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Original Investigation |

Optic Disc Characteristics in Patients With Glaucoma and Combined Superior and Inferior Retinal Nerve Fiber Layer Defects

Jin A Choi, MD, PhD1; Hae-Young Lopilly Park, MD, PhD2; Hye-Young Shin, MD3; Chan Kee Park, MD, PhD2
[+] Author Affiliations
1Department of Ophthalmology, St. Vincent’s Hospital, College of Medicine, Catholic University of Korea, Suwon, Republic of Korea
2Department of Ophthalmology, Seoul St. Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
3Department of Ophthalmology, Uijeongbu St. Mary’s Hospital, College of Medicine, Catholic University of Korea, Uijeongbu, Republic of Korea
JAMA Ophthalmol. 2014;132(9):1068-1075. doi:10.1001/jamaophthalmol.2014.1056.
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Importance  Eyes with initial bihemifield defects show faster progression compared with eyes with initial single-hemifield involvement, suggesting greater optic nerve susceptibility to glaucomatous damage. We hypothesized that certain disc phenotypes may exist in patients with glaucoma who have bihemispheric structural damage at the initial stage of the disease.

Objective  To identify the optic disc characteristics related to bihemispheric retinal nerve fiber layer (RNFL) defects in early-stage glaucoma.

Design, Setting, and Participants  A cross-sectional study of 136 patients with early-stage primary open-angle glaucoma from a glaucoma referral practice. Eyes were divided into those with RNFL defects in the superior or the inferior hemisphere (group 1) and those with bihemispheric RNFL defects (group 2). We measured the degree of horizontal tilt angle and RNFL thickness using spectral-domain optical coherence tomography. We performed multivariate logistic regression analysis to determine potential risk factors related to the bihemispheric RNFL defects.

Exposures  Bihemispheric RNFL defects.

Main Outcomes and Measures  Disc ovality (defined as the ratio between the longest and shortest diameters of the optic disc), the degree of horizontal tilt angle, and the presence of bihemispheric RNFL defects. Asymmetry in RNFL thickness between hemispheres was defined as the difference between the superior and inferior mean RNFL thickness.

Results  Disc ovality (mean [SD], 1.09 [0.12] in group 1 vs 1.18 [0.18] in group 2; difference, −0.09; 95% CI, −0.14 to −0.03), proportion of tilted discs (5.3% vs 17.5%, respectively; difference, −12.2; 95% CI, −13.0 to −11.4), and horizontal tilt angle (mean [SD], 4.17° [4.13°] vs 5.93° [4.84°], respectively; difference, −1.76; 95% CI, −3.47 to −0.03) were significantly different between groups 1 and 2 (P = .001, P = .03, and P = .045, respectively). The asymmetry in RNFL thickness decreased with increased disc ovality (exponentiation of the B coefficient, 1.67; 95% CI, 1.10-2.55; P = .02), although associations were not identified with spherical equivalent, axial length, or the angle between the temporal retinal veins. In multivariate logistic analysis, disc ovality was suggested to be an independent risk factor for bihemispheric RNFL defects, after controlling for mean deviation, age, axial length, and disc area (P = .02).

Conclusions and Relevance  Optic disc tilt appears to be associated with bihemispheric RNFL defects in patients with early glaucoma, regardless of their refractive status. These data suggest that disc tilt, associated with bihemispheric structural damages, is a risk factor for glaucoma progression.

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Figure 1.
Definition of the Horizontal Tilt Angle

A, In the extracted horizontal tomogram provided by high-definition spectral-domain optical coherence tomography, the retinal pigment epithelium (RPE)/Bruch membrane complex (black line) and the end point of the RPE/Bruch membrane into the disc boundaries are shown. A line was drawn between each RPE/Bruch membrane opening (yellow dotted line). B, An additional line connected 2 points that are located at an arbitrarily chosen distance (80 pixels) from the RPE/Bruch membrane opening on each side (blue continuous line). C, The first line was then shifted (red arrowheads) toward the additional line (yellow solid line) to measure the angle of tilt (red angle). N indicates nasal; T, temporal.

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Figure 2.
Scatterplots Showing the Relationship Between Asymmetry of the Retinal Nerve Fiber Layer (RNFL) Thickness With Ocular Variables

The asymmetry in RNFL thickness between each hemisphere was defined as the difference in mean RNFL thickness between the superior and inferior hemispheres. Correlation coefficients are calculated using the Pearson product moment correlation test. A, Disc ovality. B, Horizontal tilt angle measured by high-definition spectral-domain optical coherence tomography (OCT). C, Spherical equivalent. D, Axial length. E, Angle between the temporal retinal veins. D indicates diopter. The black lines indicate the regression line.

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Figure 3.
Representative Cases Showing the Relationship of the Extent of Disc Tilt and Bihemispheric Retinal Nerve Fiber Layer (RNFL) Defect

A, Images from a middle-aged man with early-stage open-angle glaucoma with a mean deviation (MD) of −1.06 dB. His spherical equivalent (SE) was −3.6 diopters (D) and axial length (AL) was 25.16 mm. Apparent RNFL defect at the 6 and 7 o’clock segments in the red-free photograph and high-definition spectral-domain optical coherence tomography (OCT) 30° clock-hour sector map is seen. The disc ovality was 1.03 and the OCT-measured horizontal tilt angle was 2.97°. B, Images from a middle-aged man with early-stage open-angle glaucoma with an MD of −0.16 dB. His SE was −2.6 D and AL was 24.91 mm. Apparent RNFL defects at the superior and inferior hemispheres (7 and 11 clock-hour segments) are seen in the red-free photograph and the OCT clock referent map. The disc ovality was 1.40 and the OCT-measured horizontal tilt angle was 6.56°. I indicates inferior; N, nasal; S, superior; and T, temporal.

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