Papille

Artes & Dietze, April 2013

Ziele
... das Spektrum der gesunden Papillen
kennen und verstehen lernen. und richtig einordnen.

... Zeichen von Papillenschden erkennen ... wie kann die Optometristin lernen?

Anatomie
Neuroretinaler Randsaum (neuroretinal
rim) und Cup: Doughnut.

Elschnigs Scleraler Ring Lamina cribrosa Parapapillre Nervenfaserschicht ...und, und, und!

h resolution image

Rates of Change in the Visual Field and Optic Disc in Patients with Distinct Patterns of Glaucomatous Optic Disc Damage
Alexandre S. C. Reis, MD,1,2 Paul H. Artes, PhD,1 Anne C. Belliveau, BSc,1 Raymond P. LeBlanc, MD,1 Lesya M. Shuba, MD, PhD,1 Balwantray C. Chauhan, PhD,1 Marcelo T. Nicolela, MD1
Purpose: To investigate the rate of visual eld and optic disc change in patients with distinct patterns of glaucomatous optic disc damage. Design: Prospective longitudinal study. Participants: A total of 131 patients with open-angle glaucoma with focal (n 45), diffuse (n 42), and sclerotic (n 44) optic disc damage. Methods: Patients were examined every 4 months with standard automated perimetry (SAP, SITA Standard, 24-2 test, Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA) and confocal scanning laser tomography (CSLT, Heidelberg Retina Tomograph, Heidelberg Engineering GmbH, Heidelberg, Germany) for a period of 4 years. During this time, patients were treated according to a predened protocol to achieve a target intraocular pressure (IOP). Rates of change were estimated by robust linear regression of visual eld mean deviation (MD) and global optic disc neuroretinal rim area with follow-up time. Main Outcome Measures: Rates of change in MD and rim area. Results: Rates of visual eld change in patients with focal optic disc damage (mean 0.34, standard deviation [SD] 0.69 dB/year) were faster than in patients with sclerotic (mean 0.14, SD 0.77 dB/year) and diffuse (mean 0.01, SD 0.37 dB/year) optic disc damage (P 0.003, KruskalWallis). Rates of optic disc change in patients with focal optic disc damage (mean 11.70, SD 25.5 103 mm2/year) were faster than in patients with diffuse (mean 9.16, SD 14.9 103 mm2/year) and sclerotic (mean 0.45, SD 20.6 103 mm2/year) optic disc damage, although the differences were not statistically signicant (P 0.11). Absolute IOP reduction from untreated levels was similar among the groups (P 0.59). Conclusions: Patients with focal optic disc damage had faster rates of visual eld change and a tendency toward faster rates of optic disc deterioration when compared with patients with diffuse and sclerotic optic disc damage, despite similar IOP reductions during follow-up. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. Ophthalmology 2012;119:294 303 2012 by the American Academy of Ophthalmology.

Rates of visual eld and optic disc change are among the most relevant clinical parameters in the management of glaucoma, providing an indication of the adequacy of treatment and overall prognosis.13 Most patients with glaucoma show evidence of change if observed sufciently long enough. In some patients, these changes are detectable only after many years or even decades and may have minimal impact on quality of life. Other patients have rapid rates of change that cause a substantial risk of visual impairment. Glaucoma is a progressive optic neuropathy with a wide clinical spectrum, and patients vary with respect to the sensitivity to intraocular pressure (IOP), presence of other ocular and systemic risk factors, and overall prognosis of the disease.4 7 Although this diversity has been widely recognized, there have been relatively few attempts to identify subgroups of open-angle glaucoma (OAG) that have a more or less aggressive course of the disease.8 11

Different patterns of glaucomatous damage to the optic disc have been described.12,13 There are patients who develop a more focal loss of tissue in the optic disc,14,15 which occurs from within the cup (notch) and is more frequently identied at the superior and inferior poles. The remaining neuroretinal rim is usually well preserved. Other patients have a more diffuse loss of rim tissue, with concentric cup enlargement, and no localized areas of loss or pallor.16 A third common pattern is sclerotic, where the optic disc cup is characteristically saucerized, which refers to a shallow cupping extending to the disc margins with retention of a central pale cup. This type of damage is associated with marked areas of peripapillary atrophy and choroidal sclerosis.17 Examples of these patterns of optic disc damages are shown in Figure 1. We undertook this study to investigate the rates of change in glaucomatous patients with these 3 distinct patISSN 0161-6420/12/$see front matter doi:10.1016/j.ophtha.2011.07.040

294

2012 by the American Academy of Ophthalmology Published by Elsevier Inc.

Figure 7 The Disc Damage Likelihood Scale (DDLS). This grading system is based on the radial width of the neuroretinal rim measured at its thinnest point. The unit of measurement is the rim/disc ratio, that is, the radial width of the rim compared to the diameter of the disc in the same axis. When there is no rim remaining, the rim/disc ratio is 0. The circumferential extent of rim absence (0 rim/disc ratio) is measured in degrees. For small discs (diameter <1.50 mm) the DDLS stage should be increased by 1; for large discs (diameter >2.00 mm) the DDLS stage should be decreased by 1.

rves. than (A)30This illustrates large with large cup/disc ratios patients whoratio, have been followed for more years with no disc change or any healthy other sign ofdiscs glaucoma. (B) Shows a small glaucomatous optic from disc without a large cup/disc but with an eccentric cup exhibiting an inferior focal notch associated with marked visual eld loss. (C) Depicts a large disc with no disc change or any other sign of glaucoma. (B) Shows a small glaucomatous optic disc without a large cup/disc ratio, glaucomatous cupping. ric cup exhibiting an inferior focal notch associated with marked visual eld loss. (C) Depicts a large disc with ing.

