 So I left. I left Oklahoma in 81 Long before you guys were born, but So I graduated from high school there. I and my folks were actually from Utah and so So I Graduated and came out here to school and have pretty much been here since except I was in Iowa for You know four years during residency And some fellowship there came back my wife's from California. We met here So this is pretty much our home. Yeah We raised all our kids here So it's yeah, it's been great. We liked it here. And as soon as I as soon as I left Oklahoma. Hey, good morning my parents transferred to Denver and then my my Really some of my really good friends most of them actually many of whom are still my good friends all moved to Texas So they live in Dallas and Houston So I have been back Well, it's seven o'clock We'll go ahead and get started and thanks for being here. So So today we're gonna talk about you know optic nerve which is In glaucoma, I mean bread and butter, right? That's what we're all about is protecting the optic nerve and So hopefully we can just talk about some things that'll be interesting to you and helpful Especially as you go in the clinic and so first off there are just some kind of fun facts about Optic nerve that you'll probably need to know at some point like on O caps and and things like that And so who's any of you taking no caps yet? Yeah, you have how many times you've taken it once. Yeah Can you remember by chance any questions at all that might have been optic nerve related on? O caps Yeah Yeah, it's kind of a fog after that. Yeah. No, okay. Sorry the glaucoma section at O caps is kind of varies from what I can tell but it's usually Reasonable but always they find some difficult questions, you know for all the subjects, but so when I did my Board recertification, which I've done a couple of times. There are almost always a couple of little fun facts about optic nerve One of them didn't you know like if I were to say how many you'll nerve fiber later How many nerve fibers are you know constitute the optic nerve? Do you have any idea what that number might be? There you go, that's that's the number that's been thrown around for as long as I've been you know since I was a resident 1.2 million axons Okay, and these axons are Axons are Yeah 1.2 million axons and they are kind of bundled into about a thousand fascicles in the optic nerve and so this is a picture that is kind of You know been tossed around for a long time. It's right out of the BCS series, but 1.2 million axons a thousand fascicles kind of separated by Connective tissue in the optic nerve another kind of little fun fact is How much if you're looking at detecting on a visual field? What's the T kind of the traditional teaching about how many of these nerve fibers can be lost? Before it's detectable on a visual field Any idea what that number is? Yeah, it's like 50% so that's another number to remember now. That's like a an extraordinary number now It's probably overstated Because the study that was done the landmark study that was done which was done by Harry Quigley You know the Wilmer guy when he was a young young faculty member and basically he you know counted Neurofibers in Caterbary guys, you know kind of using a process that they did to try to Estimate how many there were and then and then comparing those to the most or the last visual field that that patient had and of course It was just on a few patients you could imagine it's like four or five patients And the perimetry was actually goldmong perimetry, which is not as sensitive as Humphrey and certainly not as sensitive as some of the newer perimeters So that's probably overstated But the point is is that you can lose a lot of these nerve fibers before you? Detect it on a visual field. Okay, so that's where OCT and that kind of stuff comes in that Hopefully is giving us a little earlier detection. What about the types of cells in the the retina? There's a clue right there any what have what types of cells are there and kind of what do they do? You can look up there M&P. Does that sound familiar at all? M&P cells and and that's relevant It's clinically relevant because it's important to kind of know what we're testing when we do a visual field, okay? And a lot of the other perimeters that are out there are designed to try to specifically test One of these cell types, okay? So the P cells are by far the most numerous They're the smaller diameter axons and they also have a smaller Receptive field, okay? So, you know these axons they they all have what they call a receptive field and P cells They're smaller and these are the cells that are sensitive more to color and fine detail Okay, Machiva has a lot of P cells for example. All right the M cells are fewer in number And they have larger diameter and they have a much larger Field that they cover okay the receptive field and there's a statement there, okay? So they may be more susceptible to glaucoma damage. Well, why is that? Well the M cells tend to be congregated in the poles of the optic nerve, okay? And you know, that's where we see cupping right? We see oftentimes that that vertical cupping of the optic nerve and glaucoma and so there's some thought well Maybe these M cells since they populate that area are the ones that are the more sensitive and these particular cells are More for like motion and spatial relationship rather than fine detail The reality is probably though that the reason they show damage first is that there's just fewer of them So it's this idea of reduced redundancy There are all these P cells and the P cells have these overlapping fields, okay? And there's so many of them that you can lose a lot of P cells before you can detect that With any primetry does that make sense whereas the larger M cells they don't overlap nearly as much So when one of them dies off It kind of tends to make a blank area in the retina right that you can detect with a visual field So so it might be that there's just this reduced redundancy and that's why they're They're more tested now another set. So when you're looking at perimeters, you know, the Humphrey perimeter Tests a lot of P cells. Okay, some of the other perimeters like like frequency doubling technology Some of the motion detecting visual fields those are designed