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Normal Tension Glaucoma: Who Needs Neuroimaging?. Julie Falardeau, MD, FRCSC Casey Eye Institute Devers Eye Institute Portland, Oregon. Background. Normal tension glaucoma (NTG) is characterized by: Cupping of the optic nerve head Visual field loss Intraocular pressure (IOP)  21 mmHg

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normal tension glaucoma who needs neuroimaging

Normal Tension Glaucoma:Who Needs Neuroimaging?

Julie Falardeau, MD, FRCSC

Casey Eye Institute

Devers Eye Institute

Portland, Oregon

background
Background
  • Normal tension glaucoma (NTG) is characterized by:
    • Cupping of the optic nerve head
    • Visual field loss
    • Intraocular pressure (IOP)  21 mmHg
    • No obvious or apparent cause for these changes
nonglaucomatous optic disc cupping
Nonglaucomatous optic disc cupping
  • Following an ischemic optic neuropathy (anterior or posterior - AION or PION)
    • Temporal arteritis
      • Quigley and Anderson found that 50% of patient with arteritic -AION developed cupping, compared to 10% after non-arteritic-AION
    • Severe hypotensive/hypovolemic event
  • Demyelinating optic neuritis

Quigley et Anderson. Cupping of the optic disc in ischemic optic neuropathy. Trans Am Acad Ophthalmol Otol. 1977;83:755-762

nonglaucomatous optic disc cupping4
Nonglaucomatous optic disc cupping
  • Hereditary optic neuropathy
    • Leber’s hereditary optic neuropathy
    • Autosomal dominant optic atrophy
        • Temporal disc excavation and pallor
  • Traumatic optic neuropathy
  • Infectious
    • Syphilis
  • Toxic
    • Methanol
nonglaucomatous optic disc cupping5
Nonglaucomatous optic disc cupping
  • Compressive lesion
    • Meningioma
    • Aneurysm
    • Dolichoectasia of the internal carotid artery
    • Suprasellar mass
glaucomatous vs nonglaucomatous cupping
Glaucomatous VS Nonglaucomatous cupping
  • Distinguishing glaucomatous from non-glaucomatous disc cupping is often difficult
  • A detailed history is crucial
    • Presence of neurological symptoms
    • Chronicity and pattern of visual loss
    • History of head trauma
    • History of shock or severe low blood pressure
glaucomatous vs nonglaucomatous cupping7
Glaucomatous VS Nonglaucomatous cupping
  • Systematic approach recommended
    • Demographic characteristics
    • Visual acuity
    • Optic disc characteristics
    • Visual field findings
demographic characteristics
Demographic characteristics
  • A family history of glaucoma among first degree relatives is highly specific (96%) for glaucomatous cupping
  • Age under 50 years is 93% specific for nonglaucomatous cupping

Greenfield et al. The cupped disc: Who needs neuroimaging? Ophthalmology. 1998;105:1866-1874

visual acuity
Visual Acuity
  • Patients with nonglaucomatous cupping have significantly lower levels of visual acuity than patients with glaucoma
    • Trobe et al found all 20 patients with compressive optic neuropathy had loss of central vision
    • Greenfield et al found visual acuity < 20/40 to be 77% specific for nonglaucomatous cupping
    • Hupp et al described sparing of central acuity in 3 of 6 eyes with compressive lesions
optic disc characteristics
Optic disc characteristics
  • Glaucomatous cupping:
    • Vertical elongation
    • Cupping more than pallor
    • Greater frequency of peripapillary atrophy
    • Disc hemorrhage
        • Highly specific
  • Nonglaucomatous cupping:
    • Pallor of the neuroretinal rim
        • Highly specific sign but relatively insensitive
        • The absence of disc pallor does not exclude compressive lesions
optic nerve appearance
Optic nerve appearance
  • Baring of the circumlinear vessels and temporal saucerization
    • Common in glaucoma
    • Can also be seen in compressive optic neuropathy

Kupersmith and Krohn. Cupping of the optic disc with compressive lesions of the anterior visual pathway. Ann Ophthalmol 1984;16:948-53

visual field findings
Visual field findings
  • Glaucoma
    • Nerve-fiber-layer (arcuate) defects, bordering horizontal midline
        • Arcuate scotoma
        • Nasal step
  • Compressive lesion
    • Central scotoma
    • Temporal hemianopia
    • Incongruous hemianopia respecting the vertical meridian
    • Glaucomatous types of VF defects can occur
humphrey perimetry in patients with suprasellar mass
Humphrey perimetry in patients with suprasellar mass

Ahmed et al. Neuroradiologic screening in normal-pressure glaucoma:

study results and literature review. J Glaucoma. 2002 Aug;11(4):279-86

ntg and neuroimaging
NTG and Neuroimaging
  • Some physicians routinely obtain neuroimaging studies in patients with NTG
  • Cost-to-benefit ratio of performing such studies is unknown
ntg and neuroimaging15
NTG and Neuroimaging
  • Ahmed et al found that routine neuroimaging of NTG patients was cost-effective
    • 6.5% of 62 consecutive patients with NTG had clinically significant intracranial lesions associated with optic neuropathy and visual field loss typical of glaucoma

Ahmed et al. Neuroradiologic screening in normal-pressure glaucoma: study results and literature review. J Glaucoma. 2002 Aug;11(4):279-86

ntg and neuroimaging16
NTG and Neuroimaging
  • Steward and Reid reported compressive lesions in 2 of 53 patients (3.8%) referred for evaluation of NTG
  • In the series by Greenfield et al, none of the patients diagnosed with glaucoma had neuroradiological evidence of compressive lesion
ntg and neuroimaging17
NTG and Neuroimaging
  • In Bianchi-Marzoli at al’s series of 29 patients with cupping from unilateral compressive lesion, only one had cupping and field loss as an isolated manifestation of their optic neuropathy
  • All others had:
    • Reduced acuity
    • Decreased color vision
    • RAPD

Bianchi-Marzoli et al. Quantitative analysis of optic disc cupping in compressive optic neuropathy. Ophthalmology 1995;102:436-440.

ntg who needs neuroimaging
NTG: Who needs neuroimaging?
  • Presence of headache or other neurological symptoms
  • Symptoms of decreased vision, fluctuating vision, or visual field loss
  • Atypical visual field for glaucoma
    • Visual field defect respecting the vertical meridian
    • Junctional scotoma
    • Central or cecocentral scotoma
ntg who needs neuroimaging19
NTG: Who needs neuroimaging?
  • Atypical rate of progression of VF loss
    • Monocular or binocular
  • Pallor > cupping
  • Asymmetric cupping
    • Especially if progressive changes while IOP remains symmetric and well controlled
ntg who needs neuroimaging20
NTG: Who needs neuroimaging?
  • Most likely NTG if:
    • Vertical elongation of the cupping
    • Presence of notch
    • Presence of splinter hemorrhage
    • Family history of glaucoma