In partnership with the

Shields Gray Crescents Masquerading as

Glaucomatous Cupping of the Optic Nerve
Head
Mohamed S. Sayed, MD,1,* Michael Margolis, MD,1,2,* Jessica L. Chen, MD,1,3 Giovanni Gregori, PhD,1
Richard K. Lee, MD, PhD1

Purpose: Gray crescents characterized by darkly pigmented regions on the optic nerve head could make
assessment of cupping difficult by obscuring the true anatomic disc border. On slit-lamp examination, 2
morphologically distinct types of gray crescents at the curved disc boundary exist. The in vivo histologic char-
acteristics differentiating these 2 types are described using spectral-domain (SD) OCT.
Methods: A prospective interventional case series in a single tertiary referral center. Sixteen eyes of 10
patients with gray crescents determined through clinical examination and fundus photography underwent cross-
sectional optic nerve head and parapapillary imaging using high-resolution SD OCT. In vivo histology of gray
crescents was characterized.
Results: In SD OCT images across the areas of gray crescent, type A gray crescents represent regions where
the retinal pigment epithelium (RPE)-Bruch’s membrane complex is absent and the dark underlying choroid is
directly visible. In contrast, type B gray crescents represent regions of the retina where the RPE is clumped or
thickened, typically appearing to be folded upon itself, revealing the embryonic continuity of the RPE and
neuroretina.
Conclusions: Shields type A and B gray crescents appear different clinically because histologically they
represent differences in RPE. Type A grey crescents lack RPE, whereas type B crescents have thickened, folded
RPE. Gray crescents can obscure the true disc border and result in pseudo-cupping of the optic nerve head.
Identification of gray crescents is clinically important because failure to recognize pseudo-cupping can contribute
to overdiagnosis of glaucoma. Ophthalmology Glaucoma 2018;1:99-107 ª 2018 by the American Academy of
Ophthalmology

The intrapapillary and parapapillary regions of the optic
nerve head have variable morphologic configurations
throughout the population. This variability has been attrib-
uted to ethnicity, refractive status, and conditions affecting
the optic nerve head (e.g., glaucoma) among other factors.
Pigmentation within or in the vicinity of the optic nerve
head is an important clinical feature that, together with other
optic disc morphologic features, helps clinicians distinguish
different clinical entities that involve the optic nerve head.
Gray pigmented crescents within the optic disc border are
clinically apparent in many eyes.
In 1980, Bruce Shields1 termed a pigmented crescent
located within the disc margin of the optic nerve head a
“gray crescent.” The gray crescent is typically a slate-gray
crescentic pigmentation of the neuroretinal rim, commonly
located in the temporal or inferotemporal periphery, and
considered to be a normal anatomic variant. The gray
crescent is distinct from different variants of parapapillary
pigmentation observed outside of the disc margin. The
exact cause of this gray crescent is not known but was
thought to possibly represent areas where melanin or
melanocytes have accumulated on or within the
neuroretinal rim tissue of the nerve head.2 No difference
in the prevalence of gray crescents in glaucomatous
compared with nonglaucomatous eyes apparently exists.2
However, these gray crescents are clinically important
because they may be mistaken for parapapillary
pigmentation,3 obscure the neuroretinal rim tissue, and
give a false impression of neural retinal rim loss due to
glaucomatous damage (i.e., pseudo-cupping). This is of
particular importance when assessing cup-to-disc ratio in
African American patients, who have a higher prevalence of
both glaucoma and gray crescents.3
Shields subsequently found it necessary to distinguish his
initially described gray crescent from a different type of dark
tissue found at the curved disc boundarydthe latter previ-
ously termed conus pigmentosusddescribed as a darker,
more irregular and stereoscopically more superficial area of
retinal pigment epithelium (RPE) hypertrophy that may
cover the parapapillary scleral crescent and appears to enter
the intrapapillary disc region.3 Other investigators, seeking
to understand the epidemiologic characteristics of the gray
crescent, had unwittingly lumped the 2 categories
together, because the histologic nature of the 2 gray
crescents was not determined.2,4 For the purpose of
in vivo histologic OCT evaluation, we have designated the

