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©2003, Remo Susanna Jr, MD
Optic Nerve Head Changes In Glaucoma
By
PROF.DR. ALI KHALIFA
AL AZHAR UNIVERSITY
CAIRO, EGYPT
How to Prevent Blindness in Glaucoma “Training Course for Trainers”
Remo Susanna Jr, MD University of São Paulo - Brazil
Paris
19 – 21 September
2003
©2003, Remo Susanna Jr, MD
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Hamilton Eye Center University of San Diego, California
February 14, 2004
How to Look at the Optic Nerve
Remo Susanna Jr, MD University of São Paulo - Brazil
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD
WORKSHOP Prof. Remo Susanna Jr
Sintra, 21 de Fevereiro de 2004 Portugal
Caeser Park – Penha Longa
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©2003, Remo Susanna Jr, MD
Sintra – Portugal February 2004
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD
Latin America Glaucoma Satellite Symposium March 13, 2004
How to Prevent Blindness in Glaucoma Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
Latin America Glaucoma Satellite Meeting March 2004
Brazil Argentina Chile
Colombia Equador Mexico Peru Venezuela
©2003, Remo Susanna Jr, MD
Optic Nerve Head Changes In Glaucoma
Jedda
SAUDI ARABIA
2008
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OPTIC NERVE HEAD CHANGES IN
GLAUCOMA (Remo Susanna)
presented by
PROF. DR. ALI KHALIFA AL AZHAR UNIVERSITY
EGYPTIAN SOCIETY FOR THE GLAUCOMAS
2007-2012
©2003, Remo Susanna Jr, MD
Why Do People Go Blind From Glaucoma?
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©2003, Remo Susanna Jr, MD
The Probability of Blindness From Open-Angle Glaucoma
• 20 years of follow-up: 1965-1985
• Timolol, pilocarpine, epinephrine, acetazolamide, phospholine iodide, etc
• Glaucoma: 54% blind in one eye 22% blind in both eyes
• Ocular hypertension (OHT): 14% blind in one eye 4% blind in both eyes
Hattenhauer, et al. Ophthalmology. 1998.
©2003, Remo Susanna Jr, MD
Patients Blind From Glaucoma
• 25 (27%) blind at the first visit
• 84 (73%) blind under treatment
– 42.5% no compliance
– 57.5% good compliance
Glaucoma Is Underdiagnosed
Grant and Burke. Ophthalmology. 1982.
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©2003, Remo Susanna Jr, MD
1Friedman, et al. AGS. 2003. 2Mitchell, et al. Ophthalmology. 1996.
Glaucoma Diagnosis
• In 2000, 2.2 million Americans were diagnosed with glaucoma1
• 50% of individuals with glaucoma are undiagnosed2
• Many are undiagnosed despite having an eye exam
©2003, Remo Susanna Jr, MD
Glaucoma Diagnosis in Clinical Practice
• Intraocular pressure (IOP)
• Optic nerve head (ONH) assessment
• Standard visual fields (VFs)
• Retinal nerve fiber layer (RNFL)
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©2003, Remo Susanna Jr, MD
1Doughty and Zaman. Surv Ophthalmol. 2000. 2Liu, et al. Invest Ophthalmol Vis Sci. 2003.
Limitations of IOP
• Corneal thickness affects accuracy1
– Thin Cornea–IOP underestimated
– Thick Cornea–IOP overestimated
• IOP fluctuates2
• IOP damage threshold varies
– OHT
– Normal tension glaucoma (NTG)
©2003, Remo Susanna Jr, MD
Limitations of Visual Fields
• Subjective
• High variability
• Poor sensitivity
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First VF abnormal (GHT outside normal limits)
Second VF normal (GHT within normal limits)
Third VF abnormal (GHT outside normal limits)
Visual Fields: Highly Variable
• OHTS
– VF* abnormality not replicated 86% of the time1
*VF defect defined as GHT outside normal limits, CPSD <.05%, or both. 1Keltner, et al. Arch Ophthalmol. 2000.
©2003, Remo Susanna Jr, MD
1Quigley, et al. Arch Ophthalmol. 1982. 2Quigley, et al. Am J Ophthalmol. 1989.
