2. INTRODUCTION
Chronic progressive optic neuropathy
caused by group of ocular conditions
which lead to damage of optic nerve
with loss of visual function
Increase IOP isn’t criterian diagnostic
in glaucomatous optic significant
risk factor
3. Other factors
than IOP may
contribute to a
given individual’s
susceptibility to
glaucomatous
damage
Normal limit
Intra Ocular
Pressure (IOP)
5. the diagnosis of early
glaucomatous damage
depends on a careful
examination of the optic disc
and the nerve fiber layer
It has been prove that 30-
50% rgc lost before visual
field defect develop in
glaucoma patient on
perimetry
7. ANATOMY OF OPTIC
DISC
Distal portion of optic nerve,extends from retinal
surface to myelinated portion of optic nerve.
Composed of the nerve fibres which originates in
the Ganglionic cell layer of retina & converge upon
the nerve head from all points in the fundus.
10. Identify small and large optic discs
• Small discs: avg vertical diameter < 1.5 mm
• Large discs: avg vertical diameter > 2.2 mm
Average Large
• Size of cup varies with size of optic disc
• Large optic discs have large cups in healthy eyes
Small
1.4 1.9 2.4
OPTIC DISC – CUP SIZE
11. S
N T
I
NEURORETINAL RIM
Rim width:
Distance between
border of disc and
position of blood
vessel bending
ISNT rule:
Inferior > Superior >
Nasal > Temporal
12. THE ANTERIOR OPTIC NERVE CAN BE
DIVIDED INTO 4 LAYERS:
nerve fiber
prelaminar
laminar
retrolaminar
13. NERVE FIBER LAYER REGION
Continuous with the nerve fiber layer of the retina
Primarily composed of the axons of the RGCs in
transition from the superficial retina to the
neuronal component of the optic nerve
Viewed with the ophthalmoscope when the red-
free (green) filter
14. THE DISTRIBUTION OF NERVE FIBERS AS
THEY ENTER THE OPTIC NERVE HEAD
The axons of the ganglion cells nasal to the
optic disc run directly toward the optic nerve
head
the axons originated in the macular area,
which form the spindle-shaped papillo-
macular bundle.
The axons coming from ganglion cells
situated in the temporal fundus describe an
arcuate course around the fovea and run
toward the superior or inferior poles of the
optic disc.
15. THE PRELAMINAR AREA
known as the
choroidal part
consists of nerve
fiber bundles and
astroglia forming
tube-like sheaths
around each bundle.
16. LAMINA CRIBROSA
The laminar or
scleral portion of the
optic disc includes a
modification of the
sclera
THE MAIN
FUNCTION give
passage to the
ganglion cell axons
and the retinal blood
vessels
17. RETROLAMINAR
The most posterior layer
Composed by myelinated fibers
Circumscribed by the
leptomeninges of the central
nervous system.
18. OPTIC DISC VASCULARIZATION
The superficial nerve
fiber layer retinal
arterioles (branching
from the central
retinal artery)
The prelaminar
region Banches
from the short
posterior ciliary
arteries and by
centripetal branches
of the circle of Zinn-
Haller
The laminar region
branches of the short
posterior ciliary
arteries or from the
circle of Zinn-Haller
The retrolaminar
region Branches of
the short posterior
ciliary arteries and
pial arterial vessels.
19. PATHOGENESIS
• DIRECT COMPRESSION OF
AXONS DEFORMATION
OF THE PORES AND
CHANNELS OF THE LAMINA
CRIBROSA DISRUPT
AXOPLASMIC FLOW AND
DEATH OF THE GANGLION
CELL
• HIPOPERFUSION OF OPTIC
NERVE
AUTOREGULATION
DISFUNCTION
• AFFECTED BY SISTEMIC
HIPOPERFUSION
MECHANIC
THEORY
ISCHEMIC
THEORY
20. MEDIATOR : oksigen,
Carbondiokside, angiotensin II,
adenosin, nitrit oksida (NO), dan
endotelin I
DISFUNCTION OF AUTOREGULATION
DECREASE OCULAR BLOOD
FLOW DECREASE PERFUSION
AUTOREGULATION
THEORY
22. FUNDUSCOPY IDENTIFICATION OF
GLAUCOMATOUS OPTIC
The ability to recognize
glaucomatous changes in
the optic nerve is
fundamental to properly
DIAGNOSE and MANAGE
patients considered suspect
for glaucoma or known to
have glaucoma
Change in the
appearance of the optic
disc IN FUNDUSCOPY
is the most important
characteristic of the
glaucomatous process
23. the diagnosis of
early glaucomatous
damage depends
on a careful
examination of the
optic disc and the
nerve fiber layer
EVALUATION OF
OPTIC DISC WITH 5
RULES
• SCLERAL RING
• NEURORETINAL RIM
• NERVE FIBER LAYER
• PERIPAPILARY ATROPHY
• DISC HEMORRHAGE
24. ……………SCLERAL RING
Determining the size
of the disc =Crucial
Helps to differentiate
Physiological
cupping from
Pathological.
