Glaucoma
Relationship of Central Corneal Thickness with Optic
Disc Parameters: The Singapore Malay Eye Study
Ren-Yi Wu,1 Ying-Feng Zheng,1 Tien-Yin Wong,1,2 Carol Yim-Lui Cheung,1
Seng-Chee Loon,3 Balwantray C. Chauhan,4 and Tin Aung1,2
PURPOSE. To examine the relationship of central corneal thick-
ness (CCT) with optic disc parameters measured by confocal
scanning laser ophthalmoloscopy in a Malay population.
METHODS. This was a population-based cross-sectional study of
Asian Malay adults aged 40 – 80 years living in Singapore. Par-
ticipants had a standardized interview, examination, and imag-
ing at a study clinic. CCT was measured with an ultrasound
pachymeter. Confocal scanning laser imaging was performed
on all participants to obtain optic disc parameters. Multivariate
regression analyses controlling for age, sex, intraocular pres-
sure, and other potentially confounding factors were con-
ducted separately for disc area, rim area, cup-to-disc ratio, and
mean cup depth.
RESULTS. Of the 3280 participants in the study, 2525 (77.0%)
right eyes with reliable confocal scanning laser tomography
images were included in this analysis, with 48 eyes defined to
have primary open-angle glaucoma (POAG). In POAG subjects,
CCT was positively correlated with rim area (regression coef-
ficient of 0.372 mm2 per 100 ␮m CCT increase; P ⫽ 0.035) and
negatively correlated with cup-to-disc area ratio (⫺0.160 per
100 ␮m CCT increase; P ⫽ 0.024). There was no relationship
between CCT and disc size (P ⫽ 0.088). In the 2468 subjects
without glaucoma, there were no associations between CCT
and confocal scanning laser tomography parameters.
CONCLUSIONS. In this population-based study, decreased CCT
was associated with lower rim area and greater cup-to-disc area
in subjects with POAG, but not in subjects without glaucoma.
(Invest Ophthalmol Vis Sci. 2011;52:1320 –1324) DOI:
10.1167/iovs.10-6038
T he association between corneal properties and susceptibil-
ity to glaucoma is an area of recent interest.1–9 Central
corneal thickness (CCT) is regarded as a risk factor for the
development of primary open-angle glaucoma (POAG) among
ocular hypertensive patients1 and visual field progression in
From the 1Singapore Eye Research Institute and Singapore National
Eye Center, Singapore; 2Yong Loo Lin School of Medicine, National Uni-
versity of Singapore, Singapore; 3National University Health System, Sin-
gapore; and 4Department of Ophthalmology and Visual Sciences, Dalhou-
sie University, Halifax, Nova Scotia, Canada.
Supported by the National Medical Research Council, Singapore
(Grant No. 0796/2003), Biomedical Research Council, Singapore
(Grant No. 501/1/25-5), Singapore Prospective Study Program and
Singapore Tissue Network, A*STAR, and Canadian Institutes of Health
Research (Grant No. MOP-11357).
Submitted for publication June 11, 2010; revised August 11 and
September 21, 2010; accepted September 22, 2010.
Disclosure: R.-Y. Wu, None; Y.-F. Zheng, None; T.-Y. Wong,
None; C.Y.-L. Cheung, None; S.-C. Loon, None; B.C. Chauhan,
None; T. Aung, None
Corresponding author: Tin Aung, Singapore National Eye Centre,
11 Third Hospital Avenue, Singapore 168751; tin11@pacific.net.sg.
1320
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POAG patients.2,3 The reasons for this increased risk have not
been elucidated. Many researchers have focused on the con-
cept that thinner-than-average corneas may underestimate the
true intraocular pressure (IOP), and thicker-than-average cor-
neas may overestimate IOP.4 – 6 However, this factor alone
seems not sufficient to explain the increased susceptibility to
glaucoma found in those with thinner corneas. For example, in
the Ocular Hypertension Treatment Study, CCT was a risk
factor for the conversion of patients with ocular hypertension
to POAG, after statistical adjustment for IOP and other risk
factors.7
Another hypothesis is that CCT may reflect sclera and lam-
ina cribrosa changes associated with glaucomatous optic neu-
ropathy because of the anatomic continuity of the cornea,
sclera, and optic disc lamina. It has been shown that CCT is
correlated with anterior scleral thickness in POAG patients.10
Several studies have assessed the relationship between CCT
and objectively measured optic disc parameters, but these have
provided inconsistent results. When measured with confocal
scanning laser ophthalmoscopy (Heidelberg Retina Tomo-
graph; Heidelberg Engineering, Heidelberg, Germany), several
hospital-based studies on glaucoma patients suggested correla-
tions of CCT with optic disc area11,12 and nasal rim volume,13
while in the population-based Tajimi study from Japan, these
correlations could not be confirmed in normal subjects.14 In-
stead, correlation of CCT to cup volume was observed in that
study.14 In another population-based survey, the Bridlington
Eye Assessment Project,15 no significant relationship of CCT
with any parameter obtained with retinal tomography was
demonstrated.
In view of the clinical importance of CCT and the contro-
versy about the relationship between CCT and glaucomatous
optic neuropathy, we examined the relationships of CCT with
optic disc parameters measured quantitatively with confocal
scanning laser ophthalmoscopy (HRT II; Heidelberg Engineer-
ing) in a population-based study in Singapore.
METHODS
Study Population
The Singapore Malay Eye Study was a population-based cross-sectional
study of 3280 (78.7% response rate) Malay subjects aged 40 to 80 years
living in Singapore. The study methodology has been described previ-
ously.16,17 This study was conducted in accordance with the Declara-
tion of Helsinki, and ethics approval was obtained from the Institu-
tional Review Board.
Study Measurements
All participants underwent a standardized interview, systemic and
ocular examinations, and ocular imaging at a centralized study clinic.16
Relevant portions of the examination are presented here. Height was
measured using a wall-mounted tape and weight with a digital scale.
Body mass index (BMI) was calculated as weight (in kilograms) divided
Investigative Ophthalmology & Visual Science, March 2011, Vol. 52, No. 3
Copyright 2011 The Association for Research in Vision and Ophthalmology, Inc.
 IOVS, March 2011, Vol. 52, No. 3 Central Cornea Thickness and Optic Disc Parameters 1321