Specifically to try to test for M cells where you know by motion and whatnot with the idea being that We might be able to detect damage in those first because there are fewer of them and they don't have this field redundancy now there's another set which are these bat by stratified cells the conial cellular and They are color sensitive and they process blue-yellow and so you've heard of swap perimetry, right short wave automated short wavelength automated Permetry blue on yellow Familiar with that does that ring about any of you ever taken a swap visual field? It's torture. Let me tell you so Just as a side note all of you ought to take a visual field if you haven't yet Okay, just just take one and realize what you're asking your patient to do It's like I say we don't make any friends make you know having people do these visual fields But it's still the gold standard of following glaucoma. Okay, so the white on you know black on white We call it right you got a white background and you're usually seeing a you know a lighted dot Those are the ones that are the standard Humphrey perimetry and that's mostly testing P cells with some M cells Okay, the blue on yellow so you got a yellow background and that's what's so torturous about swap is staring at that yellow Background and then the light that presents the light stimulus is blue That's specifically trying to test these conial cellular and again the idea of trying to test cells that will give us the earlier earliest detection Because they're just fewer of those. Okay. Does that make sense? So that's just kind of That's how that becomes clinically relevant Kind of memorize this picture You might see it again, but this just basically if you can kind of have that picture in your mind. You can totally understand The visual fields that you see in the clinic. Okay, why do you see those? Arcuate changes like that, you know Well those fibers that are showing the damage first are those sweeping Arcuate fibers in the optic nerve right and so you can just see those the Papular macular bundle the the bundle running straight from the macula into the optic nerve that's overwhelmingly most of the nerve fibers in the retina serve the macula and that's why Central vision tends to be well preserved in glaucoma even though it's very advanced. Okay, and you know some of the newer ideas about testing macular thickness with the OCT as A way of maybe detecting glaucoma earlier is based on that principle that you know There's so many there that you aren't picking them up on a visual field again because they're so redundant one over the other But maybe if you actually measure the anatomy thinning that will give us the earliest detection But that kind of sweeping, you know the peripheral so you just think of that for example, why do we see? You know nasal steps, right? You know everything about this is Inversed and upside inverted and upside down right so that those nasal Defects that we see are representative of temporal Retinal nerve fibers, right and they're sweeping over the macula and there's fewer of them And so we get those nasal steps to start with and that's sweeping Arcuate, you know just that picture tells the story right there So I think that's just kind of a good picture to have just kind of imprinted on your mind when you're looking at visual fields And you'll understand the the anatomy explains what you're seeing on a visual field. Does that make sense any questions about that at all? We'll skip over this a little bit the one other thing that I think is important again for like, you know O-CAPI kind of things, you know plus obviously in the clinic is the blood supply the optic nerve, okay? This is a picture that you know when I was taking O-CAPS boards and recertification Not every time but I've certainly seen this picture just on an O-CAP test or on a board test And so just kind of knowing it's just kind of these fun facts that you just kind of need to know The blood supply of the optic nerve just and that is it right there This the very surface of the optic nerve is vascularized by the central retinal artery Then you have these pre-laminar and peripapillary coreroid and the short posterior ciliary arteries that are getting that pre-laminar area Especially those short posterior ciliary arteries, okay in the laminar region again You've got the short PCA's and the retro laminar right the retro laminar which has a you know Covering of the like the peel sheath is vascularized by peel vessels so again just something to know so that you can reproduce it on a test so The critical thing about the optic nerve obviously it's it's what's glaucoma is all about what we're trying to preserve But but really what's most important day-to-day is how to examine the optic nerve and how to you know kind of use that to Detect glaucoma and then also try to denote its progression, right? So let's just talk for a minute. What are the best tools you think what in your hands for Examining the optic nerve what you know I'm talking about lenses technique What works best for you in terms of examining the optic nerve? Okay Nineties the deal okay, so 90 is the lens of the glaucoma doctor I mean it's the lens of anybody but especially the glaucoma doctor and 90 doctor lens You just you just got to have one so the reason you got to have one is that you can get through an undilated pupil and You know you just can't dilate your dilate your patient every time But you need to look at the optic nerve every time my patients I look at the optic nerve every time All right, even if they're coming back every week for post ops. I look at the optic nerve every time It's just it just kind of ingrain it in your your evaluation process So the 90 doctor it does provide even though you can get through a small pupil It does provide pretty good magnification and you need to be able to have magnification. I tried for me for a few years The a volt lens is called the super pupil and it is amazing at the view you can get Through an undilated pupil with that thing, but I in the end I decided there was not enough Magnification and so I felt like it wasn't given me the examination that I needed So when you when you're looking through a 90-doctor lens, are you getting more of a of a monocular or binocular view? It's