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Understanding Cupping and Compressive Lesions in Normal Tension Glaucoma

This article explores the relationship between cupping of the optic nerve head and compressive lesions in patients with normal tension glaucoma (NTG). It highlights that up to 25% of NTG patients may exhibit cupping, sometimes attributed to conditions such as meningiomas or arachnoid cysts. Diagnostic imaging could be warranted, especially in younger patients or when there’s an atypical acute visual field loss. Key studies are referenced to underline the importance of recognizing intracranial lesions as potential contributors to visual field defects in NTG cases.

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Understanding Cupping and Compressive Lesions in Normal Tension Glaucoma

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  1. Is it a fish… or is it fishy?

  2. ORWhen might a cupped disc be something else? ד"ר תמר פדות קלויזמן בי"ח בני ציון ושרותי בריאות כללית - חיפה

  3. Our Patients

  4. Frequency • Up to 15-25% of patients with POAG experience NTG • In the Baltimore Eye Study: • 50% of individuals with cupping and VF changes had an IOP < 21 on a single visit • 33% had an IOP < 21 mm Hg on 2 measurements

  5. NTG and compressive lesions • Both can cause ONH cupping • Both can produce VF changes • Compression of the ON may make the nerve susceptible to damage at normal Tension

  6. Do I need to image? • Yes – Occasional pathology found, Kasta”ch – difficult patients • No – Low cost effectiveness, unnecessary radiation (CT)

  7. Meningiomas Craniopharyngiomas Pituitary tumors Cysts Chordomas Compression by normal carotid artety Aneurysms affecting the prechiasmal and/or chiasmal visual pathways. Compressive lesions to consider in NTG

  8. Compression by ICA • Gutman and Melamed (Graefes 1993) studied by CT 62 patients with NTG • 90% had either calcification or dilation of the ICA adjacent to the opening of the optic canal • Only 21% of age matched controls had similar abnormalities

  9. N. Ogata - BJO 2005 • Retrospective, 103 eyes with NTG, 104 controls • Compressive optic neuropathy by ICA in 49.5% of NTG patients • 34.6% in age matched controls • Bilateral compression 40.7% of NTG • 21.2% in controls • C/D > 0.7 – higher frequency of ICA compression Neurosurgical decompression? – don’t rush

  10. Sheba Hospital (RHB) • 40 consecutive NTG suspects referred to the neuro-ophthalmology clinic • Complete neuro-ophthalmic exam • Review of scans by neuro-ophthalmologist (RHB)and neuro-radiolosist (MB)

  11. Results

  12. NTG - Suspected findings: > visual complaint > color vision defect > optic disc pallor > atypical visual field defect for glaucoma

  13. Greenfield - Oph 1998 • A retrospective case-controlled study : • Fifty-two eyes of 29 NTG patients • All had brain CT or MRI as part of a diagnostic evaluation between 1985- 1995 • Comparison group – • 44 eyes of 28 patients withcompressive lesions and increased C/D ratio

  14. RESULTS None of the patients diagnosed with glaucoma had radiologic evidence of a mass lesion in the anterior visual pathway

  15. Glaucoma patients Older 68.7 y Better VA Vertical cupping Disc hemorrhage (13%) Less NR pallor HVF – arcuate defects aligned horizontally Compressive lesions Younger <50 y VA < 20/40 No disc hemorrhage Mostly pallor Vertically aligned defects Group characteristics

  16. CONCLUSIONS • Anterior visual pathway compression is an uncommon finding in the neuroimaging of patients with suspected NTG. • Younger age, lower levels of visual acuity, vertically aligned visual field defects, and neuroretinal rim pallor may increase the likelihood of identifying an intracranial mass lesion.

  17. Ahmed - Methods • A prospective, comparative, observational case series, 1988-1998 • 62 consecutive NTG patients had MRI • 70 progressive POAG with controlled IOP . • The prevalence of intracranial compressive lesions, demographic data, and clinical characteristics were compared. J Glaucoma, 2002

  18. RESULTS • 4 of the 62 (6.5%) patients withNTG had clinically relevant intracranialcompressive lesions involving the anterior visual pathway • 2 pituitary macroadenoma, 1 meningioma, 1 arachnoid cyst • None of the 70 patients with POAG had a compressive lesion (P = 0.039)

  19. What is the diagnosis? 24-2 HVF of a patient with pituitary macroadenoma

  20. What is the diagnosis? HVF of a patient with an arachnoid cyst

  21. CONCLUSIONS: • Intracranial compressive lesions are an important diagnostic consideration in the workup of normal-pressure glaucoma • Ahmed: Neuroimaging is cost-effective Remember: • Compressive lesions can cause cupping and mimic glaucomatous VF defects!!! Trobe et al, Arch oph 1980

  22. “Red Flags” • Mismatch between the cupping and the visual field loss (C/D 0.5 but 10°- VF remaining). • An APD or visual acuity loss out of proportion to the VF loss or cupping. • Rapid progression of visual loss. • Glaucomatous-appearing visual field loss in a patient with an anomalous or hypoplastic optic nerve (where cupping is hard to judge).

  23. Indications for neurological workup • Unexplained reduction of visual acuity • Color vision loss w/o advanced VF loss • visual field loss out of proportion to cupping • VF loss atypical for glaucoma • Optic nerve pallor in excess of cupping • Neurological symptoms.

  24. I agree with the authors • If it looks like normal-tension glaucoma, you do not have to do neuroimaging to sleep at night. Richard Mills, Discussion on Greenfield

  25. Thank You

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