Share this article on:

Optic Nerve Cupping and the Neuro-Ophthalmologist

Fraser, Clare L. MBBS, MMed, FRANZCO; White, Andrew J. R. MBBS, PhD, FRANZCO; Plant, Gordon T. MD, FRCP, FRCOphth; Martin, Keith R. DM, MRCP, FRCOphth

Section Editor(s): Liu, Grant T. MD; Kardon, Randy H. MD, PhD

doi: 10.1097/WON.0000000000000080
State-of-the-Art Review
Japanese Abstract

Background: While glaucoma is the most common cause of optic disc cupping, it can also be seen in a number of congenital and acquired optic neuropathies. It behooves both glaucoma and neuro-ophthalmic specialists to be able to differentiate glaucoma from neurological conditions, which give a similar ophthalmoscopic appearance to the optic disc.

Evidence Acquisition: This review is a combination of the authors' clinical experience from tertiary glaucoma and neuro-ophthalmology referral centers, combined with a literature review using PubMed.

Results: Even for experienced observers, differentiation between glaucomatous and nonglaucomatous cupping can be difficult. In the majority of cases, this distinction can be made following a careful clinical examination combined with a variety of imaging techniques. Possible mechanisms, which lead to changes in optic disc morphology, are reviewed.

Conclusions: Differentiating glaucomatous from nonglaucomatous optic disc cupping can be a formidable challenge for the clinician. Examination of the patient combined with imaging of the retinal nerve fiber layer and optic disc topography provides a basis to resolve this clinical conundrum.

Save Sight Institute (CLF, AJRW), University of Sydney, Sydney, Australia; Westmead Millennium Institute (AJRW), University of Sydney, Sydney, Australia; Moorfields Eye Hospital (GTP), London, United Kingdom; and Cambridge University Teaching Hospitals NHS Foundation Trust (KRM), Cambridge, United Kingdom.

Address correspondence to Clare L. Fraser, MBBS, MMed, FRANZCO, Save Sight Institute, 8 Macquarie Street, Sydney, NSW 2010, Australia; E-mail:

While pathological optic disc cupping is most commonly associated with glaucoma, it is not pathognomonic. Trobe et al (1) reported a tendency to overdiagnose glaucoma in the presence of optic disc cupping based on fundus photographs. The Optic Disc Assessment Project found that differentiating glaucoma from genetic optic neuropathies based on disc assessment alone is difficult, concluding that a careful history and clinical examination are required for accurate diagnosis (2).

Differentiating glaucomatous from nonglaucomatous optic disc cupping is the focus of this review. This requires an understanding of the normal anatomical relationships of the optic nerve head (ONH) and potential pathophysiological mechanisms that lead to configurational changes of the optic disc.

Back to Top | Article Outline


The ONH consists of 3 layers (3). The first is a continuation of the retinal nerve fiber layer (RNFL) (Fig. 1A). The second is the prelaminar layer, with loose trabecular glial tissue containing capillaries and retinal nerve fibers. Progressive loss of prelaminar neural tissues results in increased optic cup depth and width, classified as “prelaminar cupping” (Fig. 1B). The third layer lies within the scleral portion of the lamina cribrosa. Axon bundles pass though a meshwork of connective tissue covered in astrocytes and containing capillaries (4). The short posterior ciliary arteries are the sole vascular supply via a capillary network and the peripapillary choroid. The laminar extracellular matrix provides structural support and allows passage of nutritional support for the axons (5). Loss of support of deeper structures leads to posterior displacement of the lamina cribrosa and excavation beneath the anterior scleral canal (4). This has been designated “laminar cupping” (Fig. 1C). Therefore, cupping is the result not only of axonal loss but also of supportive glial tissue. Extensive axonal loss with preservation of glial structures results in a pale optic disc without cupping.

Back to Top | Article Outline

Normal Reference Values

Normal reference ranges for optic disc morphological parameters have been established in different ethnic groups (6). On clinical examination and using optical coherence tomography (OCT), the horizontal disc diameter and the disc area are significantly smaller in Caucasians and Hispanics compared to populations from South Asia, Southeast Asia, and Africa (7,8). South Asian and Hispanic participants have the thickest global RNFL measurements. Statistically significant differences have been demonstrated among racial groups for all OCT ONH and RNFL parameters except rim area (9).

The mean horizontal cup-to-disc ratio (CDR) in the Caucasian North American population is 0.25–0.49, compared to 0.35–0.66 in African-Americans (10,11). In a predominantly Caucasian European population, mean vertical CDR was 0.49 and horizontal CDR was 0.4 (12). Asymmetry of the optic disc cup diameter is <0.1 in 92% of a normal North American population (13).

Back to Top | Article Outline


Congenital Optic Disc Cupping

There are a variety of optic disc anomalies that are characterized by significant cupping. They are summarized in Table 1 and Figure 2.

Back to Top | Article Outline

Acquired Optic Disc Cupping

While glaucoma is the most frequent cause of acquired optic disc cupping, a variety of ischemic, toxic, compressive, and genetic causes can lead to optic disc excavation. Differentiating glaucomatous optic neuropathy (GON) and nonglaucomatous cupping (NGC) requires careful clinical examination and use of various imaging techniques.

Back to Top | Article Outline

Visual Acuity and Color Vision

Loss of visual acuity and color vision will occur in advanced glaucoma but usually occur early in other optic neuropathies. However, both acuity and color vision can be affected at any stage in GON if the patient develops a temporal RNFL bundle defect with a corresponding macular arcuate scotoma splitting fixation across the horizontal meridian (14). The Amsler grid and automated visual fields of the central 10° can help detect macular involvement. A particularly confusing situation for the clinician is preserved acuity with poor performance on Ishihara plates in early glaucoma. Such patients are often referred to neuro-ophthalmology. With a preserved central island of visual field, visual acuity is retained, but the paramacular field required to read Ishihara plates is lost as a result of macular arcuate defects.

Decreased visual acuity in NGC is caused by a scotoma centered on the fovea or splitting the central visual field vertically. Anterior ischemic optic neuropathy (AION) can split fixation horizontally. The altitudinal visual field defect (VFD) in AION typically involves a number of RNFL bundles subserving more than an isolated arcuate area (15). Loss of acuity out of proportion to disc cupping has been reported in NGC (16), with a reduction in acuity <20/40 having a 77% sensitivity for NGC (17).

Color vision loss in optic neuropathy classically causes a red-green deficiency, as described by Kollner in 1912 (18). Performance on Ishihara plates is a useful screening test in discriminating early glaucoma from other causes of optic neuropathy. However, if visual acuity is preserved, as is often the case in glaucoma, the color vision defect is predominantly blue yellow (18,19). Deficiencies in color vision testing (pseudoisochromatic plates, Hardy-Rand-Rittler, Farnsworth-Munsell) greater than expected from acuity or visual field loss should lead to suspicion of NGC (Table 2).

Macular and cone dystrophies can present with color vision deficits and temporal optic disc pallor and are best diagnosed with a full-field, multifocal, and pattern electroretinography (20).

Back to Top | Article Outline

Pupillary Findings

Estimates of the presence of a relative afferent pupillary defect (RAPD) in GON range between 9% and 82% (21). The magnitude of a RAPD is proportionate to the difference in visual field loss between the 2 eyes (22). A RAPD is detectable when RNFL thickness is decreased to 83% of that in the fellow eye (23). Discovery of a RAPD has been shown to be highly specific (>90%) for detecting glaucoma within a normal population (21). Although a RAPD cannot differentiate among optic neuropathies, the degree of RAPD may be important. The simple rule is that optic neuropathies that tend to be symmetrical will not show a RAPD: these are principally glaucoma, papilledema, nutritional, toxic, and genetically determined optic neuropathies. Neuroimaging should be considered if a large RAPD is present, unless there is highly asymmetric field loss, which is clearly glaucomatous (Table 2).