often in fact most often it's monocular if you're looking through an undilated and you can test that out You know next time you focus on an optic nerve through the 90 Just close one eye and then the other and you'll realize you mostly just have one eye looking at it Okay, but it so it doesn't give you super stereo But it does give you a good view through a small pupil With appropriate magnification that you can rely on that pretty well Now if you want to do something different and I have one of these in all my sets This is a lens. It's great. This is a this is the the Volk super 66, but like a Volk 78 A Volk 60. I mean 60 is like super stereo But the thing about these they're great Magnification is amazing and stereo view is amazing, but you can you almost always have to dilate the pupil That's the thing. So when you have a dilated pupil and you really want to get a great optic nerve view if you have like a 78 This is a 66 It's a it's an amazing view and it's always stereo because you're you do it with a dilated pupil So I think one of these is handy as well All right, so a 90 and something like a 66 or a 78 So this is like my you know glaucoma kit right here, you know got those two lenses have a goneo prism, right? And then of course, yep, I actually can still use this Like a 20 to you know look at the peripheral retina, but those are kind of the tools of the trade I think so with the those lenses and And let's let's kind of look at some optic nerve So I think the key to examining an optic nerve is to have just a routine in your mind about how you do it Okay, so what what are the important things to look at in evaluating an optic nerve? What are the things that you're thinking of that that you want to kind of check off when you're looking at the optic nerve? Okay, margins. Excellent. What do you mean by margins? It's like the margins of the disc itself. Okay. Okay, excellent margins color Cup, okay. What what do you what do you mean by cup? Okay, yeah, I think that's good, you know, you you can use the vessels as pretty good markers for For you know the extent and the outline of the cup now, so what would you call that cup anybody? What would you call that? Okay Anybody else? So here's the thing you're gonna have your own scale Okay, and your scale they've done studies on that where they've taken like people that have been glaucoma specialists for 25 years and had five of them look at the same nerve and they would all call it something slightly different Okay, so you're gonna have kind of your own scale about cup to disc ratio and it's just gonna kind of be yours Just just know that it's not super comparable, and then that's okay, right? That's okay That's why we look at things like you know documenting with a photo and OCT is being very important But all those things are true. So we're gonna look at margins. We're gonna look at color We're gonna look at cup Anything else we're gonna look at particular Dissized right you need to know is it just a big nerve, right? And so if you have a big nerve a bigger cup is allowable, okay Okay, that's that you know again those are good good things There's one other thing. I think it's super important The rim that's right, you know, so I really think that when you're examining an optic nerve Those are the things you check off and so you just kind of have a You know it comes becomes kind of a gestalt II thing right you're gonna look at that nerve And you're just gonna automatically you know just look at the disc Is it bigger small are the are the margins clear then you're gonna look at the cup then you're gonna look I mean for 360 degrees you're gonna look at that rim The rim is really what tells the story, okay? And we're gonna show some pictures of that but in glaucoma the rim tells the story really about whether or not it's glaucoma You know sometimes it sometimes an optic nerve is just kind of concentrically enlarge in glaucoma But more often at least in my experience you're gonna see focal thinning when you're talking about real glaucoma You're gonna see focal thinning before you see kind of to me Concentric enlargement does that make sense? I'll show you some pictures. So Examining that rim for 360 degrees is really important. And so just kind of have that checklist in your mind So normal optic nerve great, you know, we'd love all all the optic nerve to look just like this What do you think of this one? What's that? 0.5. Okay, any other comments? Yeah, they are right just a little bit. It's kind of a deep cup, isn't it a little deep? Just just you know from from this view normal or abnormal. What do you think of the rim? Maybe a bit overall pretty healthy, you know, I think I think this is a so so would you work this nerve up? When I see you sort of work up. I mean, you know get an OCT get a visual field. What if so here's I don't know if any of you Heard heard my talk the other day here But I talked about how that second study of the oats, which is a super important paper Like I say, it's a real slog to get through tons of statistics But the second oat oats to it's called, you know what I mean by oats ocular hypertension treatment study Kind of looked at this and this is the one where if you Talk about treating people, you know this treat to treat to cure late Which is kind of a cancer vernacular that in the low-risk category You would have to treat 90 patients to keep one from getting to glaucoma But if you put them in the high-risk category, it's seven to one. I mean, you know, what a difference that stratification is What are the things that allow? What were the other factors? So, you know, this this could be totally normal, you know, that nerve could be totally normal It also could be early glaucoma Maybe what would be the things that the other things what are the other parameters? That might put this into the higher-risk category Then corn is and that is the the great one right there if you look at the oats oats study and And we know we think we are grateful to just a couple of people Who when the oats study was being done and all the patients were already recruited and These couple of people one of them being Jamie Brandt at Davis who said we have got to measure the corneal Pachymetry on these people so they went back and measured Pachymetry on