Case Presentation CVV v2 Vietnam

Case Presentation:
When Large Discs Puzzle Us
Cynthia V. Verzosa, MD, DPBO, MSc
Vietnam Glaucoma Club Mid-Year Meeting

April 20-21, 2018
Chào buổi trưa
General Information
42 year old Nigerian engineer

History of the Present Illness
2014 : Tearing of both eyes

Dysfunctional Tear Syndrome
Glaucoma Suspect
Prescribed Sodium Hyaluronate drops
AVF and OCT done
2014
2014
Diagnosed as having OAG OU

Started on Latanoprost eyedrops HS OU
Shifted to Latanoprost/Timolol HS OU 6 months later
Serial AVFs and OCTs done
OCTs OD (2015-2016)
2015
2016
AVFs OD (2015-2016)
2015 2016
OCTs OS (2015-2016)
2015
2016
AVFs OS (2015-2016)
2015 2016
Progression 2016
Timolol qAM OU added
Second opinion with another Ophthalmologist (me)
Medical History
No systemic disorders (e.g., Hypertension, Diabetes,
Asthma)
No ocular surgeries
No use of steroids
No any kind of trauma to both eyes
No family history of glaucoma
No use of eye glasses
Eye Exam
OD OS
No lesions, no External Exam No lesions, no
ptosis, no proptosis ptosis, no proptosis
20/20 Visual Acuity 20/20
3 mm BRTL Pupils 3 mm BRTL
Full and equal EOMs Full and equal
Clear cornea Biomicroscopy Clear cornea

quiet anterior quiet anterior
chamber chamber
clear lens clear lens
Eye Exam
OD OS
18 mm Hg Tonometry 18 mm Hg
(GAT, 1300hrs)
Lat/Tim 9pm
Tim 7am
Angles open to CBB Gonioscopy Angles open to CBB
360° 360°
DDV 2.08 mm, Fundus DDV 2.21 mm,
DDH 1.95 mm, DDH 2.02 mm,
VCDR 0.8, VCDR 0.8, pink
pink rim, rim, (+) notch at
(-) disc hemorrhages inferotemporal area,
(-) disc hemorrhages
Pachymetry
OD = 506 µ OS = 494 µ
OCT (2017)
AVF (2017)
Course
Trial discontinuation of Latanoprost/Timolol, Timolol
IOP 3 weeks off
OU (GAT, 1400 hrs) 22 mm Hg
Gone for 6 months
Eye Exam
OD OS
21 mm Hg Tonometry 24 mm Hg
(GAT, 1315hrs)
Angles open to CBB Gonioscopy Angles open to CBB
360° 360°
DDV 2.08 mm, Fundus DDV 2.21 mm,
DDH 1.95 mm, DDH 2.02 mm,
VCDR 0.8, VCDR 0.8, pink
pink rim, rim, (+) notch at
(-) disc hemorrhages inferotemporal area,
(-) disc hemorrhages
Disc Photo OD
Disc Photo OS
Disc Photos OU
2.08 2.21
1.95 2.02
OCT (2018)
AVF (2018)
OS
OD
Is there truly glaucoma?
Classification of Glaucoma*
Glaucoma suspect – normal disc and VF associated
with elevated IOP OR suspicious disc and/or VF with
normal IOP
Ocular hypertension – normal disc, normal VF,
elevated IOP
NTG – optic nerve and VF defects with low IOPs
OAG – optic nerve and VF defects with high IOPs
*AAO Basic and Clnical Science Course Section 10, 2010-2011

Diagnostic Criteria POAG*
Multifactorial ON neuropathy with acquired optic
nerve fiber loss
Optic nerve or NFL defect must be present, or VF loss
alone; IOP elevation not required
Associated characteristics
Evidence of either or both optic disc and NFL defects
 Rim changes
 Cup changes
 RNFL changes
*Preferred Practice Patterns, POAG, AAO, 2015)

Diagnostic Criteria POAG*
Associated characteristics
Hemorrhages
Disc asymmetry
Extensive parapapillary atrophy
VF abnormality
Open angles
Results reproducible
Adult onset and absence of other known explanations for
visual findings
*Preferred Practice Patterns, POAG, AAO, 2015)