Back to Top | Article Outline

Glaucomatous Optic Disc Assessment

Focal loss of the neuroretinal rim (NRR) is reported to be 87% specific for glaucoma (1,24) and is associated with progressive disease (25,26). Other GON characteristics include normal color of the remaining NRR, vertical cup elongation, splinter hemorrhages (27), and positional changes of the optic disc vasculature (Fig. 3).

A greater proportion of glaucomatous optic disc cupping is classified as “deep” compared to NGC (2). Conformational changes within the neural canal and posterior bowing of the lamina cribrosa explain this appearance of deep cups (28) (Fig. 1C).

In an ocular hypertensive cohort, the strongest predictors of glaucomatous visual field loss were vertical CDR corrected for disc size, total NRR area, rim-to-disc area ratio, and CDR corrected for disc size (29). Tatham et al (30) showed a nonlinear relationship between estimates of retinal ganglion cell (RGC) number and CDR. Therefore, in glaucoma patients with a physiologically large CDR, even a relatively small change in CDR may be associated with a large loss of RGCs.

Peripapillary atrophy (PPA) is divided into a central (beta) zone with sclera and large choroidal vessels visible on ophthalmoscopy, and a peripheral (alpha) zone with irregular pigmentation. The size, shape, and frequency of alpha and beta PPA do not differ significantly between normal eyes and those with optic atrophy (31). However, in glaucoma, PPA is thought to be caused by ischemia (32), as the posterior ciliary arteries supply the optic disc and this region as well. While beta zone atrophy is often enlarged in glaucoma (33–35) and predictive of progression (36,37), it is not thought as essential in establishing the diagnosis of GON. However, on recent histological studies in cadaveric eyes, it was found that a more rigidly defined beta zone was strongly correlated with glaucoma (38). Progressive enlargement of beta zone atrophy is not seen in NGC (39). The PPA seen in myopia, tilted discs, and optic disc hypoplasia does not have a region of choroid interposed between the retina and the sclera, as in GON (40).

Features that do not help distinguish GON from NGC are the intraocular pressure (IOP), presence of laminar dots, and thinning of the NRR without complete obliteration (1).

Back to Top | Article Outline

Nonglaucomatous Optic Disc Assessment

Indicators and specificity (shown in brackets) of NGC reported in the literature are reduction in acuity <20/40 (77%), pallor of remaining rim (94%), patients presenting age <50 years (93%), and visual fields obeying vertical meridian (81%) (1,17). Other features typical of NGC include visual field loss with minimal cupping and retinal vasculature changes (41) (Fig. 3). In addition, a normal disc in the fellow eye with an abnormal visual field should raise concerns of chiasmal or retrochiasmal pathology. NGC has been reported in a variety of optic neuropathies including compressive (16,42–44), ischemic (45), inflammatory, and traumatic (46) neuropathies.

Compressive lesions include meningioma (42), pituitary adenoma (47), craniopharyngioma (48), and internal carotid artery aneurysm (48). Compression of the intracranial portions of the optic nerves by the supraclinoid internal carotid artery has also been reported to cause NGC (49). In compressive NGC, the median CDR asymmetry in patients was only 0.13 but significantly higher than controls who had 0.04 asymmetry (48).

Optic disc cupping may be the result of arteritic anterior ischemic optic neuropathy (A-AION) secondary to giant cell arteritis (45,50). NRR thinning and enlargement of the CDR in A-AION is similar to glaucoma, supporting the vascular theory of GON (50–53). However, other reports in patients with GON have demonstrated more marked posterior excavation and large cups with less rim volume than in those with AION (both A-AION and nonarteritic AION [NA-AION]), after adjusting for the amount of RGC loss (15).

Methanol poisoning produces profound RGC loss leading to blindness with pale, cupped optic discs (54) (Fig. 4). Loss of NRR and ONH excavation have been described in long-standing autosomal dominant optic atrophy (ADOA) (55) and Leber hereditary optic neuropathy (LHON) (2,56). Cases have been misdiagnosed as glaucoma (57). In one study, 48%–89% of ADOA patients were found to have significant NRR thinning and CDR >0.5 (58), but another found all to have NRR pallor, either temporally (52%) or globally (48%) (59). Clinical features, which should lead to genetic testing, are outlined in Table 3.

Back to Top | Article Outline


Visual Fields

Glaucomatous VFDs follow 4 major patterns: an isolated scotoma, an arcuate scotoma, nasal step (if there are both superior and inferior arcuate defects), and generalized depression (60). VFDs of NGC are more often central. Progressive glaucomatous field loss will be reflected in the changes seen at the ONH and RNFL measurements. The anatomical correlation between visual fields, RNFL trajectory, and position on the optic disc has been well described (61–63). Several groups have mapped OCT optic disc sectors with VFDs on standard automated perimetry (SAP) (64,65). There is a simple linear relationship between RNFL in superior and inferior disc sectors and corresponding arcuate SAP function (decibel units) in GON, as there is in AION (61).

Glaucoma patients are almost always tested on SAP 24-2 protocols, with central test points spaced 6° apart, thereby underestimating any macular arcuate changes. In patients with normal-tension glaucoma, VFDs often are more localized, closer to fixation, and in the superior hemifield (inferior macula) (66). The optic disc region, the most vulnerable to glaucoma damage, is the border between the temporal and inferior quadrants (67), producing macular field defects that are typically described as an arcuate “comma” or a “pistol barrel scotoma” (67,68).

The least vulnerable macular region to GON is the papillomacular bundle between the nasal fovea and the temporal optic disc (69). In contrast, the papillomacular bundle is particularly susceptible in other optic neuropathies, although the explanation for this vulnerability is unknown. Therefore, the involvement of the “central isle” of the visual field on Amsler, 10-2 SAP, or kinetic perimetry should raise the suspicion of a neurological process.

VFDs that respect the vertical meridian should be considered neurological until proven otherwise. Bitemporal visual field changes place the pathology at the optic chiasm. Homonymous defects (complete, incomplete, incongruous, and sectoral defects) are all seen with retrochiasmal pathology. An algorithm has been proposed to discriminate vertical neurological visual field abnormalities from horizontal glaucoma defects (70). However, SAP protocols can give the false appearance of VFDs respecting a vertical (or horizontal) meridian because of the sparsity of the points tested. Common mimics are temporal wedge defects extending from the blind spot as seen in optic nerve hypoplasia and acute zonal occult outer retinopathy. Kinetic visual fields are essential to more accurately assess the relationship to the horizontal and vertical meridians and to show the peripheral extent of a scotoma. SAP protocols for central fields have an extension nasally to facilitate the identification of a nasal step, but coverage temporal to the blind spot is minimal.

Back to Top | Article Outline

Retinal Nerve Fiber Layer Imaging

The confocal scanning laser ophthalmoscope (Heidelberg Retinal Tomograph [HRT]; Heidelberg Engineering, Heidelberg, Germany) provides quantitative measures of optic disc topography with reconstruction of a 3-dimensional image of the optic disc. OCT provides cross-sectional measures of RNFL thickness with the use of interferometry, using time-domain (TD-OCT) or spectral-domain (SD-OCT) methodology. Scanning laser polarimetry technology (GDx; Carl Zeiss Meditec, Dublin, CA) also provides a quantitative measure of the RNFL thickness. Using these instruments, there is a substantial overlap in structural measurements of the normal optic disc and the optic disc in GON and in NGC. This limits their diagnostic capability.

Back to Top | Article Outline


Optic nerve and RNFL imaging have allowed earlier detection of glaucoma (71). When a sloping cup is present, OCT can quantify the disc changes better than clinical observation alone. This is particularly true for comprehensive ophthalmologists; however, optic disc assessment by a glaucoma specialist is still more reliable than either (72). Neither OCT nor GDx is useful in distinguishing GON from NGC in highly myopic individuals (73). Thinning of the lamina cribrosa is present in myopic eyes with no other pathology, and refractive error leads to high artifact levels in image acquisition.