all the patients and lo and behold Pachymetry turned out to be the number one predictor of Whether or not they got glaucoma more than pressure So if this person right here with that optic nerve had what are the other parameters? So cup to disc ratios one What are the the Pachymetry is another that goes into that risk calculator? What's another age? Not exactly. I mean good good good thought, but it's not in the actual numbers of the oats What's that again not not exactly very important not exactly so there's age cup to disc ratio Pachymetry and pressure right what the pressure is and then the other added parameter is the initial mean deviation on Visual field once you get it. So if you see that optic nerve and thinking of those things What might make you go ahead and get an OCT or a visual field on that patient if they had what? Hi, if they had high if their pressure were 28 absolutely you'd be working them up if it were 19 maybe not, but the big E is Pachymetry right so that would be if that's a patient right there that I would say nerve looks like that They ought to at least get Pachymetry Okay, so they need their pressure measured of course and get a Pachymetry so if that patient right there had Pachymetry of 500 and Or a pressure of 26. I would study them on the other hand if that person had a pressure of 18 and a Pachymetry of 600 I'd probably just follow them you know without working them up So those are the kind of decisions that you can use that old study is so powerful in that regard of Kind of stratifying risk When you've got one so basically what you've got here is you've got one factor that might make you a little suspicious about glaucoma And that is they've got a bigger cup to this ratio that you might see on most patients That makes sense, but chances are that nerve is going to be normal I would say okay, but if they had some of those other risk factors, I would get some baseline studies for sure How about that optic nerve right there? any thoughts Starting to get real suspicious that you know the chance that that nerve is normal is Not zero, but it's it's getting pretty low. You know you are you are two standard deviations from the mean Away from normal for example, so what is it about that nerve that makes you think that doesn't look too normal to me? What do you what do you see? Deep cup large cup to disk absolutely What else do you know? Absolutely Absolutely, and that of everything that's been said super important as I'm examining that nerve that one is the most important That's superior rim. That is definitely thin so You're gonna work that patient up That's a patient. You're gonna work up and by work up. I mean you get your glaucoma studies Regardless of what their pressure is regardless of what their Pachymetry might be you know what I'm saying? That's a nerve that has to have some baseline studies done and I think on that one because of you know that thinning of the rim I Think there's a high probability that you would see a visual field defect in that patient And I guarantee you that you're gonna see an OCT abnormality there And that's and you know we could talk about you know those things I know you have like a visual field lectures and do you have an OCT lecture ever? I know I did the visual field for years, but I think someone else is doing that now But anyway, so you know OCT and visual fields Visual field is still the gold standard, but these these these kind of initial Patients that come in excuse me come in your clinic and you're kind of deciding on is that is that a normal nerve or not? That's when the OCT in my opinion has its most power is In those early phases where you're really trying to say is this nerve normal or not? The further you go and any of you you know in my clinic I have a ton of super advanced patients the more advanced the patient gets the less helpful OCT becomes Okay, but early on something like this that patient just walked into your clinic You're gonna work that patient up OCT is super helpful in those kind of initial when you still got some nerve to measure and You've got that focal thinning. I bet that OCT would just pick that out like crazy You know with that real focal thinning superiorly, but that's enough that I think you'd see a visual field defect to so big cup deep Definite thinning that that's a nerve you got to work up. Okay? Very good any questions about that All right, let's look at some others What do you think of that when if you just look at that? What do you think that person's refractive area is? Yeah, that that is the classic myopic nerve, okay Tilted it's got all that peripapillary atrophy. You can look at the fundus You know it's got that myopic fundus look and I truly think that differentiating a myopic nerve From a glaucoma this nerve is one of the most difficult challenges that we have Because they can look really really similar So what are some what are the same again? You have this kind of checklist in your mind of What you're gonna go through and so what what about this optic nerve? Stands out to you. The obvious one is all that peripapillary atrophy, right? So you've got all that PPA What else do you see? What do you think of the nerve itself little tilted? I think it looks very healthy actually, you know to me And the point of this slide is just to say that Sometimes you can see a really normal optic nerve surrounded by a bunch of stuff that doesn't look very normal, okay? But so in this one we the idea is to not get Distracted by all the myopic change and focus in on the nerve and kind of go through your same Checklist of things on the nerve, right? It's got good margins. The rim looks pretty good to me It's it's you know the cup is within reason and again at this optic nerve there There'd have to be something else going on they got a high pressure or something like that that would make me think well I need to work that out. Yep Yeah It's mostly by color, you know, obviously we don't have a stereo view here. So it's mostly by color and Whether or not you can see actually the lamina, you know, sometimes you can see in a really deep cup You can actually see those connective tissue separators of the Of the lamina Crobrosa now that would be a really deep cup But this one is just we say deep just based on kind of the