 2018 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ogla.2018.08.001 99

Published by Elsevier Inc. ISSN 2589-4196/18
 Ophthalmology Glaucoma Volume 1, Number 2, September/October 2018
former as a Shields type A gray crescent and the latter as a
Shields type B gray crescent.
The histologic equivalent of the gray crescent has been
suggested to be melanocyte accumulation or intrapapillary
RPE-Bruch’s membrane extension, with some OCT support
demonstrating the possibility of Bruch’s membrane to
extend beyond the optic disc border into the substance of the
optic nerve head.1,4-6 Jonas et al7 have characterized the
zones of parapapillary atrophy (PPA) histomorphologically
and by OCT.8 However, to our knowledge, the histologic
nature of the gray crescent is yet to be determined. In this
study, we compared gray crescent photographs with
spectral-domain (SD) OCT for in vivo histologic charac-
terization of eyes with gray crescents.
Our results demonstrate 2 distinct anatomic variants of
gray crescents that can be characterized histologically
in vivo using SD OCT: type A gray crescent and type B
gray crescent of the optic nerve head. Gray crescents have
significant implications for the clinical assessment of the
optic disc. Spectral-domain OCT can help identify gray
crescents and provide a more accurate measurement of the
cup-to-disc ratio. Erroneous identification of the optic disc
border as obscured by gray crescents can lead to a false
assessment of the cup-to-disc ratio and to pseudo-cupping,
which can result in overdiagnosis or misdiagnosis of
glaucoma.
Methods
The study was approved by the Institutional Review Board of the
University of Miami Miller School of Medicine and adhered to the
tenants of the Declaration of Helsinki. Informed consent was ob-
tained from the subjects after explanation of the nature and possible
consequences of the study. All participants underwent a full
ophthalmologic evaluation including visual acuity assessment,
intraocular pressure measurement, slit-lamp biomicroscopy, and
fundus examination. The inclusion criterion was a clearly identi-
fiable optic nerve head gray crescent on clinical examination.
Exclusion criteria were any optic nerve disease apart from glau-
coma (e.g., melanocytoma of the optic nerve head) and previous
retinal laser treatment or surgery.
Sixteen eyes of 10 consecutive patients with a gray crescent
were identified through clinical examination and imaged with the
RTVue high-resolution SD OCT (Optovue, Fremont, CA) and
fundus photography. A 6-mm-long retinal line scan transecting the
optic nerve head at the area of predetermined gray crescent was
taken for each eye using the RTVue SD OCT, with a default
orientation angle of 0 (left-to-right horizontal line). Each line scan
automatically averages 16 high-definition B-scan register frames
(each includes 1024 A-scans of a 0.039-second duration each) at
the same location in 0.63 seconds to improve signal. The RTVue
OCT only averages frames with good yield and correlation if eye
movement or blinking occurred during scanning. Four images with
at least 10 valid frames each were taken for every eye to increase
diagnostic precision.
A standard retinal nerve fiber layer (RNFL) analysis was per-
formed as clinically indicated in 7 patients (6 eyes with type A and
4 eyes with type B gray crescents) (Cirrus; Carl Zeiss Meditec Inc.,
Dublin, CA). Cirrus was used for RNFL analysis because this is the
standard of care in our institution. The RNFL thickness was also
measured using RTVue RNFL 3.45 scan in 2 patients. The RNFL
3.45 scan is a circular 3.45-mm scan centered on the optic disc that
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provides RNFL thickness from 4 B-scan circles, and each includes
1024 A-scans. Imaging was acquired in 0.15 seconds. Standard
colored optic nerve head photographs were taken for all patients.
Three examiners (M.M., M.S.S., and R.K.L.) examined all images.
Results
Ten eyes were found to have type A gray crescents (lighter, slate
gray; Fig 1) and 6 eyes were found to have type B grey crescents
(darker ledge of black tissue; Fig 2) by SD OCT. In 1 patient, the
right eye had a type B gray crescent and the left eye had a type A
gray crescent. Seven of the 10 eyes with type A gray crescents also
had PPA, whereas only 1 eye with type B gray crescent had
concomitant PPA. All 3 examiners agreed on the classification of
all eyes. A standard RNFL analysis was performed in 7 patients
using Cirrus (6 eyes with type A and 4 eyes with type B gray
crescents). The RNFL thickness as measured with Cirrus
correlated with the degree of glaucomatous damage, and not with
the presence or type of gray crescent. Figure 3 demonstrates that
in a typical optic nerve with a type A gray crescent, nerve fiber
layer thickness is normal, although the optic nerve head has a
pseudo-cupped appearance.
The RNFL thickness measured by the RTVue RNFL 3.45 scan
was concordant with the glaucomatous damage that would be ex-
pected in an optic disc with only the actual amount of cupping,
rather than the perceived pseudo-cupping caused by the gray
crescent. The RNFL thickness ratios as measured by the RTVue
RNFL 3.45 scan correlated with those measured with Cirrus. The
Cirrus values were, on average, lower as demonstrated in Figure 4,
which demonstrates borderline temporal RNFL thickness in the
right eye of a patient with a type A gray crescent, correlating
with actual, rather than the perceived, cup-to-disc ratio.
Discussion
The Elschnig’s ring, comprising the border tissue of
Elschnig, which is a collagenous tissue arising from the
sclera, enclosing the choroid, and joining Bruch’s mem-
brane, is widely believed to give rise to the fundoscopic
appearance of the perceived disc margin.9,10 In cross-
sectional OCT images, the termination of the Bruch’s
membrane, where the neural canal comprising retinal
ganglion cells begins at the Bruch’s membrane opening and
extends through the choroid and sclera, is believed to
represent the optic disc margin.11,12 Because the resolution
of SD OCT does not allow the distinct isolation of Bruch’s
membrane from the overlying RPE, it is acceptable to use
the RPE-Bruch’s membrane complex termination as a
surrogate for Bruch’s membrane opening.13
However, such definition of the border tissue architecture
is mostly applicable in cases in which the optic nerve head is
free of confounding anatomic features. Earlier OCT studies
have shown that what clinicians perceive as the disc margin
is not a single anatomic structure, but rather variable in ul-
trastructural terms, and can comprise border tissue, Bruch’s
membrane opening, or anterior scleral opening.14 With the
use of the current technology, these landmarks can be
highly variable and at times difficult to accurately identify,
such as in cases of high myopia. Moreover, studies also
 Sayed et al