Enhanced depth imaging OCT can been used to evaluate the types of PPA to help differentiate GON and NGC. The beta-zone atrophy, located next to the optic disc, is associated with GON (74). However, gamma-zone atrophy, defined as the region between the temporal disc margin to the beginning of Bruch's membrane, was not associated with GON and more likely a sign of NGC.

Back to Top | Article Outline

Nonglaucomatous Optic Disc Cupping

Gupta et al (75) used OCT to evaluate GON vs NGC (optic neuritis and NA-AION). In cases matched for CDR or average RNFL thickness, it was found that patients with NGC had a lower mean RNFL in the nasal and temporal quadrants (76). The pattern of RNFL thinning in ischemic optic neuropathy and ONH drusen is more likely to mimic the pattern of glaucomatous change caused by the predilection for the superior and inferior quadrants (77).

Using HRT, glaucoma patients have been shown to have less disc rim tissue, a greater cup volume, and a deeper optic cup than AION (arteritic and nonarteritic) (15). However, only in glaucoma were the laminar connective tissues damaged, resulting in retroplacement of the cup. These findings were confirmed on OCT (78) with glaucoma patients having greater RNFL thinning overall. However, in the affected hemifields, RNFL thickness was not significantly different.

With HRT, 73% of LHON patients were misclassified as having glaucoma (79). In the acute phase of LHON, RNFL thickness initially increases in the temporal and inferior quadrants, progressing to involve superior and nasal quadrants within 3 months (80). By 9 months, there is a significant reduction in RNFL thickness in all but the nasal quadrants. These changes were of greater magnitude in patients with the 11,778 mutations than the 14,484 mutations (81).

Ninety percent of a group of ADOA patients had a statistically significant reduction in temporal RNFL thickness (82). Other studies showed a reduction in all quadrants with preferential involvement of temporal and inferior sectors (76) and relative sparing of the nasal region (83). Patients with a severe disease OPA1 variant mutation, having additional symptoms such as deafness, ataxia, and myopathy, had more pronounced RNFL thinning. Other causes of NGC also have a predilection for temporal RNFL loss, including ethambutol (84,85), syphilis (86), and toxic optic neuropathies (87). Eyes affected by demyelinating optic neuritis also have a reduction in RNFL thickness predominantly in the temporal quadrant involving the papillomacular bundle (88). These changes become evident 3–6 months after the acute episode (89). In neuromyelitis optica, the superior and inferior quadrants typically are more severely affected (90).

Caution is needed when diagnosing GON on OCT in patients following cerebral infarction or other damage to the postchiasmal visual pathways. This causes RNFL thinning in a “band” pattern in the eye with the temporal hemianopia and thinning of the superior and inferior arcuate bundles in the eye with the nasal hemianopia (91). The degree of change depends on the time since stroke, location of the damage (e.g., optic tract involvement will give greater loss), and the extent of the VFD (92).

Back to Top | Article Outline

Macular Imaging

Since a large portion of macular thickness is composed of RGCs and the inner plexiform layer, the macula also loses volume as glaucomatous damage progresses. Previous studies concluded that macular segmentation to measure these layers was less accurate than RNFL thickness measured by TD-OCT (93,94). However, with newer algorithms (67), macular analysis may become more important in diagnostic decisions.

Using frequency-domain OCT to examine the macular RGC layer plus the inner plexiform layer (RGC+), GON can be differentiated from nonglaucomatous changes (67). In GON, there is arcuate thinning of the inferior retina associated with a narrow region of RNFL thinning at the border of temporal and inferior disc quadrants. Normal tension glaucoma (NTG) patients are the more likely to be referred to neuro-ophthalmology with central VFDs than those with elevated IOP, making these macular scans invaluable (95). In patients with A-AION who have outer retinal ischemia secondary to occlusion of posterior ciliary arteries, there is disruption of the inner-outer photoreceptor segment line on SD-OCT (96).

Back to Top | Article Outline

Multifocal Visual Evoked Potentials

Although multifocal visual evoked potential (mfVEP) testing has been described for many years (97,98), it is not commonly used in clinical practice. Caprioli et al (95) described the use of mfVEP to demonstrate objective VFDs in patients with disc changes but no abnormalities on SAP. In addition, the mfVEP was able to confirm central arcuate scotoma in normotensive glaucoma patients in 44% of eyes with normal SAP. This finding is because of the mfVEP protocols having greater representation of the central field than the 24-2 SAP.

The mfVEP can give additional information about visual pathways, with latency analysis showing abnormalities in compressive and inflammatory optic neuropathies (99,100). In comparison, relatively few glaucomatous eyes have latency delays (101). The domination of the “full-field” visual evoked potential by the macula severely limits its use in the diagnosis of glaucoma.

Back to Top | Article Outline

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) studies have shown morphological changes in the visual pathways of glaucoma patients, including loss of chiasmal height and reduced optic nerve cross-sectional area, which correlate with OCT RNFL thickness and VFDs (102–104). However, MRI optic nerve changes are seen with increasing age and are not specific for glaucoma (104). Glaucoma-related changes are seen in the lateral geniculate nucleus, visual cortex, and optic radiations (105,106). By analyzing the diffusion tensor imaging (DTI) features of the optic radiation, distinction between primary open angle glaucoma, NTG and controls, can be made with >90% accuracy (107). Optic nerve DTI measures correlate with changes in RNFL on HRT and glaucoma staging (108). However, reduced optic nerve volume and anisotropy on DTI also have been reported in patients with optic neuritis (109) and LHON (110). Whether MRI is more suitable diagnostically than OCT or SAP in some patients and whether these techniques can distinguish between different causes of ONH cupping remain to be seen. In NTG, diffuse cerebral ischemic changes are detectable on MRI, indicating that GON may be a manifestation of more widespread cerebrovascular disease (111,112).

Using standard MRI protocols, the optic nerve usually has a normal appearance in the acute phase of ischemic optic neuropathy. However, there are increasing reports of the detection of optic nerve ischemia with diffusion-weighted imaging (113). In comparison to optic neuritis, only 16% of NA-AION had abnormal MRIs, with increased short T1 inversion recovery or T2 signal and nerve enhancement (114). The acute T2 changes with increased intensity within the optic nerve are the result of the breakdown of the blood-brain barrier in optic neuritis. The chronic T2 hyperintensity in the affected portion of the anterior visual pathway occurs in all forms of optic neuropathy with Walleran degeneration (optic neuritis, LHON, and AION) (115). These T2 changes have not been reported in GON, which may be because the axonal loss in GON is gradual and incremental. In ADOA, there is significant thinning of the optic nerves on MRI (116). However, even in ADOA patients with extraocular neurological features, no evidence of demyelination or structural abnormalities has been documented on MRI (117). In contrast, white matter changes with a multiple-sclerosis-like phenotype are seen in some cases of LHON (118,119).

Back to Top | Article Outline


Anatomical and experimental research regarding the basis of optic disc cupping is primarily found in the glaucoma literature. These theories involve a pathophysiological mechanism at the level of the lamina cribrosa.

Back to Top | Article Outline


The biomechanical paradigm of glaucomatous ONH damage provides an explanation as to how the pressure-related stress of increased IOP and the local deforming strain within the load-bearing tissues of ONH influence the physiology of all tissues within the ONH. This theory assumes that the ONH astrocytes and glia support both the lamina cribrosa extracellular matrix and RGC axons (4).

How the ONH connective tissues respond to biomechanical stress is determined by posterior scleral compliance and rigidity (120). However, it is difficult to separate the mechanical forces leading to laminar deformation from other ONH effects caused by IOP-related stress (4). Differences in collagen genes alter the mechanical behavior of the sclera, reducing the RGC loss following chronic IOP elevation experimentally (121). However, regional differences in peripapillary fiber anisotropy seen between nonglaucoma and glaucoma eyes may represent either adaptive change in response to elevated IOP or baseline structural properties associated with predisposition to GON (122).

