Optic disc assessment RNFL Overview

8/21/2019 Optic disc assessment RNFL Overview

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2004 Remo Susanna Jr2004 Remo Susanna Jr

OPTIC DISC

ASSESSMENT/RNFL

OVERVIEW


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Outline

I. Five rules for assessment of

the optic disc in glaucoma

II. Detecting glaucoma

III. Detecting progression

IV. Examples

V. Test your skills


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FIVE RULES FOR

ASSESSMENT OF THE

OPTIC DISC IN GLAUCOMA


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Five rules for assessment of

the optic disc in glaucoma (1)

1. Observe the scleral Ring toidentify the limits and sizeof the optic disc

Photo courtesy ofPhoto courtesy of KiKiHo ParkHo Park


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1. Observe the scleral Ringto identify the limits andsize of the optic disc


2. Identify the size of theRim


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1. Observe the scleral Ring toidentify the limits and sizeof the optic disc

2. Identify the size of the Rim




3. Examine the Retinal nervefibre layer


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4. Examine the Region ofperipapillary atrophy


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4. Examine the Region ofperipapillary atrophy




5. Look for Retinal andoptic disc haemorrhages


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Rule 1

Observe the scleral Ring

to identify the limits and size

of the optic disc


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Rim width= distance

between the scleral

ring and the locationwhere the vessel is

bent (cup border) ScleralScleralringring

Cup borderCup border

The scleral ring (1)


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ScleralScleral

ringring

Rim width= distance

between the scleral

ring and the locationwhere the vessel is

bent (cup border)

KinkingKinking

of the vesselof the vessel(cup border)(cup border)

The scleral ring (2)


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Optic disc size (1)

Extremely variable

A large cupdisc ratio may not necessarily

be pathological

Large discs have large cupdisc ratios,

even though the area of the neuroretinal

rim is normal

Pathological rim loss can be missed in asmall disc, especially if generalised

SEAGIG.Asia Pacific Glaucoma Guidelines. 20032004.


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Optic disc size (2)

Can be measured using the small lightspot of a direct ophthalmoscope

The spot size can be used to estimatewhether a disc is larger or smaller thanaverage

Other forms of evaluation

conventional photographic means withan overlay grid

optic nerve head analysis



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Small aperture (5 degree)

of Welch-Allen direct

ophthalmoscope

Normal size discNormal size disc

Large discLarge disc

Small discSmall disc



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Optic disc size (4)

Indirectophthalmoscopy and

slit lamp examination Use Volk slit lamp

biomicroscopy lenses

Measure size of slitbeam

Correction factors Volk 60D: !1.0

Volk 78D: !1.1

Volk 90D: !1.3


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Optic disc size (5)

HorizontalHorizontal

disc diameterdisc diameter

VerticalVertical

discdisc

diameterdiameterScleral

ring



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The size of the cup varies with the size of the disc

Large discs have large cups in healthy eyes

Cup size is proportional to disc size in normal eyes

Optic disc size (6)

Small Average Large

Right photo courtesy ofRight photo courtesy of KiKiHo ParkHo Park


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Optic disc size (7)

Be cautious

with myopic discs

ScleralScleral

ringring

Cup borderCup border


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Rule 2

Identify the size of the

neuroretinal Rim


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The neuroretinal rim (1)

More important than the cup

The cup defines the inner edge of the rim

where most signs of glaucoma appear

Loss of tissue from inner edge of the

rim

Cardinal feature of glaucomatous opticneuropathy



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Features that indicate that glaucomatous

damage has already occurred

Notching of the rim (especially the disc margin)

Haemorrhage crossing the rim

Undercutting of the rim

Asymmetry of rim width between the eyes in the

absence of asymmetric disc size Abnormally thin rim in one or two sectors



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An approximate rule is that a vertical

cupdisc ratio of > 0.7, or loss of rim to

the disc margin anywhere outside the

temporal sector, strongly suggests

glaucoma

This may not apply if the disc isextremely large or very tilted



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The ISNT rule (1)

Normally, the thickest to thinnest parts

of the neuroretinal rim of the optic disc

follow the ISNT rule:*


* The ISNT rule is followed in approximately 80% of eyes.