In Vivo Imaging of Shields Gray Crescents

Figure 1. A and B, Type A gray crescent. The colored optic disc photographs show the true edge of the disc as seen clinically, as well as the pseudo-disc
margin constituted by the edge of the type A gray crescent. Note the gradual thinning followed by cessation of the retinal pigment epithelium (RPE)-Bruch’s
membrane complex, causing an enhancement of signal at the choroid level on spectral-domain (SD) OCT and resulting in clinical gray crescent. The white
arrow shows the termination of the RPE-Bruch’s membrane complex, and the yellow arrow points the edge of the type A gray crescent, marking the end of
the choroidal hyper-reflectivity zone. Type A gray crescent falls between the white and the yellow arrows on the OCT cross-section.

have shown that the clinically or colored fundus
photographyeidentified disc border and the disc margin as
delineated by SD OCT can poorly correlate.15,16 In addition,
there are cases in which Bruch’s membrane extends into the
substance of the optic nerve head.6
Shields gray crescents represent a deviation from the
normal anatomy, and the subjective location of the clinical
and OCT landmarks can be highly variable. In the present
study, however, we demonstrate a highly consistent ultra-
structural pattern in gray crescents using SD OCT.

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Figure 2. A and B, Type B gray crescent. Note the clumping of the retinal pigment epithelium (RPE)-Bruch’s membrane complex that appears folded upon
itself on spectral-domain (SD) OCT, resulting in a clinical gray crescent. The white arrowheads define the edges of the folded/clumped segment of RPE-
Bruch’s membrane complex underlying the clinically identifiable type B gray crescent. A, Temporal type B gray crescent showing clumping of the RPE-
Bruch’s membrane complex on SD OCT (white circle) in association with parapapillary atrophy (PPA) with thinning of the RPE-Bruch’s membrane complex
and choroidal hyperreflectivity (green circle). Note that in the colored photograph, the true disc margin is obscured and difficult to identify because of the
presence of both the type B gray crescent and PPA. B, Type B gray crescent. The colored photograph shows the true edge of the disc as clinically seen and
the edge of the type B gray crescent.