TABLE 1. Characteristics of Participants Included and Excluded in the Study

Included Excluded
Characteristics (N ⴝ 2525) (N ⴝ 755) P

Age (y) 57.0 ⫾ 10.7 64.4 ⫾ 10.5 ⬍0.001

Sex; male, n (%) 1236 (49.0) 340 (45.0) 0.056
Hypertension, n (%) 1643 (65.1) 603 (79.8) ⬍0.001
Systolic blood pressure (mm Hg) 145.2 ⫾ 22.7 153.7 ⫾ 25.5 ⬍0.001
Diastolic blood pressure (mm Hg) 79.9 ⫾ 11.0 79.2 ⫾ 11.8 0.143
Diabetes, n (%) 497 (19.7) 267 (35.4) ⬍0.001
Hemoglobin A1c (%) 6.36 ⫾ 1.46 6.78 ⫾ 1.79 ⬍0.001
Current smoking, n (%) 560 (22.2) 102 (13.2) ⬍0.001
Axial length (mm) 23.6 ⫾ 1.0 23.5 ⫾ 1.1 0.438
Central corneal thickness (␮m) 542.0 ⫾ 33.1 538.4 ⫾ 35.1 0.012
Myopia, n (%) 576 (22.8) 272 (36.1) ⬍0.001
Intraocular pressure (mm Hg) 15.37 ⫾ 3.50 15.41 ⫾ 4.20 0.784

