Clinical Examination of the Optic Nerve

  • Scott J. Fudemberg
  • Yuanjun Zhao
  • Jonathan S. Myers
  • L. Jay Katz


The optic nerve is a confluence of retinal ganglion cell axons that traverse the scleral canal to exit the eye. It ends as these axons merge with axons of the contralateral optic nerve at the optic chiasm. The optic nerve can be divided into (1) the intraocular part, comprising the retinal ganglion cell layer, the retinal nerve fiber layer, and the optic disc, and (2) the retrobulbar part, consisting of the intraorbital portion (about 25 mm long), the intracanalicular part within the osseous optic canal (4-20 mm), and the intracranial portion (about 10 mm), at which point the nerve fibers merge into the optic chiasm and the post-chiasmal optic tracts.


Optic Nerve Optic Disc Retinal Nerve Fiber Layer Optic Nerve Head Retinal Nerve Fiber Layer Thickness 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Varma RV, Spaeth GL. The Optic Nerve in Glaucoma. Philadelphia, PA: J.B. Lippincott Co.; 1993.Google Scholar
  2. 2.
    Ritch R, Shields MB, Krupin T. The Glaucomas: Basic Sciences. 2nd ed. Mosby: St. Louis; 1996:152.Google Scholar
  3. 3.
    Quigley HA, Brown AE, Morrison JD, Drance SM. The size and shape of the optic disc in normal human eyes. Arch Ophthalmol. 1990;108(1):51–57.PubMedGoogle Scholar
  4. 4.
    Caprioli J, Miller JM. Optic disc rim area is related to disc size in normal subjects. Arch Ophthalmol. 1987;105(12):1683–1685.PubMedGoogle Scholar
  5. 5.
    Fingeret M, Medeiros FA, Susanna R Jr, Weinreb RN. Five rules to evaluate the optic disc and retinal nerve fiber layer for glaucoma. Optometry. 2005;76(11):661–668.PubMedGoogle Scholar
  6. 6.
    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(7):1151–1158.PubMedGoogle Scholar
  7. 7.
    Harizman N, Oliveira C, Chiang A, et al. The ISNT rule and differentiation of normal from glaucomatous eyes. Arch Ophthalmol. 2006;124(11):1579–1583.CrossRefPubMedGoogle Scholar
  8. 8.
    Gross PG, Drance SM. Comparison of a simple ophthalmoscopic and planimetric measurement of glaucomatous neuroretinal rim areas. J Glaucoma. 1995;4:314–316.CrossRefPubMedGoogle Scholar
  9. 9.
    Choplin NT, Lundy DC, eds. Atlas of Glaucoma. London: Martin Dunitz, Ltd; 1998:68.Google Scholar
  10. 10.
    Sommer A, Katz J, Quigley HA, et al. Clinically detectable nerve fiber atrophy precedes the onset of glaucomatous field loss. Arch Ophthalmol. 1991;109:77–83.PubMedGoogle Scholar
  11. 11.
    Ritch R, Shields MB, Krupin T, eds. The Glaucomas: Basic Sciences. 2nd ed. Mosby: St. Louis; 1996:626–627.Google Scholar
  12. 12.
    Lin SC, Singh K, Jampel HD, et al. Optic nerve head and retinal nerve fiber layer analysis: a report by the American Academy of Ophthalmology. Ophthalmology. 2007;114(10):1937–1949.CrossRefPubMedGoogle Scholar
  13. 13.
    Menke MN, Knecht P, Sturm V, Dabov S, Funk J. Reproducibility of nerve fiber layer thickness measurements using 3D Fourier-domain OCT. Invest Ophthalmol Vis Sci. 2008;49(12):5386–5391.CrossRefPubMedGoogle Scholar
  14. 14.
    Jonas JB, Budde WM. Diagnosis and pathogenesis of glaucomatous optic neuropathy: morphological aspects. Prog Retin Eye Res. 2000;19(1):1–40.CrossRefPubMedGoogle Scholar
  15. 15.
    Armaly MF, Sayegh RE. The cup-disc ratio. The findings of tonometry and tonography in the normal eye. Arch Ophthalmol. 1969;82(2):191–196.PubMedGoogle Scholar
