Associations between Retinal Nerve Fiber Layer Defect and Systemic Indices According to the KNHNES 2010–2012

PURPOSE: To investigate the associations between retinal nerve fiber layer (RNFL) defects and systemic factors in the Korean population. METHODS: Based on data from the 5th Korean National Health and Nutritional Examination Survey (2010–2012), 2,999 non-glaucomatous patients and 424 glaucoma patients were included. We compared body mass index (BMI), blood pressure, and blood test values according to the presence and location of RNFL defects in the groups and analyzed whether these defects were associated with various underlying diseases. RESULTS: In the non-glaucomatous group, RNFL defects were significantly and linearly related with BMI (p = 0.035), systolic blood pressure (p < 0.001), diastolic blood pressure (p = 0.018), fasting blood glucose (p < 0.001), HbA1c (p < 0.001), serum ferritin (p = 0.008), and RNFL defects were also significantly associated with diabetes mellitus (p = 0.001), hypertension (p < 0.001), dyslipidemia (p = 0.003), a history of myocardial infarction or angina (p = 0.037), and migraines (p = 0.004). In the glaucoma group, patients who had superior RNFL defects had a significantly lower systolic blood pressure (p = 0.034) than patients who had inferior RNFL defects. The other systemic indices did not differ significantly between these two subgroups. Superior RNFL defects were significantly associated with diabetes mellitus (p = 0.047) and a history of cerebrovascular accident (p = 0.031). CONCLUSIONS: RNFL defects in both the non-glaucomatous and glaucoma groups were associated with systemic factors. We could identify that the possibility of RNFL defects can be deduced from these systemic abnormalities and active treatment is needed in abnormal systemic condition.

Comparison of Blue and Green Confocal Scanning Laser Ophthalmoscope Imaging to Detect Retinal Nerve Fiber Layer Defects

PURPOSE: We detected retinal nerve fiber layer (RNFL) defects using a confocal scanning laser ophthalmoscopy (CSLO) with both blue and green laser sources and evaluated image quality based on laser wavelength. METHODS: This was a retrospective observational case study. Blue and green CSLO images of 181 eyes with suspected glaucoma were evaluated and compared. Three independent observers identified the presence of RNFL defects and determined which CSLO imaging source provided superior visibility of the defect. After assessing the defect imaging by laser source, demographics and image quality indices of optical coherence tomography between blue better and green better groups were analyzed. RESULTS: Both blue and green CSLO showed high discriminating ability for RNFL defects. The discriminating ability of blue CSLO was significantly greater than that of green CSLO (p = 0.004). Among eyes with a detectable RNFL defect, 61.8% were better visualized with the blue laser compared to the green laser. Compared with the blue better group, the green better group was significantly older (p = 0.009), had a greater proportion of females (p = 0.005), had poorer best-corrected visual acuity (p = 0.001), more severe cataracts (p = 0.001), lower signal strength (p = 0.003), and poor image quality indices (p = 0.001). CONCLUSIONS: Both blue and green CSLO imaging was useful for detecting RNFL defects, but blue CSLO was superior to green CSLO in quality of RNFL defect imaging in most patients with clear media.

Location of Retinal Nerve Fiber Layer Defects in Open-angle Glaucoma and Associated Factors

PURPOSE: To investigate the location of retinal nerve fiber layer defects (RNFLDs) in open-angle glaucoma and the differences in systemic and ocular factors between superotemporal and inferotemporal RNFLDs. METHODS: We performed a retrospective review of the 2008 to 2012 data from the Korea National Health and Nutrition Examination Survey. Subjects aged ≥19 years with an evaluable fundus photograph of at least one eye were enrolled, and open-angle glaucoma was diagnosed according to modified International Society of Geographical and Epidemiological Ophthalmology criteria. In subjects with open-angle glaucoma, locations of RNFLDs were evaluated, and systemic and ocular factors were compared between the bilateral superotemporal RNFLD group and bilateral inferotemporal RNFLD group. RESULTS: A total of 534 subjects had open-angle glaucoma with RNFLDs. The unilateral inferotemporal region (25.8%) was the most common location for RNFLDs, followed by the unilateral superotemporal region (24.4%). Multivariate analysis revealed that hypertension was more significantly associated (p = 0.048) with the bilateral superotemporal RNFLD group than with the bilateral inferotemporal RNFLD group. CONCLUSIONS: Superotemporal RNFLDs are more related to hypertension than are inferotemporal RNFLDs.