by the square of height (in meters). Blood pressure was measured with
a digital automatic blood pressure monitor (Dinamap Model Pro Series
DP110X-RW, 100V2; GE Medical Systems Information Technologies,
Milwaukee, WI) after the participants were seated for at least 5 min-
utes. Nonfasting venous blood samples were drawn and sent for
analysis of serum hemoglobin-A1C and glucose at the National Univer-
sity Hospital Reference Laboratory on the same day.
The refraction (sphere, cylinder, and axis) of each eye was mea-
sured using an autorefractor (Canon RK 5 Auto Ref-Keratometer;
Canon, Tochigiken, Japan), the corneal curvature radius (CCR) in the
horizontal and vertical meridian was measured at the same time, and
the mean of two CCR readings was obtained. Five CCT measurements
were obtained from each eye with an ultrasound pachymeter (Advent;
Mentor O & O, Norwell, MA), and the median reading was taken.
Noncontact partial coherence laser interferometry (IOLMaster v. 3.01;
Carl Zeiss Meditec, Jena, Germany) was used to measure axial length.
Slit lamp biomicroscopy (BQ-900; Haag-Streit, Köniz, Switzerland)
was performed to identify abnormalities of the anterior segment, in-
cluding evidence of secondary glaucoma, ischemic sequelae of previ-
ous acute primary angle closure, and signs of previous surgery. IOP
was measured using a Goldmann applanation tonometer (Haag-Streit)
before pupil dilation.18 Gonioscopy was performed with a Goldmann
two-mirror gonioscope (model 903; Haag-Streit) under standard low
ambient illumination in those suspected to have glaucoma (definition
provided below). After pupil dilation, the optic disc and the retina
were evaluated with a ⫹78 D lens, at ⫻16 magnification. Vertical disc
diameter was measured with measuring graticule (Haag-Streit) exclud-
ing parapapillary atrophy and the scleral ring of Elschnig. The vertical
cup-to-disc ratio (VCDR) was then calculated. For small optic discs
with no visible cup, the measurement was taken as the diameter of the
emerging retinal vessels. Finally, automated perimetry (SITA 24-2,
Humphrey Visual Field Analyzer II; Carl Zeiss Meditec) was performed
with near-refractive correction by trained study technicians on one in
five consecutive participants who were not glaucoma suspects before
examination by study ophthalmologists and on all participants sus-
pected of having glaucoma. The visual field test was repeated if the test
reliability was not satisfactory (fixation loss ⬎20%, false positive ⬎33%,
and/or false negative ⬎33%) or if there was a glaucomatous visual field
defect.
Tomography Imaging
The tomograph used (HRT II; Heidelberg Engineering) employs a diode
laser (670 nm wavelength) to sequentially scan the optic disc and
parapapillary retina with the field of view set at 15°. Scans were
conducted through dilated pupils. Corneal curvature radius was en-
tered into the software for all subjects, and cylindrical lens power was
adapted for those with astigmatism greater than or equal to 1 D. All
examinations were performed by two trained operators.19,20 The optic
nerve head scan protocol generates a mean topography image with a
resolution of 384 ⫻ 384 generated from three individual topography
images.
Images with a mean pixel height standard deviation of ⬎50 ␮m
were excluded. After completion of the study, the optic disc margin or
contour line was defined and manually outlined by a trained ophthal-
mologist. This step was accomplished by plotting a series of six dots
around the disc margin on the reflectance image. The disc margin was
defined as the inner edge of Elschnig’s ring. The standard reference
plane is defined at 50 ␮m posterior to the mean contour line height
between 350° and 356° along the contour line. Global and regional
optic nerve head parameters were measured and generated by the
software (HRT II).
Glaucoma Diagnostic Definitions
Glaucoma suspects were defined as those participants fulfilling any of
the following criteria: IOP greater than 21 mm Hg, VCDR ⬎ 0.6 or
VCDR asymmetry ⬎ 0.2, abnormal anterior segment deposit consistent
with pseudoexfoliation or pigment dispersion syndrome, occludable
or closed anterior chamber angle (defined in the next section), periph-
eral anterior synechiae or other findings consistent with secondary
glaucoma, and known history of glaucoma.16 As indicated, these par-
ticipants underwent gonioscopy, visual field test, and a second IOP
measurement, usually on another day.
Glaucoma cases were defined according to the International Soci-
ety for Geographical and Epidemiologic Ophthalmology (ISGEO) cri-
teria based on three categories. Category 1 cases were defined as optic
disc abnormality (VCDR/VCDR asymmetry ⬎97.5 percentile or NRR
width between 11 and 1 o’clock or 5 and 7 o’clock ⬍0.1 VCDR), with
a corresponding glaucomatous visual field defect. Category 2 cases