What do we have?
What do we have?
Visual Fields OU: no defects
OCT OD: no evidence of abnormal thinning (red)
OCT OS: consistent, reproducible RNFL thinning at
the inferotemporal sector
Optic nerves
Large discs
Large CDRs
AVF OD (2014-2018)
2014 2015
2016 2017
2018
AVF OS (2014-2018)
2014 2015
2016 2017
2018
What do we have?
Optic nerves
Large discs
Large CDRs
OCT OD (2014-2018)
2014 2015
2016 2017
2018
What do we have?
Optic nerves
Large discs
Large CDRs
OCT OS (2014-2018)
2014 2015
2016 2017
2018
What do we have?
Optic nerves
Large discs
Large CDRs
Disc Photos OU
2.08 2.21
1.95 2.02
Average optic disc data*
Average* Parameter Patient Patient
OD OS
2.69 ± 0.70 mm² Disc Area 2.00 2.76
1.76 ± 0.31 mm Disc Diameter (H) 1.95 mm 2.02 mm
1.92 ± 0.29 mm Disc Diameter (V) 2.08 mm 2.21 mm
0.72 ± 0.70 mm² Cup Area 1.68 1.87
CD ratio (V) 0.90 0.81
CD ratio (H) 1.0 0.90
*Optic Disc, Cup and Neuroretinal Rim Size, Configuration and Correlations in Normal Eyes. Jonas, JB, et
al. IOVS 1988
Optic nerve*
CD ratios
Size of disc
Eccentricity of the cup within the disc
Distance between edge of cup and neuroretinal rim
*The disc damage likelihood scale: reproducibility of a new method of estimating the amount of optic

nerve damage caused by glaucoma. Spaeth GL, Henderer J, Liu C, Kesen M, Altangerel U, Bayer A, Katz
LJ, Myers J, Rhee D, Steinmann W. Transactions of American Ophthalmological Society 2002;100:181-5;
discussion 185-6.
Optic disc evaluation (5Rs)*
Ring (scleral ring)