Any variation from this rule may help todetect glaucomatous damage

Inferior > Superior > Nasal > Temporal


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The ISNT rule (2)

Rim width =

distance between

border of disc andposition of bloodvessel bending

ISNT rule

Inferior > Superior > Nasal > Temporal

NN TT

II

SS



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Localised rim thinning/notching (1)


NotchingNotching


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NotchNotch


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Localised rim thinning/notching

(3)

Photos courtesy ofPhotos courtesy of GTGTSunil and LSunil and L VijayaVijaya


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Diffuse neuroretinal loss



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Pallor (1)

Observe the colour of the rim to

identify pallor

A pale rim increases the likelihood

of a non-glaucomatous optic

neuropathy


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Pallor > cup

Pallor (2)

T

otalpallor

T

otalpallor

Pale rimPale rimCupNon-glaucomatous

neuropathy


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Pallor (3)

Cup

Diffuse pallorDiffuse pallor Pallor > cup

Non-glaucomatous

neuropathy


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Cup = pallorCup = pallor

Normal discNormal disc

If cup = pallor:If cup = pallor: normalnormal

If pallor > cup:If pallor > cup: neurological disorderneurological disorderor glaucoma with very high IOPor glaucoma with very high IOP

If cup > pallor:If cup > pallor: glaucoma or normalglaucoma or normal

Schwartz.Schwartz.ArchArch OphthalmolOphthalmol19731973; 89: 2727.2004 Remo Susanna Jr2004 Remo Susanna Jr


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Pallor (4)

Location of kinkingLocation of kinking

of the vessel of the vessel

PallorPallorCupCup


Cup > pallor

Suspect glaucoma


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Pallor (5)



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Lamina cribrosa

Striated pattern(Susanna 1983)

Acquired optic pit(Radius et al. 1978)


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Acquired pit of optic nerve

(APON)

Photo courtesy of GT Sunil and LPhoto courtesy of GT Sunil and L VijayaVijaya


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APON

Photo courtesy of Ki Ho Park

Acquired optic pitAcquired optic pit


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Large discLarge cup

Normal optic nerve head

Remember that a

normal large disc

has a large cup

ISNT rule obeyed

Cup = pallor


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Rule 3

Examine the

Retinal nerve fibre layer


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Best performed using red-free light (red-free

photographs or green light)

Look at

Look for diffuseand localisedRNFL loss

Striations

Brightness

Visibility of peripapillary retinal

vessels

RNFL examination


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Red-free photography

Bright

striation

s

Right photo courtesy ofRight photo courtesy of KiKiHo ParkHo Park


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Bright

striations

Diffuse loss

of striations

Diffuse RNFL loss (1)

Diffuse loss of striate pattern

Increased visibility of retinal vessel borders


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Diffuse RNFL loss (2)

Normal RNFLDiffuse RNFL loss


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Localised RNFL loss (1)


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Localised RNFL defectWedge-shaped dark area

Photos courtesy ofPhotos courtesy of KiKiHo ParkHo Park


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Better seen with red-free light

Hoyt WFHoyt WF et alet al.. InvestInvest OphthalmolOphthalmol19731973; 12: 81429.2004, Remo Susanna Jr2004, Remo Susanna Jr


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Wedge-shaped

dark area



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Wedge-shaped

dark area



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Rule 4

Examine the Region of

peripapillary atrophy


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Peripapillary atrophy (1)

