry, right vs. left
»Vessel bending at NRR
Less Useful»Cup/Disc Ratio
REVIEW GLAUCOMATOUS CHANGE TO ONH
Since variability of “normal” is very high, we need to know what is abnormal. Then we can differentiate.
Glaucomatous Disc Features
Some of terms you will get to know : increased (meaning it changed) cup-to-disc ratio or
significant cup asymmetry; decreased or documented change in neuroretinal
rim area; notch of the neuroretinal rim; saucerization of neuroretinal rim; flame-shaped disc hemorrhage; nerve fiber layer loss; peripapillary atrophy Laminar dot sign (non-specific)
RNFL axon organization: OS
Optic Disc
Normal: Optic Nerve, RNFL, VF RNFL Dropout, Early Notch
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 3
OPTIC NERVE EXAMINATION
Baseline Follow-up
Focal Neuroretinal Rim Narrowing
Courtesy of David S. Greenfield, MD.
NotchingNotching
Localized Rim Thinning/Notching Very Advanced Notch
NotchNotch
Inferior Temporal Notch Pre-Perimetric GlaucomaAge: 65
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 4
ISNT Rule of the NRR
Normal Nerve=» Inferior= broadest in width, then» Superior» Nasal» Temporal
Generalizations: of Rim ChangesEarly Glaucoma= » inferotemporal and superotemporal rims
Moderate Glaucoma= temporal NRRAdvanced Glaucoma= all around the Rim
Identify small and large optic discsSmall discs: avg vertical diameter <1.5 mmLarge discs: avg vertical diameter >2.2 mm
Size of cup varies with size of disc
Large discs have large cups in healthy eyes
Small
1.4
Average Large
2.4
Optic Disc Size
Measurement of optic disc size withbiomicroscopy
Volk lensMeasure length of slit beam
Avg vertical diameter: 1.8 mm
Correction factors
Volk 60D – x 1.0
Volk 78D – x 1.1Volk 90D – x 1.3
Avg horizontal diameter: 1.7 mm
Optic Disc Size Large Disc Size:
Megalopapilla = ≥ 2.5 mm2
Other Key Signs:
Baring of Vessel
Drance Hemorrhage
can be a very specificsign in glaucoma
Optic Disc Hemorrhage
Detection of disc hemorrhages requires careful optic disc examination
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 5
Optic Disc Hemorrhage
Normally disappears after 2-6 months
Drance Heme and Progression
Indicative of glaucoma progression
Flame-shaped
hemorrhage
Patient Disc Photos @ 2 Year Follow Up
IOP OD and OS was at target and stable
Four Years Later:
-3.2%
Peripapillary Atrophy PPA
Alpha zone• Hypo- and hyper-
pigmented areas
• Present in normal as well as in glaucomatous eyes
Beta zone• Atrophy of the retinal
pigment epithelium (RPE) and choriocapillaris– Large choroidal vessels
become visible
• More common in glaucomatous eyes
CASE MR
36 yo
Father has glaucoma
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 6
CASE JM54 YO, AA
IOP IOP Range = 16- 20 OD; 16-19 OS
CCT= 462 OD 468 OSCH = 8.8
Zeiss Cirrus HD-OCT RDB
Zeiss Cirrus HD-OCT RDB Megalopapilla w/o Glaucoma
Typically shows thicker pRNFL» Perhaps due to
closer to disc margin measurement
Megalopapilla w/o Glaucoma
Ganglion Cell Measures are the same
Management
This patient was treated due to significant risk factors:» IOP high of 20 mmHg
»Thin CCT
»Low CH
»OCT
How to Distinguish Physiological Cuppingfrom Glaucoma.
2019
Michael Chaglasian, OD 7
Average Disc Size, Large Cup
2.25 mm2 1.88mm2
54 yo, IOP under 20 mmHg
OCT for Large (>2.5) Disc
Will often be flagged as abnormalCan indicate either disease or
physiological variation
Change over time would define glaucoma
Treatment will depend on other clinical findings and risk factorsNormal/Near Normal VFs suggest
observation when IOP is low/normal
TIPS and PITFALLS
Do not emphasize the C/D ratio
Concentrate on the neural retinal rim
Look for focal defects (notching) and and/or generalized thinning
Evaluate symmetry between eyes
Disc Hemes
Peripapillary atrophy
Baring of circumlinearvessels Loss of NRR tissue
Use imaging and perimetry to evaluate suspicious nerves and high risk patients
Thanks