TABLE 2. Tomography Parameters of the Malay Population, Mean (SD)

All Persons Without Glaucoma POAG

Parameter (N ⴝ 2525) (N ⴝ 2468) (N ⴝ 48) P*

Disc area (mm2) 2.15 (0.48) 2.14 (0.48) 2.63 (0.50) ⬍0.001
Rim area (mm2) 1.53 (0.33) 1.55 (0.33) 1.34 (0.33) ⬍0.001
Cup-to-disc area ratio 0.26 (0.14) 0.26 (0.14) 0.47 (0.16) ⬍0.001
Mean cup depth (mm) 0.21 (0.08) 0.21 (0.08) 0.32 (0.12) ⬍0.001

POAG, primary open-angle glaucoma.

* Comparison between POAG and without glaucoma.

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 1322 Wu et al. IOVS, March 2011, Vol. 52, No. 3

had normal visual fields in both eyes on two separate occasions. A

glaucomatous visual field defect was considered to be present if the
following were found: a glaucoma hemifield test result outside normal
limits and a cluster of three or more nonedge, contiguous points, not
crossing the horizontal meridian, with a probability of ⬍5% of the age-
matched normal on the pattern deviation plot on two separate occasions.
A narrow anterior chamber angle was diagnosed if the posterior tra-
becular meshwork was seen for 180° or less of the angle circumfer-
ence during static gonioscopy.22 POAG was defined as an eye with an
evidence of glaucoma as defined above with an open angle. Final
identification, adjudication, and classification of glaucoma cases were
reviewed by the senior glaucoma specialist (TA).

FIGURE 1. Relationship of CCT with optic disc area measured by
tomography in persons without glaucoma (upper) and with primary
open-angle glaucoma (lower).
Statistical Analysis
Statistical analysis was performed using commercial software (SPSS, v.
17.0; SPSS, Chicago, IL). Since the correlations between the two eyes
for optic disc parameters were high (e.g., correlation coefficients
between right and left eyes for optic disc area ⫽ 0.85), only the data
from right eyes are included in further analysis. An unpaired t-test or ␹2
test was used to test the differences of demographic characteristics
between included and excluded participants. An unpaired t-test was
performed to examine the differences in the tomography parameters
(disc area, rim area, cup-to-disc ratio, and mean cup depth) between
eyes of POAG and those without glaucoma. In a stepwise manner,
three multiple linear regression models adjusted for age and sex; age,
sex, BMI, spherical equivalent of refraction, and axial length; and age,
sex, BMI, spherical equivalent of refraction, axial length, intraocular
pressure, and disc area were used to estimate the relationships of CCT
with each tomography parameter (disc area, rim area, cup-to-disc ratio,
and mean cup depth). BMI was included in the regression models
because it has been reported to be associated with the optic disc size
and cup-to-disc ratio in our previous study on this population.23 These
three regression models were constructed to avoid overadjusting of
confounding factors. Significance level was set at P ⬍ 0.05.

