Monday, February 27, 2006

Section 1-B. The Meaning of Cupping

The term cupping of the optic nerve describes the appearance of the optic nerve to the examining eye doctor. When the nerve is viewed through the pupil, it looks like a cup seen from above. The cup is really an empty space in the middle of the optic nerve surrounded by optic nerve fibers. With the loss of nerve fibers from glaucoma, the cup becomes progressively larger because there is less space occupied by the remaining nerve fibers. A healthy optic nerve has many nerve fibers traveling through it (approximately 1.2 million fibers), so there is usually a small cup. As progressively more nerve fibers are damaged, less nerve fibers remain. Consequently, the cup enlarges. The amount of cupping is often described by the eye doctor as the “cup-to-disc ratio” (C/D ratio).

Figure 1-5. The optic nerve is divided into tenths and the cup is compared to the entire optic nerve (optic disc) to obtain the cup-to-disc ratio. This C/D ratio here is 0.4.




Figure 1-6. Normal optic nerve - 0.3 C/D ratio

Figure 1-7. Glaucomatous optic nerve – 0.9 C/D ratio



The C/D ratio attempts to quantify the extent of axonal (nerve fiber) loss. It compares the diameter of the cup to the entire diameter of the optic nerve head (disc). The normal C/D ratio is typically less than 0.5 (meaning that the diameter of the cup is 50% the diameter of the optic nerve head). This number is not a uniform number, because eyes with glaucoma tend to have more cupping in the vertical orientation than the horizontal orientation due to a difference in axonal support structures. Therefore, a measurement in just one orientation may not fully describe the extent of cupping. Eye doctors will often draw pictures and take photographs to accurately document the appearance of a glaucomatous optic nerve. Increases in cupping or nerve fiber loss indicate poorly controlled glaucoma.

In glaucoma the position of the blood vessels within the optic nerve can shift with the progressive cupping, and this can be an important clue that the glaucoma is continuing to cause optic nerve damage. Other exam findings suggestive of glaucoma include hemorrhages (bleeding) on or near the optic nerve. This is commonly seen in poorly controlled glaucoma and is indicative of ongoing optic nerve damage or unstable glaucoma.

If glaucoma affects only one eye, there may be asymmetry of the optic nerve cupping between the two eyes. The unaffected optic nerve will look normal while the affected eye will look cupped. Asymmetry of the optic nerves is another clue that can aid in the diagnosis of glaucoma.


Figures 1-8, 1-9. There is a slight asymmetry of the cup between these eyes. The right eye (pictured at left) has a slightly larger cut than the left eye (pictured at right).

In end stage disease, the nerve may be completely cupped, with no nerve fibers left. In this case, the nerve may appear pale and vision would be poor. While most patients that receive treatment will not progress to end-stage glaucoma, those that do may eventually become totally blind.

It is rare that other optic neuropathies result in cupping of the optic nerve. Most of the time, optic nerve head cupping is caused by glaucoma, and the amount of vision loss corresponds to the extent of cupping.

29 Comments:

Anonymous Anonymous said...

I am a PA student and this information was easy to understand, the pics were great. Very helpful. Thanks

7:45 AM  
Anonymous Anonymous said...

I have just been told that I may have some "cupping" and this has explained it very well for me. Thanks

5:18 AM  
Anonymous Anonymous said...

i too have been told I have some cupping. Waiting to take "field tests" to determine further. what were your results? Very informative.

6:03 PM  
Anonymous Anonymous said...

Thank you very much it was really easy to understand!!

3:30 AM  
Blogger Suzanne said...

i have cupping . 3 and awaiting fields test is this glaucoma or macula degeneration

9:35 AM  
Blogger Flowerlady said...

Yesterday I was told I have 2% & 4% cupping of optic nerve. I have been treated for Glaucoma for 11 years.How serious is this amount of cupping ?Flowerlady

6:41 PM  
Anonymous Anonymous said...

My eye doctor told me today I need to see a specialist. On the referral paper it said .5 horizontal and .6 vertical.... what does that mean. I am freaking out because my dad had ocular melenoma..... I just dont want bad news like that. I'm not sure I can handle that.

6:23 PM  
Anonymous eebo said...

well today the doctor told me that i have abnormal cupping !:'(
my right eye 40
my left eye 50
but my I.O.P was normal in both eyes,
is there a chance the i have a a glucoma or what is going with me !im scareeed

8:25 AM  
Anonymous Anonymous said...

One of my optic nerve has been asymmetric for at least 27 years. The doctor says I have glaucoma, how can this be? Wouldn't there been eye damage by now. The field of vision test can back the same as I first had one back in the '90s. Could this be normal for me?

10:21 AM  
Blogger MedRounds Publications said...

One of the risk factors for development of glaucoma is the asymmetric cupping of the fellow eyes. Progression or change over time is one, definitive way to diagnosing glaucoma.

Based on your description of no change over 27 years, there are at least 2 possibilities. 1. You had a glaucoma insult prior to 27 years ago, but has remained stable since then. or 2. You may have asymmetric optic nerve cupping that you were born with, and not acquired as a result of glaucoma.