Back to Top | Article Outline


The vascular theory (123) emphasizes the potential importance of IOP elevation on blood flow at the ONH (124). Autoregulation is a process whereby blood flow is kept relatively constant, despite changes in the ocular perfusion pressure. However, induced levels of high IOP affect autoregulation mechanisms in the choroid (125). Whether this also is true for ONH blood flow remains controversial. There is evidence that glaucoma patients show abnormal autoregulation, although the reasons for this remain largely unknown (126). A reduction in IOP may improve the regulatory capacity of the optic disc vasculature, thereby reducing the likelihood of ischemic periods and progressive GON (125).

Back to Top | Article Outline

Cerebrospinal Fluid Pressure Gradient

The intraocular to intracranial pressure (ICP) gradient may cause changes in ONH structure and function (127). Cerebrospinal fluid (CSF) surrounds the optic nerve to the level of the lamina cribrosa, thereby directly influencing the translaminar pressure difference and laminar position. The average posterior force from IOP on the lamina is 1 mm Hg per 100 μm (assuming a mean IOP of 16 mm Hg, mean ICP of 12 mm Hg, and a lamina cribrosa thickness of 450 μm) (128). As the lamina becomes increasingly weakened and thinned with glaucoma, this posterior force is spread across a smaller tissue volume, and this may explain why continued optic nerve damage occurs even with IOP at “normal” levels (129).

Mean lumbar CSF opening pressure in NTG is 3–4 mm Hg lower than in controls (130–132). Interestingly, in large population studies, the difference between IOP measurement in controls and progressive primary open angle glaucoma is 4 mm Hg higher. In both situations, the difference in translaminar pressure gradient between the normal and glaucoma patients is the same. Even this small difference in CSF pressure may be significant in the pathogenesis of GON. In addition, Ren et al (133) found a statistically significant difference in CSF pressure in 17 ocular hypertensive patients (16.0 ± 2.5 mm Hg) compared to 71 control subjects (12.9 ± 1.9 mm Hg). The authors speculate that this finding might explain why ocular hypertension patients do not develop progressive optic disc changes.

Back to Top | Article Outline


RGCs are particularly sensitive to mitochondrial dysfunction, which is recognized as the underlying cause of optic neuropathy in LHON and ADOA (134). LHON is caused by mitochondrial DNA mutations (135), and increasingly, mitochondrial changes are thought to contribute primary open angle glaucoma pathogenesis. This could explain the morphological similarities in the optic discs of LHON and GON (2).

ADOA is the most common inherited nonglaucomatous optic neuropathy (59) and has been linked to the OPA1 gene on chromosome 3q (136). This gene encodes a mitochondrial dynamin–related protein and plays a role in the maintenance of mitochondrial cristae (134). Interestingly, OPA1 polymorphisms have been found in patients with NTG (137). Although results are controversial, a recent meta-analysis showed that some OPA1 variants may affect individual susceptibility (138). Data suggest that OPA1 deficiency impairs oxidative phosphorylation efficiency, but compensation through increases in the distal complexes of the respiratory chain may preserve mitochondrial adenosine triphosphate (ATP) production in patients who maintain normal vision (139). This raises the possibility that NTG is also an inherited optic neuropathy with similar mitochondrial dysfunction to ADOA but a different phenotypic expression (137,140).

An increase in free radical production is an early event related to increased IOP in experimental models of glaucoma (141,142). Generation of reactive oxygen species appears to be a NADPH related event that can be modulated to reduce cell death in experimental models of glaucoma (143,144).

Further analysis of mitochondrial dysfunction in glaucoma patients compared to controls has confirmed a specific reduction in ATP synthesis from mitochondrial oxidative phosphorylation (145). The RGCs are particularly vulnerable to stressors (i.e., elevated IOP) because of the very high bioenergetic demand created propagating action potentials and driving axoplasmic flow within unmyelinated axons found in the retina.

Superoxide generation is associated with axonal injury in other experimental models of optic neuropathy and can likewise be modulated (146–148). Recent attempts at neuroprotective therapies for glaucoma have, at least in part, focused on altering mitochondrial oxidative phosphorylation with some success in vitro (142,149).

Back to Top | Article Outline


In evaluating a patient with optic disc cupping, neuro-ophthalmic pathology should be considered when: 1) color vision loss is disproportionate to reduction in visual acuity and cannot be explained by the presence of macular arcuates; 2) VFDs do not correlate with optic disc changes; 3) vertically aligned VFDs are present; 4) there is a marked RAPD; and 5) the surviving neural rim of the optic disc shows pallor. Fundus imaging techniques can provide additional information in making the clinical decision between glaucomatous cupping and NGC, while neuroimaging provides information regarding the cerebral changes seen with GON and other optic neuropathies.