Visual Fields: Poor Sensitivity
• 50% of optic nerve fibers lost prior to VF defect1,2
• By the time there is a 5 dB loss, there is a corresponding 25% loss of RGCs2
A Large Number of RGCs Are Lost Prior to Detectable VF Abnormalities
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©2003, Remo Susanna Jr, MD
• Early glaucoma can be missed if a clinician relies mainly on the visual field and IOP
• Glaucoma is an optic neuropathy
• The assessment of ONH and RNFL are needed for early glaucoma diagnosis
©2003, Remo Susanna Jr, MD
Glaucoma Damage Detection
Optic Disc
SAP
RNFL
Early
Advanced
Structural Losses
Functional Losses
Blindness Alarm
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©2003, Remo Susanna Jr, MD
Five Rules for the Assessment of the Optic Nerve Head in
Glaucoma
Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD
This course was developed by:
Remo Susanna Jr, MD University of San Paulo, Brazil
Felipe Medeiros, MD
Robert N. Weinreb, MD Hamilton Glaucoma Center
University of California, San Diego
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Prof. Ali Khalifa
Prof .Remo Susanna
©2003, Remo Susanna Jr, MD
1. Look first at the rim (and not at the cup)
2. Look at the peripapillary region
3. Look at the retinal nerve fiber layer
4. Look at the lamina cribrosa
5. Look for optic disc hemorrhage
Five Rules for the Assessment of the Optic Nerve Head in Glaucoma
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©2003, Remo Susanna Jr, MD
Rule #1 Identify the Rim: Look at the Scleral Ring and Cup Border
©2003, Remo Susanna Jr, MD
Rim width = distance between
the scleral ring and the location
where the vessel is bent (cup border)
Scleral ring
Cup border
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©2003, Remo Susanna Jr, MD
Rim width = distance between
the scleral ring and the location
where the vessel is bent (cup border)
Scleral ring
Kinking
of the vessel (Cup border)
I – S – N – T rule
©2003, Remo Susanna Jr, MD
Clinical Importance of Glaucomatous Signs
Weak
Moderate
Strong
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©2003, Remo Susanna Jr, MD
The Color of the Rim
©2003, Remo Susanna Jr, MD
Cup = Pallor
Normal Disc
If cup = pallor—normal
If pallor > cup—neurological disorder or glaucoma with very high IOP
If cup > pallor—glaucoma
Schwartz. Arch Ophthalmol. 1973.
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
Non-Glaucomatous
Optic Neuropathy
To
tal p
allo
r Pale rim Cup
Pallor > Cup
©2003, Remo Susanna Jr, MD
Pallor > Cup
Non-Glaucomatous Neuropathy
Cup
Diffuse Pallor
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©2003, Remo Susanna Jr, MD
Pallor
Cup
Cup > Pallor
Glaucoma
Location of kinking
of the vessel
©2003, Remo Susanna Jr, MD
Rule #2 Look at the Peripapillary Region
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©2003, Remo Susanna Jr, MD
Peripapillary Halo
α
β
Jonas, et al. Invest Ophthalmol Vis Sci. 2000.
Alpha Zone
Beta Zone
Sensitivity 20% to 30%
Specificity 80%
360º–normotensive senil-sclerotic glaucoma
©2003, Remo Susanna Jr, MD
α
β
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©2003, Remo Susanna Jr, MD
Rule #3 Look at the Retinal Nerve
Fiber Layer
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RNFL Red-Free Photographs
Bright
striations
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Hoyt sign
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Localized RNFL Loss
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©2003, Remo Susanna Jr, MD
Localized RNFL Loss
Hoyt, et al. Invest Ophthalmol. 1973.
Better seen with red-free light
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD
Localized RNFL Loss
Localized RNFL loss – wedge-shaped dark area
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©2003, Remo Susanna Jr, MD
Diffuse RNFL Loss
Bright
striations Diffuse loss
of striations
Diffuse RNFL loss – diffuse loss of the striate pattern +
increased visibility of retinal vessel borders
©2003, Remo Susanna Jr, MD
Diffuse RNFL Loss
Normal RNFL
RNFL reflex
Striations – brightness
Visibility of peripapillary retinal vessels
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©2003, Remo Susanna Jr, MD
Rule #4 Look at The Lamina Cribrosa
©2003, Remo Susanna Jr, MD
Striated pattern (Susanna) Susanna R Jr. Can J Ophthalmol. 1983.
Aquired optic pit (Radius) Radius RL, et al. Br J Ophthalmol. 1978.
