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C-56708

Optic nerve head signs of glaucoma

This visual recognition feature requires the practitioner to interpret features of glaucoma which may be present at the optic nerve head.

Image A

Image A 

01 A 67-year-old patient presents with intraocular pressure of 15mmHg. Which of the following is not shown in the image?

a) Superior neuroretinal rim notch 
b) Beta peripapillary atrophy 
c) Broken ISNT rule 
d) Baring of a circumlinear vessel

02 Which of the following would not be appropriate to investigate the possibility of glaucoma further? 

a) Measurement of central corneal thickness 
b) Asking the patient about migraine and peripheral vascular disorders 
c) Esterman visual fields 
d) None of these options 

03 Which of the following would help most to confirm a diagnosis of glaucoma? 

a) Superior visual field defect 
b) Inferior retinal nerve fibre layer outside normal limits on OCT 
c) Superior visual field defect and an inferior retinal 
nerve fibre layer outside normal limits on OCT 
d) None of these options 

Image B

Image B

04 So-called ‘flame haemorrhages’ are: 

a) Shaped this way due to their location within the retinal nerve fibre layer 
b) Most commonly situated at the superior-temporal or inferior-temporal disc margins 
c) Also known as Drance or splinter haemorrhages 
d) All of these options 

05 Optic disc haemorrhages caused by glaucoma are: 

a) Always flame-shaped 
b) Typically transient, lasting a few months 
c) Found mostly in cases with high intraocular pressure 
d) A common side effect of topical ocular hypotensives 

06 Optic disc haemorrhages may also be caused by: 

a) Systemic cardiovascular conditions and diabetes 
b) Anterior ischaemic optic neuropathies 
c) Posterior vitreous detachment 
d) All of these options 

Image C

Image C

07 When viewed monoscopically, the border between the neuroretinal rim and optic cup is best defined by: 

a) Colour change 
b) The region containing visible lamina pores 
c) Changes in direction of blood vessels 
d) Shadowing at the outer cup edge

08 The arrow indicates: 

a) Baring of a circumlinear vessel, indicating possible erosion of the neuroretinal rim outwards from the position of the vessel 
b) Bayonetting of a vessel, indicating longstanding, probably physiological cupping 
c) Bayonetting of a vessel indicating possible deepening of the cup 
d) A vessel following the depth contour of the cup, indicating a shallow cup 

09 The vertical disc diameter measures 1.4mm using a Volk Super 66D lens at the slit lamp. The disc is: 

a) A small disc, more likely to be glaucomatous since glaucoma is more common in smaller discs 
b) A small disc, more likely to be glaucomatous as physiological cups of this size are less common in smaller discs 
c) A large disc, more likely to be glaucomatous as glaucoma is more common in larger discs 
d) A large disc, less likely to be glaucomatous as physiological cups of this size are more common in larger discs 

Image D

Image D

10 Labels i and ii in the image indicate: 

a) i = alpha peripapillary atrophy (PPA); ii = beta PPA 
b) i = beta PPA; ii = alpha PPA 
c) Both indicate alpha PPA 
d) Both indicate beta PPA

11 Which of the following statements is false? 

a) Alpha PPA represents irregular pigmentation of the RPE and is unrelated to glaucoma 
b) Beta PPA represents RPE atrophy and is associated with increased likelihood of glaucoma 
c) The location of beta PPA often corresponds to the region of localised neuroretinal rim loss 
d) Beta PPA is only present in highly myopic and/or glaucomatous eyes 

12 Which of the following statements is false? 

a) Beta PPA, even if physiological, can cause enlargement of the physiological blind spot that may be measureable by perimetry 
b) Beta PPA can enlarge in area with progression of glaucomatous disc damage 
c) Where both alpha and beta PPA are present, the beta PPA is always situated nearer to the disc margin 
d) In fast-progressing cases, the enlargement of PPA may be restricted by diode laser photocoagulation

About the authors

Dr Jonathan Denniss PhD, MOptom (Hons), MCOptom is a lecturer in optometry at the University of Bradford. His research interests are in glaucoma, AMD and the measurement of visual function. 

Dr Samantha Strong PhD, BSc (Hons), AFHEA is a post-doctoral researcher based in the School of Optometry and Vision Science at the University of Bradford.