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Clinical Evaluation of Optic Nerve Head in Glaucoma--2  

2014-05-21 23:48:06|  分类: ophthalmology 眼 |  标签: |举报 |字号 订阅

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Staging and Quantification of Optic Nerve Head Damage in Glaucoma

Staging and quantification is necessary once optic nerve head changes have been noticed. Categorizing patients according to severity is important in giving them prognosis, monitoring progress deciding management and counseling patients.62

In 1960 Armaly devised the first methodology for quantitatively evaluating disk damage. The method received world wide acceptance and is still commonly used today.75,76 The examiner compared the cup diameter to the entire disk diameter in any axis and expressed it as a ratio.

Read-Spaeth system: The system was described in 1974 and was also based upon the cup/disk ratio. The severity of disk damage was classified into six stages.

Richardson system: The classification system included optic disk changes and visual fields.

Stage 1a: Low-risk subject; normal visual fields and cup/disk ratio (< 0.3 and pink rim of uniform width without asymmetry).

Stage 1b: High-risk subject; 1a with family history of glaucoma, vascular disease, pseudoexfoliation, pigment dispersion or large cups.

Stage 2: Early glaucomatous damage; incomplete Bjerrum defect or nasal step with cup disk alterations (cup/disk ratio >0.3 with vertical widening of cup, asymmetry or neuroretinal rim, disk hemorrhage).

Stage 3: Late stage glaucoma; arcuate scotoma with cup/disk ratio < 0.8, pale rim of uneven width.

Stage 4: End stage glaucoma; central or temporal visual island with narrow pale rim.

The above systems have two major shortcomings as cup/ disk ratios are not highly valid indicators of health and disease of optic nerve. The systems assume that that cups start centrally and progress concentrically. Although this occurs in some cases, the nerve damage frequently occurs eccentrically. The second problem is that the above systems do not take into consideration the disk size. It is now well-known that the size of the cup varies with the size of the disk with lower cup/disk ratios still being significant in small sized disks.

Read and Spaeth for the first time brought attention towards measuring rim width ; they noted that onset of visual field loss was related to remaining rim width. This study formed the basis for later staging systems like the Nesterov's system, Jonas method and disk damage likelihood scale:

The scale is the latest entry to the list of methodologies for the the staging of optic nerve damage. It was devised by Spaeth et al. The scale divides disk damage into 10 grades of severity. It is better able to monitor disease progression than the other scales. Disk drawings are made after a slit lamp biomicroscopic examination and the size of the disk is measured by comparing to the beam length. The DDLS score is derived from the DDLS chart.

DDLS scores of 1 through 3 are rarely associated with glaucomatous visual field loss. Some individuals are born with DDLS three optic disks, whereas others begin with DDLS one disk. For this reason, noting that a person has a DDLS three optic disks indicates that it is reasonably healthy and that there is no visual field loss. This score is not proof that the disk's health has not worsened, however, because it could have been a stage 1 or 2 in the past. The DDLS allows you to quantify the amount of damage that the optic nerve has sustained. Visual field loss usually will not occur before stage 5. The differentiation between very early and no damage is important, because a neuroretinal rim that has already narrowed is likely to become narrower still, whereas an undamaged rim is far more likely to remain stable. Unless glaucomatous progression has stabilized (e.g. in cases of inactive glaucoma secondary to trauma or corticosteroids), a DDLS score of 6 through 10 strongly supports aggressive treatment. The DDLS grading performs well compared to C/D ratio and HRT-II evaluation.77


ournal of Current Glaucoma Practice

Shibal Bhartiya et al


Table 4: Differentiation of glaucomatous from nonglaucomatous optic atrophy in presence of optic disk cupping

Clinical Evaluation of Optic Nerve Head in Glaucoma--2 - movie6521 - have a good time !!

DISK DAMAGE LIKELIHOOD SCALE

Narrowest width of rim (rim to disk ratio)

Clinical Evaluation of Optic Nerve Head in Glaucoma--2 - movie6521 - have a good time !!

Differentiation of Glaucomatous vs Nonglaucomatous Optic Neuropathy

Glaucomatous and nonglaucomatous optic neuropathy may be difficult to distinguish and both can be associated with cupped disks along with a decreased diameter of the retinal arterioles, focal arteriole narrowing, and a reduced visibility of the RNFL.3,11 Increasing excavation and enlargement of the optic cup occurs most commonly in glaucoma, but can occur in arteritic anterior ischemic optic neuropathy and compressive lesions on the optic nerve, such as sphenoid wing meningioma. However, in these last two cases, the neuroretinal rim typically will have pallor whereas glaucoma will not. Localized RNFL defects can be found in glaucoma and in many types of nonglaucomatous optic nerve damage, such as in optic disk drusen and long-standing papilledema. Compared with nonglaucomatous optic nerve atrophy, the optic cup enlarges and deepens in glaucomatous optic neuropathy, and, in a complementary manner, the neuroretinal rim decreases. In addition to glaucoma, an enlargement of the optic cup and a loss of neuroretinal rim may be found in patients after arteritic anterior ischemic optic neuropathy and in a few patients with intrasellar or suprasellar tumors. Because parapapillary atrophy does not usually occur in eyes with nonglaucomatous optic nerve damage, it is helpful for the differentiation of glaucomatous versus nonglaucomatous optic neuropathy (Table 4).

In conclusion, a detailed evaluation of the optic disk and retinal fiber layer by stereoscopic slit lamp biomicroscopic techniques provides the clinician with an excellent method for early detection of glaucoma and in monitoring its progression. Annual disk photographs (both color and red free) should be made the standard practice pattern for follow up of a glaucoma patient.

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JAYPEE

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ournal of Current Glaucoma Practice

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