Optic Disc Assessment RNFL Overview

OPTIC DISC
ASSESSMENT/RNFL
OVERVIEW
2004 Remo Susanna Jr
Outline
I.
Five rules for assessment of

the optic disc in glaucoma
II. Detecting glaucoma
III. Detecting progression
IV. Examples
V. Test your skills
FIVE RULES FOR

ASSESSMENT OF THE
OPTIC DISC IN GLAUCOMA

the optic disc in glaucoma (1)
1. Observe the scleral Ring to
identify the limits and size
of the optic disc
Photo courtesy of Ki Ho Park

1. Observe the scleral Ring
to identify the limits and
size of the optic disc
2. Identify the size of the Rim

1. Observe the scleral Ring to
identify the limits and size
of the optic disc
3. Examine the Retinal nerve
fibre layer

fibre layer
4. Examine the Region of
peripapillary atrophy

fibre layer
4. Examine the Region of
5. Look for Retinal and
optic disc haemorrhages
Rule 1
Observe the scleral Ring

to identify the limits and size
of the optic disc
The scleral ring (1)

Rim width = distance
between the scleral
ring and the location
where the vessel is
bent (cup border)
Scleral
ring
Cup border
The scleral ring (2)

Rim width = distance
between the scleral
ring and the location
where the vessel is
bent (cup border)
Scleral
ring
Kinking
of the vessel
(cup border)
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 a

small disc, especially if generalised
SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.
Optic disc size (2)

Can be measured using the small light
spot of a direct ophthalmoscope
The spot size can be used to estimate
whether a disc is larger or smaller than
average
Other forms of evaluation

conventional photographic means with
an overlay grid
optic nerve head analysis
Normal size disc
Small disc
Large disc
Small aperture (5 degree)

of Welch-Allen direct
ophthalmoscope
Optic disc size (4)

Indirect
ophthalmoscopy and
slit lamp examination
Use Volk slit lamp
biomicroscopy lenses
Measure size of slit
beam
Correction factors
Volk 60D: 1.0
Volk 78D: 1.1
Volk 90D: 1.3
Optic disc size (5)
Vertical
disc
diameter
Scleral
ring
Horizontal
disc diameter
Optic disc size (6)

The size of the cup varies with the size of the disc
Large discs have large cups in healthy eyes
Small
Average
Large
Cup size is proportional to disc size in normal eyes

Right photo courtesy of Ki Ho Park
Optic disc size (7)

Be cautious
with myopic discs
Cup border
Scleral
ring
Rule 2
Identify the size of the

neuroretinal Rim
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 optic
neuropathy

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

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 is
extremely large or very tilted
The ISNT rule (1)

Normally, the thickest to thinnest parts
of the neuroretinal rim of the optic disc
follow the ISNT rule:*
Inferior > Superior > Nasal > Temporal
Any variation from this rule may help to
detect glaucomatous damage
* The ISNT rule is followed in approximately 80% of eyes.
The ISNT rule (2)

Rim width =
distance between
border of disc and
position of blood
vessel bending
ISNT rule
Inferior >
Superior >
Nasal >
Temporal
I
Localised rim thinning/notching (1)
Notching
Notch
Localised rim thinning/notching

(3)
2004 Remo Susanna Photos

Jr
courtesy of GT Sunil and L Vijaya
2004 Remo Susanna Jr Photos courtesy of GT Sunil and L Vijaya
Diffuse neuroretinal loss
Photos courtesy of GT Sunil and L Vijaya
Pallor (1)
Observe the colour of the rim to
identify pallor
A pale rim increases the likelihood
of a non-glaucomatous optic
neuropathy
Pallor (2)
Total pallor
Pallor > cup
Cup
Pale rim
Non-glaucomatous
neuropathy
Pallor (3)
Diffuse pallor
Cup
Pallor > cup
Non-glaucomatous
neuropathy
Normal disc
Cup = pallor
If cup = pallor: normal

If pallor > cup: neurological disorder
or glaucoma with very high IOP
If cup > pallor: glaucoma or normal
2004Remo
Susanna
Jr
2004 Remo
Susanna
Jr
Schwartz. Arch Ophthalmol 1973;

1973 89: 2727.
Pallor (4)
Cup > pallor
Cup
Pallor
Location of kinking
of the vessel
2004 Remo Susanna
Photo Jr
courtesy of Ki Ho Park
Suspect glaucoma
Pallor (5)
Lamina cribrosa
Striated pattern
(Susanna 1983)
Acquired optic pit

(Radius et al. 1978)
Acquired pit of optic nerve

(APON)
Photo courtesy of GT Sunil and L Vijaya
APON
Acquired optic pit

Normal optic nerve head

Remember that a
normal large disc
has a large cup
ISNT rule obeyed
Cup = pallor
Large cup
Large disc
Rule 3
Examine the
Retinal nerve fibre layer
RNFL examination
Best performed using red-free light (red-free
photographs or green light)
Look at
Striations
Brightness
Visibility of peripapillary retinal
vessels
Look for diffuse and localised RNFL loss

Red-free photography
Bright
striation
s
Right photo courtesy of Ki Ho Park
Diffuse RNFL loss (1)

Diffuse loss of striate pattern
Increased visibility of retinal vessel borders
Bright
striations
Diffuse loss
of striations
Diffuse RNFL loss (2)

Normal RNFL
Diffuse RNFL loss
Localised RNFL loss (1)
Localised RNFL defect

Wedge-shaped dark area
Photos courtesy of Ki Ho Park

Better seen with red-free light
2004, Remo Susanna Jr
Hoyt WF et al.
al. Invest Ophthalmol 1973;
1973 12: 81429.