Back to Top | Article Outline


1. Trobe JD, Glaser JS, Cassady J, Herschler J, Anderson DR. Nonglaucomatous excavation of the optic disc. Arch Ophthalmol. 1980;98:1046–1050.
2. O'Neill EC, Danesh-Meyer HV, Kong GX, Hewitt AW, Coote MA, Mackey DA, Crowston JG. Optic disc evaluation in optic neuropathies: the optic disc assessment project. Ophthalmology. 2011;118:964–970.
3. Burgoyne CF, Downs JC. Premise and prediction-how optic nerve head biomechanics underlies the susceptibility and clinical behavior of the aged optic nerve head. J Glaucoma. 2008;17:318–328.
4. Burgoyne CF. A biomechanical paradigm for axonal insult within the optic nerve head in aging and glaucoma. Exp Eye Res. 2011;93:120–132.
5. Anderson DR. Ultrastructure of human and monkey lamina cribrosa and optic nerve head. Arch Ophthalmol. 1969;82:800–814.
6. Quigley HA, Brown AE, Morrison JD, Drance SM. The size and shape of the optic disc in normal human eyes. Arch Ophthalmol. 1990;108:51–57.
7. Mansour AM. Racial variation of optic disc size. Ophthalmic Res. 1991;23:67–72.
8. Girkin CA, McGwin G Jr, Sinai MJ, Sekhar GC, Fingeret M, Wollstein G, Varma R, Greenfield D, Liebmann J, Araie M, Tomita G, Maeda N, Garway-Heath DF. Variation in optic nerve and macular structure with age and race with spectral-domain optical coherence tomography. Ophthalmology. 2011;118:2403–2408.
9. Knight OJ, Girkin CA, Budenz DL, Durbin MK, Feuer WJ; Cirrus OCTNDSG. Effect of race, age, and axial length on optic nerve head parameters and retinal nerve fiber layer thickness measured by Cirrus HD-OCT. Arch Ophthalmol. 2012;130:312–318.
10. Beck RW, Messner DK, Musch DC, Martonyi CL, Lichter PR. Is there a racial difference in physiologic cup size? Ophthalmology. 1985;92:873–876.
11. Varma R, Tielsch JM, Quigley HA, Hilton SC, Katz J, Spaeth GL, Sommer A. Race-, age-, gender-, and refractive error-related differences in the normal optic disc. Arch Ophthalmol. 1994;112:1068–1076.
12. Ramrattan RS, Wolfs RC, Jonas JB, Hofman A, de Jong PT. Determinants of optic disc characteristics in a general population: The Rotterdam Study. Ophthalmology. 1999;106:1588–1596.
13. Armaly MF. Genetic determination of cup/disc ratio of the optic nerve. Arch Ophthalmol. 1967;78:35–43.
14. Pickett JE, Terry SA, O'Connor PS, O'Hara M. Early loss of central visual acuity in glaucoma. Ophthalmology. 1985;92:891–896.
15. Danesh-Meyer HV, Boland MV, Savino PJ, Miller NR, Subramanian PS, Girkin CA, Quigley HA. Optic disc morphology in open-angle glaucoma compared with anterior ischemic optic neuropathies. Invest Ophthalmol Vis Sci. 2010;51:2003–2010.
16. Kupersmith MJ, Krohn D. Cupping of the optic disc with compressive lesions of the anterior visual pathway. Ann Ophthalmol. 1984;16:948–953.
17. Greenfield DS, Siatkowski RM, Glaser JS, Schatz NJ, Parrish RK II. The cupped disc. Who needs neuroimaging? Ophthalmology. 1998;105:1866–1874.
18. Pacheco-Cutillas M, Edgar DF, Sahraie A. Acquired colour vision defects in glaucoma-their detection and clinical significance. Br J Ophthalmol. 1999;83:1396–1402.
19. Drance SM, Lakowski R, Schulzer M, Douglas GR. Acquired color vision changes in glaucoma. Use of 100-hue test and Pickford anomaloscope as predictors of glaucomatous field change. Arch Ophthalmol. 1981;99:829–831.
20. Holder GE. Pattern electroretinography (PERG) and an integrated approach to visual pathway diagnosis. Prog Retin Eye Res. 2001;20:531–561.
21. Chang DS, Xu L, Boland MV, Friedman DS. Accuracy of pupil assessment for the detection of glaucoma: a systematic review and meta-analysis. Ophthalmology. 2013. [published ahead of print June 25, 2013] doi: 10.1016/j.ophtha.2013.04.012.
22. Schiefer U, Dietzsch J, Dietz K, Wilhelm B, Bruckmann A, Wilhelm H, Kitiratschky V, Januschowski K. Associating the magnitude of relative afferent pupillary defect (RAPD) with visual field indices in glaucoma patients. Br J Ophthalmol. 2012;96:629–633.
23. Chew SS, Cunnningham WJ, Gamble GD, Danesh-Meyer HV. Retinal nerve fiber layer loss in glaucoma patients with a relative afferent pupillary defect. Invest Ophthalmol Vis Sci. 2010;51:5049–5053.
24. Healey PR, Mitchell P. Presence of an optic disc notch and glaucoma. J Glaucoma. [published ahead of print July 8, 2010] doi:10.1097/IJG.0b013e3181e87f20.
25. Wang YX, Hu LN, Yang H, Jonas JB, Xu L. Frequency and associated factors of structural progression of open-angle glaucoma in the Beijing Eye Study. Br J Ophthalmol. 2012;96:811–815.
26. De Moraes CG, Demirel S, Gardiner SK, Liebmann JM, Cioffi GA, Ritch R, Gordon MO, Kass MA; Ocular Hypertension Treatment Study G. Rate of visual field progression in eyes with optic disc hemorrhages in the ocular hypertension treatment study. Arch Ophthalmol. 2012;130:1541–1546.
27. Healey PR, Mitchell P, Smith W, Wang JJ. Optic disc hemorrhages in a population with and without signs of glaucoma. Ophthalmology. 1998;105:216–223.
28. Strouthidis NG, Fortune B, Yang H, Sigal IA, Burgoyne CL. Longitudinal change detected by spectral domain optical coherence tomography in the optic nerve head and peripapillary retina in experimental glaucoma. Invest Ophthalmol Vis Sci. 2011;52:1206–1219.
29. Jonas JB, Bergua A, Schmitz-Valckenberg P, Papastathopoulos KI, Budde WM. Ranking of optic disc variables for detection of glaucomatous optic nerve damage. Invest Ophthalmol Vis Sci. 2000;41:1764–1773.
30. Tatham AJ, Weinreb RN, Zangwill LM, Liebmann JM, Girkin CA, Medeiros FA. The relationship between cup-to-disc ratio and estimated number of retinal ganglion cells. Invest Ophthalmol Vis Sci. 2013;54:3205–3214.
31. Jonas JB, Fernandez MC, Naumann GO. Parapapillary atrophy and retinal vessel diameter in nonglaucomatous optic nerve damage. Invest Ophthalmol Vis Sci. 1991;32:2942–2947.
32. Arnold AC. Fluorescein angiographic characteristics of the optic disc in ischemic and glaucomatous optic neuropathy. Curr Opin Ophthalmol. 1995;6:30–35.
33. Primrose J. Early signs of the glaucomatous disc. Br J Ophthalmol. 1971;55:820–825.
34. Wilensky JT, Kolker AE. Peripapillary changes in glaucoma. Am J Ophthalmol. 1976;81:341–345.
35. Jonas JB, Fernandez MC, Naumann GO. Glaucomatous parapapillary atrophy. Occurrence and correlations. Arch Ophthalmol. 1992;110:214–222.
36. Budde WM, Jonas JB. Enlargement of parapapillary atrophy in follow-up of chronic open-angle glaucoma. Am J Ophthalmol. 2004;137:646–654.
37. Tezel G, Kolker AE, Wax MB, Kass MA, Gordon M, Siegmund KD. Parapapillary chorioretinal atrophy in patients with ocular hypertension. II. An evaluation of progressive changes. Arch Ophthalmol. 1997;115:1509–1514.
38. Jonas JB, Jonas SB, Jonas RA, Holbach L, Dai Y, Sun X, Panda-Jonas S. Parapapillary atrophy: histological gamma zone and delta zone. PLoS One. 2012;7:e47237.
39. Jonas JB. Clinical implications of peripapillary atrophy in glaucoma. Curr Opin Ophthalmol. 2005;16:84–88.
