ORIGINAL STUDY
A Comparison of Optic Nerve Head Topographic
Measurements by Stratus OCT in Patients With
Macrodiscs and Normal-sized Healthy Discs
Funda E. Onmez, MD,* Banu Satana, MD,w Cigdem Altan, MD,w
Berna Basarir, MD,w and Ahmet Demirok, MDw
Purpose: To evaluate and compare optic nerve head parameters
and retinal nerve ber layer (RNFL) thickness between large discs
and normal-sized vital discs using Stratus optical coherence
tomography (OCT).
Methods: A total of 293 healthy eyes (145 with macrodisc and 148
with normal-sized disc) were enrolled in the study. After a complete
ophthalmic evaluation, measurement of optic nerve head parame-
ters and RNFL thickness using OCT was performed in all subjects.
Optic disc areas larger than 2.80 mm2 were accepted as macrodiscs.
All OCT parameters were compared between normal-sized discs
and macrodiscs.
Results: Participants mean age was 46.5 10.6 years (range, 13 to
74 y). Average optic disc areas were 2.19 0.29 and 3.02
0.29 mm2 in the normal and the macrodisc groups, respectively.
The optic disc area (P < 0.0001), the cup area (P < 0.0001), the
horizontal cup disc ratio (P < 0.0001), the vertical cup disc ratio
(P < 0.0001), and the cup disc area ratio (P < 0.0001) were found
to be signicantly dierent in the macrodisc group and the control
group. Rim areas (P = 0.57) and RNFL thicknesses (inferior,
superior, and mean) were found to be similar in both groups
(P = 0.75, 0.65, 0.85, respectively).
Conclusions: A macrodisc may have a macrocup and should not be
misdiagnosed as glaucoma. The present study showed that macro-
discs are identical to normal-sized discs in terms of rim area and
RNFL thickness. We suggest that these 2 OCT parameters can help
to dierentiate a healthy macrodisc from a glaucomatous optic disc.
Key Words: optical coherence tomography, glaucoma, large optic
disc, macrodisc, optic nerve head analysis
(J Glaucoma 2014;23:e152e156)
G laucoma is an irreversible optic neuropathy charac-
terized by a progressive injury to the optic nerve and
the retinal nerve ber layer (RNFL).1 Early detection of
glaucomatous changes of the optic nerve head (ONH) is
essential in the prevention of progression of glaucoma.
Clinical estimation of the vertical cup/disc ratio (C/D)
remains the most frequently performed assessment of the
Received for publication January 29, 2013; accepted September 11,
2013.
From the *Department of Ophthalmology, Education and Research
Hospital, Sakarya University, Sakarya; and wDepartment of Oph-
thalmology, Beyoglu Eye Education and Research Hospital,
Istanbul, Turkey.
Disclosure: The authors declare no conict of interest.
Reprints: Funda E. Onmez, MD, Kemalpasa Mah. 111. Sokak Platin
Park Sitesi 14/A Blok Daire: 2, Serdivan, Sakarya 54055, Turkey
(e-mail: ebru.funda@gmail.com).
Copyright r 2013 by Lippincott Williams & Wilkins
DOI: 10.1097/IJG.0000000000000021
e152 | www.glaucomajournal.com J Glaucoma
optic disc in the diagnosis and follow-up of glaucoma. The
cup/disc ratio is physiologically related to the optic disc
size.24
In recent years, new technologies for quantitative and
objective optic disc assessment have become available such
as confocal scanning laser ophthalmoscopy (eg, Heidelberg
retina tomograph), scanning laser polarimetry (eg,
GDx-VCC), and optical coherence tomography (OCT;
eg, Stratus OCT). Using these technologies, quantitative
measurements of the optic disc size and the RNFL
thickness and optic cup measurements can be performed,
and these measurements may be used to help distinguish
healthy optic discs from discs with glaucomatous optic
neuropathies. Previous studies showed that OCT obtains
accurate and reproducible RNFL and optic disc analysis.5,6
Visual eld (VF) loss correlates with RNFL thickness as
determined by OCT in glaucoma patients.7 In the present
study, we used Stratus OCT for ONH and RNFL analysis.