Wedge-shaped
dark area

Wedge-shaped
dark area
Rule 4
Examine the Region of

Peripapillary atrophy (1)

Alpha zone
Hypo- and hyperpigmented areas
Present in normal as well
as in glaucomatous eyes
Beta zone
Atrophy of the retinal

pigment epithelium and
choriocapillaris
Large choroidal vessels
become visible
More common in
glaucomatous eyes

Alpha zone
Beta zone
Sensitivity
2030%
Specificity
80%
360 ring
normotensive
senile sclerotic
glaucoma
zone
zone

Jonas JB et al. Invest Ophthalmol Vis Sci 2000; 41: 176473.

Beta zone
Width of beta zone
inversely correlates
with rim width at
same area
Larger beta zone
thinner rim
Progression of beta
zone associated
with progressive
glaucoma
Thin rim
Larger zone
Rule 5
Look for Retinal and

optic disc haemorrhages
Optic disc haemorrhage (1)
Flame-shaped
haemorrhage
Flame-shaped
haemorrhage
Photo courtesy of Prin RojanaPongpun


Detection of disc haemorrhages requires
careful optic disc examination
Middle and right photos courtesy of Ki Ho Park

Detection of disc haemorrhages requires
careful optic disc examination

Normally disappears after 13 months
Indicative of glaucomatous progression

Normally disappears
after 13 months
Indicative of
glaucoma
progression
Flame-shaped
haemorrhage
Optic disc
haemorrhage (7)
DETECTING GLAUCOMA
ISNT rule is not obeyed

Glaucoma
Glaucoma small disc

Peripapillary atrophy
Narrowing of retinal arteries
Generalised RNFL
Large cup for a small disc
Nasal cupping
Haemorrhage
Read RM, Spaeth GL. Trans Am Acad Ophthalmol

Otolaryngol 1974; 78: OP25574.
Notch (1)
Notch
RNFL defect
Peripapillary
atrophy (beta zone)
Hitchings RA, Spaeth GL. Br J Ophthalmol 1976; 60: 77885.
Notch (2)
Images courtesy of GT Sunil and L Vijaya
Notch (3)
Images courtesy of GT Sunil and L Vijaya
Cupdisc ratio asymmetry > 0.2*
*After accounting for disc size asymmetry.

Armaly MF. Arch Ophthalmol 1967; 78: 543.
Glaucoma (1)
RNFL loss
Notching
Glaucoma (2)
Cup asymmetry exceeds disc asymmetry

Glaucoma (3)
Localised loss of both
inferior and superior
neuroretinal rim
Classic inferior notch
(small arrows)
RNFL defect in
superior and inferior
arcuate area (large
arrows)
Glaucoma (4)
Neuroretinal rim
thinning
The cup extends to
the disc rim
Circumlinear blood
vessel baring
Bayoneting of the
blood vessels
Peripapillary atrophy
DETECTING PROGRESSION
Generalised rim thinning
10 years
Progressive rim thinning (1)

Enlargement of localised RNFL defect
4 years
Progressive rim thinning (2)
2004 Remo Susanna Jr Images courtesy of GT Sunil and L Vijaya
5 years
5 months
10 years
Save me,
please
EXAMPLES
Example 1
Glaucoma or normal?
Use the 5 rules
1 Observe the scleral Ring
to identify the limits of the
optic disc and its size
2 Identify the size of the Rim
3 Examine the Retinal nerve
fibre layer
4 Examine the Region of
5 Look for Retinal and optic
disc haemorrhages
Example 1
1. Small disc size
2. Rim thinning
(inferiorly)
ISNT rule:
3. Localised RNFL
defect (inferiorly)
4. No significant
5. Haemorrhage
GLAUCOMA
Example 2
Glaucoma or normal?
Use the 5 rules
fibre layer
disc haemorrhages
Example 2
1. Average disc size
2. Normal rim
ISNT rule: +
3. Normal RNFL
4. No significant
5. No haemorrhage
NORMAL
Example 3
Glaucoma or normal?
Use the 5 rules
fibre layer
disc haemorrhages
Example 3
1.
2.
3.
4.
5.
Average disc size