color and you can kind of see in that one You can just kind of see just barely a little bit of that kind of grayish Lamina in the bottom of the cup. Can you see what I'm talking about this just kind of those gray little speckles and That's kind of the top of the cup, you know, we could be hallucinating but But it is sort of there. Yeah Yeah, and Yeah, that's they call it zone. You know, there's that have that zone one and in my mind the zone one is The the zone right next to the optic nerve that that's my very simplistic way of thinking of Peri papillary atrophy and this zone one There's this German fellow who is the one that's kind of championed that idea of this zone one Peri papillary atrophy is being a marker for glaucoma and so this if I were to say I don't have a pointer but if I were to say here on this one that the zone one would be that Darker rim of peri peri papillary atrophy that is right next to the optic nerve and Then the kind of lighter area that extends out beyond that and you kind of see that boundary there that would be zone two I Will tell you honestly That is not something that to me clinically, you know like on patient 55 that day that has Really had a lot of clinical help for me, but it's certainly something well described is that idea of zone one's on tube And that's how I divide them up Okay, very good. How about this optic nerve? Can't just kind of What's that? I'm sorry Definitely does that does to me too Anything else about it? Deep so once again that thinning of the superior rim of this optic nerve to me is the most striking feature that's the one that gets your attention in the clinic, you know, you look at that optic nerve and You're doing your checklist, right? And one of the checklist one of the most important is that for 360 degrees You're looking around that optic nerve rim Okay, 360 degrees and you come to that superior part and you go whoa that that is that's thin That's almost like a focal notch Okay, now a focal notch Is kind of the in my mind the Pathognomonic optic nerve sign of glaucoma. There's just Not really anything else that does that in Studies that have been done that have looked at optic nerves That some of which are you know, you know many many optic nerve some of them that went on to have other diagnoses, you know, like a Optic nerve tumor or something like that, right masquerading the one thing that kind of came out fell out as the most specific For glaucoma is that focal notch Number two is probably disc hemorrhage classic disc hemorrhage. Okay, so when you're kind of looking optic nerve and wondering Do I need to is this like something else? That if you can see that focal notch That you can pretty much hang your hat on that that that is glaucoma Okay, and that's kind of getting to be a pretty focal notch right there All right, and again, that's a patient. You're gonna work up for sure Right and almost almost for sure you're for sure you're gonna see that on an OCT and why do I say that? Well, because you've got all that Measurable inferior rim that's gonna get measured and then compared right so you're gonna see on an OCT You're gonna see a focal defect there, right? And that's probably enough of a notch that I bet you're gonna see that on visual field as well So I bet both come up positive For findings in this optic nerve All right, let's look at some others How about that one big I mean it's a big disc That's a really big cup Anything else about it? Yeah, so here here's an example of just Concentric in my view pretty concentric enlargement of the cup without Much notching, okay, so what if that patient here, I mean we're probably gonna work that up Aren't we that's a nerve that you're probably not not gonna let walk out of your clinic without getting something done Okay, so we're at minimum going to get an OCT in a visual field and that's probably one that I would have a little Suspicion of that what if that what if that person right there? What if that person has a pressure of 15 and pretty you know normal picimetry and You get their studies back and they're a little bit equivocal You know, you know that doesn't really look like a glaucoma fielder Kind of just diffuse loss on those CT for example Yeah, that's a that's an oddish-looking nerve and I Yeah, I think if you were to if that if that patient came in with a pressure of 15 and Normal picimetry not a family history You know that might be one to have a low threshold To think about working out that with that kind of concentric enlargement like that And we're we'll talk about that again here in a little bit. Let me make sure I'm not running over time More the same any thoughts on this one? What's that? Big notch You see anything else? Can any of you see in that photo that kind of nerve fiber layer defect? I can see it better on my screen than you can up there, but there is that little we'll show a better example There's that little band of slightly darker retina extending from that notch in that arc you had fashion Right here There's the inferior border of it and here's the superior border of it. Can you see that? Okay, can I do it up here? I can't but anyway this I'll show you another picture That inferior border is like right up there if I were taller I can show you I'll show you a different picture Looking at nerve fiber layer defects again is I think really hard to do in the clinic But sometimes you catch it on a photo and there's just another Marker of a focal defect usually though the reason it's not as important in my mind is usually the nerve is already told the story Okay, but you hear a lot about you know taking red-free photographs and Looking at nerve fiber layer defects again. Usually the optic nerves told the story. This is classic glaucoma focal notch big cup All your testing will be done. Now here is some zone one Prairie papillary atrophy see that right there that would be more glaucomatous than myopic in my opinion right there So that's when you you know, that's when you look back and you go wow We are we are really in trouble here. You know you hate I put this photo in because This is a patient that I'm looking at for the first time, you know And we're making the diagnosis and my gosh their nerve looks like that That that's really a that's a sad day, you know because