Clinical Examination of Clinical Examination of the


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Clinical Examination of the Optic p Disc for Glaucoma Risk Dale K. Heuer, MD Professor & Chairman Department of Ophthalmology Medical College of Wisconsin Director, Froedtert & Medical College of Wisconsin Eye Institute Milwaukee, Wisconsin [email protected] edu [email protected]

Disclosures • DSMB Member: Aeon Astron; Innovia • Lecture Honorarium via Unrestricted Educational Grant to Jobson Publishing: Alcon Laboratories, Inc.

Anterior Ischemic Optic p Neuropathy p y “Disc--at“Disc at-Risk” • Discs have small to no cup • Some have indistinct margins • Vascular origin can be atypical

images courtesy of Dr. Bernd Remler

Lee* (Arch A h Ophthalmol O hth l l 2001;119:1069) 2001 119 1069) “What should the physician do with this information?” • “Understanding these results suggests that clinicians and clinical evaluations remain integral parts of any care system that seeks to diagnose and treat glaucoma. glaucoma ” *editorial regarding Zangwill et al: Discrimination between normal and glaucomatous eyes using the HRT, GDx, and OCT (Arch Ophthalmol 2001;119:985)

Lee* (Arch A h Ophthalmol O hth l l 2001;119:1069) 2001 119 1069) “What should the physician do with this information?” • “Understanding these results suggests that clinicians and clinical evaluations remain integral parts of any care system that seeks to diagnose and treat glaucoma. glaucoma ” *editorial regarding Zangwill et al: Discrimination between normal and glaucomatous eyes using the HRT, GDx, and OCT (Arch Ophthalmol 2001;119:985)

AAO Summaryy Benchmark for PPP Guidelines POAG and POAG Suspects (2013) • Evaluation of optic nerve head and RNFL w/ magnified stereoscopic visualization* • Documentation of optic nerve head appearance by color stereophotography or computer-based image analysis† *A:III = recommendation w/ high importance to clinical care [A], supported by consensus of expertt opinion i i in i absence b off evidence id that th t meets t Levels I and II [III] †A:II

= recommendation w/ high importance to clinical li i l care [A] [A], supported t d by b sufficiently ffi i tl rigorous published evidence, but not by a randomized controlled trial [II].

Five Rules for Assessment of the Optic Disc in Glaucoma* 1) Observe scleral Ring to identify limits of optic disc and its size 2) Identify size of Rim 3) Examine E amine Retinal NFL 4) Examine Region of parapapillary atrophy 5) Look for Retinal and optic disc hemorrhages *“The 5Rs” for optic disc/RNFL examination developed by Drs. Robert Weinreb, Felipe Medeiros, & Remo Susanna (from FORGE I; available at http://one.aao.org/forge-i-and-ii)

Assessment of the Optic p Disc in Glaucoma* (for the mnemonically impaired) ? Disc size ? Rim width ? Optic disc hemorrhages (ODHs) ? Parapapillary atrophy (β-PPA) (β PPA) ? Retinal nerve fiber layer (RNFL) defects image from FORGE (Focusing on Reframing Glaucoma Education) I *from my as-yet unpublished “A Donut Lover’s Guide to Clinical Disc Examination”

Assessment of the Optic p Disc in Glaucoma* (for the mnemonically impaired) ? Disc size ? Rim width ? Optic disc hemorrhages (ODHs) ? Parapapillary atrophy (β-PPA) (β PPA) ? Retinal nerve fiber layer (RNFL) defects

*from my as-yet unpublished “A Donut Lover’s Guide to Clinical Disc Examination”

Assessment of the Optic p Disc in Glaucoma

Disc Size: BEWARE of Smaller Discs image modified from FORGE I

Scleral ring

V ti l Vertical disc diameter

Horizontal disc diameter

• As clinicians, we are inevitably more suspicious of large discs (b (because off associated i t d larger l cups) than small discs, but • Disc size is not risk factor for glaucoma development* or progression† *Zangwill et al. (Arch Ophthalmol 2005;123:1188) †Jost et al. al (Invest Ophthalmol Vis Sci 2004;45:2613)

Assessment of the Optic p Disc in Glaucoma

Disc Size: Rim Width

ISNT Rule • Rim width width:: distance between border of disc and d position iti off bl blood d vessel bending • ISNT rule rule:: Inferior > Superior > Nasal > Temporal content and image modified from FORGE I

ISNT Rule • Rim width width:: distance between border of disc and d position iti off blood bl d vessel bending • ISNT rule rule:: Inferior > Superior > Nasal > Temporal content and image modified from FORGE I

Assessment of the Optic p Disc in Glaucoma

Optic Disc Hemorrhages (ODHs) indicative of higher risk of glaucoma development and progression

Assessment of the Optic p Disc in Glaucoma

Optic Disc Hemorrhages (ODHs) • Detection of disc hemorrhages requires careful optic disc examination • In OHTS, 84% only detected by Optic Disc Reading Center (not by OHTS investigators on clinical examinations)

Assessment of the Optic p Disc in Glaucoma

Parapapillary Atrophy (β (β-PPA) • β-PPA zone • Width of β-PPA inversely correlates with rim width in same area • Larger β-PPA area associated with thinner rim • Presence and extent of β-PPA associated with risk of progression • Enlargement of β-PPA often associated with progressive glaucoma

Assessment of the Optic p Disc in Glaucoma

Retinal Nerve Fiber Layer (RNFL) defects • Best performed with red-free light (red-free photographs or green li ht) light) • Look at striations, brightness, and visibility of parapapillary retinal vessels

Bright striations

• Look for diffuse and localized RNFL loss; in former • Diffuse loss of striate pattern and increased visibility of retinal vessel borders

Diffuse loss of striations

Assessment of the Optic p Disc in Glaucoma Retinal Nerve Fiber Layer (RNFL) defects

Clinical Examination of the Optic p Disc for Glaucoma Risk Summary: Beware • Disc size: small discs (because our index of suspicion is low with smaller cups) • Rim width: generalized thinning (ISNT rule) or focal thinning/notching • Optic disc hemorrhages • β-parapapillary β ill atrophy t h • Retinal nerve fiber layer defects