40. Jonas JB, Konigsreuther KA, Naumann GO. Optic disc histomorphometry in normal eyes and eyes with secondary angle-closure glaucoma. II. Parapapillary region. Graefes Arch Clin Exp Ophthalmol. 1992;230:134–139.
41. Piette SD, Sergott RC. Pathological optic-disc cupping. Curr Opin Ophthalmol. 2006;17:1–6.
42. Kalenak JW, Kosmorsky GS, Hassenbusch SJ. Compression of the intracranial optic nerve mimicking unilateral normal-pressure glaucoma. J Clin Neuroophthalmol. 1992;12:230–235; discussion 236–237.
43. Manor RS. Documented optic disc cupping in compressive optic neuropathy. Ophthalmology. 1995;102:1577–1578.
44. Qu Y, Wang YX, Xu L, Zhang L, Zhang J, Wang L, Yang L, Yang A, Wang J, Jonas JB. Glaucoma-like optic neuropathy in patients with intracranial tumours. Acta Ophthalmol. 2011;89:e428–e433.
45. Saito H, Tomidokoro A, Tomita G, Araie M, Wakakura M. Optic disc and peripapillary morphology in unilateral nonarteritic anterior ischemic optic neuropathy and age- and refraction-matched normals. Ophthalmology. 2008;115:1585–1590.
46. Steinsapir KD, Goldberg RA. Traumatic optic neuropathy. Surv Ophthalmol. 1994;38:487–518.
47. Hildebrand GD, Russell-Eggitt I, Saunders D, Hoyt WF, Taylor DS. Bow-tie cupping: a new sign of chiasmal compression. Arch Ophthalmol. 2010;128:1625–1626.
48. Bianchi-Marzoli S, Rizzo JF III, Brancato R, Lessell S. Quantitative analysis of optic disc cupping in compressive optic neuropathy. Ophthalmology. 1995;102:436–440.
49. Jacobson DM. Symptomatic compression of the optic nerve by the carotid artery: clinical profile of 18 patients with 24 affected eyes identified by magnetic resonance imaging. Ophthalmology. 1999;106:1994–2004.
50. Danesh-Meyer HV, Savino PJ, Sergott RC. The prevalence of cupping in end-stage arteritic and nonarteritic anterior ischemic optic neuropathy. Ophthalmology. 2001;108:593–598.
51. Hayreh SS, Jonas JB. Optic disc morphology after arteritic anterior ischemic optic neuropathy. Ophthalmology. 2001;108:1586–1594.
52. Sebag J, Thomas JV, Epstein DL, Grant WM. Optic disc cupping in arteritic anterior ischemic optic neuropathy resembles glaucomatous cupping. Ophthalmology. 1986;93:357–361.
53. Quigley H, Anderson DR. Cupping of the optic disc in ischemic optic neuropathy. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol. 1977;83:755–762.
54. Sanaei-Zadeh H, Zamani N, Shadnia S. Outcomes of visual disturbances after methanol poisoning. Clin Toxicol (Phila). 2011;49:102–107.
55. Votruba M, Thiselton D, Bhattacharya SS. Optic disc morphology of patients with OPA1 autosomal dominant optic atrophy. Br J Ophthalmol. 2003;87:48–53.
56. Ortiz RG, Newman NJ, Manoukian SV, Diesenhouse MC, Lott MT, Wallace DC. Optic disk cupping and electrocardiographic abnormalities in an American pedigree with Leber's hereditary optic neuropathy. Am J Ophthalmol. 2003;113:561–566.
57. Lauer SA, Ackerman J, Sunness J, Bluth EM, Kim CK. Leber's optic atrophy with myopia masquerading as glaucoma: case report. Ann Ophthalmol. 1985;17:146–148.
58. Fournier AV, Damji KF, Epstein DL, Pollock SC. Disc excavation in dominant optic atrophy: differentiation from normal tension glaucoma. Ophthalmology. 2001;108:1595–1602.
59. Votruba M, Moore AT, Bhattacharya SS. Clinical features, molecular genetics, and pathophysiology of dominant optic atrophy. J Med Genet. 1998;35:793–800.
60. Kitazawa Y, Yamamoto T. Glaucomatous visual field defects: their characteristics and how to detect them. Clin Neurosci. 1987;4:279–283.
61. Hood DC, Kardon RH. A framework for comparing structural and functional measures of glaucomatous damage. Prog Retin Eye Res. 2007;26:688–710.
62. Airaksinen PJ, Doro S, Veijola J. Conformal geometry of the retinal nerve fibre layer. Proc Natl Acad Sci U S A. 2008;105:19690–19695.
63. Morrison JC, Pollack IP. Glaucoma: Science and Practice. New York, NY: Thieme, 2003.
64. Garway-Heath DF, Poinoosawmy D, Fitzke FW, Hitchings RA. Mapping the visual field to the optic disc in normal tension glaucoma eyes. Ophthalmology. 2000;107:1809–1815.
65. Anton A, Yamagishi N, Zangwill L, Sample PA, Weinreb RN. Mapping structural to functional damage in glaucoma with standard automated perimetry and confocal scanning laser ophthalmoscopy. Am J Ophthalmol. 1998;125:436–446.
66. Araie M. Pattern of visual field defects in normal-tension and high-tension glaucoma. Curr Opin Ophthalmol. 1995;6:36–45.
67. Hood DC, Raza AS, de Moraes CG, Liebmann JM, Ritch R. Glaucomatous damage of the macula. Prog Retin Eye Res. 2013;32:1–21.
68. Hood DC, Raza AS, de Moraes CG, Odel JG, Greenstein VC, Liebmann JM, Ritch R. Initial arcuate defects within the central 10 degrees in glaucoma. Invest Ophthalmol Vis Sci. 2011;52:940–946.
69. Plant GT, Perry VH. The anatomical basis of the caecocentral scotoma. New observations and a review. Brain. 1990;113:1441–1457.
70. Boland MV, McCoy AN, Quigley HA, Miller NR, Subramanian PS, Ramulu PY, Murakami P, Danesh-Meyer HV. Evaluation of an algorithm for detecting visual field defects due to chiasmal and postchiasmal lesions: the neurological hemifield test. Invest Ophthalmol Vis Sci. 2011;52:7959–7965.
71. Mwanza JC, Oakley JD, Budenz DL, Anderson DR; Cirrus Optical Coherence Tomography Normative Database Study Group. Ability of cirrus HD-OCT optic nerve head parameters to discriminate normal from glaucomatous eyes. Ophthalmology. 2011;118:241–248 e241.
72. Vessani RM, Moritz R, Batis L, Zagui RB, Bernardoni S, Susanna R. Comparison of quantitative imaging devices and subjective optic nerve head assessment by general ophthalmologists to differentiate normal from glaucomatous eyes. J Glaucoma. 2009;18:253–261.
73. Melo GB, Libera RD, Barbosa AS, Pereira LM, Doi LM, Melo LA Jr. Comparison of optic disk and retinal nerve fiber layer thickness in nonglaucomatous and glaucomatous patients with high myopia. Am J Ophthalmol. 2006;142:858–860.
74. Dai Y, Jonas JB, Huang H, Wang M, Sun X. Microstructure of parapapillary atrophy: beta zone and gamma zone. Invest Ophthalmol Vis Sci. 2013;54:2013–2018.
75. Gupta PK, Asrani S, Freedman SF, El-Dairi M, Bhatti MT. Differentiating glaucomatous from non-glaucomatous optic nerve cupping by optical coherence tomography. Open Neurol J. 2011;5:1–7.
76. Barboni P, Savini G, Parisi V, Carbonelli M, La Morgia C, Maresca A, Sadun F, De Negri AM, Carta A, Sadun AA, Carelli V. Retinal nerve fiber layer thickness in dominant optic atrophy measurements by optical coherence tomography and correlation with age. Ophthalmology. 2011; 118:2076–2080.
77. Pasol J. Neuro-ophthalmic disease and optical coherence tomography: glaucoma look-alikes. Curr Opin Ophthalmol. 2011;22:124–132.
78. Horowitz J, Fishelzon-Arev T, Rath EZ, Segev E, Geyer O. Comparison of optic nerve head topography findings in eyes with non-arteritic anterior ischemic optic neuropathy and eyes with glaucoma. Graefes Arch Clin Exp Ophthalmol. 2010;248:845–851.
79. Mashima Y, Kimura I, Yamamoto Y, Ohde H, Ohtake Y, Tanino T, Tomita G, Oguchi Y. Optic disc excavation in the atrophic stage of Leber's hereditary optic neuropathy: comparison with normal tension glaucoma. Graefes Arch Clin Exp Ophthalmol. 2003;241:75–80.