Alpha zone

Hypo- and hyper-

pigmented areas

Present in normal as wellas in glaucomatous eyes

Beta zone

Atrophy of the retinal

pigment epithelium and

choriocapillaris

Large choroidal vessels

become visible

More common in

glaucomatous eyes



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Alpha zone

Beta zone

Sensitivity2030%

Specificity

80%

360 ring

normotensive

senile sclerotic

glaucoma

Jonas JB et al. Invest Ophthalmol Vis Sci2000; 41: 176473.


zone

zone



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Beta zone

Width of beta zoneinversely correlateswith rim width atsame area

Larger beta zone!thinner rim

Progression of betazone associatedwith progressiveglaucoma

Thin rimThin rim

LargerLarger zonezone



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Rule 5

Look for Retinal and

optic disc haemorrhages


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Optic disc haemorrhage (1)

Photo courtesy of Ki Ho Park

Flame-shapedFlame-shaped

haemorrhagehaemorrhage


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Photo courtesy of Prin RojanaPongpun

Flame-shapedhaemorrhage


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Middle and right photos courtesy ofMiddle and right photos courtesy of KiKiHo ParkHo Park

Detection of disc haemorrhages requires

careful optic disc examination


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Detection of disc haemorrhages requires

careful optic disc examination



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Normally disappears after 13 months

Indicative of glaucomatous progression



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Normally disappears

after 13 months

Indicative ofglaucoma

progression

Flame-shapedFlame-shaped

haemorrhagehaemorrhage


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Optic disc

haemorrhage (7)

Photos courtesy of GT Sunil and L Vijaya


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DETECTING GLAUCOMA


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ISNT rule is not obeyed

GlaucomaGlaucoma

2004, Remo Susanna Jr2004, Remo Susanna Jr


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Glaucoma small disc

Peripapillary atrophy

Narrowing of retinal arteries

Generalised RNFL

Large cup for a small disc



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HaemorrhageHaemorrhage

Read RM, Spaeth GL. Trans Am Acad Ophthalmol

Otolaryngol1974; 78: OP25574.

Nasal cupping


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2004 Remo Susanna Jr2004 Remo Susanna Jr Hitchings RA, Spaeth GL. Br J Ophthalmol1976; 60: 77885.

NotchNotch

RNFL defectRNFL defect PeripapillaryPeripapillary

atrophy (atrophy (beta zone)beta zone)

Notch (1)


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Notch (2)

Photos courtesy of GT Sunil and L Vijaya


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Images courtesy of GT Sunil and L Vijaya


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Notch (3)

Photos courtesy of GT Sunil and LPhotos courtesy of GT Sunil and L VijayaVijaya


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Images courtesy ofImages courtesy of GTGTSunil and LSunil and L VijayaVijaya


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2004 Remo Susanna Jr2004 Remo Susanna Jr Armaly MF.Arch Ophthalmol1967; 78: 543.

Cupdisc ratio asymmetry > 0.2*

*After accounting for disc size asymmetry.


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Notching

RNFL loss

Glaucoma (1)


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Glaucoma (2)

Cup asymmetry exceeds disc asymmetry


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Glaucoma (3)

Localised loss of both

inferior and superior

neuroretinal rim Classic inferior notch

(small arrows)

RNFL defect in

superior and inferiorarcuate area (large

arrows)



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Glaucoma (4)

Neuroretinal rim

thinning

The cup extends tothe disc rim

Circumlinear blood

vessel baring

Bayoneting of theblood vessels

Peripapillary atrophy



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DETECTING PROGRESSION


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10 years

Generalised rim thinning


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Enlargement of localised RNFL defectEnlargement of localised RNFL defect

4 years

Progressive rim thinning (1)


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Progressive rim thinning (2)

A

B

Images courtesy ofImages courtesy of GTGTSunil and LSunil and L VijayaVijaya


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5 years


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5 months


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10 years


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Save me,please



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EXAMPLES


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Example 1

Glaucoma or normal?

