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A Comparison of Optic Nerve Head Topographic

Measurements by Stratus OCT in Patients With
Macrodiscs and Normal-sized Healthy Discs
Funda E. Onmez, MD,* Banu Satana, MD,w Cigdem Altan, MD,w
Berna Basarir, MD,w and Ahmet Demirok, MDw

optic disc in the diagnosis and follow-up of glaucoma. The

Purpose: To evaluate and compare optic nerve head parameters cup/disc ratio is physiologically related to the optic disc
and retinal nerve ber layer (RNFL) thickness between large discs size.24
and normal-sized vital discs using Stratus optical coherence In recent years, new technologies for quantitative and
tomography (OCT).
objective optic disc assessment have become available such
Methods: A total of 293 healthy eyes (145 with macrodisc and 148 as confocal scanning laser ophthalmoscopy (eg, Heidelberg
with normal-sized disc) were enrolled in the study. After a complete retina tomograph), scanning laser polarimetry (eg,
ophthalmic evaluation, measurement of optic nerve head parame- GDx-VCC), and optical coherence tomography (OCT;
ters and RNFL thickness using OCT was performed in all subjects. eg, Stratus OCT). Using these technologies, quantitative
Optic disc areas larger than 2.80 mm2 were accepted as macrodiscs. measurements of the optic disc size and the RNFL
All OCT parameters were compared between normal-sized discs
and macrodiscs.
thickness and optic cup measurements can be performed,
and these measurements may be used to help distinguish
Results: Participants mean age was 46.5 10.6 years (range, 13 to healthy optic discs from discs with glaucomatous optic
74 y). Average optic disc areas were 2.19 0.29 and 3.02 neuropathies. Previous studies showed that OCT obtains
0.29 mm2 in the normal and the macrodisc groups, respectively. accurate and reproducible RNFL and optic disc analysis.5,6
The optic disc area (P < 0.0001), the cup area (P < 0.0001), the Visual eld (VF) loss correlates with RNFL thickness as
horizontal cup disc ratio (P < 0.0001), the vertical cup disc ratio
(P < 0.0001), and the cup disc area ratio (P < 0.0001) were found
determined by OCT in glaucoma patients.7 In the present
to be signicantly dierent in the macrodisc group and the control study, we used Stratus OCT for ONH and RNFL analysis.
group. Rim areas (P = 0.57) and RNFL thicknesses (inferior, A challenging factor in the evaluation of a glaucoma
superior, and mean) were found to be similar in both groups suspect with large cups is to decide whether the cup is
(P = 0.75, 0.65, 0.85, respectively). physiological in a large disc or pathologic in a small-sized
disc. Similarly, a small C/D ratio in an ocular hypertensive
Conclusions: A macrodisc may have a macrocup and should not be
misdiagnosed as glaucoma. The present study showed that macro-
patient may be pathologic if the disc is small. Therefore,
discs are identical to normal-sized discs in terms of rim area and patients who have physiological large cups in large discs
RNFL thickness. We suggest that these 2 OCT parameters can help can be misdiagnosed as glaucoma patients or patients with
to dierentiate a healthy macrodisc from a glaucomatous optic disc. small discs, a small C/D ratio, and a high intraocular
pressure (IOP) can be misdiagnosed as ocular hypertensive
Key Words: optical coherence tomography, glaucoma, large optic instead of glaucomatous.
disc, macrodisc, optic nerve head analysis To the best of our knowledge, there have been no valid
(J Glaucoma 2014;23:e152e156) database addressing the ONH parameters in healthy mac-
rodiscs measured by Stratus OCT. Therefore, this study
was designed to evaluate and compare ONH parameters
between large discs and normal-sized discs.
G laucoma is an irreversible optic neuropathy charac-
terized by a progressive injury to the optic nerve and
the retinal nerve ber layer (RNFL).1 Early detection of METHODS
glaucomatous changes of the optic nerve head (ONH) is We conducted a prospective, cross-sectional, and
essential in the prevention of progression of glaucoma. comparative study. The study population consisted of
Clinical estimation of the vertical cup/disc ratio (C/D) patients who came to the ophthalmology clinic for a regular
remains the most frequently performed assessment of the eye examination. Before being included in the study, each
individual was informed of its purpose, and written consent
Received for publication January 29, 2013; accepted September 11, to participate was obtained from them. All eligible subjects
2013. ranged in age from 13 to 74 years.
From the *Department of Ophthalmology, Education and Research Recent studies performed with Stratus OCT have
Hospital, Sakarya University, Sakarya; and wDepartment of Oph-
thalmology, Beyoglu Eye Education and Research Hospital,
documented the mean optic disc area for white patients as
Istanbul, Turkey. approximately 2.20 0.3 mm2.6,812 On the basis of the
Disclosure: The authors declare no conict of interest. Gaussian-like distribution curve of the optic disc area, mac-
Reprints: Funda E. Onmez, MD, Kemalpasa Mah. 111. Sokak Platin rodiscs can be dened morphometrically as being larger than
Park Sitesi 14/A Blok Daire: 2, Serdivan, Sakarya 54055, Turkey
the mean plus 2 SD. In this study, we dened macrodiscs as
Copyright r 2013 by Lippincott Williams & Wilkins being larger than 2.80 mm2.13 In contrast, normal disc size
DOI: 10.1097/IJG.0000000000000021 was dened by a disc area between 1.4 and 2.80 mm2.

