A presentation on clinical evaluation of optic disc changes seen in various ophthalmic conditions.

1. CLINICAL EVALUATION OF
OPTIC DISC CHANGES
Dr Saurabh Kushwaha
Resident (Ophthalmology)

2. SCOPE
• Papillary changes
• Vascular changes
• Peripapillary changes

3. CLINICAL EVALUATION
• Slit-lamp funduscopy
• Monocular direct ophthalmoscope examination
• Photographs of the ONH
• Clinician’s disc drawings

4. PAPILLARY CHANGES
• Size
• Shape
• Neuroretinal rim (NRR)
• Cupping
• Colour
• Asymmetry

5. PAPILLARY CHANGES
• SIZE
– Diameter varies between 0.85 mm to 2.86 mm
– Mean of 1.88 mm vertically and 1.77 mm
horizontally
– Optic Disc is vertically oval
– Avg disc area of 2.42 mm2
– Deciding C/D ratio
– Prognostic indicator

6. • Disc size varies on average between racial
groups and is largest in Africans
• Vertical diameter is the parameter most
frequently used clinically

8. • Large discs are believed to be more likely
to sustain damage, particularly in NTG

9. SHAPE

10. NRR
• The neuroretinal rim (NRR) is the orange-
pink tissue between the outer edge of the cup
and the optic disc margin

11. ISNT RULE
• The inferior rim is the broadest followed by
the superior, nasal and temporal
• This has high sensitivity (81%) for glaucoma
but is not specific (32%)

12. SUBTYPES: GLAUCOMATOUS DAMAGE
• Focal ischaemic discs
- localized superior and/or inferior notching
- associated with localized field defects
• Myopic disc with glaucoma
- refers to a tilted (obliquely inserted), shallow disc
with a temporal crescent of PPA
- Dense superior or inferior scotomas threatening
fixation are common.
- most common in younger male patients.

13. • Sclerotic discs
- shallow, saucerized cup and a gently sloping NRR,
variable PPA and peripheral visual field loss
- older age group; and both gender
- associated with systemic vascular disease.
• Concentrically enlarging discs
- fairly uniform NRR thinning
- associated with diffuse visual field loss
- IOP is significantly elevated at presentation

14. CUPPING
• Physiological cup is a depression in the Optic
Disc
• If thinning of the Optic Disc NRR occurs - the
optic disc appears pathologically cupped
(excavated)
• Usual cause is glaucoma
• Slow death of optic nerve axons and their
supporting glial cells

15. CUPPING

16. • Lamina cibrosa thins out and moves out and
posteriorly

17. COLOUR
• Cup appears pale due to presence of glial
tissue at that site (No neuronal tissue)
• NRR appears orangish red or pink in colour
• When we have pallor > cupping ---- non
glaucomatous damage
• When cupping > pallor ----- glaucomatous
damage

19. ASYMMETRY
• Greater than 0.2 CDR difference between the
two disc s/o glaucoma changes
• However, asymmetry in size of Optic Disc,
cup, width of NRR, vessel course and
Peripapillary changes are to be noted

20. LAMINAR DOT SIGN
• The laminar dot sign occurs in advancing
glaucoma.
• Grey dot-like fenestrations in the lamina
cribrosa become exposed as the NRR recedes.
• The fenestrations sometimes appear linear
and this itself may be a sign of advanced
damage, indicating distortion of the lamina.
• The dots may be seen in normal eyes.

21. LAMINAR DOT SIGN

22. VASCULAR CHANGES
• Nasalization of vessels
• Bayonetting of vessels
• Baring of circumlinear vessels
• Collaterals

23. NASALIZATION

24. NASALIZATION

25. BAYONETTING
• If notching at optic cup continues and
reaches the Optic Disc margin – a
sharpened rim will be formed
• Retinal vessels will bend at sharpened rim
causing bayonetting of vessels

26. BAYONETTING

27. BARING OF CIRCUMLINEAR
VESSELS (BCLV)
• Can be associated with non
glaucomatous changes
• May be present in large
discs
• If present in glaucomatous
disc may show visual field
defects

28. COLLATERALS
• Collaterals between two veins at the disc are
relatively uncommon.
• They are probably caused by chronic low-grade
circulatory obstruction.
• Retinal vascular tortuosity may also occur.

