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  5. FP262 : Comparative study of Retinal Nerve Fibre Layer- Glaucomatous and Non Glaucomatous Optic Atrophy.

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Dr. Ashit Hasmukhlal Shah, S08841, Dr. Parth Rana, Dr. Kashyap Patel,Dr. Mehul Ashvin Kumar Shah

INTRODUCTION: atrophy Optic (OA) is death of retinal ganglion cell axons that comprise the optic nerve (ON) with the resulting picture of a pale ON

Objective: Our aim is to know RNFL average in  different condition of optic nerve diseases.

Method– This is prospective cohort study all enrolled patient’s history, detailed ocular examination & OCT of every patient done. Data retrieved from hospital records & analysed using SPSS22.

Result :Our cohort consisted of  224 eyes, 115 (51%) were Glaucomatous optic neuropathy (GON), 109(49%) Non- glaucomatous optic neuropathy (NGON).Mean RNFL thickness in subjects with GON & NGON was 65.63 micron & 95.19 micron respectively. Relationship between types of ON & RNFL thickness was statistically significant. (P<0.000)

Conclusion: Average RNFL thickness significant different in case glaucomatous and other optic atrophy.

INTRODUCTION

Optic atrophy refers to the death of the retinal ganglion cell axons that comprise the optic nerve with the resulting picture of a pale optic nerve on  funduscopy.(1)Optic atrophy is somewhat of a misnomer as atrophy implies disuse and optic nerve damage is better termed optic neuropathy. Since optic nerve damage cannot be reversed by any current therapy, close surveillance with structural as well as functional testing, combined with  early intervention is required to preserve sight. Anything that can compromise ganglion cell function can cause (over time) optic atrophy (and more broadly optic neuropathy). In optic nerve atrophy, there is loss of axons and shrinkage of myelin leading to gliosis and Widening of the optic cup.(2)Certain disc appearances can help to determine the cause for the optic nerve damage.(3)Sector disc pallor in an older individual could have been caused by NAION. Severe optic atrophy with gliosis again in an elderly person could have been due to giant cell arteritis. Damage from Papilledema may leave retinal folds and sometimes glistening bodies in the Optic nerve head. Cupping is suggestive of glaucoma. Optical coherence tomography (OCT), a non-invasive imaging modality that uses low coherence light to obtain a high-resolution cross section of biological structures, is changing the field of ophthalmology. The technology has evolved dramatically since its first description by Huang et al in 1991.(4)The current spectral domain (SD) OCT technology collects up to 55,000 a scans per second with an axial resolution of 5 μm a 100-Fold improvement over the earlier generation TD-OCT.(5)Not surprisingly, SD-OCT has been shown to have better diagnostic ability for various types of optic atrophy  than TD-OCT.(6)Obtaining large data cubes quickly reduces test retest variability, allows three dimensional reconstruction and alignment, improves registration, and facilitates test retest comparisons.

Optical coherence tomography (OCT) is a noncontact, non-invasive diagnostic technique that allows measurement of RNFL thickness by in vivo visualization of the retina and RNFL with good reproducibility. (7-11)This RNFL thickness is of particular interest in numerous neurologic disorders such as optic neuropathies. OCT provides accurate assessment of the optic disk and retinal nerve fibre layer (RNFL) morphology which is important for glaucoma subjects, as  structural damage in glaucoma often occurs before detectable loss in visual function.(12-14)High diagnostic sensitivity and specificity in diagnosing glaucoma has been shown for OCT RNFL measurement.(15-18)

Optic atrophy is not a complete diagnosis but is a hallmark of the optic nerve changes that have occurred consequent to insults of various aetiologies. It is therefore, not a diagnosis but an ocular sign that warrants further investigation into its cause and the underlying possible systemic associations. (19,20)Optic atrophy is usually not difficult to diagnose (characteristic pale optic disc), it is assessed on basis of structural findings of optic nerve head on slit lamp biomicroscopy. But it is highly subjective and not readily quantified,

The use of OCT quantifies the assessment and makes it objective. Is OCT a reliable tool for differentiation between glaucomatous and non-glaucomatous optic neuropathies?