e152 | J Glaucoma  Volume 23, Number 8, October/November 2014

J Glaucoma  Volume 23, Number 8, October/November 2014 ONH Parameters of Macrodiscs by Stratus OCT

All subjects underwent a complete ophthalmic evalu- system: in Stratus OCT, it is 3.382. The ocular magnication
ation, including medical history, IOP measurement, VF factor q of the eye can be determined with the formula
testing, central corneal thickness (CCT) measurement with q = 0.01306 (axial length 1.82).17 Therefore, given a value,
corneal ultrasound pachymeter, undilated and dilated bio- s, obtained with OCT, the real size of the RNFL peripapillary
microscopy, and dilated fundus examination. Ophthalmic scan circle can be determined by means of the formula
evaluation, VF testing, and OCT imaging were all per- t = 3.3820.01306 (axial length 1.82) s.
formed in 1 month. Because the Littmann formula refers to linear magni-
All tested eyes had a best corrected visual acuity above cation, we modied the equation to t2 = p2 q2  s2 for
20/25, spherical refractive error within 2.0 D, cylindrical area magnication according to the suggestion of Leung
error within 2.0 D, and IOPr21 mm Hg. Patients with et al.19
signicant ocular disorder, optic nerve diseases such as
glaucoma, a history of intraocular surgery and systemic Statistical Analysis
diseases with possible ocular involvement, such as diabetes OCT parameters compared between normal and large
mellitus, were excluded from the study. OCT scans with a discs were as follows: optic disc area (mm2), cup area
signal strength of <6 were also excluded. All the subjects (mm2), rim area (mm2), horizontal C/D ratio, vertical C/D
had to have a reliable (xation loss, false-positive, and ratio, C/D area ratio, and RNFL thickness (inferior,
false-negative error <10%) and normal (absence of all 3 of superior, and mean). All Statistical analyses were per-
Anderson and Patellas criteria14) Humphrey 30-2 SITA- formed with SPSS software (SPSS for Windows Version
standard testing. One eye of each participant was enrolled. 15.0; SPSS Inc., Chicago, IL). Categorical variables were
If both eyes met the inclusion criteria, the eye with larger compared by w2 analysis, and continuous variables with
disc area was selected. normal distributions were compared by Student t test. The
All optic disc and RNFL measurements were per- Kolmogorov-Smirnov nonparametric test was used to
formed using the fast optic disc-scanning protocol and evaluate the normal distribution of numerical data. Results
automated ONH analysis using version 3.0 Stratus OCT of the measurements were expressed as mean SD. Pear-
analysis software (Stratus OCT, software version 3.0; Carl son correlation coecients and multivariate linear regres-
Zeiss Meditec Inc., Dublin, CA). A maximum of 2 ONH sion analyses were performed to evaluate the relationship
scans of each subject were obtained, and the better of the 2 between optic disc area and other OCT parameters.
scans was chosen for interpretation. ONH evaluation con- P < 0.05 was considered statistically signicant.
sisted of 6 radial scans centered on the ONH, spaced 30
degrees apart (Fast Optic Disc acquisition protocol). The RESULTS
machine automatically dened the edge of the optic disc as
A total of 293 healthy eyes (145 with macrodiscs and