were defined as having a severely damaged optic disc (VCDR or VCDR
asymmetry ⬎99.5th percentile) in the absence of adequate perfor-
mance in a visual field test. In diagnosing category 1 or 2 glaucoma, it
was required that there should be no other explanation for the VCDR
finding (dysplastic disc or marked anisometropia) or visual field defect
(retinal vascular disease, macular degeneration, or cerebrovascular
diseases). Category 3 cases were defined as subjects without visual
field or optic disc data who were blind (corrected visual acuity, ⬍3/60)
and who had previous glaucoma surgery or have IOP ⬎99.5 percen-
tile.21
VCDR used in defining glaucoma suspects and glaucoma cases
were based on clinical optic disc assessment during slit lamp biomi-
croscopy. Definition of glaucoma cases was performed by investigators
masked to clinical data such as CCT.
To determine normative values for optic disc parameters (VCDR
and VCDR asymmetry) and IOP, we used data from the one in five
consecutive participants who were not glaucoma suspects and who
RESULTS
Of 3280 participants, 224 were unable to complete the tomog-
raphy test or had missing imaging data, and 281 had poor
tomography image quality (SD ⬎ 50 ␮m). Of the remaining
2775 subjects, 194 with a history of intraocular surgery (in-
cluding cataract, glaucoma, vitro-retinal surgery) or retinal laser
photocoagulation, 48 with severe diabetic retinopathy and
eight with retinal vein occlusion were further excluded, leav-
ing 2525 right eyes (77.0%) for the final analyses. The demo-
graphic features and ocular biometric measurements of the
included, and excluded participants are listed in Table 1. In
general, excluded subjects were older and had higher levels of
systolic blood pressure, hemoglobin-A1c, and higher preva-
lence of hypertension and diabetes, but lower prevalence of
smoking. In addition, when compared with eyes included for
analysis, excluded eyes had smaller mean CCT and higher
proportion of myopia, but similar axial length and IOP.

TABLE 3. Relationships of Central Corneal Thickness (per 100 ␮m) with Tomography Parameters, All Persons (N ⫽ 2525)

Regression Coefficient, Regression Coefficient, Regression Coefficient,

Parameter Model 1 P Model 2 P Model 3 P

Disc area (mm2) ⫺0.034 0.253 ⫺0.018 0.541 ⫺0.039 0.203

Rim area (mm2) ⫺0.005 0.797 0.005 0.802 0.027 0.130
Cup-to-disc area ratio ⫺0.009 0.305 ⫺0.008 0.372 ⫺0.011 0.136
Mean cup depth (mm) ⫺0.008 0.124 ⫺0.005 0.402 ⫺0.008 0.107

Linear regression models adjusted for the following: Model 1—age, sex; Model 2—age, sex, body mass index, spherical equivalent, and axial
length; and Model 3—age, sex, body mass index, spherical equivalent, axial length, intraocular pressure, and disc area.

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 IOVS, March 2011, Vol. 52, No. 3 Central Cornea Thickness and Optic Disc Parameters 1323

TABLE 4. Relationships of Central Corneal Thickness (per 100 ␮m) with Tomography Parameters, Persons without Glaucoma (N ⫽ 2468)

Regression Coefficient, Regression Coefficient, Regression Coefficient,

Parameter Model 1 P Model 2 P Model 3 P

Disc area (mm2) ⫺0.026 0.383 ⫺0.008 0.781 ⫺0.029 0.344

Rim area (mm2) ⫺0.010 0.640 ⫺0.001 0.991 0.004 0.831
Cup-to-disc area ratio ⫺0.005 0.555 ⫺0.003 0.721 ⫺0.012 0.177
Mean cup depth (mm) ⫺0.006 0.232 ⫺0.002 0.670 ⫺0.008 0.127

Linear regression models adjusted for the following: Model 1—age, sex; Model 2—age, sex, body mass index, spherical equivalent, and axial
length; and Model 3—age, sex, body mass index, spherical equivalent, axial length, intraocular pressure, and disc area.

