papille (vortrag in aalen, optometrie '13 der vdco)

7/28/2019 Papille (Vortrag in Aalen, Optometrie '13 der VDCO)

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PapilleArtes & Dietze, April 2013


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Ziele

... das Spektrum der gesunden Papillen

kennen und verstehen lernen.

... Zeichen von Papillenschden erkennenund richtig einordnen.

... wie kann die Optometristin lernen?


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Anatomie Neuroretinaler Randsaum (neuroretinal

rim) und Cup: Doughnut.

Elschnigs Scleraler Ring

Lamina cribrosa

Parapapillre Nervenfaserschicht ...und, und, und!


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Rates of Change in the VisualField and Optic Disc in Patients withDistinct Patterns of GlaucomatousOptic 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 field and optic disc change in patients with distinct patterns ofglaucomatous 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 4years. During this time, patients were treated according to a predefined protocol to achieve a target intraocularpressure (IOP). Rates of change were estimated by robust linear regression of visual field 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 field change in patients with focal optic disc damage (mean 0.34, standarddeviation [SD] 0.69 dB/year) were faster than in patients with sclerotic (mean0.14, 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 inpatients with focal optic disc damage (mean 11.70, SD 25.5103 mm2/year) were faster than in patients withdiffuse (mean9.16, SD 14.9103 mm2/year) and sclerotic (mean0.45, SD 20.6103 mm2/year) optic discdamage, although the differences were not statistically significant (P 0.11). Absolute IOP reduction fromuntreated levels was similar among the groups (P 0.59).

Conclusions: Patients with focal optic disc damage had faster rates of visual field change and a tendencytoward faster rates of optic disc deterioration when compared with patients with diffuse and sclerotic optic discdamage, despite similar IOP reductions during follow-up.

Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.Ophthalmology 2012;119:294303 2012 by the American Academy of Ophthalmology.

Rates of visual field and optic disc change are among themost relevant clinical parameters in the management of

glaucoma, providing an indication of the adequacy of treat-ment and overall prognosis.13 Most patients with glaucomashow evidence of change if observed sufficiently longenough. In some patients, these changes are detectable onlyafter many years or even decades and may have minimalimpact on quality of life. Other patients have rapid rates ofchange that cause a substantial risk of visual impairment.

Glaucoma is a progressive optic neuropathy with a wideclinical spectrum, and patients vary with respect to thesensitivity to intraocular pressure (IOP), presence of otherocular and systemic risk factors, and overall prognosis ofthe disease.47 Although this diversity has been widelyrecognized, there have been relatively few attempts to iden-tify subgroups of open-angle glaucoma (OAG) that have amore or less aggressive course of the disease.811

Different patterns of glaucomatous damage to the opticdisc have been described.12,13 There are patients who de-

velop a more focal loss of tissue in the optic disc,

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whichoccurs from within the cup (notch) and is more frequentlyidentified at the superior and inferior poles. The remainingneuroretinal rim is usually well preserved. Other patientshave a more diffuse loss of rim tissue, with concentric cupenlargement, and no localized areas of loss or pallor. 16 Athird common pattern is sclerotic, where the optic disc cupis characteristically saucerized, which refers to a shallowcupping extending to the disc margins with retention of acentral pale cup. This type of damage is associated withmarked areas of peripapillary atrophy and choroidal sclero-sis.17 Examples of these patterns of optic disc damages areshown in Figure 1.

We undertook this study to investigate the rates ofchange in glaucomatous patients with these 3 distinct pat-

294 2012 by the American Academy of Ophthalmology ISSN 0161-6420/12/$see front matter

Published by Elsevier Inc. doi:10.1016/j.ophtha.2011.07.040


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Figure 8 Optic nerves. (A) This illustrates large healthy discs with large cup/disc ratios from patients who have been followed for more

than 30 years with no disc change or any other sign of glaucoma. (B) Shows a small glaucomatous optic disc without a large cup/disc ratio,

but with an eccentric cup exhibiting an inferior focal notch associated with marked visual field loss. (C) Depicts a large disc with

glaucomatous cupping.


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FIGURE 1

Disc DamageLikelihoodScale (DDLS) nomogram. DDLSisbased ontheradialwidth oftheneuroretinalrimmeasured atitsthinnestpoint. Unit of

measurementisrim/disc ratio (ie, theradialwidth oftherim comparedto thediameter ofthedisc inthesame axis). Whenthereisno rimremaining,

therim/disc ratio is 0. The circumferentialextent ofrim absence (0 rim/disc ratio) ismeasuredindegrees. Cautionmustbetakento differentiatethe

actual absence ofrimfromsloping oftherim as, forexample, can occurtemporallyinsomepatientswithmyopia. Aslopingrimisnot an absentrim.