Multicolor imaging for retinal nerve fiber layer defect in glaucoma

Glaucoma is a progressive optic neuropathy associated with irreversible loss of retinal ganglion cells (RGC). This emblematic localized retinal nerve fiber layer defect (RNFLD) can be the earliest sign to detect the ongoing glaucomatous damage. Slitlamp biomicroscopy [90D & 78D], colour and redfree fundus photography, OCT & HRT are used conventionally for early detection of RNFLD. Multicolour Imaging (MCI) is a new non-invasive retinal imaging modality available in Spectralis platform which simultaneously acquires three reflectance images of the retina using three individual lasers producing a composite image thereby allowing analysis of changes at various levels within the retina. MCI provides sharper image, enables imaging through small pupil and hazy media. Current report describes 2 cases where in MCI proved superior to CFP and conventional redfree photograph in delineating area of RNFLD. This is the first report of MCI in RNFL imaging. The present report highlights the role of MCI in detection of RNFLD.

A Case of Retinal Herniation through Peripapillary Pit Resulting in Retinal Nerve Fiber Layer Defect

PURPOSE: To report a case of glaucoma suspect with peripapillary pit, which enlarged in size with retinal herniation through the pit, and resulted in retinal nerve fiber layer defect and corresponding visual field defect. CASE SUMMARY: A 34-year-old male was referred to our glaucoma clinic for glaucoma evaluation. The intraocular pressure was 15 mmHg in the right eye and 14 mmHg in the left eye. The refractive error in spherical equivalence was −12.75 diopters (D) in the right eye and −11.50 D in the left eye. The axial length was 28.70 mm in the right eye and 28.15 mm in the left eye. On optical coherence tomography (OCT), the retinal nerve fiber layer thickness was within normal limits in both eyes. A peripapillary pit was found in both eyes, which measured 155 µm in the right eye and 625 µm in the left eye in maximal horizontal diameters. Two year follow-up OCT images showed that the peripapillary pit in the right eye enlarged to 239 µm and retinal herniation occurred through the pit, resulting in a retinal nerve fiber layer defect and a corresponding visual field defect. However, the peripapillary pit in the left eye had no significant change. CONCLUSIONS: Glaucoma patients or suspects, with peripapillary pits need close observation because of the possibility of a retinal nerve fiber layer defect in the direction of the pit.

Comparison between time-domain and spectral-domain OCT in the detection of retinal nerve fiber layer defects in glaucoma patients / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To compare the use of the instruments' built-in normative databases, the sensitivities of time-domain optical coherence tomography (Stratus OCT) and spectral-domain OCT(Spectralis OCT) in the detection of retinal nerve fiber layer (RNFL) defects in patients with glaucoma. METHODS: Fifty-two eyes of 35 patients with open angle glaucoma were included. A total of 69 hemiretinas with photographically identified RFNL defects were analyzed using the fast RNFL scan of Stratus OCT and the circle scan in Spectralis OCT. The OCT parameters were evaluated at 5% and 1% abnormality levels using the instruments' built-in normative databases. The diagnostic sensitivity of each parameter was compared between the two devices. RESULTS: The Spectralis OCT detected RNFL defects within each quadrant more frequently than the Stratus OCT at both the 5% (79 7% vs 63 8%,P=0 01) and 1% (56 5% vs 40 6%, P = 0 01) abnormality levels. At the 1% abnormality level,the sensitivity was significantly higher in the standard sector of Spectralis OCT than in the clock-hour sector of the Stratus OCT(68 1% vs 39 1%,P<0 01). CONCLUSIONS: Using the instruments' built - in normative databases, the diagnostic sensitivity of the Spectralis OCT parameters was higher than that of the Stratus OCT parameters for detecting glaucomatous RNFL defects.

Retinal Nerve Fiber Layer Defect Associated with Astrocytic Hamartoma in a Patient with Tuberous Sclerosis

PURPOSE: To report the progression of an astrocytic hamartoma of the right optic nerve head as well as the retina, and the progression of retinal nerve fiber defect associated with astrocytic hamartoma in a patient with tuberous sclerosis. CASE SUMMARY: A 6-year-old boy with tuberous sclerosis and an astrocytic hamartoma of the right optic nerve head, which was found at the time of ophthalmologie examinations, was referred from the pediatric neurologist for evaluation of the vigabatrin-associated visual field changes. Fundus examination revealed 1/2 disc diameter (DD)-sized astrocytic hamartoma located at the margin of the superior part of the optic nerve. The retina of the left eye was normal. Eighteen months after the first visit, enlarged optic disc hamartoma of the right eye and newly onset retinal astrocytic hamartoma located approximately 1.5 DD inferior to the fovea of the left eye were found. Three years later, an increase in the size of the astrocytic hamartoma of the right optic nerve and development of retinal nerve fiber defects were observed. CONCLUSIONS: Astrocytic hamartoma in patients with tuberous sclerosis is usually stable without progression. However, in our patient, astrocytic hamartoma showed progression, and development of retinal nerve fiber defects occurred. Regular follow-up is necessary for astrocytic hamartoma in patients with tuberous sclerosis.

