Normal Tension Glaucoma:

Who Needs Neuroimaging?

Julie Falardeau, MD, FRCSC
Casey Eye Institute
Devers Eye Institute
Portland, Oregon

Background

Normal tension glaucoma (NTG) is

characterized by:

Cupping of the optic nerve head

Visual field loss
Intraocular pressure (IOP) 21 mmHg
No obvious or apparent cause for these
changes

Nonglaucomatous optic
disc cupping

Following an ischemic optic neuropathy

(anterior or posterior - AION or PION)

Temporal arteritis

Quigley and Anderson found that 50% of patient with

arteritic -AION developed cupping, compared to 10%
after non-arteritic-AION

Severe hypotensive/hypovolemic event

Demyelinating optic neuritis

Quigley et Anderson. Cupping of the optic disc in ischemic optic

neuropathy. Trans Am Acad Ophthalmol Otol. 1977;83:755-762

Nonglaucomatous optic
disc cupping

Hereditary optic neuropathy

Lebers hereditary optic neuropathy

Autosomal dominant optic atrophy

Traumatic optic neuropathy

Infectious

Temporal disc excavation and pallor

Syphilis

Toxic

Methanol

Nonglaucomatous optic
disc cupping

Compressive lesion

Meningioma
Aneurysm
Dolichoectasia of the internal carotid
artery
Suprasellar mass

Glaucomatous VS
Nonglaucomatous cupping

Distinguishing glaucomatous from nonglaucomatous disc cupping is often

difficult

A detailed history is crucial

Presence of neurological symptoms

Chronicity and pattern of visual loss
History of head trauma
History of shock or severe low blood pressure

Glaucomatous VS
Nonglaucomatous cupping

Systematic approach recommended

Demographic characteristics
Visual acuity
Optic disc characteristics
Visual field findings

Demographic characteristics

A family history of glaucoma among

first degree relatives is highly
specific (96%) for glaucomatous
cupping
Age under 50 years is 93% specific
for nonglaucomatous cupping

Greenfield et al. The cupped disc: Who needs neuroimaging?

Ophthalmology. 1998;105:1866-1874

Visual Acuity

Patients with nonglaucomatous cupping

have significantly lower levels of visual
acuity than patients with glaucoma

Trobe et al found all 20 patients with compressive

optic neuropathy had loss of central vision
Greenfield et al found visual acuity < 20/40 to be
77% specific for nonglaucomatous cupping
Hupp et al described sparing of central acuity in 3
of 6 eyes with compressive lesions

Optic disc characteristics

Glaucomatous cupping:

Vertical elongation
Cupping more than pallor
Greater frequency of peripapillary atrophy
Disc hemorrhage

Highly specific

Nonglaucomatous cupping:

Pallor of the neuroretinal rim

Highly specific sign but relatively insensitive

The absence of disc pallor does not exclude compressive
lesions

Optic nerve appearance

Baring of the circumlinear vessels

and temporal saucerization

Common in glaucoma
Can also be seen in compressive optic
neuropathy

Kupersmith and Krohn. Cupping of the optic disc with compressive

lesions of the anterior visual pathway. Ann Ophthalmol 1984;16:948-53

Visual field findings

Glaucoma

Nerve-fiber-layer (arcuate) defects, bordering horizontal

midline

Arcuate scotoma
Nasal step

Compressive lesion

Central scotoma
Temporal hemianopia
Incongruous hemianopia respecting the vertical meridian
Glaucomatous types of VF defects can occur

Humphrey perimetry in patients

with suprasellar mass

Ahmed et al. Neuroradiologic screening in normal-pressure glaucoma:

study results and literature review. J Glaucoma. 2002 Aug;11(4):279-86

NTG and Neuroimaging

Some physicians routinely obtain

neuroimaging studies in patients
with NTG
Cost-to-benefit ratio of performing
such studies is unknown

NTG and Neuroimaging

Ahmed et al found that routine

neuroimaging of NTG patients was
cost-effective

6.5% of 62 consecutive patients with NTG had

clinically significant intracranial lesions
associated with optic neuropathy and visual
field loss typical of glaucoma

Ahmed et al. Neuroradiologic screening in normal-pressure glaucoma:

study results and literature review. J Glaucoma. 2002 Aug;11(4):279-86

NTG and Neuroimaging

Steward and Reid reported

compressive lesions in 2 of 53
patients (3.8%) referred for evaluation
of NTG
In the series by Greenfield et al, none
of the patients diagnosed with
glaucoma had neuroradiological
evidence of compressive lesion

NTG and Neuroimaging

In Bianchi-Marzoli at als series of 29

patients with cupping from unilateral
compressive lesion, only one had cupping
and field loss as an isolated manifestation
of their optic neuropathy
All others had:

Reduced acuity
Decreased color vision
RAPD

Bianchi-Marzoli et al. Quantitative analysis of optic disc cupping in compressive optic

neuropathy. Ophthalmology 1995;102:436-440.

NTG: Who needs neuroimaging?

Presence of headache or other neurological

symptoms

Symptoms of decreased vision, fluctuating

vision, or visual field loss

Atypical visual field for glaucoma

Visual field defect respecting the vertical meridian

Junctional scotoma
Central or cecocentral scotoma

NTG: Who needs neuroimaging?

Atypical rate of progression of VF

loss

Monocular or binocular

Pallor > cupping

Asymmetric cupping

Especially if progressive changes while

IOP remains symmetric and well
controlled

NTG: Who needs neuroimaging?

Most likely NTG if:

Vertical elongation of the cupping

Presence of notch
Presence of splinter hemorrhage
Family history of glaucoma