A challenging factor in the evaluation of a glaucoma
suspect with large cups is to decide whether the cup is
physiological in a large disc or pathologic in a small-sized
disc. Similarly, a small C/D ratio in an ocular hypertensive
patient may be pathologic if the disc is small. Therefore,
patients who have physiological large cups in large discs
can be misdiagnosed as glaucoma patients or patients with
small discs, a small C/D ratio, and a high intraocular
pressure (IOP) can be misdiagnosed as ocular hypertensive
instead of glaucomatous.
To the best of our knowledge, there have been no valid
database addressing the ONH parameters in healthy mac-
rodiscs measured by Stratus OCT. Therefore, this study
was designed to evaluate and compare ONH parameters
between large discs and normal-sized discs.
METHODS
We conducted a prospective, cross-sectional, and
comparative study. The study population consisted of
patients who came to the ophthalmology clinic for a regular
eye examination. Before being included in the study, each
individual was informed of its purpose, and written consent
to participate was obtained from them. All eligible subjects
ranged in age from 13 to 74 years.
Recent studies performed with Stratus OCT have
documented the mean optic disc area for white patients as
approximately 2.20 0.3 mm2.6,812 On the basis of the
Gaussian-like distribution curve of the optic disc area, mac-
rodiscs can be dened morphometrically as being larger than
the mean plus 2 SD. In this study, we dened macrodiscs as
being larger than 2.80 mm2.13 In contrast, normal disc size
was dened by a disc area between 1.4 and 2.80 mm2.
 Volume 23, Number 8, October/November 2014
J Glaucoma  Volume 23, Number 8, October/November 2014 ONH Parameters of Macrodiscs by Stratus OCT

All subjects underwent a complete ophthalmic evalu-
ation, including medical history, IOP measurement, VF
testing, central corneal thickness (CCT) measurement with
corneal ultrasound pachymeter, undilated and dilated bio-
microscopy, and dilated fundus examination. Ophthalmic
evaluation, VF testing, and OCT imaging were all per-
formed in 1 month.
All tested eyes had a best corrected visual acuity above
20/25, spherical refractive error within 2.0 D, cylindrical
error within 2.0 D, and IOPr21 mm Hg. Patients with
signicant ocular disorder, optic nerve diseases such as
glaucoma, a history of intraocular surgery and systemic
diseases with possible ocular involvement, such as diabetes
mellitus, were excluded from the study. OCT scans with a
signal strength of <6 were also excluded. All the subjects
had to have a reliable (xation loss, false-positive, and
false-negative error <10%) and normal (absence of all 3 of
Anderson and Patellas criteria14) Humphrey 30-2 SITA-
standard testing. One eye of each participant was enrolled.
If both eyes met the inclusion criteria, the eye with larger
disc area was selected.
All optic disc and RNFL measurements were per-
formed using the fast optic disc-scanning protocol and
automated ONH analysis using version 3.0 Stratus OCT
analysis software (Stratus OCT, software version 3.0; Carl
Zeiss Meditec Inc., Dublin, CA). A maximum of 2 ONH
scans of each subject were obtained, and the better of the 2
scans was chosen for interpretation. ONH evaluation con-
sisted of 6 radial scans centered on the ONH, spaced 30
degrees apart (Fast Optic Disc acquisition protocol). The
machine automatically dened the edge of the optic disc as
the end of the retinal pigment epithelium/choriocapillaris.
The resultant image could be corrected manually when the
machine did not identify the edge correctly. Eleven eyes
needed manual correction, and this correction of the
automatic ONH tracing was performed by 2 investigators
(F.E.O. and C.A.). The fast RNFL algorithm was used to
measure the RNFL thickness with the Stratus OCT. Three
scan images were obtained from each subject, with each
image consisting of 256 A-scans along a 3.4-mm-diameter
circular ring around the optic disc. These values were
averaged to yield 12 clock-hour thicknesses, 4 quadrant
thicknesses, and a global average RNFL thickness
measurement.