A Single Isolated Cotton-Wool Spot not Associated with Systemic Diseases

PURPOSE: To present a case of a single isolated cotton-wool spot in a healthy patient. CASE SUMMARY: A 43-year-old woman with no systemic disease complained of sudden inferior field defect of the right eye. On fundoscopic examination of the right eye, a single soft white spot was observed in the superotemporal vascular arcade. An elevated hyper-reflective area in the inner retina corresponding to a white spot was observed on optical coherence tomography. Automated perimetry revealed an arcuate field defect which was wider than the cotton-wool spot. A complete workup for systemic diseases was within normal range except a positive rheumatoid factor. At the 2-week follow-up, the patient's subjective symptom improved and the white spot decreased. After 6 months, the cotton-wool spot disappeared and slit-like retinal nerve fiber layer (RNFL) defects corresponding to the location of the cotton-wool spot was noticed. One year later, disc and RNFL defect were unchanged but the previous field defect disappeared. CONCLUSIONS: Isolated cotton-wool spots can occur without serious systemic diseases in healthy patients. A single isolated cotton-wool spot in the present case disappeared spontaneously leaving permanent structural damage on the retina over time.

A Single Isolated Cotton-Wool Spot not Associated with Systemic Diseases

PURPOSE: To present a case of a single isolated cotton-wool spot in a healthy patient. CASE SUMMARY: A 43-year-old woman with no systemic disease complained of sudden inferior field defect of the right eye. On fundoscopic examination of the right eye, a single soft white spot was observed in the superotemporal vascular arcade. An elevated hyper-reflective area in the inner retina corresponding to a white spot was observed on optical coherence tomography. Automated perimetry revealed an arcuate field defect which was wider than the cotton-wool spot. A complete workup for systemic diseases was within normal range except a positive rheumatoid factor. At the 2-week follow-up, the patient's subjective symptom improved and the white spot decreased. After 6 months, the cotton-wool spot disappeared and slit-like retinal nerve fiber layer (RNFL) defects corresponding to the location of the cotton-wool spot was noticed. One year later, disc and RNFL defect were unchanged but the previous field defect disappeared. CONCLUSIONS: Isolated cotton-wool spots can occur without serious systemic diseases in healthy patients. A single isolated cotton-wool spot in the present case disappeared spontaneously leaving permanent structural damage on the retina over time.

False Negative Findings of Optical Coherence Tomography in Eyes with Localized Nerve Fiber Layer Defects

PURPOSE: To identify the risk factors associated with false negative findings of optical coherence tomography (Stratus OCT) in patients with photographic localized retinal nerve fiber layer (RNFL) defects. METHODS: Twenty-four patients with preperimetric glaucoma and 173 patients with perimetric glaucoma, all with localized RNFL defects were included in the present study. The patients were divided into 2 groups according to the presence or absence of detection of photographic defects by OCT. Gender, age, refractive error, diabetes, hypertension, central corneal thickness, type of glaucoma, mean deviation, pattern standard deviation, average RNFL thickness, disc area, and photographic RNFL defect related variables (location, number, and angular width) were compared between the 2 groups. Each variable was initially evaluated by univariate analysis and significant variables (p < 0.1) were included in the logistic regression analysis. RESULTS: Photographic RNFL defects were not detected by OCT in 51 (25.9%) of the 197 eyes. The angular locations and widths of RNFL defects by OCT were significantly correlated with those of RNFL defects by red-free RNFL photographs (Pearson correlation coefficient R = 0.98 and 0.64, respectively). Logistic regression analysis revealed the risk factors for false negative findings of OCT included average RNFL thickness (odds ratio = 1.106, 95% confidence interval [CI] = 1.057-1.156, p < 0.001) and angular width of defect (odds ratio = 0.929, 95% CI = 0.884-0.977, p = 0.004). CONCLUSIONS: This present study suggests that false negative findings of OCT in patients with photographic localized RNFL defects were associated with thicker RNFL thickness and smaller angular width of RNFL defect.