We would advise you to ask these questions to your treating physician or seek another opinion from an ophthalmologist / glaucoma specialist in your area.

Thank you.

Young H. Kwon, MD PhD

10:51 AM  
Blogger Rashmi said...

Hello Doctor...My 6 month old son has been diagonised with infantile glaucoma...he has had a surgery in his left eye 2 months back. In the follow up check up the doctor has stated in his report as follows: "Fundus showed 0.2 Cupping in Right Eye and 0.3 Cupping in Left Eye". Also the horizontal corneal diameter in his right eye is 11.5 mm and in left eye, it is 12.5 mm. Is it normal values or any cause of concern? Does the values indicate that he may have glaucoma in his right eye as well? Is there any good hope for his future vision, keeping in mind his present eye condition? would await a response from your side...

11:45 PM  
Blogger MedRounds Publications said...

Dear Rashmi:

There is asymmetry between the fellow eyes in cupping and corneal diameter. This suggests that there is asymmetric intraocular pressure and possibly congenital glaucoma. You should find out if the intraocular pressures (IOP) are elevated, because elevated IOP is a hallmark of congenital/infantile glaucoma.

Approximately 2/3 of the congenital glaucoma occurs in both eyes and the rest in just one eye. Both eyes should be followed carefully.

It is also important to make sure that your child does not develop amblyopia (lazy eye) by getting appropriate refraction and patching treatment as needed. We usually involve pediatric ophthalmologist as well as glaucoma specialist in these cases.

If everyone works together diligently and with some luck, the child can go on to have good eye sight.

Best wishes.

Young H. Kwon, MD PhD

8:53 AM  
Anonymous Anonymous said...

I have had glaucoma for 25 years. I am now 53. I have lost quite a bit of sight in the right eye, that I lost real fast and then no more, and none in the left until just recently I have lost a tiny bit in the left, not sure what my cupping is, my doctor wants to do surgery on my right eye since IOP is 23, but I want to do it on my left (IOP 18 last visit) to make sure I don't lose any more sight in it. My IOP in the past has always been lower in right than left now last 2 visits it's opposite. Do I have the wrong thinking wanting to do my left eye first? This is because I will have to go off Diamox Sequels after surgery, this will make my left eye IOP go up & maybe more sight loss. I don't know what to do. Can you give a suggestion.

12:37 AM  
Blogger MedRounds Publications said...

Physicians typically do glaucoma surgery in the worse eye first because it has certain risks as well as benefit. On the other hand, your concerns are also legitimate. I would voice your concerns to your doctor and see his response. Perhaps there is something he can do in the left eye short of doing surgery. You can also obtain a second opinion regarding the glaucoma surgery.

Best wishes,

Young H. Kwon, MD PhD

8:28 PM  
Blogger Rashmi said...

Dear Doctor,

Thanks for your previous response. Further to my previous queries, i have the following doubts as well:

The IOP was 30 in his left eye on the day the surgery was done...he has been given spectacles by doctor for his left eye, stating that it is needed to avoid lazy eye(-3 Power). His right eye corneal diameter was 11mm 2 months back and now it has increased to 11.5mm..the doctor said that this may be due to increased pressure in right eye (i dont know the values)...does that mean that he may have to be operated in his right eye as well?...doctor, are there examples of people who had developed congenital / infantile glaucoma and have lived with considerably manageable eye sight throughout the life....being a mother of this child, i am constantly worried a lot about this...

4:18 AM  
Blogger MedRounds Publications said...

Dear Doctor,

Thanks for your previous response. Further to my previous queries, I have the following doubts as well:

The IOP was 30 in his left eye on the day the surgery was done...he has been given spectacles by doctor for his left eye, stating that it is needed to avoid lazy eye(-3 Power). His right eye corneal diameter was 11mm 2 months back and now it has increased to 11.5mm..the doctor said that this may be due to increased pressure in right eye (i dont know the values)...does that mean that he may have to be operated in his right eye as well?...doctor, are there examples of people who had developed congenital / infantile glaucoma and have lived with considerably manageable eye sight throughout the life....being a mother of this child, i am constantly worried a lot about this...

9:11 AM  
Blogger MedRounds Publications said...

I would talk to your physician about the left eye having increased in size. It may be that he is developing glaucoma in that eye also. Would need to know the eye pressure etc...

Yes, the visual outcome of people with congenital glaucoma spans a wide spectrum. There is no single predictable visual outcome. It depends on many factors including time of diagnosis, treatment(s), diligent follow-up and teamwork between physician(s) and family. There are many children with glaucoma who go on to have (near) normal vision if everything works out. They go on to attend school normally and lead normal lives. That is the ultimate goal. If you are constantly worried, please share your concern with your doctor.

Best wishes,

Young H. Kwon, MD PhD

9:11 AM  
Anonymous Anonymous said...

I am a 51 year old female who has been treated for glaucoma since I was 22. Eight months ago I had a trabeculectomy in my right eye, as a result of the surgery I developed a cataract, and then had to have cataract surgery. Now I see halos and constant glare. Lazer treatment did not help at all.On 5-11-09 I will have a trabectulectomy in my left eye and my doctor wants to do a cateract surgery at the same time.I am afraid of seeing halos in both eyes. Should I just have the trabulectomy and hope & pray I don't develop a cateract or have both surgerys because more than likely I will develop a cataract?