the end of the retinal pigment epithelium/choriocapillaris.
148 with normal-sized discs) were enrolled in the study.
The resultant image could be corrected manually when the
Participants mean age was 46.5 10.6 years (range, 13 to
machine did not identify the edge correctly. Eleven eyes
74 y). In Table 1, the demographic and clinical character-
needed manual correction, and this correction of the
istics were compared between the 2 groups. The CCT was
automatic ONH tracing was performed by 2 investigators
found to be slightly more in the macrodisc group
(F.E.O. and C.A.). The fast RNFL algorithm was used to
(P = 0.04), whereas there was no statistical dierence in
measure the RNFL thickness with the Stratus OCT. Three
IOP measurements (P = 0.51), axial length (P = 0.68), and
scan images were obtained from each subject, with each
VF indices (mean deviation and pattern SD: P = 0.13, 0.56,
image consisting of 256 A-scans along a 3.4-mm-diameter
circular ring around the optic disc. These values were
In Table 2, the OCT optic disc parameters and RNFL
averaged to yield 12 clock-hour thicknesses, 4 quadrant
thicknesses were compared between the 2 groups. The optic
thicknesses, and a global average RNFL thickness
disc area (P < 0.0001), the cup area (P < 0.0001), the hori-
zontal C/D ratio (P < 0.0001), the vertical C/D ratio
Good-quality scans had to have focused images from
(P < 0.0001), and the C/D area ratio (P < 0.0001) were
the ocular fundus, adequate signal strength (> 6 for
found to be signicantly dierent in the macrodisc group and
RNFL), and the presence of a centered circular ring around
the control group. The rim area (P = 0.575) and RNFL
the optic disc (for RNFL scans). For ONH scans, the radial
scans had to be centered on the optic disc. RNFL scans
were also evaluated as to the adequacy of the algorithm for TABLE 1. Demographic and Clinical Characteristics of the Study
detection of the RNFL. Groups
The default axial length and the refraction for the optic Macrodisc Normal
disc measurement in every OCT scan were set to 24.46 mm Group Group P
and 0 D, respectively. For this reason, the exact disc size in an
Age (mean SD) (y) 46.33 10.3 46.85 9.0 0.65
eye with axial length dierent from 24.46 mm and/or refrac- Male/female [n (%)] 70 (48.2)/75 73 (49.3)/75 0.15
tion <0 D would be dierent than the printout values. (51.8) (51.7)
Therefore, manual correction for optic disc measurements is MD (db) 1.10 1.35 1.39 1.24 0.13
necessary. To correct axial length-related ocular magnica- PSD (db) 1.99 1.16 1.92 0.82 0.56
tion, we applied the Littmann formula (t = pqs), as Intraocular pressure 15.4 2.73 14.9 3.01 0.51
modied by Bennet and later adopted by Leung et al and (mean SD) (mm Hg)
Kang et al.1518 In this Formula, t is the actual fundus Central corneal thickness 560.4 38.2 557.7 33.2 0.04
dimension, s is the measurement on OCT, p is the magni- (mean SD) (mm)
cation factor related to the imaging system, and q is the Axial length (mm) 23.29 0.80 23.25 0.83 0.68
magnication factor related to the eye. Factor p is instrument MD indicates mean deviation; PSD, pattern SD.
dependent and remains a constant in a telecentric imaging

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Onmez et al J Glaucoma  Volume 23, Number 8, October/November 2014