Lamina Cribrosa
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©2003, Remo Susanna Jr, MD
Remember That a Normal Large Disc Has a Large Cup
©2003, Remo Susanna Jr, MD
Cup = Pallor
ISNT rule obeyed
Large disc Large cup
Normal Disc
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©2003, Remo Susanna Jr, MD
Be Cautious With Myopic Discs
©2003, Remo Susanna Jr, MD
Cup Size
Scleral ring
Cup border
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©2003, Remo Susanna Jr, MD
Rule #5 Look for Optic Disc Hemorrhage
©2003, Remo Susanna Jr, MD
Flame-shaped
hemorrhage
• Normally disappear after 2 to 6 months
• Indicative of glaucoma progression
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©2003, Remo Susanna Jr, MD
Detection of disc hemorrhages requires careful optic disc examination
©2003, Remo Susanna Jr, MD
Detecting Glaucoma
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©2003, Remo Susanna Jr, MD
ISNT Rule Is Not Obeyed
Glaucoma
©2003, Remo Susanna Jr, MD
Glaucoma – Small Disc
Peripapillary Halo
Narrowing of Retinal Arteries
Generalized RNFL
Large Cup for a Small Disc
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
Small aperture (5 degree)
of Welch-Allen direct
ophthalmoscope
Normal size disc Small disc
Large disc
©2003, Remo Susanna Jr, MD
Optic Disc Size
Measurement of optic disc size:
• Biomicroscopy:
– Volk lens
– Measure size of slit beam
• Correction factors:
– Volk 60D – x 1.0
– Volk 78D – x 1.1
– Volk 90D – x 1.3
Average vertical diameter: 1.8 mm
Average horizontal diameter: 1.7 mm
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©2003, Remo Susanna Jr, MD
Optic Disc Size
Small Medium Large
Size of the cup varies with size of the disc
Identify Small and Large Optic Discs Small Discs: Average Diameter < 1.5 mm Large Discs: Average Diameter > 2.2 mm
©2003, Remo Susanna Jr, MD Read and Spaeth. Trans Am Acad Ophthalmol Otolaryngol. 1974.
Hemorrhage
Nasal Cupping
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©2003, Remo Susanna Jr, MD
Notch
RNFL defect Peripapillary
atrophy (β zone)
Hitchings and Spaeth. Br J Ophthalmol. 1976.
Notch
©2003, Remo Susanna Jr, MD
Notching
Glaucoma
RNFL loss
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©2003, Remo Susanna Jr, MD Armaly. Arch Ophthalmol. 1967.
Cup/Disc Ratio Asymmetry 0.2
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
Detecting Progression (Compare Photographs During
Follow-Up)
©2003, Remo Susanna Jr, MD
10 Years
Generalized Rim Thinning
Varma R, et al. Am J Ophthalmol. 1992.
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©2003, Remo Susanna Jr, MD 4 Years
Enlargement of Localized RNFL Defect
Progressive Rim Thinning
©2003, Remo Susanna Jr, MD Uchida, et al. Ophthalmology. 1998.
5 Years
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©2003, Remo Susanna Jr, MD
5 Months
©2003, Remo Susanna Jr, MD
Corresponding VF defects
(previous slide)
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©2003, Remo Susanna Jr, MD 10 Years
©2003, Remo Susanna Jr, MD
Optic Nerve Head Evaluation Test II
20 seconds/Test
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©2003, Remo Susanna Jr, MD
Small disc
Small cup
RNFL reflex
Normal
Test 1
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD Test 2
Disc hemorrhage ISNT rule not obeyed
Glaucoma
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Large disc
Large cup
ISNT rule obeyed
Normal RNFL
Pallor = Cup
Normal
Test 3
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD
Notching superiorly
Beta-zone
Superior and inferior RNFL drop-out
ISNT rule not obeyed
Glaucoma
Test 4
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD Test 5
Beta-zone
Notching superiorly and inferiorly
Hemorrhage
Glaucoma
©2003, Remo Susanna Jr, MD
Inferior notching
Inferior beta-zone
Inferior RNFL defect
Glaucoma
Test 6
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
ISNT rule not obeyed
Inferior peripapillary halo
Inferior notching
Nasal cupping
Glaucoma
Test 7
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD Test 8
ISNT rule obeyed
Whitish RNFL reflex
Normal disc
©2003, Remo Susanna Jr, MD
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Small disc
Beta-zone
Large cup for a small disc
Nasal cupping
Glaucoma
Test 9
©2003, Remo Susanna Jr, MD
©2003, Remo Susanna Jr, MD Test 10
ISNT rule not obeyed
Inferior peripapillary halo
Inferior notching
Nasal cupping
Glaucoma
©2003, Remo Susanna Jr, MD
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©2003, Remo Susanna Jr, MD
Thank You