Rim (neuroretinal rim)
Region around the nerve (peripapillary area)
Retinal nerve fiber layer
RBCs (hemorrhage)
*Five rules to evaluate the optic disc and retinal nerve fiber layer for glaucoma. Fingeret M, Medeiros FA,
Susanna R Jr, Weinreb RN. Optometry 2005 Nov;76(11):661-8.
Ring*
Scleral ring – disc borders
White tissue
Myopic discs
Ring
Rim*
ID the scleral ring
ID the cup border
Rim width = distance between the scleral ring and the
cup border
ISNT Rule: I > S > N > T
*Evaluation of the "IS" Rule to Differentiate Glaucomatous Eyes From Normal. Law SK, Kornmann HL,
Nilforushan N, Moghimi S, Caprioli J. Journal of Glaucoma 2016 Jan;25(1):27-32.
Rim
Rim
Rim
Rim
Rim*
Color – pinkish
Pallor - cup
Pallor = cup normal
Pallor > cup non-glaucoma (neurological)
Pallor < cup glaucoma
Rim
2.08 2.21
1.95 2.02
Region around the Optic Disc*
2 types of peripapillary atrophy
Alpha-zone – patchy areas hypo- and hyper-
pigmentation
 Non-specific
Beta zone – adjacent to scleral ring
 Specific for glaucoma
 Areas of atrophy of RPE and choriocapillaris
 Choroidal vessels visualized
 Width inversely correlated to neuroretinal rim thickness
*Ranking of optic disc variables for detection of glaucomatous optic nerve damage. Jonas JB, Bergua A,
Schmitz-Valckenberg P, Papastathopoulos KI, Budde WM. Invest Ophthalmol Vis Sci. 2000;41:1764-1773.
Region around the Optic disc
RNFL*
Examine the RNFL
Color photograph
Red free photograph
Look for striations, brightness, and the visibility of the
peripapillary vessels.
Loss of RNFL
Dark bands
Increased visibility of retinal vessel borders
RNFL
RBCs (disc hemorrhage)*
Intentional search for optic disc hemorrhage
Lasts for 4-8 weeks, can remain up to 6 months
May leave a notch, RNFL defect, pigment deposit
Indicative of progression
RBCs
Pre-perimetric glaucoma, OU
To treat or not to treat?
OHTS (2002, 2007)
Ocular Hypertension Treatment Study
Ocular hypertensive patients: medication vs
observation
1637 patients
Follow-up duration: 5 years
Findings:
Risk factors: advanced age, increased CDR, IOP, and
PSD, reduced CCT
Lowering IOP by 22.5% reduced development of
glaucoma from 9.5% to 4.4% over 5 years
CNTGS (1998)
Collaborative Normal Tension Glaucoma Study
NTG patients randomized to observation or to 30%
reduction of IOP
230 patients
Lowering IOP by at least 30% reduced rate of VF
progression from 35% to 12%
CIGTS (2001)
Collaborative Initial Glaucoma Treatment Study
Newly diagnosed POAG: medication vs trab
607 patients
Follow-up period: 5 years
Findings: lowering IOP with medications as effective
as lowering IOP with trab in limiting progression
EMGT (2002)
Early Manifest Glaucoma Trial
Newly diagnosed glaucoma: betaxolol and ALT vs
observation
255 patients
Findings: lowering IOP by 25% reduced risk of
progression from 62% to 45% over 5 years
How do we monitor the patient?
Optic Nerve Head Imaging
Photographs
OCT
Ganglion Cell
OCTA
Photographs
Allows assessment:
Color
Pallor
Disc hemorrhages
Narrowing of retinal arteries and dilation of retinal veins
at the disc margin
Peripapillary atrophy
Texture of the rim tissue, blood vessels
OCT
RNFL thickness*
Form and function
40% loss of functional RNFL found in pre-perimetric
glaucoma**
*Diagnosis of pre-perimetric glaucoma using optical coherence tomography. Salkumar SJ, Jose S, Bhat S, G M.
Giridhar A. Kerala Journal of Ophthalmology. XX(1):39-42.
**Correlation between retinal nerve fiber layer thickness and visual field sensitivity: diffuse atrophy imaging study.
Ophthalmic Surgery, Lasers, and Imaging. 2012 Nov-Dec;43(6 Suppl):575-82.
OCT
May have better ability to detect glaucomatous

