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CHAPTER 11

THE OPTIC DISC IN GLAUCOMA:
A LONGITUDINAL STUDY

11.1 The menu ’determine topographic difference’ (in the menu ’processing’)
When the follow up of a patient is carried out, two topographic images taken at dif-
ferent times are analyzed. This analysis reveals any significant difference between them.
When this type of analysis is performed, the HRT software displays the first and the sec-
ond tomography (the summation and topographical images of each one) and an analysis
of the topographical changes between them (figure 11.1). Both tomographies must be
similar, i.e., the optic nerve head must be approximately centered in both 10 degree
fields. Otherwise the images cannot be aligned and a warning message appears to indicate
that the analysis cannot be performed.
In the topographic difference image, the structures that moved in a posterior direc-
tion (thus becoming deeper) appear bright, whereas those structures that moved in an
anterior direction (thus becoming more superficial) appear dark. Together with the topo-
graphic difference image, the so-called significance marker image is displayed which
indicates the locations where significant height change occurred. In the significance
marker image, all structures that became significantly deeper in the follow up examina-
tions appear in red color, and all structures that became significantly more prominent
appear in green color. Locations with no significant height change are displayed in black.
A height change is assumed to be significant if it is more than two times the local stan-
dard deviation (variability) of the height measurements.
It is important to stress that since the structures that vary are the neuroretinal rim, the
peripapillary region and the cup, the change manifests itself in the anterior or posterior
displacement of their surfaces. Isolated red or green picture elements in the significance
marker image therefore cannot be considered as significant change. However, there are
significant surface height changes if clusters of red or green picture elements appear.
When there is no significant height change, then often the outline of the optic nerve head
appears and the vessels have a small red and green contour, with no large colored areas.
With the 3D-movie option, the difference image shifts from right to left and it projects
the green surfaces towards the front and the red surfaces towards the back.
The topographic difference image and the significance marker image appear when
menu ’show result’ is selected.
In the menu ’display image series’, for each tomography the summation and the to-
pographical image is displayed. Each image can be observed separately and successively.
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Fig. 11.1

In the menu ’topo map’ (topographic map), the local height change and the local
standard deviation appears in each of the 256 x 256 little squares (picture elements).

11.2 Longitudinal study in the follow up of a glaucoma case
Female patient, 68 years of age, with a diagnosis of combined pathogenesis glau-
coma. The intraocular pressure was 50 mmHg with maximum therapy. The visual field
had a mean defect of 8.9 db and a corrected loss variance of 79.1. The optic nerve tomog-
raphy showed an evolution in phase 4. A trabeculectomy was performed.
We are going to perform the study of the preoperative and postoperative optic nerve
head and visual field images. Figure 11.2 is a preoperative image and figure 11.3 was
taken after surgery. From phase 4 of the glaucoma evolution before surgery it changed to
phase 2 after surgery. The most important parameters and their values appear in both
figures.
Before surgery, the entire optic disc area is occupied by the cup (in red). The NRR is
very thin, and its slope (in blue) has almost disappeared. In the superior and inferior tem-
poral quadrants of the contour line profile, there is a great depression that falls below the
reference plane. The retinal fiber nerve layer (RFNL) thickness is substantially decreased
(figure 11.2).
Figure 11.3 shows that the degree of optic nerve alteration has changed from phase 4
to phase 2 after surgery. When the intraocular pressure fell, the nerve tissue became de-
compressed and the NRR reappeared (in green and blue). The depression of the superior
and inferior temporal quadrants has disappeared and the contour line profile (green
curve), recovers its normal appearance, with two camel humps. The retinal nerve fiber
layer thickness (distance between the red line and green curve), has considerably in-
creased.
Figure 11.4 shows the horizontal cross sections of the topography images before and
after surgery. The change in the cross section of the optic nerve head is noteworthy. The
topographical image of the optic disc appears on the left of each section. The superior and
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Fig. 11.2

Fig. 11.3

inferior arrows show how the depression has disappeared. The tissues have decompressed
due to the barometric action of the intraocular pressure, but the destruction of fibers can-
not be reversed.
Figure 11.5 shows the visual fields before and after surgery, where a remarkable im-
provement of the function of the optic nerve is evident. It is very important to keep in
mind that this improvement is due to the decrease or disappearance of the barometric
effect after surgery.
In figure 11.6, a comet-shaped image can be observed in green, where its head rep-
resents the anterior displacement of the deepest part of the cup and of the NRR, and its
tail represents the displacement in the same direction of the retinal fiber bundle belonging
to this sector of the NRR. The (red and green) significance marker image is obtained by
comparing the images before and after surgery. Note that only the surfaces, and not the
lines (since they are not significant), must be taken into account.
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Fig. 11.4