  16. 16.
    Carpel EF, Engstrom PF. The normal cup-disk ratio. Am J Ophthalmol. 1981;91(5):588–597.PubMedGoogle Scholar
  17. 17.
    Armaly MF. The correlation between appearance of the optic cup and visual function. Trans Am Acad Ophthalmol Otolaryngol. 1969;78:898.Google Scholar
  18. 18.
    Spaeth GL, Henderer J, Liu C, et al. The disc damage likelihood scale: reproducibility of a new method of estimating the amount of optic nerve damage caused by glaucoma. Trans Am Ophthalmol Soc. 2002;100:181-185. discussion 5–6.PubMedGoogle Scholar
  19. 19.
    Susanna R Jr, Vessani RM. New findings in the evaluation of the optic disc in glaucoma diagnosis. Curr Opin Ophthalmol. 2007;18(2):122–128.CrossRefPubMedGoogle Scholar
  20. 20.
    Jonas JB. Optic disk size correlated with refractive error. Am J Ophthalmol. 2005;139(2):346–348.CrossRefPubMedGoogle Scholar
  21. 21.
    Balazsi AG, Drance SM, Schulzer M, Douglas GR. Neuroretinal rim area in suspected glaucoma and early chronic open-angle glaucoma. Correlation with parameters of visual function. Arch Ophthalmol. 1984;102(7):1011–1014.PubMedGoogle Scholar
  22. 22.
    Caprioli J, Miller JM, Sears M. Quantitative evaluation of the optic nerve head in patients with unilateral visual field loss from primary open angle glaucoma. Ophthalmology. 1987;94:1484–1487.PubMedGoogle Scholar
  23. 23.
    Trobe JD, Glaser JS, Cassady J, et al. Nonglaucomatous excavation of the optic disc. Arch Ophthalmol. 1980;98:1046–1050.PubMedGoogle Scholar
  24. 24.
    Armaly MF. Genetic determination of cup/disc ratio of the optic nerve. Arch Ophthalmol. 1967;78(1):35–43.PubMedGoogle Scholar
  25. 25.
    Drance S, Anderson DR, Schulzer M, for the Collaborative Normal-Tension Glaucoma Study Group. Risk factors for progression of visual field abnormalities in normal-tension glaucoma. Am J Ophthalmol. 2001;131(6):699–708.CrossRefPubMedGoogle Scholar
  26. 26.
    Healey PR, Mitchell P, Smith W, Wang JJ. Optic disc hemorrhages in a population with and without signs of glaucoma. Ophthalmology. 1998;105(2):216–223.CrossRefPubMedGoogle Scholar
  27. 27.
    Tezel G, Kolker AE, Wax MB, et al. Parapapillary chorioretinal atrophy in patients with ocular hypertension. II. An evaluation of progressive changes. Arch Ophthalmol. 1997;115:1509–1514.PubMedGoogle Scholar
  28. 28.
    Uchida H, Ugurlu S, Caprioli J. Increasing peripapillary atrophy is associated with progressive glaucoma. Ophthalmology. 1998;96:16.Google Scholar
  29. 29.
    Morrison JC, Pollack IP. Glaucoma: A Clinical Guide. China: Thieme; 2003:99.Google Scholar
  30. 30.
    Levin LA, Arnold AC. Neuro-Ophthalmology: The Practical Guide. China: Thieme; 2005:110.Google Scholar
  31. 31.
    Doro S, Lessell S. Cup-disc ratio and ischemic optic neuropathy. Arch Ophthalmol. 1985;103(8):1143–1144.PubMedGoogle Scholar
  32. 32.
    Aumiller MS. Optic disc drusen: complications and management. Optometry. 2007;78(1):10–16.PubMedGoogle Scholar
  33. 33.
    Miller NR, Walsh FB, Hoyt WF, Newman NJ, Biousse V, Kerrison JB. Walsh and Hoyt’s Clinical Neuro-Ophthalmology: The Essentials. Baltimore: Lippincott Williams & Wilkins; 2007:91.Google Scholar
  34. 34.
    Susanna R, Drance S, Medeiros FA. The Optic Nerve in Glaucoma. Amsterdam: Kugler Publications; 1995:130.Google Scholar