Progressive Localized Retinal Nerve Fiber Layer Defect Following Cotton Wool Spots and a Dot Hemorrhage

We report two cases of progressive localized retinal nerve fiber layer (RNFL) defect following cotton wool spots and a dot hemorrhage, 63-year-old woman with RNFL defect in inferior temporal retina of the right eye and 43-year-old man with RNFL defect in superior temporal retina of the right eye. Case 1 showed a dot hemorrhage adjacent to RNFL defect in the right eye and a new slit-like localized RNFL defect in the left eye 5 months later. The visual field in the left eye demonstrated corresponding field defect 9 months later. Case 2 showed a slit-like RNFL defect starting from cotton wool spots in the right eye and corresponding visual field defect. Cotton wool spots and dot hemorrhages represented ischemic damages at the nerve fiber layer. Two noticeable cases showed the progression of RNFL defect caused by repetitive localized microvascular ischemic events, resulting in visual field loss.

Visual Field Defect Developed after Internal Limiting Membrane Peeling in a Patient with Epiretinal Membrane

PURPOSE: To report a case of visual field defect developed after internal limiting membrane (ILM) peeling in a patient with macular epiretinal membrane (ERM). CASE SUMMARY: A 33-year-old female without a history of specific diseases presented with a gradually decreased visual acuity in the right eye for 3 years. The patient was diagnosed as having macular ERM and underwent vitrectomy. During ILM peeling, retinal hemorrhage occurred in the superior region of macula, which spontaneously disappeared 2 weeks after surgery. Transmission electron microscopy showed Muller cell end feet with damaged appearance adherent to the ILM. At 3 months after surgery, the patient developed retinal nerve fiber layer (RNFL) defect in the area where the spot retinal hemorrhage had occurred. Optical coherence tomography showed focal RNFL thinning in the superotemporal region. The automated perimetry revealed corresponding inferior nasal step and scotomas in the right eye. Intraocular pressure was normal throughout the follow-up period and there was no evidence of glaucomatous optic disc change. CONCLUSIONS: The results obtained from the patient in the present study indicated that visual field defect may be the result of a mechanical damage to the RNFL during ILM peeling.

Comparison of the Results between Heidelberg Retina Tomography II and Stratus Optical Coherence Tomography in Glaucoma

PURPOSE: To evaluate the ability of Stratus OCT and HRT II with Moorfields' analysis to detect localized RNFL defects and to evaluate the accordance of Stratus OCT and HRT II results in glaucoma patients. METHODS: A total of 60 patients (119 eyes) who had localized RNFL defects of either eye in red-free fundus photographs unserwent evaluation by Stratus OCT and HRT II. For the results of Stratus OCT and HRT II with Moorfields' analysis, normal distribution percentiles less than 5% were considered a significant RNFL defect. For each disc, superotemporal and inferotemporal portions were evaluated. The diagnostic abilities of Stratus OCT and HRT II to detect localized RNFL defects were calculated. The results of HRT II were compared with those of Stratus OCT. RESULTS: The overall sensitivity, specificity, positive predictive value and negative predictive value to detect localized RNFL defects were 67.9%, 88.9%, 84.3% and 76.5% in Stratus OCT and 67.3%, 64.8%, 62.2% and 69.6% in HRT II, respectively. Compared with Stratus OCT, 67.2% of HRT II results were in accord in the superotemporal portion and 68.9% in the inferotemporal portion. The accordance of detection of RNFL defects between the two instruments in the inferotemoral portion was higher (79.2%) than others. CONCLUSIONS: Stratus OCT with a normative database is a useful aid to detect localized RNFL defects in early glaucoma. If observation of topographic changes of the optic disc with HRT II is added, results will be even better.

The Detection of Retinal Never Fiber Layer Defect by Modification of Non-mydriatic Digital Fundus Photograph