Fig. 11.5

Other authors, such as Irak, Weinreb and collaborators (HRT Symposium, ARVO
1995) have studied this effect of surgery on the optic nerve.
Generally, when making these comparisons, the thickness of the retinal nerve fiber
layer must be related with preoperative and postoperative intraocular pressures. After
surgery, the area, the volume and the maximum cup depth decrease, as well as the cup /
disc area ratio (cup area / optic disc area). The NRR area and volume increase.
Figure 11.7 shows the comet-shaped image with the differential analysis performed
with the PeriData program, between the pre- and postoperative visual fields, where the
improvement between both exams can be seen. This improvement is shown in the cumu-
lative defect curve (Bebie’s Curve), by the vertical lines above the curve.
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Fig. 11.6

Fig. 11.7

11.3 Longitudinal study in the follow up of a posterior displacement: its importance
for a differential diagnosis
A 50-year-old female patient was treated during two years for unilateral glaucoma
by five ophthalmologists. The last ophthalmologist referred her for surgery because her
left eye failed to keep its intraocular pressure regulated with maximum therapy and it had
a visual field with severe 3rd degree defects. Before surgery, the intraocular pressure was
18 mmHg in the right eye and 28 mmHg in the left eye. It was striking that the visual
acuity in her right eye was 18/20 and in her left eye 0.1/20 (!!!). While the visual field of
the right eye was normal, the defects in the left eye were very marked, with an MD of
24.2 and a CLV of 41. The configuration of the visual field was not typical of glaucoma.
Immediately after surgery, the intraocular pressure of her left eye fell to 16 mmHg
and it called our attention that the MD had decreased to 9.
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Fig. 11.8a

Fig. 11.8b

Figure 11.8a shows the visual field before surgery (with atypical damage for glau-
coma) and figure 11.8b shows the visual field after surgery. The patient’s HRT exam is
shown in figure 11.9. The topographical image shows the optic nerve structures displaced
towards the front, in dark shades, and especially the ectasic of the venous vessels. In the
cross section of the optic nerve, a dilated venous vessel is seen, protruding towards the
vitreous body and widely surpassing the level of the peripapillary retina.
In figure 11.10, in the stereometric analysis, on the top left-hand side of the figure,
the optic nerve appears with a very small red zone belonging to the cup and a large NRR
with its flat and sloping parts (green and blue respectively). The part in green, clearly
shows (white arrow) the venous vessel that extends forward. On the right, the topo-
graphic map shows the protrusion of the venous vessel in the vitreous body and measures
it in microns. The measured parameters are normal, the same as the contour line.
Faced with a unilateral glaucoma, with an abnormal visual field, atypical for a glau-
coma, and with an optic disc with completely normal parameters, I decided to perform an
echography. Figure 11.12 shows the echogram evidencing that it is a case of meningioma
of the optic nerve sheaths. This meningioma is one of the most important compressive
optic neuropathies.
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Fig. 11.9

Fig. 11.10

Fig. 11.11
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Fig. 11.12

Fig. 11.13

In figure 11.11, the stereometric analysis after surgery shows that the protruding ve-
nous vessels have disappeared in the Measure menu as well as in the topographic map.
In figure 11.12, the B-scan echography shows a retro-ocular tumor. The A-scan
echography shows the thickened optic nerve and the typical peaks of the optic nerve
sheaths, which are highly reflective. At the bottom, the normalized echographic outline
after the surgical tumor extirpation, is shown.
Figure 11.13 illustrates the orbital axial computer tomography, which clearly shows
the tumor that deviates the optic nerve.
Figure 11.14 is the topographic difference image of the follow up, which automati-
cally compares the eye before and after surgery. Note at the top of the figure the red sur-
faces representing the back movement of the venous vessels in comparison to the rest of
the structures. This shows the back movement of the optic nerve structures in an antero-
posterior direction. The case was a glaucoma secondary to venous hypertension in the
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Fig. 11.14

Fig. 11.15

tenonian and conjunctival episcleral veins caused by the compression of vessels at the
retro-ocular orbit produced by the tumor.
Finally, for teaching purposes, we have compared the difference images of the first
patient (glaucoma) with those of the second patient (meningioma). In the upper part of
figure 11.15, the results of the patient with meningioma show red surfaces, especially due
to the backwards movement of the central vessels and of the optic nerve structures that
have moved backward. In the lower part of the same figure, in the image of the patient
operated for glaucoma, there is a green surface indicating that after surgery the optic
nerve tissues have moved significantly towards the front.
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