Good-quality scans had to have focused images from
the ocular fundus, adequate signal strength (> 6 for
RNFL), and the presence of a centered circular ring around
the optic disc (for RNFL scans). For ONH scans, the radial
scans had to be centered on the optic disc. RNFL scans
were also evaluated as to the adequacy of the algorithm for
detection of the RNFL.
The default axial length and the refraction for the optic
disc measurement in every OCT scan were set to 24.46 mm
and 0 D, respectively. For this reason, the exact disc size in an
eye with axial length dierent from 24.46 mm and/or refrac-
tion <0 D would be dierent than the printout values.
Therefore, manual correction for optic disc measurements is
necessary. To correct axial length-related ocular magnica-
tion, we applied the Littmann formula (t = pqs), as
modied by Bennet and later adopted by Leung et al and
Kang et al.1518 In this Formula, t is the actual fundus
dimension, s is the measurement on OCT, p is the magni-
cation factor related to the imaging system, and q is the
magnication factor related to the eye. Factor p is instrument
dependent and remains a constant in a telecentric imaging
system: in Stratus OCT, it is 3.382. The ocular magnication
factor q of the eye can be determined with the formula
q = 0.01306 (axial length 1.82).17 Therefore, given a value,
s, obtained with OCT, the real size of the RNFL peripapillary
scan circle can be determined by means of the formula
t = 3.3820.01306 (axial length 1.82) s.
Because the Littmann formula refers to linear magni-
cation, we modied the equation to t2 = p2 q2  s2 for
area magnication according to the suggestion of Leung
et al.19
Statistical Analysis
OCT parameters compared between normal and large
discs were as follows: optic disc area (mm2), cup area
(mm2), rim area (mm2), horizontal C/D ratio, vertical C/D
ratio, C/D area ratio, and RNFL thickness (inferior,
superior, and mean). All Statistical analyses were per-
formed with SPSS software (SPSS for Windows Version
15.0; SPSS Inc., Chicago, IL). Categorical variables were
compared by w2 analysis, and continuous variables with
normal distributions were compared by Student t test. The
Kolmogorov-Smirnov nonparametric test was used to
evaluate the normal distribution of numerical data. Results
of the measurements were expressed as mean SD. Pear-
son correlation coecients and multivariate linear regres-
sion analyses were performed to evaluate the relationship
between optic disc area and other OCT parameters.
P < 0.05 was considered statistically signicant.
RESULTS
A total of 293 healthy eyes (145 with macrodiscs and
148 with normal-sized discs) were enrolled in the study.
Participants mean age was 46.5 10.6 years (range, 13 to
74 y). In Table 1, the demographic and clinical character-
istics were compared between the 2 groups. The CCT was
found to be slightly more in the macrodisc group
(P = 0.04), whereas there was no statistical dierence in
IOP measurements (P = 0.51), axial length (P = 0.68), and
VF indices (mean deviation and pattern SD: P = 0.13, 0.56,
respectively).
In Table 2, the OCT optic disc parameters and RNFL
thicknesses were compared between the 2 groups. The optic
disc area (P < 0.0001), the cup area (P < 0.0001), the hori-
zontal C/D ratio (P < 0.0001), the vertical C/D ratio
(P < 0.0001), and the C/D area ratio (P < 0.0001) were
found to be signicantly dierent in the macrodisc group and
the control group. The rim area (P = 0.575) and RNFL
TABLE 1. Demographic and Clinical Characteristics of the Study
Groups
Macrodisc Normal
Group Group P
Age (mean SD) (y) 46.33 10.3 46.85 9.0 0.65
Male/female [n (%)] 70 (48.2)/75 73 (49.3)/75 0.15
(51.8) (51.7)
MD (db) 1.10 1.35 1.39 1.24 0.13
PSD (db) 1.99 1.16 1.92 0.82 0.56
Intraocular pressure 15.4 2.73 14.9 3.01 0.51
(mean SD) (mm Hg)
Central corneal thickness 560.4 38.2 557.7 33.2 0.04
(mean SD) (mm)
Axial length (mm) 23.29 0.80 23.25 0.83 0.68
MD indicates mean deviation; PSD, pattern SD.