Among 2525 right eyes with eligible tomography data, 57
were diagnosed as glaucoma. Of these, 48 eyes were diagnosed
as POAG (42 of category 1 and 6 of category 2). The tomogra-
phy parameters of all eligible, nonglaucoma, and POAG eyes
are shown in Table 2. When compared with those without
glaucoma, POAG eyes had significant greater disc area, cup-to-
disc area ratio, and mean cup depth but smaller rim area (all
P ⬍ 0.001). No significant difference was observed in all
tomography parameters between all eligible eyes and those
without glaucoma.
The mean CCT was 536.1⫾33.6 ␮m and 542.1⫾33.0 ␮m
for POAG eyes and eyes without glaucoma, respectively (P ⫽
0.213). This difference of the means was statistically nonsignif-
icant (P ⫽ 0.954, test of variance) after further adjustment for
age and sex.
Figure 1 shows the distribution of CCT by optic disc area in
persons without glaucoma (upper plot) and with POAG (lower
plot). Linear regression revealed the relationships of CCT with
disc area were nonsignificant in persons without glaucoma
(P ⫽ 0.383) and in those with POAG (P ⫽ 0.088). Table 3
shows results of a linear regression test of CCT with tomogra-
phy parameters in the study population. None of the correla-
tions between CCT and tomography parameters were signifi-
cant (all P ⬎ 0.05). Similar results were obtained in persons
without glaucoma (Table 4). However, in POAG eyes (Table 5),
increased CCT was significantly correlated with increased rim
area (P ⫽ 0.035) but decreased cup-to-disc ratio (P ⫽ 0.024).
Specifically, after adjustment for confounding factors of age,
sex, BMI, spherical equivalent of refraction, axial length, IOP,
and disc area, per 100 ␮m increase in CCT was associated with
a 0.372 mm2 increase in rim area, respectively, and a 0.160
decrease in cup-to-disc area ratio.
DISCUSSION
In this adult population of Malay ethnicity, no significant rela-
tionships between CCT and tomography parameters were ob-
served in eyes without glaucoma. However, we found that CCT
was correlated with rim area and cup-to-disc area ratio in POAG
eyes. These associations persisted after adjusting for age, sex,
and other confounding factors. Our study results provide in-
teresting data addressing the relationship between CCT and
glaucoma on a population level.
Our observation that CCT was not associated with tomog-
raphy parameters in persons without glaucoma is in line with
the finding in another population-based study, the Bridlington
Eye Assessment Project,15 conducted on normal white subjects
over 65 years of age (mean age of 73.3 years), in which
glaucoma persons were also excluded. However, in the Tajimi
study,14 CCT was found to be inversely correlated with cup
volume in 1769 normal Japanese adults aged 40 years or more.
It has to be noted that the correlation of CCT to cup volume
shown in the Tajimi study was rather weak (partial correlation
coefficient, ⫺0.05; P ⫽ 0.040), so a chance finding cannot be
excluded, and the clinical implication of such a weak correla-
tion need to be confirmed. Furthermore, about one-fourth
(23%) participants were excluded from the analysis in our
study, whereas one-third were excluded in the Tajimi study for
various exclusion criteria. Hence the discrepancy in the finding
between the studies may reflect differences in the study design
and sample size.
Several hospital-based studies on POAG patients have
showed correlations of CCT with optic disc area11,12 and nasal
rim volume.13 However, our study found that CCT was asso-
ciated with decreased cup-to-disc ratio and increased rim area
in POAG patients independent of age, sex, BMI, spherical
equivalent, axial length, and disc area. One possible reason for
the discrepancy could be that the definition of glaucoma was
different in our study compared with those hospital-based
studies. As the ISGEO scheme was used for glaucoma diagnosis
in our study, eyes with “pseudonormal” small optic cups might
have been misclassified as nonglaucomatous. On the other
hand, there were six eyes with abnormally large disc VCDR but
without visual field data that were classified as POAG (ISGEO
category 2). Because of the cross-sectional nature of our study,
the clinical significance of the correlations found in our study
needs to be evaluated in longitudinal studies.
It is unclear why a significant correlation between CCT and
HRT parameters was seen only in POAG patients. The possi-
bility of a chance finding cannot be excluded because of the
cross-sectional nature of the study, as well as the relative small
POAG sample size (n ⫽ 48). One may speculate that our
findings reflect a specific racial feature in this Malay popula-
tion. However, the relation between CCT and glaucoma devel-
opment has been found in various populations of different
ethnicities.3,7,24,25 One possible explanation is that eyes with