Notching (inferiorly
and superiorly)
ISNT rule:
RNFL loss
No significant
No haemorrhage
GLAUCOMA
Example 4
Glaucoma or normal?
Use the 5 rules
fibre layer
disc haemorrhages
Example 4
2. Rim thinning
(inferiorly)
ISNT rule:
3. RNFL loss: diffuse
4. Peripapillary atrophy:
beta zone
5. No haemorrhage
GLAUCOMA
Example 5
Glaucoma or normal?
Use the 5 rules
fibre layer
disc haemorrhages
Example 5
1. Large disc size
2. Normal
ISNT rule: +
3. Normal RNFL
4. No significant
5. No haemorrhage
NORMAL
Example 6
Glaucoma or normal?
Use the 5 rules
fibre layer
disc haemorrhages
Example 6
2. Rim thinning
(inferiorly)
ISNT rule:
3. RNFL loss: diffuse
(inferiorly)
4. Peripapillary atrophy:
beta zone
5. Haemorrhage:
reabsorbing
GLAUCOMA
TEST YOUR SKILLS
Evaluation form
Name: _________________________________
TEST #: _________
( ) 1. ISNT rule not obeyed
( X ) 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
Date: ___/___/____
Test I
Test 1
Test 2
Test 3
Test 4
Test 5
Test 6
Test 7
Test 8
Test 9

2004,
2004, Remo
Remo Susanna
Susanna Jr
Jr
Test 10
Test I
Put your 3D glasses on
Test 1
Test 2
Test 3
Test 4
Test 5
Test 6
Test 7
Test 8
Test 9
Test 10
Test I
Discussion
Small disc
Small cup
RNFL reflex
Normal
Test 1
Disc
haemorrhage
ISNT rule not
obeyed
Glaucoma
Test 2
Large disc
Large cup
ISNT rule obeyed
Normal RNFL
Pallor = cup
Normal
Test 3
Notching superiorly
Beta zone
Superior and inferior
RNFL drop-out
ISNT rule not
obeyed
Glaucoma
Test 4
Beta zone
Notching
superiorly and
inferiorly
Haemorrhage
Glaucoma
Test 5
Inferior notching
Inferior beta zone
Inferior RNFL defect
Glaucoma
Test 6
ISNT rule not

obeyed
Inferior
peripapillary
atrophy
Inferior notching
Nasal cupping
Glaucoma
Test 7
ISNT rule obeyed

Whitish RNFL reflex
Normal disc
Test 8
Small disc
Beta zone
Large cup for
a small disc
Nasal cupping
Glaucoma
Test 9
ISNT rule not

obeyed
Inferior
peripapillary
atrophy
Inferior notching
Nasal cupping
Glaucoma
Test 10
Test II
Put your 3D glasses on
Test 1
Test 2
Test 3
Test 4
Test 5
Test 6
Test 7
Test 8
Test 9
Test 10
Test 11
Test 12
Test 13
B
Test 14
Test 15
Test 16
Right eye
Left eye
Test 17
B
Test 18
Test 19
Test 20

Optic Disc Assessment RNFL Overview

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OPTIC DISC

2004 Remo Susanna Jr

Five rules for assessment of

2004 Remo Susanna Jr

FIVE RULES FOR

2004 Remo Susanna Jr

Five rules for assessment of

2004 Remo Susanna Jr

Photo courtesy of Ki Ho Park

Five rules for assessment of

2004 Remo Susanna Jr

Photo courtesy of Ki Ho Park

Five rules for assessment of

2004 Remo Susanna Jr

Photo courtesy of Ki Ho Park

Five rules for assessment of

2004 Remo Susanna Jr

Photo courtesy of Ki Ho Park

Five rules for assessment of

Photo courtesy of Ki Ho Park

Observe the scleral Ring

2004 Remo Susanna Jr

The scleral ring (1)

2004 Remo Susanna Jr

The scleral ring (2)

Optic disc size (1)

Pathological rim loss can be missed in a

2004 Remo Susanna Jr

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

Optic disc size (2)

Other forms of evaluation

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

Normal size disc

Small aperture (5 degree)

Optic disc size (4)

Optic disc size (5)

Photo courtesy of Ki Ho Park

Optic disc size (6)

Cup size is proportional to disc size in normal eyes

Right photo courtesy of Ki Ho Park

Optic disc size (7)

2004 Remo Susanna Jr

Identify the size of the

2004 Remo Susanna Jr

The neuroretinal rim (1)

Loss of tissue from inner edge of the

2004 Remo Susanna Jr

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

The neuroretinal rim (2)

Notching of the rim (especially the disc margin)

2004 Remo Susanna Jr

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

The neuroretinal rim (3)

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

The ISNT rule (1)

SEAGIG. Asia Pacific Glaucoma Guidelines. 20032004.

The ISNT rule (2)

Localised rim thinning/notching (1)

Photo courtesy of Ki Ho Park

Localised rim thinning/notching (2)

2004 Remo Susanna Jr

Localised rim thinning/notching

2004 Remo Susanna Photos