TABLE 2. A Comparison of OCT Parameters (Magnification Corrected) Between Macrodiscs and Normal Discs
Macrodisc Group Normal Group P
Optic disc area (mm2) 3.02 0.29 (2.81-3.95) 2.19 0.29 (1.54-2.80) < 0.0001
Cup area (mm2) 1.37 0.61 (0.03-3.1) 0.67 0.46 (0.03-2.06) < 0.0001
Rim area (mm2) 1.65 0.51 (0.52-2.62) 1.62 0.45 (0.57-2.51) 0.575
Horizontal C/D ratio 0.66 0.16 (0.10-0.98) 0.51 0.18 (0.16-0.96) < 0.0001
Vertical C/D ratio 0.58 0.14 (0.11-0.9) 0.45 0.15 (0.09-0.91) < 0.0001
C/D area ratio 0.42 0.17 (0.01-0.9) 0.27 0.18 (0.02-0.91) < 0.0001
Superior RNFL thickness (mm) 119.99 15.39 (81.39-157.92) 118.95 16.08 (82.04-170.3) 0.653
Inferior RNFL thickness (mm) 124.39 16.38 (81.48-177.5) 123.82 18.09 (82.65-156.54) 0.758
Average RNFL thickness (mm) 144.14 8.06 (71.10-124.95) 144.32 8.17 (72.19-126.78) 0.851
OCT indicates optical coherence tomography; RNFL, retinal nerve ber layer.

thicknesses (inferior, superior, and mean) were found to be pseudoglaucomatous physiological large cup was intro-
similar in both groups (P = 0.758, 0.653, 0.851, respectively). duced by Jonas et al24 and the morphologic characteristics
In the correlation analysis, a strong positive correlation of physiological large cups were dened as an abnormally
was detected between the OD area and the cup area large optic disc area, a large C/D ratio, normal neuroretinal
(r = 0.637, P < 0.0001). Moderate positive correlations were rim area and conguration, and normal parapapillary
found between the OD area and the horizontal C/D ratio, the RNFL.
vertical C/D ratio, and the C/D area ratio (r = 0.507, In a study performed with confocal scanning laser
P < 0.0001; r = 0.516, P < 0.0001; r = 0.504, P < 0.0001, ophthalmoscopy, Cankaya and Simsek25 showed that
respectively). However, the correlation between the OD area macrodiscs have a larger rim area than normal-sized discs.
and the rim area was not statistically signicant (r = 0.078, In contrast, our study revealed that there was no signicant
P = 0.182). A weak positive correlation was found between dierence in the rim area between the 2 groups. Although
the OD area and the average RNFL thickness (r = 0.157, dierent studies revealed that the neuroretinal rim area
P = 0.007). In the multiple linear regression analyses, the increases as the disc size increases, there was no signicant
cup area (P < 0.0001), the horizontal C/D ratio (P < 0.0001), correlation detected between these 2 parameters in our
the vertical C/D ratio P < 0.0001), the C/D area ratio study group.4,2527
(P < 0.0001), and the average RNFL thickness (P < 0.001) Savini et al27 showed that the RNFL thickness meas-
remained signicantly related to the optic disc area (Table 3). ured by Stratus OCT was associated with the ONH size.
Budenz et al28 have also demonstrated thicker RNFLs by
OCT in larger optic discs. However, a human histologic
DISCUSSION study revealed that the average RNFL thickness was not
The present study was designed with the main objec- related to the disc area.29 Recently, Huang and colleagues
tive of evaluating and comparing the ONH parameters reported that the RNFL thickness measured by OCT was
between large discs and normal-sized discs. not correlated with the Heidelberg Retina Tomograph-
In our study, we revealed that macrodiscs have a larger determined optic disc area, which was magnication
cup area, horizontal C/D ratio, vertical C/D ratio, and C/D corrected. Their results suggested that this was due to
area ratio than normal-sized discs by OCT. Moreover, magnication variation related to axial length variation
RNFL thicknesses, rim areas, and VF indices (MD, pattern within the human population. Their evidences support
SD) of macrodiscs were similar to those of normal subjects. magnication as the link between RNFL thickness and disc
This is the rst study to evaluate the ONH parameters of area.30 Previous investigators did not take the magnication
macrodiscs using OCT. variation into account.27,28 In our study, we corrected axial
As large ONHs have large cups, they can be misdiag- length-related ocular magnication using the Littmann
nosed and treated as glaucoma. Therefore, the dierentiation formula. We found that RNFL thicknesses were similar in
of ONH parameters between normal and macrodiscs is macrodiscs and normal-sized discs, and there was a weak
extremely important for the dierential diagnosis of a correlation between RNFL thickness and the optic disc size.
healthy macrodisc from glaucomatous optic neuropathy. Viestenz et al31 reported that eyes with macrodiscs and
The vertical cup/disc ratio is positively correlated with normal IOP had a thicker CCT than healthy discs in
optic disc size in normal and glaucomatous eyes.2,2021 The patients without glaucoma. However, in our study, the
Blue Mountains Eye Study showed a positive relationship CCT of eyes with macrodiscs was slightly thicker than eyes
between the cup/disc ratio and the disc size.2 The impor- with normal-sized discs, but the IOP was found to be
tance of assessing the cup/disc ratio corrected for disc size similar between the 2 groups.
was studied by Jonas and colleagues. They showed that the Large discs have a large total lamina cribrosa area and
vertical cup/disc ratio corrected for disc size had the highest more lamina pores than small discs. These pores allow more
diagnostic power compared with other optic disc parame- space for nerve bers to travel through, and therefore, they
ters for distinguishing normal subjects from preperimetric reduce the risk of compression to the optic nerve axons.12 In
glaucoma patients.21,22 Our study showed that there were contrast, the pressure dierential across the lamina cribrosa
moderate positive correlations between the optic disc size can produce an increased deformation and displacement of
and vertical, horizontal, and area C/D ratios. the central tissue in macrodiscs, leading to greater glaucoma
Several publications revealed that a macrodisc may susceptibility in these eyes.32,33 Burgoyne and colleagues
have a macrocup because of the direct relationship between suggested that mechanical failure of the connective tissue
the disc area and the cup area.12,23 The term of the lamina cribrosa underlies glaucomatous cupping.