Figure 8

Optic nerves. (A) This illustrates large healthy discs with large cup/disc ratios from patients who have been followed for more

Spaeth et al

FIGURE 1 Disc Damage Likelihood Scale (DDLS) nomogram. DDLS is based on the radial width of the neuroretinal rim measured at its thinnest point. Unit of measurement is rim/disc ratio (ie, the radial width of the rim compared to the diameter of the disc in the same axis). When there is no rim remaining, the rim/disc ratio is 0. The circumferential extent of rim absence (0 rim/disc ratio) is measured in degrees. Caution must be taken to differentiate the actual absence of rim from sloping of the rim as, for example, can occur temporally in some patients with myopia. A sloping rim is not an absent rim. Because rim width is a function of disc size, disc size must be evaluated prior to attributing a DDLS stage. This is done with a 60D to 90D lens with appropriate corrective factors. The Volk 66D lens minimally underestimates the disc size. Corrective factors for other lenses are: Volk 60D ! .88, 78D ! 1.2, 90D ! 1.33; Nikon 60D ! 1.03, 90D ! 1.63.

TABLE I: THE DISC DAMAGE LIKELIHOOD SCALE

RESULTS

SURVEY OF OPHTHALMOLOGY VOLUME 43 NUMBER 4 JANUARYFEBRUARY 1999

MAJOR REVIEW
Ophthalmoscopic Evaluation of the Optic Nerve Head
JOST B. JONAS, MD, WIDO M. BUDDE, MD, AND SONGHOMITRA PANDA-JONAS, MD
Department of Ophthalmology and Eye Hospital, University Erlangen-Nrnberg, Erlangen, Germany
Abstract. Optic nerve diseases, such as the glaucomas, lead to changes in the intrapapillary and parapapillary region of the optic nerve head. These changes can be described by the following variables: size and shape of the optic disk; size, shape, and pallor of the neuroretinal rim; size of the optic cup in relation to the area of the disk; configuration and depth of the optic cup; ratios of cup-to-disk diameter and cup-to-disk area; position of the exit of the central retinal vessel trunk on the lamina cribrosa surface; presence and location of splinter-shaped hemorrhages; occurrence, size, configuration, and location of parapapillary chorioretinal atrophy; diffuse and/or focal decrease of the diameter of the retinal arterioles; and visibility of the retinal nerve fiber layer (RNFL). These variables can be assessed semiquantitively by ophthalmoscopy without applying sophisticated techniques. For the early detection of glaucomatous optic nerve damage in ocular hypertensive eyes before the development of visual field loss, the most important variables are neuroretinal rim shape, optic cup size in relation to optic disk size, diffusely or segmentally decreased visibility of the RNFL, occurrence of localized RNFL defects, and presence of disk hemorrhages. (Surv Ophthalmol 43:293320, 1999. 1999 by Elsevier Science Inc. All rights reserved.) Key words. cup/disk ratio neuroretinal rim optic cup optic disk optic disk hemorrhages optic disk pallor parapapillary atrophy peripapillary scleral ring retinal nerve fiber layer retinal vessel diameter

I. Optic Disk Size

A. BIOLOGIC AND DEMOGRAPHIC CORRELATES

The optic disk area is not constant among individuals but shows an interindividual variability of about 0.80 mm2 to almost 6.00 mm2, or about 1:7, in a normal white population (Figs. 15).21,25,61,118,227,268,278 There are normal eyes with rather small optic disks, and there are normal eyes with very large optic disks.24 The optic disk area is independent of age beyond an age of about 3 to 10 years.21,25,118,227,278 In regard to gender, body length, and refractive error, the results of several studies are partially contradictory. Some investigations suggested that optic disk size does not vary between women and men,25,118,278 whereas in a recent epidemiologic study, mean optic disk area was 3.2% larger in men than in women.227
293
1999 by Elsevier Science Inc. All rights reserved.

In the same epidemiologic investigation,227 with the exclusion of very tall and very small people, disk area increased by 0.02 mm2 with each 10-cm increase in body length, whereas in a smaller nonepidemiologic study, disk area was independent of body size and body weight.112 Within a range of 5 to 5 diopters (D) of refractive error, optic disk size was statistically independent of ametropia in previous studies,25,118,278 whereas in a recent epidemiologic investigation,227 disk area linearly increased by 1.2% 0.15% for each diopter increase toward myopia. All studies agree that the optic disk is significantly larger in eyes with high myopia122,227,278 and that it is significantly smaller in eyes with marked hyperopia (more than 5 D) than in eyes with a normal refractive error. Size of the optic disk varies with race.40,172,269,278 Whites have relatively small optic disks, followed in

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0.6

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response latency (s)

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positive rate in VFnegative group

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positive rate in VFpositive group

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response latency (s)

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Durchschittlicher Kliniker

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