r 2013 Lippincott Williams & Wilkins www.glaucomajournal.com | e153

Onmez et al
TABLE 2. A Comparison of OCT Parameters (Magnification Corrected) Between Macrodiscs and Normal Discs
Macrodisc Group
Optic disc area (mm2) 3.02 0.29 (2.81-3.95)
Cup area (mm2) 1.37 0.61 (0.03-3.1)
Rim area (mm2) 1.65 0.51 (0.52-2.62)
Horizontal C/D ratio 0.66 0.16 (0.10-0.98)
Vertical C/D ratio 0.58 0.14 (0.11-0.9)
C/D area ratio 0.42 0.17 (0.01-0.9)
Superior RNFL thickness (mm) 119.99 15.39 (81.39-157.92)
Inferior RNFL thickness (mm) 124.39 16.38 (81.48-177.5)
Average RNFL thickness (mm) 144.14 8.06 (71.10-124.95)
OCT indicates optical coherence tomography; RNFL, retinal nerve ber layer.
thicknesses (inferior, superior, and mean) were found to be
similar in both groups (P = 0.758, 0.653, 0.851, respectively).
In the correlation analysis, a strong positive correlation
was detected between the OD area and the cup area
(r = 0.637, P < 0.0001). Moderate positive correlations were
found between the OD area and the horizontal C/D ratio, the
vertical C/D ratio, and the C/D area ratio (r = 0.507,
P < 0.0001; r = 0.516, P < 0.0001; r = 0.504, P < 0.0001,
respectively). However, the correlation between the OD area
and the rim area was not statistically signicant (r = 0.078,
P = 0.182). A weak positive correlation was found between
the OD area and the average RNFL thickness (r = 0.157,
P = 0.007). In the multiple linear regression analyses, the
cup area (P < 0.0001), the horizontal C/D ratio (P < 0.0001),
the vertical C/D ratio P < 0.0001), the C/D area ratio
(P < 0.0001), and the average RNFL thickness (P < 0.001)
remained signicantly related to the optic disc area (Table 3).
DISCUSSION
The present study was designed with the main objec-
tive of evaluating and comparing the ONH parameters
between large discs and normal-sized discs.
In our study, we revealed that macrodiscs have a larger
cup area, horizontal C/D ratio, vertical C/D ratio, and C/D
area ratio than normal-sized discs by OCT. Moreover,
RNFL thicknesses, rim areas, and VF indices (MD, pattern
SD) of macrodiscs were similar to those of normal subjects.
This is the rst study to evaluate the ONH parameters of
macrodiscs using OCT.
As large ONHs have large cups, they can be misdiag-
nosed and treated as glaucoma. Therefore, the dierentiation
of ONH parameters between normal and macrodiscs is
extremely important for the dierential diagnosis of a
healthy macrodisc from glaucomatous optic neuropathy.
The vertical cup/disc ratio is positively correlated with
optic disc size in normal and glaucomatous eyes.2,2021 The
Blue Mountains Eye Study showed a positive relationship
between the cup/disc ratio and the disc size.2 The impor-
tance of assessing the cup/disc ratio corrected for disc size
was studied by Jonas and colleagues. They showed that the
vertical cup/disc ratio corrected for disc size had the highest
diagnostic power compared with other optic disc parame-
ters for distinguishing normal subjects from preperimetric
glaucoma patients.21,22 Our study showed that there were
moderate positive correlations between the optic disc size
and vertical, horizontal, and area C/D ratios.