Examining B-scan images across the areas of gray cres-
cent in the optic discs of 16 eyes with gray crescents, dif-
ferences in the RPE-Bruch’s membrane complex of the
retina explain the 2 clinically identified types of gray cres-
cents. Although clinically subtle by stereo slit-lamp bio-
microscopy and often difficult to distinguish, type A gray
crescents appeared lighter (slate gray) and more sloped at
the temporal disc border (Fig 1A and B), whereas type B
gray crescents appeared darker and had a more sharply
delineated, almost overhanging ledge of black tissue at the
internal temporal disc border when viewed in stereo (Fig
2A and B). The different types of gray crescents were

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In Vivo Imaging of Shields Gray Crescents

Figure 3. A and B, Normal nerve fiber layer assessment in gray crescent. A, Note the difference between the perceived optic disc border (green arrows) and the
actual optic disc border (black arrows) in the left eye of a patient with a temporal type A gray crescent, adding a pseudo-cupping component to the cup-to-disc
ratio. Also note the presence of parapapillary atrophy (PPA) outside the actual optic disc border. The PPA appears lighter in color compared with the adjacent
temporal gray crescent. B, Standard retinal nerve fiber layer (RNFL) analysis (Cirrus; Carl Zeiss Meditec Inc., Dublin, CA) demonstrating normal average RNFL
thickness and normal RNFL thickness in the temporal quadrant of left eye, corresponding to the location of the gray crescent, despite suspicious thinning of
superior RNFL on the quadratic map. Left eye analyses demarcated by black line; temporal RNFL demarcated by red line in RNFL thickness map.

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Figure 4. AeC, The retinal nerve fiber layer (RNFL) thickness as measured by RTVue (Optovue, Fremont, CA) RNFL 3.45 scan and Cirrus RNFL
analysis. A, Temporal type A gray crescent in the right eye, with a gradual thinning of the RPE-Bruch’s membrane complex and enhancement of signal at
the choroid level on spectral-domain (SD) OCT and resulting in clinical gray crescent. Note the difference between the perceived optic disc border (green
arrows) and the actual optic disc border (black arrows). B, RTVue RNFL 3.45 scan showing only borderline temporal thinning on the RNFL, less than would
be expected in the apparent degree of cupping implied by the gray crescent. C, Cirrus RNFL analysis showing temporal borderline RNFL thickness,
correlating with the measurement obtained by the RTVue RNFL 3.45 scan. Note the lower values of the Cirrus RNFL analysis. Right eye analyses marked by
black line on Cirrus printout.

much easier to differentiate with in vivo histologic
assessment using SD OCT. Clinically, both types of gray
crescents give the appearance of pseudo-cupping because
they obscure a significant portion of the neuroretinal rim,
thereby increasing the amount of perceived cupping as the
inner rim of the gray crescent is mistaken to be the true disc
margin.
Type A gray crescents, which appear slate gray, dark
areas around the temporal portion of the optic nerve disc on
color photographs (Fig 1A and B), represent regions where
the RPE and Bruch’s membrane are absent and where light
penetrates readily through that region of the optic nerve
head border. This is similar in microstructure to the OCT
morphology of the gamma zone of PPA as demonstrated