29. PERIPAPILLARY CHANGES
• RNFL defects
• RNFL hemorrhages
• Peripapillary changes

30. RNFL DEFECTS
• Dark stripes or wedge
shaped defects in the
peripalliary region
• Can parallel the normal
retinal striations or
diffuse loss of striations
• Often follow disc
hemorrhages and
correlate with visual
field defects
Normal RNFL striations

31. RNFL DEFECTS

32. RNFL DEFECTS

33. DISC HEMORRHAGES
• Early sign of glaucoma
• Hemorrhage  disc changes  field
defects
• Most common site - inferior quadrant
• Also at focal rim notch or at focal
RNFL defects
• Risk factor for the development and
progression of glaucoma
• Common in NTG and DM

34. DISC HEMORRHAGES

35. GRAY CRESCENT
• Seen within peripheral tissues of ONH
• Scleral lip is peripheral to the gray crescent
• Often bilateral and it is usually located along
temporal or infero-temporal disc margin.
• Grey crescent is due to internal extension of
Bruch's membrane in the peripapillary scleral
ring.

36. GRAY CRESCENT

37. ZONE BETA
• Seen between peripheral NRR and zone
alpha.
• It represents retraction of RPE from the disc
margin due to atrophy of RPE.
• Sclera and large choroidal vessels are visible
due to RPE atrophy.
• Location and extent of zone beta atrophy
correlates with visual field loss.
• Indicates area has poor perfusion
• Seen in POAG and NTG.

38. ZONE ALPHA
• Seen as irregular hyperpigmentation and
hypopigmentation.
• Due to parapapillary crescent of RPE
irregularity close to the margin of Bruch's
membrane.
• Present in almost all normal eyes.

39. PERIPAPILLARY CHANGES

40. STAGING SYSTEMS
• Armaly’s Method - cup to disc ratio
• Read-Spaeth Method - rim width
• Shiose’s Method - quantitative disc pattern
• Richardson’s Method - correlation of disc
damage with the
• Nesterov’s method - a combination of the cup
disc ratio and circumferential rim loss.
• Jonas Method - progressive rim loss.
• Spaeth’s Method - Disc Damage Likelihood
Scale (DDLS)

41. DISC DAMAGE LIKELIHOOD
SCORE (DDLS)
• Unlike the CDR, which focuses on the
excavation, the DDLS is based directly on
the thickness of the neuroretinal rim and
takes into account the optic disc size.
• DDLS estimates the glaucomatous damage
of the optic disc more precisely than the
currently used method.

42. DISC DAMAGE LIKELIHOOD
SCORE (DDLS)
• Describes quantitatively the changes that occur
in the Optic Nerve Head (ONH)
• It is used to quantify the health of the optic disc,
specifically as it relates to glaucoma.
• Two characteristics of the disc: (1) the width of
the neuroretinal rim and (2) the size of the optic
disc.
• DDLS scale goes from 1 to 10, 1 being the most
normal and 10 the most pathologic.

43. DISC DAMAGE LIKELIHOOD
SCORE (DDLS)
• First, one measures the size of the optic disc and
classifies the disc as small, average, large, or very
large. Small is less than 1.5 mm in height, average
between 1.5 and 2.0 mm in height, large between
2 and 3 mm in height, and very large greater than 3
mm
• Next, one looks for where the neuroretinal rim is
the narrowest. The narrowest rim would be 0 and
the widest rim possible would be 5.
• Discs with DDLS of 6 or more are never normal.

44. DISC DAMAGE LIKELIHOOD
SCORE (DDLS)

45. DISC DAMAGE LIKELIHOOD
SCORE (DDLS)

46. THANK YOU