you're so far down the line That you're just you're just in the trying to hang on game from the first moment you meet them So That's that's a bad bad nerve right there, but sometimes that that's just an example of end stage Glaucoma, so how are you gonna follow that nerve right there? Yeah, yeah, it just in general your only way to follow them as a visual field I mean OCT would give you no information and I would tell you that at that point even clinical examination You just can't differentiate Change and so visual field 10-2 size 5 target, you know, whatever it takes But honestly in and eyes like this what the patient says is Really important because you're just Grabbing at things to try to monitor them with and so if they come in and they say I just really feel like my vision is Worsened over the past, you know four months or whatever You just you just have to believe them in that case and just say okay You know that says that becomes as good as a visual field in my mind when Disease gets this advanced All right Now there is a nerve fiber layer defect. Can you see that right there? That wedge coming down from that inferior notch Okay, so again That's great, and that's really cool if you catch it on a photograph Chances your chance of seeing that in the clinic with a 90-diapter lens is low because you just can't get that big wide Panoramic view but again the nerve has already told you the story, you know You can see that notch right there, but that is a good example of a nerve fiber layer defect And then I have one other high mag view again. You've got that notch inferiorly and Then you've got that wedge of discoloration of the retina extending from that Can you see that there when I talked about so just nerve fiber there? But again now see now This is a nerve that is that's just such a classic glaucoma nerve right there because you got a lot of healthy rim But then boom you're looking at that inferior things. You know I'm talking about and then just There's that notch right there Yeah, you bet I mean a lot of it depends on background, you know what their kind of Background pigmentation is and things like that Okay, now The obvious thing so it looks really obvious right there it is boom But in all of the studies all of the big glaucoma studies have been done where there have been reading centers And that would be oats normal tension glaucoma ages You know all those major studies where the reading centers the number one missed finding Disc everage the number one by far and most of the people in the clinic looking at these nerves are You know glaucoma specialists. They've looked at thousands and thousands of octet nerves, but it's the number one missed finding is Didn't put down didn't detect a disc average on that day There's a classic disc hemorrhage if by chance you see one that is really really specific for Glaucoma, okay. Now the thing about it though is that a disc hemorrhage can look You know they're all they can be very different this this one could not be more classic right it extends off the disc Margin is that kind of flame-shaped hemorrhage all you know all the descriptives that you hear about You know there it is so that's a great example, but just to show a few others Spot the one here right here. They see that Everybody see the one I'm talking about down if you're really there runs along a vessel Those are the hardest ones to detect the ones that run right along a vessel and they and you kind of think that's just part of The vessel or maybe a vessel But like this one it runs right along the side now notice this one is in a Already existing notch right that inferior rim is thinner than the superior agree and And there's the disc hemorrhage and that's common that you're going to see disc hemorrhages in previous areas of notch or You see a disc hemorrhage and then they come back through a four months later, and there's a notch there I've seen that many times before. What do we guess? infarction just ischemia and And it just you know it just infarcts and it has causes a little hemorrhage right there now What causes the infarction that is the million dollar question? Is it is it barotrauma, you know pressure damage, or is it a vascular insufficiency? That that's the million dollar question, but it's thought to be infarction And I was just gonna ask what when we see a desk disc hemorrhage. What what do we interpret that as? Meaning yeah, the glaucoma is not under good enough control So do we always treat a disc hemorrhage to when we see this camera should we always ramp up the treatment? Often, I mean I often we do now if that next step is Treveculectomy You know I might look for confirmation on a visual field I guess what I'm saying is if nothing else had changed and I see a disc hemorrhage And I've already got them on three meds, and they've had SLT and the next steps are Treveculectomy I don't think I would do a Treveculectomy based on a disc hemorrhage. Okay, does that make sense? You know in when we're talking about ramping up treatment in glaucoma so much of it is well What is the next step now if that patient comes in with that disc hemorrhage? And they're just on latinopros once a day, and we haven't tried anything else. Absolutely. We're gonna ramp that up Okay, we're gonna start them on a second drop maybe talk to him about laser Treveculoplasty, you know because our next step is pretty minimal risk But again, it's always about what the next step is but but in general in general when we see a disc hemorrhage We're probably gonna ramp the treatment up. Okay Just a couple other examples here. That's a disc hemorrhage Looks very different doesn't it but it is we would interpret that as a disc hemorrhage Everybody see what I'm talking about there just that blush of hemorrhage. It's actually down in the cup Down in fear early there Okay, you spot that one I'd watch it the classic disc hemorrhage will go away now I realize some diabetic hemorrhages can go away as well But if this had a otherwise more normal nerve normal pressure diabetic with diabetic retinopathy You know yeah, I might I might watch that I might not just assume right off Oh, you got you also have glaucoma if all the other parameters were pretty normal But but in this setting with that nerve, that's a disc hemorrhage