Several publications revealed that a macrodisc may
have a macrocup because of the direct relationship between
the disc area and the cup area.12,23 The term
e154 | www.glaucomajournal.com
J Glaucoma  Volume 23, Number 8, October/November 2014
Normal Group P
2.19 0.29 (1.54-2.80) < 0.0001
0.67 0.46 (0.03-2.06) < 0.0001
1.62 0.45 (0.57-2.51) 0.575
0.51 0.18 (0.16-0.96) < 0.0001
0.45 0.15 (0.09-0.91) < 0.0001
0.27 0.18 (0.02-0.91) < 0.0001
118.95 16.08 (82.04-170.3) 0.653
123.82 18.09 (82.65-156.54) 0.758
144.32 8.17 (72.19-126.78) 0.851
pseudoglaucomatous physiological large cup was intro-
duced by Jonas et al24 and the morphologic characteristics
of physiological large cups were dened as an abnormally
large optic disc area, a large C/D ratio, normal neuroretinal
rim area and conguration, and normal parapapillary
RNFL.
In a study performed with confocal scanning laser
ophthalmoscopy, Cankaya and Simsek25 showed that
macrodiscs have a larger rim area than normal-sized discs.
In contrast, our study revealed that there was no signicant
dierence in the rim area between the 2 groups. Although
dierent studies revealed that the neuroretinal rim area
increases as the disc size increases, there was no signicant
correlation detected between these 2 parameters in our
study group.4,2527
Savini et al27 showed that the RNFL thickness meas-
ured by Stratus OCT was associated with the ONH size.
Budenz et al28 have also demonstrated thicker RNFLs by
OCT in larger optic discs. However, a human histologic
study revealed that the average RNFL thickness was not
related to the disc area.29 Recently, Huang and colleagues
reported that the RNFL thickness measured by OCT was
not correlated with the Heidelberg Retina Tomograph-
determined optic disc area, which was magnication
corrected. Their results suggested that this was due to
magnication variation related to axial length variation
within the human population. Their evidences support
magnication as the link between RNFL thickness and disc
area.30 Previous investigators did not take the magnication
variation into account.27,28 In our study, we corrected axial
length-related ocular magnication using the Littmann
formula. We found that RNFL thicknesses were similar in
macrodiscs and normal-sized discs, and there was a weak
correlation between RNFL thickness and the optic disc size.
Viestenz et al31 reported that eyes with macrodiscs and
normal IOP had a thicker CCT than healthy discs in
patients without glaucoma. However, in our study, the
CCT of eyes with macrodiscs was slightly thicker than eyes
with normal-sized discs, but the IOP was found to be
similar between the 2 groups.
Large discs have a large total lamina cribrosa area and
more lamina pores than small discs. These pores allow more
space for nerve bers to travel through, and therefore, they
reduce the risk of compression to the optic nerve axons.12 In
contrast, the pressure dierential across the lamina cribrosa
can produce an increased deformation and displacement of
the central tissue in macrodiscs, leading to greater glaucoma
susceptibility in these eyes.32,33 Burgoyne and colleagues
suggested that mechanical failure of the connective tissue
of the lamina cribrosa underlies glaucomatous cupping.
r 2013 Lippincott Williams & Wilkins
J Glaucoma  Volume 23, Number 8, October/November 2014
TABLE 3. Linear Regression Analysis: The Association Between Optic Disc Area and Other OCT Parameters in the Overall Population
Pearson Correlation
Variables r P
2
Rim area (mm ) 0.078
Cup area (mm2) 0.637
Horizontal C/D ratio 0.507
Vertical C/D ratio 0.516
C/D area ratio 0.504
Superior RNFL thickness (mm) 0.156
Inferior RNFL thickness (mm) 0.108
Average RNFL thickness (mm) 0.157
R2
Adjusted R2
*Multivariate linear regression analysis.
b indicates regression coecients; OCT, optical coherence tomography; RNFL, retinal nerve ber layer.