5:00 PM  
Blogger Andrew Doan, MD, PhD said...

Dear Anonymous (51 year old woman who has been treated for glaucoma since age 22):

Trabeculectomy may make your cataract worse. Therefore, your doctor likely wants to do a combined surgery and remove your cataract at the same time as your trabeculectomy surgery.

Do you see halos and constant glare out of the eye that had the cataract removed or do you see halos and constant glare out of the eye with the cataract present? I ask because the cataract may cause halos and glare too.

Sometimes patients report seeing halos and glare because of the lens implanted in the eye. The type of lens also makes a difference too. Do you know what type of lens was implanted in the eye? Was it a multifocal or "premium" intraocular lens?

Best regards,
Andrew Doan, MD, PhD

8:33 PM  
Anonymous Anonymous said...

I am the 51 year old woman who has been treated for glaucoma since age 22. Thank you for your response. I see halos and constant glare out of the eye that had the cataract removed.I do not know what type of lens that was implanted. All I know is that the trabeculectomy was successful, but because of the trama of the surgery I developed a cataract,and the halos only started after the cataract surgery. I do not have a cataract in the eye I'm about to have a trabeculetomy in, but my doctor wants to go ahead and do a cataract surgery at the same time because he thinks I will probably develop one again. thank you for any advice,Sarah

5:07 PM  
Anonymous Anonymous said...

I have been having an increase in visual acuity problems of late. I wear contact lenses for myopia. I also have severe dry eye syndrome and using Restatis. Newly diagnosed is 0.8 and 0.9 optic disc cupping in my left and right eyes (respectively). I did the visual field test and retinal pictures taken. IOP OU is 13.
What can these findings indicate? What other tests might need to be performed to help diagnose? Is there sound data that proves effecacy in lowering normotensive IOP to help protect the remaining optic nerves?
What journals do you suggest will help me understand? Thanks.
Krissa

8:23 PM  
Anonymous Anonymous said...

Iam a 37 years old female. I am hypermetrope. I suffer from eye strain. C/D ratio was 0.1, 0.5 in the left and right eyes respectively. I have borderline GHF testing and moderate reduction of RNFL thickness in the right eye.What's wrong with my right eye.

1:27 PM  
Blogger MedRounds Publications said...

Dear 37 years old female with 0.1 and 0.5 C/D:

You may have normal tension glaucoma if you have signs of glaucomatous optic nerve damage with normal intraocular pressures. "The Collaborative Normal Tension Glaucoma Study" showed that lowering the intraocular pressure by 30% decreased the rate of optic nerve damage in NTG. This can be achieved through medical or surgical means. Please talk to your physician about your diagnosis and the best method of treatment of your glaucoma.

Young H. Kwon, MD PhD

3:42 PM  
Anonymous Anonymous said...

I'm a37 years old female with With Cupping on the right eye (optic disc cup on the right eye double that on the left eye) normal IOP (12) normal RNFL thickness. Field of vision was done for 3 times(it was at first borderline GHT for the rt eye, then showed a paracenteral scotoma for the rt eye, at the third time the lft eye wasn't properly covered , but the field of vision was normal). My physician advised me to monitor the IOP and to repeat the field of vision after a year

1:05 PM  
Anonymous Anonymous said...

I am a medical student, and I found this patient tutorial incredibly helpful. Thank you.

6:48 PM  
Anonymous Anonymous said...

I'm the 37 years old female with 0.1,0.5 C/D.I was examined by an ophthalmology consultant, he made me repeat the OCT which he found to be stable for 6 months, my second field of vision testing showed a paracentral scotoma in the rt eye,when I repeated the field of vision for the third time it was normal, but my rt eye was not properly covered. My IOP is 12 all over the daytime. Pachymetery showed central corneal thickness more than 600. My doctor recommended follow up by IOP after further 6 months and OCT and field of vision after 1 year. Do I still have risk of developing glaucoma?

11:47 AM  
Blogger MedRounds Publications said...

Dear Dear 37 years old female with 0.1 and 0.5 C/D:

You may still be at risk for glaucoma in the future and need yearly follow-up.

Good luck,
Andrew Doan, MD, PhD

6:14 PM  
Blogger MedRounds Publications said...

Dear 55 female with 7.4 cupping:

Did your eye doctor scan your optic nerve with an OCT? Did he perform a visual field test? The judgement of cupping is subjective unless it's done by one doctor and/or compared with previous stereo photographs of the optic nerve.

The diagnosis of glaucoma is made when there is progression, i.e. increased cupping over time, increase in visual field loss, bleeding of the optic nerve, and/or thinning of the nerve fiber layer when measured on OCT. Thus, unless your doctor sees changes, you may not have glaucoma yet.

Andrew Doan, MD, PhD

3:23 AM  
Blogger Allison said...

Hi im a medical student currently on my 1st day in ophthalmology posting. Thanks for this information. It's simple and easy to understand :)

9:22 AM  

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