PURPOSE: To evaluate the efficiency of digital retinal nerve fiber layer (RNFL) photographs converted from a non-mydriatic digital fundus camera for detecting RNFL defects. METHODS: Ninety-five eyes were evaluated with both a non-mydriatic digital fundus photograph and a digital RNFL photograph by two glaucoma specialists independently. The red-free, monochrome modified digital fundus photograph was acquired from non-mydriatic digital fundus photographs using Photoshop 7.0. Whether a localized wedge-shaped or diffuse RNFL defect existed or not was evaluated on a non-mydriatic digital fundus photograph and a modified digital fundus photograph, and inter- and intraobserver agreement were also evaluated. Regarding the use of digital RNFL photographs as a standard method, we calculated the sensitivity, specificity, and positive and negative predictive values of the two types of photographs. RESULTS Interobserver agreement (Cohen's kappa values) about localized RNFL defects observable on digital RNFL photographs, non-mydriatic digital fundus photographs, and modified digital fundus photographs were 0.749, 0.634, and 0.793, respectively, but all were 0.417 or less with regard to diffuse RNFL defects. Regarding localized RNFL defects, the sensitivity, specificity, and positive and negative predictive values of modified digital fundus photographs were 85.7%, 95.5%, 85.7% and 94.1%, respectively, showing superiority to those of non-mydriatic digital fundus photographs. But, in cases of diffuse RNFL defect, the sensitivity and specificity of modified digital fundus photographs were 60.0% and 97.8%, respectively, indicating no superiority to non-mydriatic digital fundus photographs. CONCLUSIONS: The localized RNFL defect can be detected more efficiently with modified digital fundus photographs than non-mydriatic digital fundus photographs, but the diffuse RNFL defect cannot.

The Detection of Retinal Never Fiber Layer Defect by Modification of Non-mydriatic Digital Fundus Photograph

PURPOSE: To evaluate the efficiency of digital retinal nerve fiber layer (RNFL) photographs converted from a non-mydriatic digital fundus camera for detecting RNFL defects. METHODS: Ninety-five eyes were evaluated with both a non-mydriatic digital fundus photograph and a digital RNFL photograph by two glaucoma specialists independently. The red-free, monochrome modified digital fundus photograph was acquired from non-mydriatic digital fundus photographs using Photoshop 7.0. Whether a localized wedge-shaped or diffuse RNFL defect existed or not was evaluated on a non-mydriatic digital fundus photograph and a modified digital fundus photograph, and inter- and intraobserver agreement were also evaluated. Regarding the use of digital RNFL photographs as a standard method, we calculated the sensitivity, specificity, and positive and negative predictive values of the two types of photographs. RESULTS Interobserver agreement (Cohen's kappa values) about localized RNFL defects observable on digital RNFL photographs, non-mydriatic digital fundus photographs, and modified digital fundus photographs were 0.749, 0.634, and 0.793, respectively, but all were 0.417 or less with regard to diffuse RNFL defects. Regarding localized RNFL defects, the sensitivity, specificity, and positive and negative predictive values of modified digital fundus photographs were 85.7%, 95.5%, 85.7% and 94.1%, respectively, showing superiority to those of non-mydriatic digital fundus photographs. But, in cases of diffuse RNFL defect, the sensitivity and specificity of modified digital fundus photographs were 60.0% and 97.8%, respectively, indicating no superiority to non-mydriatic digital fundus photographs. CONCLUSIONS: The localized RNFL defect can be detected more efficiently with modified digital fundus photographs than non-mydriatic digital fundus photographs, but the diffuse RNFL defect cannot.

Clinical Course of the Eyes with Retinal Nerve Fiber Layer Defect and Normal Visual Field

PURPOSE: To investigate the clinical course of eye with retinal nerve fiber layer (RNFL) defect without visual field (VF) defect, and to assess the risk factors for the progression of RNFL defect and the development of VF defect. METHODS: We performed retrospective chart review of the patients who had had RNFL photography and Humphrey visual field test. The seventy six eyes of 76 patients showed RNFL defect with normal VF. RESULTS: The average follow-up period was 36.6 months. Among the 76 eyes, 64 eyes (84%) showed neither the progression of RNFL defect nor the development of VF defect. Six eyes (8%) showed progression of RNFL defect without VF deterioration and 4 eyes (5%) showed development of VF defect without progression of RNFL defect. Two eyes (3%) showed both progression of RNFL defect and development of VF defect. The progression of RNFL defect was significantly related to the disc hemorrhage and the number of anti-glaucoma medications and less significantly to intraocular pressure (IOP) fluctuation (p=0.051). The development of VF defect was related to the number of anti-glaucoma medications. CONCLUSIONS: The majority (84%) of eyes with RNFL defect but normal VF did not show any sign of glaucomatous progression for average 36.6 months. The VF defect developed in 8% and the RNFL defect progressed in 11%. The factors related to progression of RNFL defect were the disc hemorrhage, the number of anti-glaucoma medications and IOP fluctuation. The factors related to the development of VF defect was the number of anti-glaucoma medications.