DDLS to Evaluate the Optic Disc AOA 2014 - … to Evaluate the Optic Disc George L. Spaeth, ... • Bayer, et al, ... The Bible • c/d’s don’t work

5/19/2014

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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




Birth Death


?

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




Birth Death


?

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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




Birth Death


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




Birth Death


?

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




Birth Death


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




Birth Death


?

• “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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Documents

DDLS to Evaluate the Optic Disc AOA 2014 - … to Evaluate the Optic Disc George L. Spaeth, ... • Bayer, et al, ... The Bible • c/d’s don’t work