80. Barboni P, Carbonelli M, Savini G, Ramos Cdo V, Carta A, Berezovsky A, Salomao SR, Carelli V, Sadun AA. Natural history of Leber's hereditary optic neuropathy: longitudinal analysis of the retinal nerve fiber layer by optical coherence tomography. Ophthalmology. 2010;117:623–627.
81. Seo JH, Hwang JM, Park SS. Comparison of retinal nerve fibre layers between 11778 and 14484 mutations in Leber's hereditary optic neuropathy. Eye (Lond). 2010;24:107–111.
82. Kim TW, Hwang JM. Stratus OCT in dominant optic atrophy: features differentiating it from glaucoma. J Glaucoma. 2007;16:655–658.
83. Yu-Wai-Man P, Bailie M, Atawan A, Chinnery PF, Griffiths PG. Pattern of retinal ganglion cell loss in dominant optic atrophy due to OPA1 mutations. Eye (Lond). 2011;25:596–602.
84. Zoumalan CI, Agarwal M, Sadun AA. Optical coherence tomography can measure axonal loss in patients with ethambutol-induced optic neuropathy. Graefes Arch Clin Exp Ophthalmol. 2005;243:410–416.
85. Chai SJ, Foroozan R. Decreased retinal nerve fibre layer thickness detected by optical coherence tomography in patients with ethambutol-induced optic neuropathy. Br J Ophthalmol. 2007;91:895–897.
86. Rosdahl JA, Asrani S. Glaucoma masqueraders: diagnosis by spectral domain optical coherence tomography. Saudi J Ophthalmol. 2012;26:433–440.
87. Moura FC, Monteiro ML. Evaluation of retinal nerve fiber layer thickness measurements using optical coherence tomography in patients with tobacco-alcohol-induced toxic optic neuropathy. Indian J Ophthalmol. 2010;58:143–146.
88. Trip SA, Schlottmann PG, Jones SJ, Altmann DR, Garway-Heath DF, Thompson AJ, Plant GT, Miller DH. Retinal nerve fiber layer axonal loss and visual dysfunction in optic neuritis. Ann Neurol. 2005;58:383–391.
89. Costello F, Coupland S, Hodge W, Lorello GR, Koroluk J, Pan YI, Freedman MS, Zackon DH, Kardon RH. Quantifying axonal loss after optic neuritis with optical coherence tomography. Ann Neurol. 2006;59:963–969.
90. Naismith RT, Tutlam NT, Xu J, Klawiter EC, Shepherd J, Trinkaus K, Song SK, Cross AH. Optical coherence tomography differs in neuromyelitis optica compared with multiple sclerosis. Neurology. 2009;72:1077–1082.
91. Jindahra P, Petrie A, Plant GT. Retrograde trans-synaptic retinal ganglion cell loss identified by optical coherence tomography. Brain. 2009;132:628–634.
92. Jindahra P, Petrie A, Plant GT. The time course of retrograde trans-synaptic degeneration following occipital lobe damage in humans. Brain. 2012;135:534–541.
93. Tan O, Chopra V, Lu AT, Schuman JS, Ishikawa H, Wollstein G, Varma R, Huang D. Detection of macular ganglion cell loss in glaucoma by Fourier-domain optical coherence tomography. Ophthalmology. 2009;116:2305–2314 e2301–e2302.
94. Tan O, Li G, Lu AT, Varma R, Huang D; Advanced Imaging for Glaucoma Study Group. Mapping of macular substructures with optical coherence tomography for glaucoma diagnosis. Ophthalmology. 2008;115:949–956.
95. Caprioli J, Sears M, Spaeth GL. Comparison of visual field defects in normal-tension glaucoma and high-tension glaucoma. Am J Ophthalmol. 1986;102:402–404.
96. Kardon RH. Role of the macular optical coherence tomography scan in neuro-ophthalmology. J Neuroophthalmol. 2011;31:353–361.
97. Klistorner AI, Graham SL, Grigg J, Balachandran C. Objective perimetry using the multifocal visual evoked potential in central visual pathway lesions. Br J Ophthalmol. 2005;89:739–744.
98. Klistorner A, Graham SL. Objective perimetry in glaucoma. Ophthalmology. 2000;107:2283–2299.
99. Xue K, Wang M, Qian J, Yuan Y, Zhang R. Multifocal visual evoked potentials in unilateral compressive optic neuropathy secondary to orbital tumors. Eur J Ophthalmol. 2013;23:571–577.
100. Fraser C, Klistorner A, Graham S, Garrick R, Billson F, Grigg J. Multifocal visual evoked potential latency analysis: predicting progression to multiple sclerosis. Arch Neurol. 2006;63:847–850.
101. Grippo TM, Hood DC, Kanadani FN, Ezon I, Greenstein VC, Liebmann JM, Ritch R. A comparison between multifocal and conventional VEP latency changes secondary to glaucomatous damage. Invest Ophthalmol Vis Sci. 2006;47:5331–5336.
102. Iwata F, Patronas NJ, Caruso RC, Podgor MJ, Remaley NA, Kupfer C, Kaiser-Kupfer MI. Association of visual field, cup-disc ratio, and magnetic resonance imaging of optic chiasm. Arch Ophthalmol. 1997;115:729–732.
103. Kashiwagi K, Okubo T, Tsukahara S. Association of magnetic resonance imaging of anterior optic pathway with glaucomatous visual field damage and optic disc cupping. J Glaucoma. 2004;13:189–195.
104. Zhang YQ, Li J, Xu L, Zhang L, Wang ZC, Yang H, Chen CX, Wu XS, Jonas JB. Anterior visual pathway assessment by magnetic resonance imaging in normal-pressure glaucoma. Acta Ophthalmol. 2012;90:e295–e302.
105. Engelhorn T, Michelson G, Waerntges S, Struffert T, Haider S, Doerfler A. Diffusion tensor imaging detects rarefaction of optic radiation in glaucoma patients. Acad Radiol. 2011;18:764–769.
106. Gupta N, Ang LC, Noel de Tilly L, Bidaisee L, Yucel YH. Human glaucoma and neural degeneration in intracranial optic nerve, lateral geniculate nucleus, and visual cortex. Br J Ophthalmol. 2006;90:674–678.
107. El-Rafei A, Engelhorn T, Warntges S, Dorfler A, Hornegger J, Michelson G. Glaucoma classification based on visual pathway analysis using diffusion tensor imaging. Magn Reson Imaging. 2013;31:1081–1091.
108. Chang ST, Xu J, Trinkaus K, Pekmezci M, Arthur SN, Song SK, Barnett EM. Optic nerve diffusion tensor imaging parameters and their correlation with optic disc topography and disease severity in adult glaucoma patients and controls. J Glaucoma. [published ahead of print April 29, 2013] doi: 10.1097/IJG.0b013e318294861d.
109. Kolbe S, Chapman C, Nguyen T, Bajraszewski C, Johnston L, Kean M, Mitchell P, Paine M, Butzkueven H, Kilpatrick T, Egan G. Optic nerve diffusion changes and atrophy jointly predict visual dysfunction after optic neuritis. Neuroimage. 2009;45:679–686.
110. Milesi J, Rocca MA, Bianchi-Marzoli S, Petrolini M, Pagani E, Falini A, Comi G, Filippi M. Patterns of white matter diffusivity abnormalities in Leber's hereditary optic neuropathy: a tract-based spatial statistics study. J Neurol. 2012;259:1801–1807.
111. Harris A, Wirostko B. Cerebral blood flow in glaucoma patients. J Glaucoma. 2013;22(suppl 5):S46–S48.
112. Stroman GA, Stewart WC, Golnik KC, Cure JK, Olinger RE. Magnetic resonance imaging in patients with low-tension glaucoma. Arch Ophthalmol. 1995;113:168–172.
113. He M, Cestari D, Cunnane MB, Rizzo JF III. The use of diffusion MRI in ischemic optic neuropathy and optic neuritis. Semin Ophthalmol. 2010;25:225–232.
114. Rizzo JF III, Andreoli CM, Rabinov JD. Use of magnetic resonance imaging to differentiate optic neuritis and nonarteritic anterior ischemic optic neuropathy. Ophthalmology. 2002;109:1679–1684.