changes in ocular hypertensives*
Not all RNFL defects are glaucomatous**
*Application of optical coherence tomography in glaucoma suspect eyes. Zajac-Pytrus H, Grzybowski a. Pomorska M,
Kryzzanowska-Berkowska P, Misiuk-Hojlo M, Clinical and Experimental Optometry. 2012 Jan;95(1):78-88.
**Are all retinal nerve fiber layer defects on optic coherence tomography glaucomatous? Gur Gungor S, Ahmet A.
Turkish Journal of Ophthalmology 2017 Oct;45(5):267-73
Ganglion Cell Complex
Dendrites – inner plexiform layer
Cell body – ganglion cell layer
Axons – nerve fiber layer
Ganglion cell complex decreases as severity of
glaucoma increases*
Ganglion cell asymmetry analysis**
Increasing AUCs with increasing severity
Good diagnostic tool for early glaucoma
*Utility of ganglion cell complex analysis in early diagnosis and monitoring of glaucoma using a different spectral
domain optical coherence tomography. Bhagat PR, Deshpande KV, Natu B. Journal of Curent Glaucoma Practice 2014
Sep-Dec;8(3):101-6.
**Diagnostic ability of macular ganglion cell asymmetry for glaucoma. Hwang YH, Ahn SI, Ko SJ. Clinical 8):720-
6.Experimental Ophthalmology 2015 Nov;43(
OCTA
Evaluate microvascular changes of the optic nerve
head (lower flow index and vessel density in pre-
perimetric eyes)*
Pre-perimetric vs mild POAG**
*Optical coherence tomography angiography in pre-perimetric open angle glaucoma. Cennamo G, Montorio D,
Velotti N, Sparnelli F, Reibaldi M, Cennamo G. Graeffes Archive for Clinical and Experimental Ophthalmology
2017 sept;255(9):1787-1793.
**Retinal vessel density from optical coherence tomography angiography to differentiate early glaucoma, pre-
perimetric glaucoma, and normal eyes. Akil H, Huang AS, Francis BA, Sadda SR, Chopra V. PLoS One. 2017 Feb
2;12(2):e0170476
Summary
42 year old African
Large discs, large CDRs
No visual field defects
RNFL OD borderline
RNFL OS thinning in IT sector
IOP OD borderline OS above 21 mm Hg
OD
OS
Summary
Meticulous study of the optic nerve
Judicious use of diagnostic tests (OCT, AVF, fundus
photographs)
Consider risks of patient
Individualized treatment plan
Cảm ơn bạn!
Thank you!
Maraming salamat!
There are some simple tools you can use to really
determine the optic disc size. The simplest is to use the
direct ophthalmoscope. Use the smallest aperture, which is
5 degrees, and place it over the optic disc. The size of the
smallest aperture is approximately the size of the average
optic disc: approximately 5 degrees horizontal and
approximately
7 degrees vertical. This casts a light measuring 1.5mm
This is a very practical way to see if the disc is small, big,
or normal. If the disc fits on that target, the disc is normal.
If the disc is smaller than that target, the disc is small. And
if the disc is larger than the target, it is a large disc.
Ophthalmoscopic Findings*
Asymmetry of Optic Cups
Abnormal Cupping
Saucerization
Atrophy
*Chandler and Grant’s Glaucoma, Fifth Edition. Kahook MY, Schuman JS eds. Pages 81-94
Ophthalmoscopic Findings
Asymmetry of Optic Cup
Enlargement of the cup in all directions
Difference of > 0.2 between cups
Normal variations
Depends on optic disc size
Note also shape and depth of cups
Ophthalmoscopic Findings*
Abnormal Cupping
Usually downward and temporally
Excavation towards to the rim – visual field defect
Rim contour
 Lower rim – narrower excavation
 Upper rim – wider excavation
Saucerization
Slight backward bowing in the periphery of a portion or
the entire disc
Definite glaucomatous change
Atrophy
When coupled with cupping – VF defects
Whiteness and lack of fine vessels in the discs
Ganglion Cell Complex (2014-2018)
2014 2015
2016 2017 2018

Optic disc size measurement*
 Biomicroscopy:
Volk lens
Measure size of slit beam
 Correction factors:
Volk 60D – x 1.0
Volk 78D – x 1.1
Volk 90D – x 1.3
*Biomicroscopic measurement of the optic disc with a high-power positive lens. Siamak AS, Maar N,
Biowski R, Stur M. Journal of Glaucoma 2001; Jan 42(1):153-7.
ONH Parameters (2014-2018)
2014 2015 2016 2017 2018
AGIS (1998)
Advanced Glaucoma Intervention Study
POAG after medical treatment failure with no previous
surgery: ALT vs Trab
591 patients, 789 eyes
Follow-up duration: 4-7 years
Findings: at 5 years, white patients had less
progression if treated with trab first; black patients had
less progression if treated with ALT first

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Case Presentation:

When Large Discs Puzzle Us

Cynthia V. Verzosa, MD, DPBO, MSc

Vietnam Glaucoma Club Mid-Year Meeting

42 year old Nigerian engineer

2014 : Tearing of both eyes

Diagnosed as having OAG OU

20/20 Visual Acuity 20/20

3 mm BRTL Pupils 3 mm BRTL

Full and equal EOMs Full and equal

Clear cornea Biomicroscopy Clear cornea

*AAO Basic and Clnical Science Course Section 10, 2010-2011

*Preferred Practice Patterns, POAG, AAO, 2015)

*Preferred Practice Patterns, POAG, AAO, 2015)

2.69 ± 0.70 mm² Disc Area 2.00 2.76

1.76 ± 0.31 mm Disc Diameter (H) 1.95 mm 2.02 mm

1.92 ± 0.29 mm Disc Diameter (V) 2.08 mm 2.21 mm

0.72 ± 0.70 mm² Cup Area 1.68 1.87

CD ratio (V) 0.90 0.81

CD ratio (H) 1.0 0.90

*The disc damage likelihood scale: reproducibility of a new method of estimating the amount of optic

Ring (scleral ring)

May have better ability to detect glaucomatous

2016 2017 2018

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