Get a little harder, but there is one there Everybody see that one Down in fear early there just right off that vessel just a small little disc hemorrhage right there So they come in all safety sizes, but if you see one It means different things certainly, you know there they are indeed more common in this thing We call normal pressure glaucoma. Okay, so it's like one of those things normal pressure glaucoma Sometimes you're there in the clinic and you're wondering gosh, is this something else? I mean this pressure has never been above 15 and yet they're losing field and whatever if you see a focal notch Or if you see a disc hemorrhage That is overwhelmingly Likely to be glaucoma. Okay those two things Okay These this is same patient two eyes Left eye right eye. What's that? That is a lot of asymmetry so what starts running through your mind you're just seeing that patient Let's say that patient was referred into you Because this is a common thing. Okay, let's say that patient was referred into you They're already on three drops. Okay, or something maybe they've already had SLT They seem to be getting worse and their pressure is 15 What what what do you kind of need to do? Scan them so exactly so you're on that that course this is that needs to be explained that kind of asymmetry Needs to be explained. So here's the first thing I do in this setting. Okay, they're already being treated Right, so the first thing I've got to do is I've got to go back through the notes Get old notes and if I find that because this is you know, sometimes you don't get this information at first You have to go dig for it. You've got to you've got to explain that Now the first thing I do is I get the old notes now if this patient and then they're probably already pseudophagic, right? So if this patient eight years ago Ten years ago came into their referring ophthalmologist with a pressure of 42 and they had exfoliation disease I'm done I've explained it their pressure was 40 in the past or traumatic glaucoma or something like that You know what I mean? Somewhere in the past they had this documented Major pressure episode that would be an explanation But if I go back through their record and their pressure has never been Above 20 and they've just been treated because they came in and their optic nerve kind of looked like this That's that I'm gonna scan that patient, right? So asymmetry like that You just got to explain that and and oftentimes it's just documenting a high pressure in the past But you're obligated to document that so that you can explain it But that's a if you can't find a high-pressure episode in that patient and definitely you'd scan that patient a few more I don't mean to play read my mind, but that's just a funky looking nerve, right? I mean, that's just an anomalous nerve and and I have that phrase I just write it down. This is an anomalous nerve and by that I mean, you know we're not going to be able to tell much by looking at that optic nerve, right and Who knows what's going on there? So that's where we're going to rely again heavily on Visual field right because that that OCT is going to be funky as well So that's just a nerve that it's it's it's a congenital nerve anomalous nerve And you're just gonna have to follow visual field data and pressure data on that. Does that make sense? this is So drusen and high pressure is just a nightmare Because you just never know what you're measuring right because drusen can cause horrible looking Visual fields in and of itself. So what are you going to do? How are you going to follow? that nerve and that patient and And what are you gonna? What's your threshold for treatment things like that any thoughts on that about drusen and Absolutely Absolutely, it does it they can look extraordinarily similar So, I mean everything you're saying is very true And so basically this is one situation where you oftentimes end up just treating the pressure, you know I you know that if that patient walked into my clinic Me and and this is my my opinion and had a pressure of Above 22 I'd treat him, you know because it you just don't know So this is a Clinical situation where you oftentimes just end up treating a pressure which we hate to do right we hate to say that to just treat A pressure but the reality is sometimes in glaucoma you do, you know Like some of these horrible nerves that have that we've looked at today You know if those patients have a pressure of 20 or 22 you just go, you know, this is this is a mismatch here This is not gonna do well and and we look to bring their pressure down and this is another example It's just sometimes you just have to treat the pressure in these patients. I've Trapped patients with bad drusen and pressure and bad fields and pressure that I just could get under control because I I mean I just don't know their feels getting worse. Is it drusen glaucoma? I don't know. So we just talk how you know the patient. I have a long talk about Our inability to really differentiate and you know, I've gone to trabeculectomy in some of them So it's this is a hard situation Yeah, that is the thing that's exactly the idea right there and if you talk to our neuro ophthalmologist here I think all of them are very much believers in that this idea of the two-hit Notion that if they have both Graves disease and pressure they have both drusen and pressure if they have both optic neuritis And pressure that that kind of double hit is makes them really susceptible Yeah, that's that's exactly the the philosophy right there And that's why I say often in them we just treat the pressure Even if we don't have evidence that it's the glaucoma that's doing it versus the drusen We just treat the pressure to again try to you know eliminate one of the two hits can't do anything about the drusen But we can lower the pressure Okay, great excellent Let's go to that one. What do you see there common optic neurofine well not common, but certainly not rare What's that? It is a pit. That's a pit pit can be congenital Can be acquired. I mean you can get a pit From glaucoma and I've got lots of patients over the years that have have an acquired pit That you can see develop So that's just another that can be a sign for sure a pretty advanced glaucoma is the development of a pit But