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In Vivo Imaging of Shields Gray Crescents
Figure 4. (contiued).
by Dai et al8 (Fig 2A). However, the type A gray crescents
appear to lie well within the boundaries of the disc margin as
identified by a careful clinical fundoscopic examination,
unlike the gamma zone of PPA, which lies outside the
clinically identifiable disc border. This loss of RPE-
Bruch’s membrane complex in the type A gray crescents
allows increased penetration of light and greater
illumination of deeper tissue, which appears as brightness
on the B-scans and en face SD OCT optic nerve image,
thereby revealing the underlying choroid. The area is
therefore dark on slit-lamp examination because the under-
lying darker choroid is directly visible.
In contrast, type B gray crescents represent regions of the
retina where the RPE-Bruch’s membrane complex is
clumped or thickened, typically appearing to be folded upon
itself, revealing the embryonic continuity of the RPE and
neuroretina. The blocked light due to this thickened RPE
gives the region its dark appearance, as RPE is a dark pig-
mented layer of the retina. This is supported by the previous
finding that Bruch’s membrane may on occasions extend
into the substance of the optic nerve head6 and is consistent
with the previous stereoscopic observation suggesting that
conus pigmentosus (called “type B gray crescent”) is more
superficial than the type A gray crescent.3
The demographic characteristics of gray crescents have
been reported.2,3 Type A gray crescents were found to be
more prevalent among African Americans (27%) than
among whites in one study (7.4%),3 whereas another study2
found the prevalence of gray crescents in an all-white
population to be significantly higher (22%), probably
because no distinction between type A and type B gray
crescents was made in the latter, possibly attributing the
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difference to a higher prevalence of type B among the white
population compared with type A gray crescents. These
studies demonstrate that although gray crescents were more
common in women than in men, age, sex, refractive error,
intraocular pressure, and unlike PPA,17 the degree of
glaucomatous damage did not correlate with the prevalence
of gray crescents. In our observation, the association of
gray crescents with PPA seems to be common, contrary to
findings of the Reykjavik Eye Study, which suggested that
the prevalence of gray crescents is inversely related to the
presence of PPA.2 Given the small number of participants
in our study, we did not evaluate demographic data. The
aim of our study is to characterize the histologic nature of
gray crescents using in vivo high-resolution SD OCT.
Our study shows that Shields type A and B gray cres-
cents appear different clinically because histologically they
represent differences in the RPE-Bruch’s membrane layer.
Spectral-domain OCT is useful for identifying and charac-
terizing in vivo the different anatomic variants of gray
crescents that represent pseudo-cupping clinically at the slit
lamp. Along with the correlative use of color photos, SD
OCT may be useful to distinguish type A gray crescents
from type B gray crescents.
Bruce Shields1 initially described dark areas around the
temporal areas of the optic nerve disc as a gray crescent,
now recognized to be a type A gray crescent. This type of
gray crescent has a loss of the RPE-Bruch’s membrane
layer and appears slate gray on color photographs (Fig 1).
This loss of RPE-Bruch’s membrane complex allows
increased penetration of light and greater illumination of
deeper tissue, which appears as brightness on the B-scans
and en face SD OCT optic nerve image, thereby revealing
the underlying choroid. We are unsure which anatomic
layer represents the gray area on the OCT en face optic
nerve head image. Stereoscopic views of the optic nerve
head in patients who have the gray crescents demonstrate
sloping, which may provide a false impression of cupping
because the disc border is mistaken to be the edge of the
gray crescent. This “pseudo-cupping” may be misleading
to the clinician as glaucomatous damage to the optic nerve
head.
A different anatomic version of gray crescents previously
termed conus pigmentosus has been described, now termed
the “type B gray crescent.” The RPE in type B gray cres-
cents appears to be thickened and possibly folded upon it-
self, revealing the embryonic continuity of the RPE and
neuroretina (Fig 2A and B).
The clinical importance of the gray crescent, as pointed
out by Shields,1 is its role in creating a pseudo-cupped
appearance to the optic nerve. This pseudo-cupping occurs
because the disc rim edge from the border tissue of Elschnig
to the interior rim of the cup may appear to be significantly
reduced because the edge of the inner rim of the gray
crescent is mistaken to be the disc border. Spectral-domain
OCT not only can identify the type of gray crescent but also
can reveal pseudo-cupping from a gray crescent observed
clinically because the nerve fiber thickness analysis should
demonstrate a normal RNFL. Identifying the presence of
gray crescents may decrease the incidence of overcalling an
optic nerve as having glaucomatous cupping.
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In patients with glaucoma who also have a gray crescent,
the amount of RNFL present is typically much greater than
expected based on clinical examination. Recognizing
pseudo-cupping is of a particular importance in an era when
the reliance on imaging in the diagnosis and follow-up of
patients with glaucoma has dramatically increased, because
although routine RNFL analysis may reveal a normal RNFL
thickness, cup-to-disc ratio assessment may still lie outside
normal limits in red lettering or boxes in patients with
gray crescents, possibly contributing to overdiagnosis and
overtreating these patients.18 The understanding of the
ultrastructure of gray crescents adds a new dimension to
our ability to interpret RNFL analyses in eyes with gray
crescent, because commonly used OCT platforms use
automated algorithms that define the margin of the optic
disc at the termination of Bruch’s membrane, and these
platforms may therefore underestimate the circumpapillary
RNFL thickness in type A gray crescents in which an early
termination of Bruch’s membrane is present, as shown in
our results, potentially missing RNFL that extends beyond
Bruch’s membrane termination (Fig 1A). Moreover, SD
OCT line scans transecting the optic nerve head may be an
important modality for following patients with glaucoma
with gray crescents for progression, because pseudo-cupping
may make assessing true increases in the cup-to-disc ratio
difficult by serial slit-lamp examination of the optic nerve head.
In conclusion, SD OCT is a powerful new approach for
viewing cross-sectional retinal ultrastructure in vivo.
Spectral-domain OCT is useful for identifying and charac-
terizing in vivo the different anatomic variants of optic
nerve head gray crescents and, along with the correlative use
of color photos, differentiating gray crescents as type A and
type B anatomic gray crescents based on differences in the
RPE-Bruch’s membrane complex. Shields gray crescents
may be mistaken clinically as an increased cup-to-disc ratio
with the internal border of the gray crescent mistaken for the
disc border. Clinicians should be aware that the presence of
these disc changes may alter the appearance of the optic
disc, making the optic nerve head appear rather more cup-
ped than it truly is. Distinct ultrastructural patterns exist for
the 2 types of gray crescents identified. These patterns are
not associated with corresponding RNFL thinning as would
be expected of the more illusively cupped discs when the
presence of the gray crescents is overlooked. Spectral-
domain OCT is clinically helpful for differentiating true
cupping from pseudo-cupping. In combination with quan-
titative measurements of the nerve fiber layer with SD OCT
and performing retinal histology in vivo with OCT cross-
sectional analysis of cupping, a physiologically normal
optic nerve head with a gray crescent (pseudo-cupped) can
be distinguished from a glaucomatous optic nerve head with
nerve fiber loss.
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 Sayed et al