Therefore, large discs may be more susceptible to pressure
damage as per Laplace law.34 However, there is no large
randomized study on this issue, and further investigation is
needed. Burk et al35 concluded that statistically normal IOP
readings should not be considered as protection against
future glaucomatous damage, especially in ONHs with
increased cupping and large disc areas.
OCT is accepted as an eective tool for early glaucoma
detection and follow-up to monitor glaucoma pro-
gression.36 One of the major limitations of our study was
that we used time domain OCT instead of the new-gen-
eration spectral domain OCT. Imaging with spectral
domain OCT has enabled clinicians to visualize main
structures of the ONH like Bruch membrane (BM) and its
termination. Also, in most eyes, there is an invisible
extension of the BM internal to the clinically determined
disc margin. As such, current methods of neuroretinal rim
tissue assessment, including cup-to-disc ratio and rim area,
are unlikely to represent the remaining amount of neural
tissue. Reis et al37 indicate that what we perceive as the
optic disc margin in an individual eye is rarely a single
structure; most frequently, it is some aspect of the BM and
border tissue, and less frequently, a BM opening or border
tissue alone. However, in the comparison of the diagnostic
accuracy of SD-OCT and Stratus OCT for glaucoma,
studies revealed that the diagnostic power of the 2 OCTs is
equal in eyes with primary open-angle glaucoma, primary
angle-closure glaucoma, and preperimetric glaucoma.3843
In conclusion, a macrodisc may have a macrocup and
should not be misdiagnosed as glaucoma. The present study
showed that macrodiscs are identical to normal-sized discs
in terms of rim area and RNFL thickness. We suggest that
these 2 OCT parameters can help to dierentiate a healthy
macrodisc from a glaucomatous optic disc. Because of their
mechanical properties, these eyes are probably more
susceptible to an increased IOP, leading to glaucomatous
neuropathy.12 Hence, follow-up examinations of patients
with macrodiscs are extremely important in the early
diagnosis of glaucoma.
REFERENCES
1. Sommer A, Miller NR, Pollack I, et al. The nerve fiber layer in
the diagnosis of glaucoma. Arch Ophthalmol. 1977;95:21492156.
2. Crowston JG, Hopley CR, Healey PR, et al. The effect of optic
disc diameter on vertical cup to disc ratio percentiles in a
population based cohort: the Blue Mountains Eye Study. Br J
Ophthalmol. 2004;88:766770.
r 2013 Lippincott Williams & Wilkins
ONH Parameters of Macrodiscs by Stratus OCT
Multivariate Analysis*
b P
0.182
< 0.0001 2.46 < 0.0001
< 0.0001 0.31 < 0.0001
< 0.0001 0.37 < 0.0001
< 0.0001 2.49 < 0.0001
0.008 0.09 0.779
0.066
0.007 0.14 < 0.001
0.825
0.821
3. Garway-Heath DF, Ruben ST, Viswanathan A, et al. Vertical
cup/disc ratio in relation to optic disc size: its value in the
assessment of the glaucoma suspect. Br J Ophthalmol.
1998;82:11181124.
4. Jonas JB, Gusek GC, Naumann GO. Optic disc, cup and
neuroretinal rim size, configuration and correlations in
normal eyes. Invest Ophthalmol Vis Sci. 1988;29:11511158.
5. Olmedo M, Cadarso-Suarez C, Gomez-Ulla F, et al. Re-
producibility of optic nerve head measurements obtained by
optical coherence tomography. Eur J Ophthalmol. 2005;
15:486492.
6. Paunescu LA, Schuman JS, Price LL, et al. Reproducibility of
nerve fiber thickness, macular thickness, and optic nerve head
measurements using Stratus OCT. Invest Ophthalmol Vis Sci.
2004;45:17161724.
7. Kanamori A, Nakamura M, Escano MF, et al. Evaluation of
the glaucomatous damage on retinal nerve fiber layer thickness
measured by optical coherence tomography. Am J Ophthalmol.
2003;135:513520.
8. Samarawickrama C, Hong T, Jonas JB, et al. Measurement of
normal optic nerve head parameters. Surv Ophthalmol.