Becauserimwidthis a function ofdisc size, disc sizemustbeevaluatedpriorto attributing a DDLSstage. Thisisdonewith a 60Dto 90Dlenswith

appropriate correctivefactors. TheVolk66Dlensminimallyunderestimatesthedisc size. Correctivefactorsfor otherlenses are:Volk60D! .88, 78D! 1.2, 90D! 1.33;Nikon 60D! 1.03, 90D! 1.63.


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293

MAJOR REVIEW

SURVEY OF OPHTHALMOLOGY VOLUME 43

NUMBER 4

JANUARYFEBRUARY 1999

1999 by Elsevier Science Inc. 0039-6257/99/$19.00All rights reserved. PII S0039-6257(98)00049-6

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 para-papillary region of the optic nerve head. These changes can be described by the following variables: sizeand shape of the optic disk; size, shape, and pallor of the neuroretinal rim; size of the optic cup in rela-tion to the area of the disk; configuration and depth of the optic cup; ratios of cup-to-disk diameter andcup-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 ofparapapillary 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 byophthalmoscopy without applying sophisticated techniques. For the early detection of glaucomatousoptic nerve damage in ocular hypertensive eyes before the development of visual field loss, the mostimportant variables are neuroretinal rim shape, optic cup size in relation to optic disk size, diffusely orsegmentally decreased visibility of the RNFL, occurrence of localized RNFL defects, and presence ofdisk hemorrhages. (

Surv Ophthalmol 43

:293320, 1999. 1999 by Elsevier Science Inc. All rightsreserved.)

Key words.

cup/disk ratio

neuroretinal rim

optic cup

optic disk

optic diskhemorrhages

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 individ-uals but shows an interindividual variability of about

0.80 mm

2

to almost 6.00 mm

2

, or about 1:7, in a nor-mal 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 opticdisks.

24

The optic disk area is independent of age be-yond an age of about 3 to 10 years.

21,25,118,227,278

In re-gard to gender, body length, and refractive error,the results of several studies are partially contradic-tory. Some investigations suggested that optic disksize does not vary between women and men,

25,118,278

whereas in a recent epidemiologic study, mean opticdisk area was 3.2% larger in men than in women.

227

In the same epidemiologic investigation,

227

with theexclusion of very tall and very small people, disk area

increased by 0.02 mm

2

with each 10-cm increase inbody length, whereas in a smaller nonepidemiologicstudy, 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 statisticallyindependent of ametropia in previous studies,

25,118,278

whereas in a recent epidemiologic investigation,

227

disk area linearly increased by 1.2%

0.15% foreach diopter increase toward myopia. All studiesagree that the optic disk is significantly larger in eyeswith high myopia

122,227,278

and that it is significantlysmaller 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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positive rate in VFnegative group

positive

rate

in

VFpositive

group

0.0 0.2 0.4 0.6 0.8 1.0

0.0

0.2

0.4

0.6

0.8

1.0

A

B

C

D

AUC=0.84

94%

r=0.65

mean.Diff=0.81

criterion=0.74

I

!0

5

10

15

20

25

30

response

response

atencys

d h p h n s p d d d

0

5

10

15

20

25

30

40 31 6 9 14


positive

rate

in

VFpositive

group

0.0 0.2 0.4 0.6 0.8 1.0

0.0

0.2

0.4

0.6

0.8

1.0

A

B

C

D

AUC=0.75

69%

r=0.73

mean.Diff=0.42

criterion=0.02

0

5

10

15

20

25

30

response

response

atenc

y

s

d h p h n s p d d d

0

5

10

15

20

25

30

15 27 21 19 18


positive

rateinVFpositive

group

0.0 0.2 0.4 0.6 0.8 1.0

0.0

0.2

0.4

0.6

0.8

1.0

A

B

C

D

AUC=0.56

18%

r=0.3

mean.Diff=0.85

criterion=0.32

Y

0

5

10

15

20

25

30

response

response

atencys

d h p h n s p d d d

0

5

10

15

20

25

30

33 20 12 16 19

Experte

Durchschittlicher

Kliniker

Impostor

papille (vortrag in aalen, optometrie '13 der vdco)

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