they can also just be you know congenital So again, it's just another thing that makes it a little difficult to follow when they have a pit unless you have documented In your own kind of record the that they acquired that pit over the advancement of their glaucoma But a congenital pits kind of hard to interpret again This is just kind of a few pictures that make things difficult and then here's a nerve I know you can't see it in stereo, but this is when you talked about margins So this is one where the you know the margins are a little blurred there, right? And you got that peripapillary atrophy and that's kind of a junkie nerve to try to follow as well And you know, are they are they enough to all those nerves blurred enough that you'd scan that patient? Well, you know maybe I would try to get an OCT on that patient I try to get a field on just see what it showed But that's that's a nerve There's going to be a little bit hard to follow and just another example of Optic nerves that you look at and you sometimes are put in a position to try to follow them So just in summary, I think you know, you got to have the right tools to look at the optic nerve That's what it's all about. You have to have a a method in your mind That when you examine an optic nerve in the clinic You're just going to checklist off certain things, but it has to include everything you've said Which is margin color cup Rim is super important Focal notching and or thinning disc hemorrhages, you know, all of those things just need to be a part of your Routine for looking at optic nerve and and you know, you just you have to be able to get that view and I have some patients that I just have to dilate every time I see them their pupils are so small Or they have some opacity, you know a little cataract or something just the wrong place or something That I just have to dilate them every time and you know, that's just the way it is. They know that Um, but you have to be able to evaluate the nerve taking a photograph with you of the optic nerve at some point early on is indispensable And I should take more pictures. Uh, there's a couple of things that There's a logistical thing in that you can't just saying you can't bill for a photo and an OCT on the same day So you have to split those up, but to have a baseline photo I don't take I don't much take photos every year. Some people do But I mostly just get a baseline one and then use that as you know to follow But to have a photograph Is just really an important thing to do early on. Okay OCT great, especially early It gets less helpful late and the longitudinal use of OCT You know, we wish it were better. That's been studied for several years now and there's you know, there is Gazillion dollar grant out there to study longitudinal OCT and so far it's kind of come up with not much so I think again to in that early detection is where OCT has the most power and the more advanced the disease get the less Helpful it becomes I still get a lot of OCTs even serial OCTs I don't make tons of treatment decisions on an OCT change And if I don't see an OCT change of at least 10 microns, I think that's the same. That's kind of my my scale about 10 microns That's more just global. Yeah looking at that global thickness, but the same looking for focal changes, you know But it's got to be like a three micron five micron change on OCT. That's just That's just noise, you know to me also just one last thing on an OCT When you're looking at using it for optic nerves Anything that takes that OCT does zero is almost always an artifact So, you know when you're looking at OCT and you see it dipping down to zero in one or more places Sometimes it's just the whole thing is dipping down to zero. You know what I mean? It's just you got to throw that out that is inadequate And you know don't even use that to interpret. Okay, and there's some eyes. You just can't get an OCT And I've I I write up in that little especially comments box No more OCTs because it just doesn't work in that patient The visual field is still the gold standard. I know patients hate it and it's fraught with you know issues I totally get that but it's especially for advanced patients. It is still the gold standard So optic nerve. It's just learn to examine the optic nerve look at it every time Know what other parameters make an optic nerve at higher risk. We've talked about those vachymetry pressure age And then also that initial mean deviation value on a visual field. Those are the ones that go in that risk stratifier Great, we're almost out of time any we are at a time any questions or anything? Yes Undetermined I mean it's it's it's real and there are studies out on it. Um, but I think it's You know, it's it's it's one of those things that it it's not a hundred percent defined. Um I don't I don't have a machine up here. I'm not clamoring to get one um Pachymetry indispensable indispensable hysteresis kind of in emerging, you know technology that We'll see how it goes certainly like anything it has it's you know evangelicals about its importance, but It hasn't certainly doesn't match up to pachymetry because it just doesn't have the data to to back it up Does that have any theology or you say VEPs? I don't but again, you know, it focal ERG people VEP they're they're Well, I I guess I shouldn't say never. I mean I I do in certain circumstances like I do in uh patients I can't communicate with like we get a lot of them in kids get a lot of them in You know nonverbal patients for whatever reason absolutely in that setting But as just far as like the you know, the bread and butter following a communicative Patient in the clinic VEPs for me very few same with focal ERGs, but again, you can absolutely find The advocates out there for those things Um, you know, I think this kind of macular thinness is probably of all the things that we've mentioned here That's probably the one that is emerging the most As far as being a that's probably going to be a pretty helpful tool um Is those macular thickness maps as a as a sign and detector of glaucoma And again the idea being there's so many of those macular fibers that You can detect thinning of that anatomically before you can measure it with any kind of functional test Because there's just so many of them You