Large discs have big
physiological cups.
Small Discs have
small cups or no
cups
25. LARGE DISK WITH LARGE CUP, AVERAGE
SIZE DISK WITH AVERAGE SIZED CUP AND
NO CUP IN A SMALL DISK
27. The cup–disc ratio is normally
between 0.1 and 0.4,
although as many as 5% of
individuals without glaucoma
will have cup–disc ratios
larger than 0.6.
Glaucoma cup-disc ratio >
0,6
28. TO DETERMINE THE CUP MARGIN—THE SECOND KINK
(BLUE ARROW) IS THE CUP EDGE (THE FIRST KINK IN THE VESSEL-
RED ARROW)
30. VERTICAL CUP DISC RATIO
• VERTICALLY OVAL OPTIC DISC
• HORIZONTALLY OVAL OPTIC CUP
• IN NORMAL EYES: HORIZONTAL CD RATIO > THAN VERTICAL CD
RATIO
• IN GLAUCOMATOUS EYES: VERTICAL CD RATIO > THAN THE
HORIZONTAL CD RATIO
31. …..NEURORETINAL RIM (NRR)
• THE OPTIC DISK IS VERTICALLY OVAL AND THE
CUP IS HORIZONTALLY OVAL
• ISNT RULE
• LOSS OF NRR FROM THE INNER EDGE OF RIM
I>S>N>T
GLAUCOMATOUS
OPTIC
32. THE NEURRETINAL RIM LOSS IN
GLAUCOMA
Usual sequence of NRR loss in
Glaucoma:
• Inferotemporal
• Superotemporal
• Horizontal temporal
• Inferonasal
• Superonasal
33. Notching
LOCALIZED RIM THINNING/NOTCHING
localized rim loss that may
extend to the disc margin
superior and/or inferior notching
may be associated with
localized field defects with early
threat to fixation.
34. NERVE FIBER LAYER
• RNFL DEFECT PRECEDES DETECTABLE OPTIC
DISC AND VISUAL FIELD CHANGES
• IT CAN BE
• LOCALIZED WEDGE SHAPED DEFECT
• DIFFUSE DEFECT THAT ARE LARGER AND HAVE
INDISTINCT BORDERS
• MORE EVIDENT FOLLOWING DISC HAEMORRHAGE
• RED FREE LIGHT ARE USED TO SEE THE DEFECTS
35. RETINAL NERVE FIBRE LAYER DEFECT
• Can be detected before visual field defect has
developed
• Focal type of NTG
• Early to medium advanced Glaucomatous damage
Localized
RNFL defects:
• More difficult to detect
• Peripapillary retinal vessels appear bare
• Underlying Choroidal vessels more clearly seen
Diffuse loss of
RNFL:
38. ………PERIPAPILLARY ATROPHY
• PERIPAPILLARY ATROPHY (PPA)
SURROUNDING THE OPTIC NERVE HEAD
MAY BE OF SIGNIFICANCE IN GLAUCOMA
• A SIGN OF EARLY DAMAGE IN PATIENTS
WITH OCULAR HYPERTENSION.
