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J.M. Roth, S.J. Bass, S. Nath, A.A. Sadun, J. Sherman; Optic Nerve Head Drusen Mask Glaucomatous Cupping . Invest. Ophthalmol. Vis. Sci. 2003;44(13):642.
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Purpose: To demonstrate that optic nerve head drusen are often undiagnosed, yet are implicated in chronic open angle glaucoma (COAG) occurring in the absence of optic nerve head cupping, and to document an association of small cup-to-disc ratios in COAG patients with the presence of optic disc drusen. Methods: We performed a retrospective study of data from 31 consecutive eyes diagnosed with COAG yet having a small cup-to-disc ratio (0.3 or less) on stereo disc photography, confirmed with Heidelberg Retinal Tomography (HRT). Diagnosis of glaucoma was based on two or more of the following three criteria: a) elevated intraocular pressure (22 mmHg or greater), b) focal glaucomatous visual field loss on either standard or short wavelength automated perimetry (defined as 3 or more statistically significant contiguous nasal defect points 5 dB or greater, or 2 or more statistically significant contiguous nasal defect points 10 dB or greater) and c) nerve fiber layer loss on (GDx) scanning laser polarimetry (neural net number greater than 40 and/or statistically significant superior/inferior nerve fiber layer (NFL) asymmetry). The presence of optic disc drusen was assessed by ophthalmoscopic examination, review of stereo disc photography and B-scan ultrasonography. Results: In these thirty-one eyes with a mean cup-to-disc ratio of 0.17+/-0.05, 26/31 eyes (84%) had elevated IOPs, 26/31 eyes (84%) had glaucomatous visual field loss and 29/31 eyes (94%) demonstrated NFL loss on scanning laser polarimetry. Optic disc drusen were detected in 21/31 eyes (68%) by review of stereo disc photos and/or with ultrasonography (the 95% confidence range for the percentage of glaucomatous eyes without cupping having optic disc drusen is 52% to 86%). In 6 of these 21 eyes (29%), the optic disc drusen were not originally detected by ophthalmoscopic examination alone. Conclusion: Glaucoma can exist in patients with small cup-to-disc ratios. The absence of pathological cupping in COAG is often due to optic disc drusen. Glaucomatous field defects in patients without cupping should alert the clinician to the possibility of optic disc drusen. Subjective visual fields and objective devices (such as scanning laser polarimetry (GDx), retinal tomography (HRT), ocular coherence tomography (OCT) and ophthalmic ultrasonography) are often helpful in identifying glaucoma patients with small cup to disc ratios and disc drusen.
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