METHODS:

Objectives : 1.To compare the RNFL patterns and optic disc changes in glaucomatous and non-glaucomatous optic atrophy by OCT.2 To study variations in RNFL pattern in glaucomatous and non-glaucomatous optic atrophy by OCT .All patients presenting to The Department of Glaucoma and The Department of Retina at Drashti Netralaya, Dahod, Gujaratfrom January 2012 to October 2016 with optic neuropathy, as determined by the Glaucoma and Retina Specialist were enrolled in this study. All patients had a complete neuro ophthalmic examination which included: Ophthalmic and systemic history, Distance visual acuity, Intraocular pressure , Cycloplegic refraction, Slit lamp examination of anterior segment bilaterally, Dilated fundus examination bilaterally by either indirect ophthalmoscope or slit lamp biomicroscopy. Informed written consent was taken from each patient before conducting the test. Exclusion criteria were as follows: Uveitis, Age related macular degeneration, Conditions with hazy optical media i.e. corneal opacity, cataract, etc., Patients of age less than 18 yrs, Mixed or unclear diagnosis, Poor OCT quality, defined by signal strength <4 or poor alignment on the individual OCT scans, Retinal pathology (i.e. diabetic retinopathy, cystoid macular edema, central retinal vein occlusion, or history of retinal laser treatment)Included subjects underwent retinal scanning using Cirrus HDOCT instrument. The type of optic neuropathy was studied in correlation with the OCT findingsAll scans were acquired with the same Cirrus HDOCT device using the optic disc cube 200 × 200 protocol and macular cube 512 × 128 protocol in eyes dilated with tropicamide 1% and phenylephrine 2.5%. After properly seating and aligning the subject, the iris was brought into view using the mouse driven alignment system, and the line scanning ophthalmoscopic image was focused. The ONH or the macular cube was then centered on the live image before the centering, and enhancement was optimized. After the scanning process was launched, the instrument’s 840nm wavelength laser beam generated a cube of data measuring 6 × 6 mm after scanning 200 horizontal line scans comprising 512 Ascans each in the macular cube 512 × 128 protocol and a cube of data measuring 6 × 6 mm after scanning a series of 200 Bscans with 200 Ascans per Bscan (40,000 points) in the optic disc cube 200 × 200 protocol.Data reported by the machine includes: Average RNFL thickness, rim area, optic disc area, cuptodisc area ratio value overall and for the vertical axes, cup volume and central macular thickness.

In our primary analysis we compared the optic disc cube 200*200 protocol variables namely: Average RNFL thickness, rim area, optic disc area, cup-to-disc area ratio value overall and for the vertical axes, cup volume of Cirrus HD OCT with the type of optic neuropathy (glaucomatous or non-glaucomatous).

In our secondary analysis, we chose to compare the central macular thickness measured by macular cube 512*128 protocol of Cirrus HD OCT  with the type of optic neuropathy (glaucomatous or non-glaucomatous).All results were tabulated, P values were calculated and Bonferroni adjusted when appropriate.

 

RESULT: Our cohort consisted of 224 eyes, 115 (51%) were Glaucomatous optic neuropathy (GON), 109(49%) Non- glaucomatous optic neuropathy (NGON).Mean RNFL thickness in subjects with GON & NGON was 65.63 micron & 95.19 micron respectively. Relationship between types of ON & RNFL thickness was statistically significant. (P<0.000)

DISCUSSION:

The relationship between type of optic neuropathy and cup volume was found to be statistically insignificant. (P<0.175)The reason for this statistical insignificant relationship could be:

  • The cup volume is related to the optic cup size, which in turn is related to race.
  • It also depends on the refractive status of the individual where hyperopes show smaller cup volume, and high myopes have larger cup volume.
  • Optic disc excavation is the consequence of three related events: (1) loss of neural rim axons; (2) elongation, stretching, and collapse of the laminar beams and their posterior axial displacement (bowing); and (3) outward, centrifugal rotation of the laminar insertion into the scleral insertion zone. Thus, cup volume in different types of optic neuropathies is related to the pathological changes occurring during the disease process, and cannot be correlated to classify the glaucomatous changes from non glaucomatous ones. A similar finding was seen by Masayuki Hata et al(157) who compared optic disc morphology of compressive optic neuropathy and glaucomatous optic neuropathy using OCT and hypothesized that that the pathogenesis of optic nerve degeneration in glaucomatous optic neuropathy is located at the LC, while the pathogenesis of other optic neuropathies is not. In our study for the 115 glaucomatous eyes, the mean central macular thickness was found to be 230 with maximum frequency in 201 to 250 group while in the non glaucomatous 109 eyes the mean central macular thicknesswas found to be 204 with maximum frequency in 151 to 200group.The relationship between type of optic neuropathy and central macular thickness was found to be statistically significant. (P<0.000)This positive correlation can be explained within accordance to Zeimer et al’s(158)hypothesis which states that the ganglion cells and NFL contribute 30% to 35% of the retina thickness in the macula, where the ganglion cells are known to be most concentrated(158,159 )Further as the macula is that region of the retina where the ganglion cell layer is more than one cell thick and because the photoreceptor layer is not believed to decrease in thickness in glaucoma, this loss of retinal thickness is attributed mainly to ganglion cell and NFL(158,-160)