39. Alpha zone-irregular hypo or hyper
pigmented zone associated with
chorioretinal thinning
Beta zone, which is due to atrophy
of the RPE and choriocapillaris,
leading to increased visibility of the
large choroidal vessels and
sclera
40. OPTIC DISC HEMORRHAGE
• AT THE MARGIN OF THE DISC
• HALLMARK OF GLAUCOMATOUS
OPTIC NERVE DAMAGE
• 4 TO 7 % OF EYES WITH
GALUCOMA
• FOUND IN EARLY & MODERATELY
ADVANCED GLAUCOMA AND
RARE IN VERY ADVANCED
STAGE
• LOCATED USUALLY IN THE
INFEROTEMPORAL &
SUPEROTEMPORAL DISC
MARGINS
• ASSOCIATED WITH LOCALIZED
RNFL DEFECT AND
NEURORETINAL RIM NOTCHES .
• SUGGESTS PROGRESSION.
• MORE COMMON IN NTG
42. CONCLUSION
• OPTIC DISC IS PART OF OPTIC NERVE THAT SENSITIVE WITH INCREASE OF INTRA
OCULAR PRESSURE
• GLAUCOMATOUS OPTIC IS CAUSED BY MECHANICAL, ISCHEMIC, AND
AUTOREGULATORY THEORY
• IT CAN MAKE AXON DAMAGE, AKTIVATION OF GLIAL CELL,TISSUE REMODELING,
AND OCULAR BLOOD FLOW CHANGE.
• EVALUATION WITH FUNDUSCOPY WITH FIVE RULES : IDENTIFICATION OF
SCLERAL RING, NEURORETINAL RIM, RETINAL NERVE FIBER LAYER, PERIPAPILER
ATHROPY AND DISC HEMMORHAGE.
55. DETERMINE DISK SIZE DECREASE THE HEIGHT OF THE SLIT BEAM
TO COINCIDE WITH THE DISK MARGIN.
READ THE MEASUREMENT FROM THE SCALE
56. Small glaucomatous optic disc:
pseudonormal
but glaucomatous minicupping
in minidisc.
Note: small optic cup
despite the smallness of the
optic disc; abnormal shape of
the neuroretinal
rim (contradicting ISNT rule);
decreased visibility of the retinal
nerve fiber layer
57. • THE OPTIC NERVE HEAD IS SLIGHTLY VERTICALLY OVAL, WITH THE VERTICAL
DIAMETER BEING ABOUT 9% LARGER THAN THE HORIZONTAL ONE.
• MORPHOMETRIC STUDIES HAVE SHOWN THAT ITS AREA VARIES BETWEEN 0.86
AND 5.86 MM2
• IN HIGHLY HYPEROPIC EYES, THE OPTIC DISC AREA TENDS TO BE SMALLER,
WHEREAS
• HIGHLY MYOPIC EYES ARE ASSOCIATED WITH LARGE OPTIC DISCS.
58. • THE CUPS ARE HORIZONTALLY OVAL, WITH THE HORIZONTAL DIAMETER BEING
ABOUT 8% LONGER THAN THE VERTICAL DIAMETER.
• THE SIZE AND DEPTH OF THE CUP IS HIGHLY VARIABLE, AND DEPENDS ON THE SIZE
OF THE OPTIC DISCS.
• THIS LEADS TO IMPORTANT CLINICAL GUIDELINES: LARGE DISCS MAY BE
ASSOCIATED WITH PHYSIOLOGICALLY LARGE CUPS, WHICH RESEMBLE
GLAUCOMATOUS DAMAGE.
• ON THE OTHER HAND, APPARENTLY NORMAL CUPS IN SMALL DISCS MAY ALREADY
BE A SIGN OF GLAUCOMATOUS DAMAGE.
59. NRR
• THE MAIN FOCUS OF THE OPTIC DISC EVALUATION IN GLAUCOMA
• SIGNIFICANTLY BROADER IN THE INFERIOR POLE, AND BECOMES
PROGRESSIVELY NARROWER AT THE SUPERIOR, NASAL, AND FINALLY THE
TEMPORAL DISC REGION (ISN’T RULE).
60. LAMINAR DOT SIGN
• BECAUSE THE FIBERS CHANGE DIRECTION ABRUPTLY, BENDING
CENTRIFUGALLY, A CENTRAL CONCAVITY OR ‘CUP’ IS CREATED, THE BASE OF
WHICH APPEARS MORE YELLOW-WHITE BECAUSE OF THE UNDERLYING
COLLAGENOUS FIBERS OF THE LAMINA CRIBROSA.