TABLE 5. Relationships of Central Corneal Thickness (per 100 ␮m) with Tomography Parameters, Persons with POAG (N ⫽ 48)

Regression Coefficient, Regression Coefficient, Regression Coefficient,

Parameter Model 1 P Model 2 P Model 3 P

Disc area (mm2) ⫺0.440 0.088 ⫺0.438 0.102 ⫺0.441 0.118

Rim area (mm2) 0.391 0.026 0.376 0.031 0.372 0.035
Cup-to-disc area ratio ⫺0.187 0.019 ⫺0.218 0.014 ⫺0.160 0.024
Mean cup depth (mm) ⫺0.085 0.154 ⫺0.077 0.217 ⫺0.061 0.329

Linear regression models adjusted for the following: Model 1—age, sex; Model 2—age, sex, body mass index, spherical equivalent, and axial
length; and Model 3—age, sex, body mass index, spherical equivalent, axial length, intraocular pressure, and disc area.

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 1324 Wu et al.
decreased CCT may have more chance of developing more
advanced disease. This hypothesis needs to be confirmed by
further longitudinal studies. Nevertheless, it is also possible
that CCT decreases as glaucoma progresses; that is, a thinner
CCT could be the result of the glaucomatous process that can
be detected and measured in the anterior segment (i.e., cor-
nea), whereas optic disc cupping and rim loss are the result of
the glaucomatous process to the posterior segment (i.e., optic
disc nerve head).
The strengths of our study include its large population-
based design. In addition, reliable ocular measurements includ-
ing optic disc parameters by tomography were obtained by
standardized protocols. However, our study had several limita-
tions. Firstly, the cross-sectional nature of the study prevented
inferring causality or a chronological order of the correlation.
In particular, the temporal relationship between CCT and optic
disc parameters in POAG patients remains uncertain. Second,
as mentioned above, like other population-based studies that
have used the ISGEO scheme for glaucoma diagnoses, devia-
tion in glaucoma classification seemed to be inevitable, espe-
cially those eyes with “pseudonormal” or “pseudoabnormal”
optic cups but normal IOPs. Both conditions might have im-
posed bias on the correlation of CCT with rim area and mean
RNFL thickness-related optic disc parameters. However, we
believe that such errors have been minimized because each
subject was carefully examined by experienced ophthalmolo-
gists, and all fundus images were reviewed by a senior glau-
coma specialist. Third, about one-fourth of eyes were excluded
because of unavailability or poor quality of tomography images
or ocular abnormalities. When compared with those included,
the excluded subjects were significantly older and had smaller
CCT and a higher prevalence of myopia. It has been reported
that age and refractive error are correlated with many tomog-
raphy parameters.14 Although not influencing the final results,
it is possible that these differences may have influenced the
correlations tested in the study.
In summary, in a population-based study of Malay persons
aged 40 to 80 years, CCT was found to be correlated with rim
area and cup-to-disc ratio (tomography measurements) only in
POAG patients, independent of axial length, IOP, disc area, and
other confounding factors. No significant correlation between
CCT and optic disc parameters was seen in subjects without
glaucoma. The clinical significance of these findings requires
further investigation.
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