DR.

BHARTI AHUJA
 GLAUCOMA –a chronic progressive optic neuropathy
caused by a group of ocular conditions which lead to
damage of optic nerve with loss of visual function.
 Optic nerve head changes associated with glaucoma are
thought to be seen prior to the development of visual field
loss.
 The aim of this communication is to describe the
morphological changes of the optic nerve head in
glaucoma, discuss the differential diagnosis and
highlight the techniques of clinical evaluation of
the optic disc.
• Optic disc-Colour,shape,size
• Optic cup
• Cup disc ratio
• Neuroretinal rim (NRR)
• Peripapillary chorioretinal atrophy
• Retinal vessels
• Retinal nerve fiber layer(RNFL)
LARGE DISC WITH GLAUCOMA

SMALL DISC WITH GLAUCOMA

• Direct ophthalmoscopy
• Slit lamp-high power concave lens
(Goldmann,hruby)

- high power convex lens (60,78,90D)

• Fundus photography -Stereoscopic photographs

• Recent laser imaging techniques
 Cup- disk ratio(assymetry)
 Neuroretinal rim(NRR)Evaluation
 Vascular changes
 Configuration of vessels
 Peripapillary atrophy
 Retinal nerve fiber layer
abnormalities(RNFL)
 C/D=0.2

C/D=0.7
C/D=0.9
Zone alpha
o Outer
o Irregular
hypo/hyperpigmented region
of RPE ,parapapillary choroid.
o Corresponds to choroidal
crescant.
o Normal area=0.4sq mm
o In glaucoma=0.65 sq mm
o Contribute to relative
scotoma.
o Commonly seen in normal
eyes.
o Pigmentary irregularities in
RPE.
Zone beta
o Inner
o A marked atrophy of
RPE,Choriocapillaries.
o Scleral crescant
o 0.13 sq mm
o 0.79 sq mm
o Absolute scotoma
o 15-20% normals.
o Complete loss of RPE cells
& a marked loss of
photoreceptors
Hemorrhages over the disc margin
This sign occurs from
loss of rim tissue that
previously supported
the disc vessel.
Note sharp edge of the two
disc vessels at 12 o’clock
in a patient with bean
potting of the optic nerve
from end-stage glaucoma.
RNFL Defect
 LASER SCANNING IMAGING
TECHNIQUES
SLO(1979)
SLP/RNFL
CSLO/SLT(1987)
RTA analyser
GDx
HRA

•HRT
GDxFCC GDxVCC
•TOPss
Stereophotogrammetry
CSLO
Rasterstereography OCT
(zeiss
Rodenstock CSLT Stratus)
(ONHA)
HRT(scanning laser
TOPCON ophthalmoscopy)
IMAGENET
GDx(scanning laser
HUMPHREY polarimetry)
RETINAL
ANALYSER(HRA) SLP
 Objective,quantitative assessment of
peripapillary RNFL.
 Measures the retardation of a polarized laser
light passing through tissues having the
physical property of form birefringence.
 Near infrared laser(780 nm)
 Commercially available models-
(GDxFCC,GDxVCC)
 Undilated pupil(2 mm)
 0.7 seconds
Representation printout of GDx VCC RNFL ANALYSER
 ADVANTAGES LIMITATIONS
 Easy to operate.  Doesn’t measure actual
 Doesn’t require pupillary dilatation. RNFL thickness.
Reproducibility.
  Low sensitivity,specificity
Doesn’t require a reference plane.

for detection of pre
Can detect glaucoma on first

examination
perimetric glaucoma in
 Early detection before std visual field.
clinical studies.
 Comparison with age matched  Limited use in moderate
normative data. and advanced glaucoma.
 No database from indian
population
 Affected by anterior and
posterior segment lesions.
 Real time, 3D Imaging
 Helium neon DIODE LASER(670 nm)
 Transverse resolution-10 microns
 Axial resolution-300 microns

ADVANTAGES
•EASY TO PERFORM
•Reduced need for pupillary
dilatation ,clear media
•REPRODUCIBLE
LIMITATIONS
•Data interpretation
•No precise mst of NFLT
•expensive
 HRT II C
HRT I

 NOV 1991  APRIL 1999

 32 scans  16-64scans
 Field of view can be  Only 15×15 degrees
set to 3
levels(10×10,15;20
deg)
 384×384 pixels
 256×256px resolution
 Both ONH and
macular images  ONH only
 Non invasive,real time ,high resolution
technology provides optical cross sections of a
scanned region.
 Diode laser(820 nm);laser interferometry.
 To assess the retinal nerve fiber layer and
identify potential structural changes indicative
of early glaucoma.
 Physiological cupping
 Optic nerve coloboma
 Congenital optic disk pit
 Anterior ischemic optic neuropathy(AION)
 Neurological causes
Optic disc coloboma
AION
Morning glory syndrome
• Examination and documentation of the optic disc
and retinal nerve fiber layer (RNFL) is essential for
diagnosis and monitoring of glaucoma.
• Stereoscopic fundoscopic examination combined
with photography remains still the gold
standard for early perimetric glaucoma. The
combination of StratusOCT average RNFL
thickness(GDxVCC) and HRT III cup-to-disk area
ratio will provide a high diagnostic precision.
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