61.
62.
63. • THE BLOOD VESSELS SUPPLYING THE OPTIC NERVE HEAD HAVE TIGHT
JUNCTIONS, NON-FENESTRATED ENDOTHELIUM, AND ABUNDANT PERICYTES
NERVE-BLOOD BARRIER.
• THE VASCULAR PERFUSION PRESSURE OF THE OPTIC DIFFERENCE BETWEEN
THE MEAN LOCAL ARTERIAL PRESSURE AND THE IOP.
• THE ARTERIES SUPPLYING BLOOD TO THE OPTIC NERVE HEAD CAN
AUTOREGULATE, ADEQUATE BLOOD FLOW DESPITE VARIATIONS IN PERFUSION
PRESSURE.
• OPTIC NERVE DAMAGE MAY OCCUR WHEN THE PERFUSION PRESSURE IS
INSUFFICIENT TO PROVIDE ADEQUATE BLOOD FLOW TO THE NERVE AND WHEN
AUTOREGULATION MECHANISMS ARE IMPAIRED.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83. PATTERNS OF GLAUCOMATOUS
PROGRESSION
Adapted from Tuulonen and Airaksinen. Am J Ophthalmol. 1991.
Type of progression
of disc abnormality
First glaucomatous
optic disc change
Disc cup enlargement
Disc cup enlargement
with local notching
Local notch
Pale neuroretinal rim;
no change of configuration
Normal optic disc
(left eye)
Diffuse enlargement:
round-shaped
Diffuse enlargement:
vertically oval
Broader local notch
Pale rim; no change
of configuration
13%
9%
56%
22%
84.
85. • AXONS FROM PERIPHERAL RETINAL GANGLION
CELLS OCCUPY A MORE PERIPHERAL POSITION
IN THE OPTIC NERVE.
• AXONS FROM RETINAL AREAS CLOSER TO THE
DISC ARE LOCATED MORE CENTRALLY IN THE
NERVE.
86.
87. • NOW THAT WE HAVE DISCUSSED THE IMPORTANCE OF EXAMINING THE RETINAL NERVE FIBER LAYER. NOW,
LET’S GO TO THE NEXT QUESTION: HOW TO EXAMINE THE RNFL?
• FEW STUDIES HAVE COMPARED THE SENSITIVITY OF OPTIC DISC AND RNFL ASSESSMENT. FROM ANNUAL
EXAMINATIONS OF 813 OCULAR HYPERTENSIVE EYES, OPTIC DISC AND RETINAL NERVE FIBER LAYER
PHOTOGRAPHS WERE COMPARED IN TWO AGE-MATCHED SUBGROUPS: 37 EYES THAT CONVERTED TO
ABNORMAL VISUAL FIELD TESTS AT THE END OF A 5-YEAR PERIOD AND 37 CONTROL EYES THAT RETAINED
NORMAL FIELD TESTS. OPTIC DISC CHANGE WAS DETECTED IN ONLY 7 OF 37 (19%) CONVERTERS TO FIELD LOSS
AND IN 1 OF 37 (3%) CONTROLS. PROGRESSIVE RETINAL NERVE FIBER LAYER LOSS WAS OBSERVED IN 18 OF 37
(49%) CONVERTERS AND IN 3 OF 37 (8%) CONTROLS. IN THIS IMPORTANT STUDY, SERIAL RETINAL NERVE FIBER
LAYER EXAMINATION WAS MORE SENSITIVE THAN COLOR OPTIC DISC PHOTOGRAPH EVALUATION IN THE
DETECTION OF PROGRESSIVE GLAUCOMA DAMAGE AT THIS EARLY STAGE OF GLAUCOMA.
88.
89. PRE PERIMETRIC DIAGNOSIS OF GLAUCOMATOUS
OPTIC NERVE DAMAGE
• MOST IMPORTANT VARIABLES
• SHAPE OF THE NRR
• SIZE OF THE CUP IN RELATION TO THE OPTIC DISC
• DIFFUSE OR FOCAL RNFL DEFECTS
• DISC HEMORRHAGES