Use the 5 rules

1 Observe the scleral Ring

to identify the limits of theoptic disc and its size

2 Identify the size of the Rim

3 Examine the Retinal nervefibre layer

4 Examine the Region ofperipapillary atrophy

5 Look for Retinal and opticdisc haemorrhages


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1. Small disc size

2. Rim thinning(inferiorly)

ISNT rule:3. Localised RNFL

defect (inferiorly)

4. No significantperipapillary atrophy

5. Haemorrhage

GLAUCOMA

Example 1


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Example 2

Glaucoma or normal?

Use the 5 rules








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1. Average disc size

2. Normal rim

ISNT rule:

3. Normal RNFL

4. No significant


5. No haemorrhage

NORMAL

Example 2

+


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Example 3

Glaucoma or normal?

Use the 5 rules








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2. Notching (inferiorly

and superiorly)

ISNT rule:

3. RNFL loss

4. No significant


5. No haemorrhage

GLAUCOMA

Example 3


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Example 4

Glaucoma or normal?

Use the 5 rules








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2. Rim thinning

(inferiorly)

ISNT rule:

3. RNFL loss: diffuse

4. Peripapillary atrophy:

beta zone

5. No haemorrhage

GLAUCOMA

Example 4


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Example 5

Glaucoma or normal?

Use the 5 rules








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1. Large disc size

2. Normal

ISNT rule:

3. Normal RNFL

4. No significant


5. No haemorrhage

NORMAL

Example 5

+


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Example 6

Glaucoma or normal?

Use the 5 rules








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2. Rim thinning(inferiorly)

ISNT rule:3. RNFL loss: diffuse

(inferiorly)

4. Peripapillary atrophy:beta zone

5. Haemorrhage:reabsorbing

GLAUCOMA

Example 6


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TEST YOUR SKILLS


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Evaluation form

Name: _________________________________ Date: ___/___/____

TEST #: _________

( ) 1. ISNT rule not obeyed

( ) 2. Vertical enlargement of the cup( ) 3. Peripapillary atrophy: beta and or alpha zone

( ) 4. Notching

( ) 5. Nasal cupping

( ) 6. Disc haemorrhages

( ) 7. Localised or diffuse pallor of the optic disc

( ) 8. Localised RNFL defect

( ) 9. Diffuse loss of the RNFL

( ) 10. Acquired pit of the optic disc

CONCLUSION

( ) Glaucoma

( ) Normal

X


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Test I


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2004, Remo Susanna Jr2004, Remo Susanna Jr Test 1


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Test 42004, Remo Susanna Jr2004, Remo Susanna Jr


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2004, Remo Susanna Jr2004, Remo Susanna Jr Test 102004, Remo Susanna Jr2004, Remo Susanna Jr


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Test I

Put your 3D glasses on


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2004 Remo Susanna Jr2004 Remo Susanna Jr Test 1


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Test I

Discussion


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Small disc

Small cup

RNFL reflex

Normal



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Disc

haemorrhage

ISNT rule not

obeyed

Glaucoma



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Large disc

Large cup

ISNT rule obeyed

Normal RNFL

Pallor = cup

Normal



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Notching superiorly

Beta zone

Superior and inferior

RNFL drop-out

ISNT rule not

obeyed

Glaucoma



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Beta zone

Notching

superiorly and

inferiorly

Haemorrhage

Glaucoma



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Inferior notching

Inferior beta zone

Inferior RNFL defect

Glaucoma



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ISNT rule not

obeyed

Inferior

peripapillaryatrophy

Inferior notching

Nasal cupping

Glaucoma



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ISNT rule obeyed

Whitish RNFL reflex

Normal disc



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Small disc

Beta zone

Large cup for

a small disc

Nasal cupping

Glaucoma



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ISNT rule not

obeyed

Inferior

peripapillaryatrophy

Inferior notching

Nasal cupping

Glaucoma



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Test II

Put your 3D glasses on


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A

B



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Right eye

Left eye2004, Remo Susanna Jr2004, Remo Susanna Jr Test 17


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A

B



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Documents

Optic disc assessment RNFL Overview