115. Batioglu F, Atilla H, Eryilmaz T. Chiasmal high signal on magnetic resonance imaging in the atrophic phase of leber hereditary optic neuropathy. J Neuroophthalmol. 2003;23:28–30.
116. Votruba M, Leary S, Losseff N, Bhattacharya SS, Moore AT, Miller DH, Moseley IF. MRI of the intraorbital optic nerve in patients with autosomal dominant optic atrophy. Neuroradiology. 2000;42:180–183.
117. Baker MR, Fisher KM, Whittaker RG, Griffiths PG, Yu-Wai-Man P, Chinnery PF. Subclinical multisystem neurologic disease in “pure” OPA1 autosomal dominant optic atrophy. Neurology. 2011;77:1309–1312.
118. Kuker W, Weir A, Quaghebeur G, Palace J. White matter changes in Leber's hereditary optic neuropathy: MRI findings. Eur J Neurol. 2007;14:591–593.
119. Perez F, Anne O, Debruxelles S, Menegon P, Lambrecq V, Lacombe D, Martin-Negrier ML, Brochet B, Goizet C. Leber's optic neuropathy associated with disseminated white matter disease: a case report and review. Clin Neurol Neurosurg. 2009;111:83–86.
120. Bellezza AJ, Rintalan CJ, Thompson HW, Downs JC, Hart RT, Burgoyne CF. Anterior scleral canal geometry in pressurised (IOP 10) and non-pressurised (IOP 0) normal monkey eyes. Br J Ophthalmol. 2003;87:1284–1290.
121. Steinhart MR, Cone FE, Nguyen C, Nguyen TD, Pease ME, Puk O, Graw J, Oglesby EN, Quigley HA. Mice with an induced mutation in collagen 8A2 develop larger eyes and are resistant to retinal ganglion cell damage in an experimental glaucoma model. Mol Vis. 2012;18:1093–1106.
122. Pijanka JK, Coudrillier B, Ziegler K, Sorensen T, Meek KM, Nguyen TD, Quigley HA, Boote C. Quantitative mapping of collagen fiber orientation in non-glaucoma and glaucoma posterior human sclerae. Invest Ophthalmol Vis Sci. 2012;53:5258–5270.
123. Hayreh SS. Progression the understanding of the vascular etiology of glaucoma. Curr Opin Ophthalmol. 1994;5:26–35.
124. Douglas GR. Pathogenetic mechanisms of glaucoma not related to intraocular pressure. Curr Opin Ophthalmol. 1998;9:34–38.
125. Schmidl D, Garhofer G, Schmetterer L. The complex interaction between ocular perfusion pressure and ocular blood flow—relevance for glaucoma. Exp Eye Res. 2011;93:141–155.
126. Caprioli J, Coleman AL. Blood pressure, perfusion pressure, and glaucoma. Am J Ophthalmol. 2010;149:704–712.
127. Morgan WH, Yu DY, Balaratnasingam C. The role of cerebrospinal fluid pressure in glaucoma pathophysiology: the dark side of the optic disc. J Glaucoma. 2008;17:408–413.
128. Berdahl JP, Allingham RR. Intracranial pressure and glaucoma. Curr Opin Ophthalmol. 2010;21:106–111.
129. Jonas JB, Berenshtein E, Holbach L. Anatomic relationship between lamina cribrosa, intraocular space, and cerebrospinal fluid space. Invest Ophthalmol Vis Sci. 2003;44:5189–5195.
130. Berdahl JP, Fautsch MP, Stinnett SS, Allingham RR. Intracranial pressure in primary open angle glaucoma, normal tension glaucoma, and ocular hypertension: a case-control study. Invest Ophthalmol Vis Sci. 2008;49:5412–5418.
131. Berdahl JP, Allingham RR, Johnson DH. Cerebrospinal fluid pressure is decreased in primary open-angle glaucoma. Ophthalmology. 2008;115:763–768.
132. Ren R, Jonas JB, Tian G, Zhen Y, Ma K, Li S, Wang H, Li B, Zhang X, Wang N. Cerebrospinal fluid pressure in glaucoma: a prospective study. Ophthalmology. 2010;117:259–266.
133. Ren R, Zhang X, Wang N, Li B, Tian G, Jonas JB. Cerebrospinal fluid pressure in ocular hypertension. Acta Ophthalmol. 2011;89:e142–e148.
134. Carelli V, Ross-Cisneros FN, Sadun AA. Mitochondrial dysfunction as a cause of optic neuropathies. Prog Retin Eye Res. 2004;23:53–89.
135. Mackey DA, Oostra RJ, Rosenberg T, Nikoskelainen E, Bronte-Stewart J, Poulton J, Harding AE, Govan G, Bolhuis PA, Norby S. Primary pathogenic mtDNA mutations in multigeneration pedigrees with Leber hereditary optic neuropathy. Am J Hum Genet. 1996;59:481–485.
136. Kjer B, Eiberg H, Kjer P, Rosenberg T. Dominant optic atrophy mapped to chromosome 3q region. II. Clinical and epidemiological aspects. Acta Ophthalmol Scand. 1996;74:3–7.
137. Aung T, Ocaka L, Ebenezer ND, Morris AG, Krawczak M, Thiselton DL, Alexander C, Votruba M, Brice G, Child AH, Francis PJ, Hitchings RA, Lehmann OJ, Bhattacharya SS. A major marker for normal tension glaucoma: association with polymorphisms in the OPA1 gene. Hum Genet. 2002;110:52–56.
138. Guo Y, Chen X, Zhang H, Li N, Yang X, Cheng W, Zhao K. Association of OPA1 polymorphisms with NTG and HTG: a meta-analysis. PLoS One. 2012;7:e42387.
139. Van Bergen NJ, Crowston JG, Kearns LS, Staffieri SE, Hewitt AW, Cohn AC, Mackey DA, Trounce IA. Mitochondrial oxidative phosphorylation compensation may preserve vision in patients with OPA1-linked autosomal dominant optic atrophy. PLoS One. 2011;6:e21347.
140. Aung T, Ocaka L, Ebenezer ND, Morris AG, Brice G, Child AH, Hitchings RA, Lehmann OJ, Bhattacharya SS. Investigating the association between OPA1 polymorphisms and glaucoma: comparison between normal tension and high tension primary open angle glaucoma. Hum Genet. 2002;110:513–514.
141. Ko ML, Peng PH, Ma MC, Ritch R, Chen CF. Dynamic changes in reactive oxygen species and antioxidant levels in retinas in experimental glaucoma. Free Radic Biol Med. 2005;39:365–373.
142. Liu Q, Ju WK, Crowston JG, Xie F, Perry G, Smith MA, Lindsey JD, Weinreb RN. Oxidative stress is an early event in hydrostatic pressure induced retinal ganglion cell damage. Invest Ophthalmol Vis Sci. 2007;48:4580–4589.
143. Fujita T, Hirooka K, Nakamura T, Itano T, Nishiyama A, Nagai Y, Shiraga F. Neuroprotective effects of angiotensin II type 1 receptor (AT1-R) blocker via modulating AT1-R signaling and decreased extracellular glutamate levels. Invest Ophthalmol Vis Sci. 2012;53:4099–4110.
144. Yuki K, Ozawa Y, Yoshida T, Kurihara T, Hirasawa M, Ozeki N, Shiba D, Noda K, Ishida S, Tsubota K. Retinal ganglion cell loss in superoxide dismutase 1 deficiency. Invest Ophthalmol Vis Sci. 2011;52:4143–4150.
145. Lee S, Sheck L, Crowston JG, Van Bergen NJ, O'Neill EC, O'Hare F, Kong YX, Chrysostomou V, Vincent AL, Trounce IA. Impaired complex-I-linked respiration and ATP synthesis in primary open-angle glaucoma patient lymphoblasts. Invest Ophthalmol Vis Sci. 2012;53:2431–2437.
146. Kanamori A, Catrinescu MM, Kanamori N, Mears KA, Beaubien R, Levin LA. Superoxide is an associated signal for apoptosis in axonal injury. Brain. 2010;133:2612–2625.
147. Qi X, Lewin AS, Hauswirth WW, Guy J. Optic neuropathy induced by reductions in mitochondrial superoxide dismutase. Invest Ophthalmol Vis Sci. 2003;44:1088–1096.
148. Nguyen SM, Alexejun CN, Levin LA. Amplification of a reactive oxygen species signal in axotomized retinal ganglion cells. Antioxid Redox Signal. 2003;5:629–634.
149. Wood JP, Mammone T, Chidlow G, Greenwell T, Casson RJ. Mitochondrial inhibition in rat retinal cell cultures as a model of metabolic compromise: mechanisms of injury and neuroprotection. Invest Ophthalmol Vis Sci. 2012;53:4897–4909.
© 2013 by North American Neuro-Ophthalmology Society