Thus, according to Zeimer et al’s hypothesis, it would be logical to expect that glaucoma detection would be most readily accomplished through macular thickness assessment. Jeong et al.(161)studied accuracy of SD OCT in diagnosing glaucoma and found that regarding use of OCT for glaucoma diagnosis, partial inner macular thickness parameters carry similar diagnostic capability compared to RNFL thickness parameters. Similarly Greenfield DS et al(162)studied macular thickness in normal and glaucomatous eyes using optical coherence tomography and concluded that macular thickness changes are well correlated with changes in visual function and RNFL structure in glaucoma and may be a surrogate indicator of retinal ganglion cell loss. Viviane Guedes et al (163)studied macular thickness in normal and glaucomatous eyes using OCT and found that inner ring, outer ring, and mean macular thickness measured by OCT were found to be significantly different between normal subjects and advanced glaucomatous eyes (P < 0.001). They also found that among the macular cube parameters outer ring was the only macular parameter that could significantly differentiate between normal and early glaucoma (P=0.008).

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TABLE-1 AGE AND SEX DISTRIBTION

 

 AGE SEX Total
F M
  0 TO 10 3 0 3
11 TO 20 7 11 18
21 TO 30 10 31 41
31 TO 40 7 31 38
41 TO 50 8 25 33
51 TO 60 15 31 46
61 TO 70 10 23 33
71 TO 80 3 9 12
Total 63 161 224

 

TABLE-2 CLINICAL DIAGNOSIS

 

CLINICAL DIAGNOSIS Frequency Percent
  Cavernous optic atrophy 115 51.3
Consecutive optic atrophy 78 34.8
Primary optic atrophy 14 6.3
Secondary optic atrophy 17 7.6
Total 224 100.0

 

TABLE- 3 COMPARATIVE STUDY OF VISUAL ACUITY AMONGS GLAUCOMATOUS AND NON GLAUCOMATOUS OPTIC ATROPHY

 

VISISUAL

ACUIETY

 CATEGORY Total
GLAUCOMA NON GLAUCOMATUS
  <1/60 23 23 46
1/60 TO 3/60 15 27 42
6/60 TO 6/36 8 14 22
6/24 TO 6/18 30 19 49
6/12 TO 6/9 26 19 45
6/6 TO 6/5 13 7 20
Total 115 109 224

P=0.06

 

TABLE-4 COMPARATIVE STUDY OF RNFL AMONGST GLAUCOMATOUS AND NON GLAUCOMATOUS OPTIC ATROPHY

 

OPTIC ATROPHY CATEGORIES RETINAL NERVE FIBRE LAYER CATEGORIES Total
0 TO 30 31 TO 60 61 TO 90 91 TO 120 121 TO 150 151 TO 180 181 TO 210 211 TO 240
  GLAUCOMA 8 47 40 17 2 0 1 0 115
NON GLAUCOMATUS 3 14 29 37 21 4 0 1 109
Total 11 61 69 54 23 4 1 1 224

P=0.000

 

TABLE-5 COMPARATIVE STUDY OF CMTL AMONGST GLAUCOMATOUS AND NON GLAUCOMATOUS OPTIC ATROPHY

 

OPTIC ATROPHY CATEGORIES CENTRAL MACULAR THICKNESS CATEGORIES Total
51 TO 100 3.00 151 TO 200 201 TO 250 251 TO 300 301 TO 350 >350
  GLAUCOMA 1 6 10 63 24 4 7 115
NON GLAUCOMATUS 2 16 39 37 12 1 2 109
Total 3 22 49 100 36 5 9 224

P=0.000

 

 

 

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