2012;57:317336.
9. Savini G, Espana EM, Acosta AC, et al. Agreement between
optical coherence tomography and digital stereophotography
in vertical cup-to-disc ratio measurement. Graefes Arch Clin
Exp Ophthalmol. 2009;247:377383.
10. Marsh BC, Cantor LB, WuDunn D, et al. Optic nerve head
(ONH) topographic analysis by stratus OCT in normal subjects:
correlation to disc size, age, and ethnicity. J Glaucoma. 2010;
19:310318.
11. Schuman JS, Wollstein G, Farra T, et al. Comparison of optic
nerve head measurements obtained by optical coherence
tomography and confocal scanning laser ophthalmoscopy.
Am J Ophthalmol. 2003;135:504512.
12. Hoffmann EM, Zangwill LM, Crowston JG, et al. Optic disk
size and glaucoma. Surv Ophthalmol. 2007;52:3249.
13. Shaarawy T, Sherwood MB, Hitchings RA, et al. Diagnosis
of glaucoma. Glaucoma: Expert Consult Premium Edition
Volume 1. Medical Diagnosis and Therapy. UK: Saunders
Elsevier; 2009:213214.
14. Anderson DR, Patella VM. Automated Static Perimetry.
2nd ed. St.Louis: Mosby; 1999:121190.
15. Leung CK, Mohamed S, Leung KS, et al. Retinal nerve fiber layer
measurements in myopia: an optical coherence tomography study.
Invest Ophthalmol Vis Sci. 2006;47:51715176.
16. Littmann H. Determination of the real size of an object on the
fundus of the living eye. Klin Monatsbl Augenheilkd.
1982;180:286289.
17. Bennett AG, Rudnicka AR, Edgar DF. Improvements on
Littmanns method of determining the size of retinal features
by fundus photography. Graefes Arch Clin Exp Ophthalmol.
1994;232:361367.
www.glaucomajournal.com | e155
Onmez et al
18. Kang SH, Hong SW, Im SK, et al. Effect of myopia on the
thickness of the retinal nerve fiber layer measured by Cirrus
HD optical coherence tomography. Invest Ophthalmol Vis Sci.
2010;51:40754080.
19. Leung CK, Cheng AC, Chong KK, et al. Optic disc measure-
ments in myopia with optical coherence tomography and
confocal scanning laser ophthalmoscopy. Invest Ophthalmol
Vis Sci. 2007;48:31783183.
20. Britton RJ, Drance SM, Schulzer M, et al. The area of the
neuroretinal rim of the optic nerve in normal eyes. Am J
Ophthalmol. 1987;103:497504.
21. Jonas JB, Bergua A, Schmitz-Valckenberg P, et al. Ranking of
optic disc variables for detection of glaucomatous optic nerve
damage. Invest Ophthalmol Vis Sci. 2000;41:17641773.
22. Jonas JB, Budde WM. Diagnosis and pathogenesis of
glaucomatous optic neuropathy: morphological aspects. Prog
Retin Eye Res. 2000;19:140.
23. Jonas JB, Schmidt AM, Muller-Bergh JA, et al. Human optic
nerve fiber count and optic disc size. Invest Ophthalmol Vis Sci.
1992;33:20122018.
24. Jonas JB, Zach FM, Gusek GC, et al. Pseudoglaucomatous
physiologic large cups. Am J Ophthalmol. 1989;107:137144.
25. Cankaya AB, Simsek T. Topographic differences between large
and normal optic discs: a confocal scanning laser ophthalmo-
scopy study. Eur J Ophthalmol. 2012;22:6369.
26. Caprioli J, Miller JM. Optic disc rim area is related to the disc
size in normal subjects. Arch Ophthalmol. 1987;105:16831685.
27. Savini GZ, Zanini M, Carelli V, et al. Correlation between
retinal nerve fiber layer thickness and optic nerve head size:an
optical coherence tomography study. Br J Ophthalmol.
2005;89:489492.