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J Glaucoma  Volume 23, Number 8, October/November 2014 ONH Parameters of Macrodiscs by Stratus OCT

TABLE 3. Linear Regression Analysis: The Association Between Optic Disc Area and Other OCT Parameters in the Overall Population
Pearson Correlation Multivariate Analysis*
Variables r P b P
Rim area (mm ) 0.078 0.182
Cup area (mm2) 0.637 < 0.0001 2.46 < 0.0001
Horizontal C/D ratio 0.507 < 0.0001 0.31 < 0.0001
Vertical C/D ratio 0.516 < 0.0001 0.37 < 0.0001
C/D area ratio 0.504 < 0.0001 2.49 < 0.0001
Superior RNFL thickness (mm) 0.156 0.008 0.09 0.779
Inferior RNFL thickness (mm) 0.108 0.066
Average RNFL thickness (mm) 0.157 0.007 0.14 < 0.001
R2 0.825
Adjusted R2 0.821
*Multivariate linear regression analysis.
b indicates regression coecients; OCT, optical coherence tomography; RNFL, retinal nerve ber layer.

Therefore, large discs may be more susceptible to pressure 3. Garway-Heath DF, Ruben ST, Viswanathan A, et al. Vertical
damage as per Laplace law.34 However, there is no large cup/disc ratio in relation to optic disc size: its value in the
randomized study on this issue, and further investigation is assessment of the glaucoma suspect. Br J Ophthalmol.
needed. Burk et al35 concluded that statistically normal IOP 1998;82:11181124.
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detection and follow-up to monitor glaucoma pro- optical coherence tomography. Eur J Ophthalmol. 2005;
gression.36 One of the major limitations of our study was 15:486492.
that we used time domain OCT instead of the new-gen- 6. Paunescu LA, Schuman JS, Price LL, et al. Reproducibility of
eration spectral domain OCT. Imaging with spectral nerve fiber thickness, macular thickness, and optic nerve head
measurements using Stratus OCT. Invest Ophthalmol Vis Sci.
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structures of the ONH like Bruch membrane (BM) and its 7. Kanamori A, Nakamura M, Escano MF, et al. Evaluation of
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