In Vivo Imaging of Shields Gray Crescents
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Footnotes and Financial Disclosures
Originally received: May 4, 2018.
Final revision: July 30, 2018.
Accepted: August 1, 2018.
Available online: August 7, 2018. Manuscript no. 2018-12.
1
Bascom Palmer Eye Institute, University of Miami Miller School of
Medicine, Miami, Florida.
2
Fillmore Eye Clinic, Deming, New Mexico.
3 Data collection: Margolis, Sayed, Chen, Lee
Palo Alto Eye Group, Palo Alto, California.
*M.S.S. and M.M. share equal contribution (co-first authorship).
Financial Disclosure(s):
The author(s) have made the following disclosure(s): G.G.: Consultant e
Carl Zeiss.
R.K.L.: Support e Walter G. Ross foundation and was supported by NIH
grant K08 EY016775.
The Bascom Palmer Eye Institute is supported by National Institutes of
Health (NIH) Center Grant P30-EY014801 and an unrestricted grant from
Research to Prevent Blindness. The RTVue SD OCT (Optovue, Fremont,
CA) used in this study was loaned by Optovue for research purposes.
spectral domain optical coherence tomography data sets. Invest
Ophthalmol Vis Sci. 2009;50:214e223.
12. Burgoyne CF, Downs JC, Bellezza AJ, Hart RT. Three-
dimensional reconstruction of normal and early glaucoma
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13. Strouthidis NG, Yang H, Downs JC, Burgoyne CF. Compar-
ison of clinical and three-dimensional histomorphometric optic
disc margin anatomy. Invest Ophthalmol Vis Sci. 2009;50:
2165e2174.
14. Drexler W, Fujimoto JG. State-of-the-art retinal optical
coherence tomography. Prog Retin Eye Res. 2008;27:45e88.
15. Manassakorn A, Ishikawa H, Kim JS, et al. Comparison of
optic disc margin identified by color disc photography and
high-speed ultrahigh-resolution optical coherence tomography.
Arch Ophthalmol. 2008;126:58e64.
16. Strouthidis NG, Yang H, Reynaud JF, et al. Comparison of
clinical and spectral domain optical coherence tomography
optic disc margin anatomy. Invest Ophthalmol Vis Sci.
2009;50:4709e4718.
17. Tezel G, Kolker AE, Wax MB, et al. Parapapillary chorior-
etinal atrophy in patients with ocular hypertension. II. An
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18. Chong GT, Lee RK. Glaucoma versus red disease: imaging
and glaucoma diagnosis. Curr Opin Ophthalmol. 2012;23:
79e88.
HUMAN SUBJECTS: Human subjects were included in this study. The
human ethics committees at the University of Miami Miller School of
Medicine approved the study. All research adhered to the tenets of the
Declaration of Helsinki. All participants provided informed consent.
No animal subjects were used in this study.
Author Contributions:
Conception and design: Margolis, Sayed, Gregori, Lee
Analysis and interpretation: Margolis, Sayed, Chen, Lee
Obtained funding: N/A
Overall responsibility: Sayed, Lee
Abbreviations and Acronyms:
PPA ¼ parapapillary atrophy; RNFL ¼ retinal nerve fiber layer;
RPE ¼ retinal pigment epithelium; SD ¼ spectral domain.
Correspondence:
Richard K. Lee, MD, PhD, Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, 900 NW 17th St., Miami, FL 33136. E-
mail: rlee@med.miami.edu.
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