28. Budenz DL, Anderson DR, Varma R, et al. Determinants of
normal retinal nerve fiber layer thickness measured by
Stratus OCT. Ophthalmology. 2007;114:10461052.
29. Varma R, Skaf M, Barron E. Retinal nerve fiber layer thickness
in normal human eyes. Ophthalmology. 1996;103:21142119,
Erratum in:Ophthalmology 1997;104:174.
30. Huang D, Chopra V, Lu AT, et al. Advanced Imaging for
Glaucoma Study-AIGS Group. Does optic nerve head size
variation affect circumpapillary retinal nerve fiber layer
thickness measurement by optical coherence tomography?
Invest Ophthalmol Vis Sci. 2012;53:49904997.
31. Viestenz A, Wakili N, Junemann AG, et al. Comparison
between central corneal thickness and IOP in patients
with macrodiscs with physiologic macrocup and normal-
sized vital discs. Graefes Arch Clin Ophtalmol. 2003;241:
652655.
e156 | www.glaucomajournal.com
J Glaucoma  Volume 23, Number 8, October/November 2014
32. Jonas JB, Budde WM, Panda-Jonas S. Ophthalmoscopic
evaluation of the optic nerve head. Surv Ophthalmol. 1999;43:
293320.
33. Jonas JB, Mardin CY, Schlotzer-Schrehardt U, et al. Morph-
ometry of the human lamina cribrosa surface. Invest Oph-
thalmol Vis Sci. 1991;32:401405.
34. Burgoyne CF, Downs JC, Bellezza AJ, et al. The optic nerve
head as a biomechanical structure: a new paradigm for
understanding the role of IOP-related stress and strain in the
pathophysiology of glaucomatous optic nerve head damage.
Prog Retin Eye Res. 2005;24:3973.
35. Burk RO, Rohrschneider K, Noack H, et al. Are large optic
nerve heads susceptible to glaucomatous damage at normal
intraocular pressure? A three-dimensional study by laser
scanning tomography. Graefes Arch Clin Exp Ophthalmol.
1992;230:552560.
36. Chang R, Budenz DL. New developments in optical coherence
tomography for glaucoma. Curr Opin Ophthalmol. 2008;19:
127135.
37. Reis AS, OLeary N, Yang H, et al. Influence of clinically
invisible, but optical coherence tomography detected, optic
disc margin anatomy on neuroretinal rim evaluation. Invest
Ophthalmol Vis Sci. 2012;53:18521860.
38. Moreno-Montanes J, Olmo N, Alvarez A, et al. Cirrus high-
definition optical coherence tomography compared with
Stratus optical coherence tomography in glaucoma diagnosis.
Invest Ophthalmol Vis Sci. 2010;51:335343.
39. Leung CK, Cheung CY, Weinreb RN, et al. Retinal nerve fiber
layer imaging with spectral-domain optical coherence tomog-
raphy: a variability and diagnostic performance study. Oph-
thalmology. 2009;116:12571263.
40. Sung KR, Kim DY, Park SB, et al. Comparison of retinal
nerve fiber layer thickness measured by Cirrus HD and Stratus
optical coherence tomography. Ophthalmology. 2009;116:
12641270.
41. Leite MT, Zangwill LM, Weinreb RN, et al. Effect of disease
severity on the performance of Cirrus spectral-domain OCT for
glaucoma diagnosis. Invest Ophthalmol Vis Sci. 2010;51:
41044109.
42. Chang RT, Knight OJ, Feuer WJ, et al. Sensitivity and
specificity of time-domain versus spectral-domain optical
coherence tomography in diagnosing early to moderate
glaucoma. Ophthalmology. 2009;116:22942299.
43. Chen HY, Chang YC, Wang IJ, et al. Comparison of glaucoma
diagnoses using Stratus and Cirrus optical coherence tomo-
graphy in different glaucoma types in a Chinese population.
J Glaucoma. 2013;22:638646.
r 2013 Lippincott Williams & Wilkins