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

mchaglas@ico.edu

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

mchaglas@ico.edu