  1. Ahn JK, Kang JH, Park KH. Correlation between a disc hemorrhage and peripapillary atrophy in glaucoma patients with a unilateral disc hemorrhage. J Glaucoma. 2004;13:9-14.CrossRefPubMedGoogle Scholar
  2. Budde WM, Jonas JB. Enlargement of parapillary atrophy in follow-up of chronic open-angle glaucoma. Am J Ophthalmol. 2004;137:646-654.PubMedGoogle Scholar
  3. Jonas JB. Clinical implications of peripapillary atrophy in glaucoma. Curr Opin Ophthalmol. 2005;16:84-88.CrossRefPubMedGoogle Scholar
  4. Jonas JB, Nguyen XN, Gusek GC, Naumann GOH. Parapapillary chorioretinal atrophy in normal and glaucoma eyes. Invest Ophthalmol Vis Sci. 1989;30:908-918.PubMedGoogle Scholar
  5. Jonas JB, Gusek GC, Fernández MC. Correlation of the blind spot size to the area of the optic disc and parapapillary atrophy. Am J Ophthalmol. 1991;111:559-565.PubMedGoogle Scholar
  6. Jonas JB, Fernández MC, Naumann GOH. Glaucomatous parapapillary atrophy: occurrence and correlations. Arch Ophthalmol. 1992;110:214-222.PubMedGoogle Scholar
  7. Jonas JB, Budde W, Panda-Jonas S. Ophthalmoscopic evalua­tion of the optic nerve head. Surv Ophthalmol. 1999;43:293-320.CrossRefPubMedGoogle Scholar
  8. Jonas JB, Budde WM, Lang PJ. Parapapillary atrophy in the chronic open-angle glaucomas. Graefe´s Arch Clin Exp Ophthalmol. 1999;237:793-797.Google Scholar
  9. 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;41:1764-1773.PubMedGoogle Scholar
  10. Law SK, Choe R, Caprioli J. Optic disk characteristics before the occurrence of disk hemorrhage in glaucoma patients. Am J Ophthalmol. 2001;132:411-413.CrossRefPubMedGoogle Scholar
  11. Rath EZ, Rehany U, Linn S, Rummelt S. Correlation between optic disc atrophy and aetiology: anterior ischaemic optic neuropathy vs optic neuritis. Eye. 2003;17:1019-1024.CrossRefPubMedGoogle Scholar
  12. Tezel G, Dorr D, Kolker AE, et al. Concordance of parapapillary chorioretinal atrophy in ocular hypertension with visual field defects that accompany glaucoma development. Ophthalmology. 2000;107:1194-1199.CrossRefPubMedGoogle Scholar


  1. Bell RA, Waggoner PM, Boyd WM, et al. Clinical grading of relative afferent pupillary defects. Arch Ophthalmol. 1993;111:938-942.PubMedGoogle Scholar
  2. Bergamin O, Zimmerman MB, Kardon RH. Pupil light reflex in normal and diseased eyes: diagnosis of visual dysfunction using waveform partitioning. Ophthalmology. 2003;110:106-114.CrossRefPubMedGoogle Scholar
  3. Chen PP, Park RJ. Visual field progression in patients with initially unilateral visual field loss from chronic open-angle glaucoma. Ophthalmology. 2000;107:1688-1692.CrossRefPubMedGoogle Scholar
  4. Digre KB. Principles and techniques of examination of the pupils, accommodation, and lacrimation. In: Miller NR, Newman NJ, eds. Walsh and Hoyt’s Clinical Neuro-Ophthalmology. 6th ed. Baltimore: Lippincott Williams & Wilkins; 2005:715-737.Google Scholar
  5. Glazer-Hockstein C, Brucker AJ. The detection of a relative afferent pupillary defect. Am J Ophthalmol. 2002;134:142-143.CrossRefPubMedGoogle Scholar
  6. Kalaboukhova L, Fridhammar V, Lindblom B. Relative afferent pupillary defect in glaucoma: a pupillometric study. Acta Ophthalmol Scand. 2007;85:519-525.CrossRefPubMedGoogle Scholar
  7. Kawasaki A, Moore P, Kardon RH. Variability of the relative afferent pupillary defect. Am J Ophthalmol. 1995;120:622-633.PubMedGoogle Scholar
  8. Kerrison JB, Buchanan K, Rosenberg ML, et al. Quantification of optic nerve axon loss associated with a relative afferent pupillary defect in the monkey. Arch Ophthalmol. 2001;119:1333-1341.PubMedGoogle Scholar
  9. Lagreze WD, Kardon RH. Correlation of relative afferent pupillary defect and estimated retinal ganglion cell loss. Graefes Arch Clin Exp Ophthalmol. 1998;236:401-404.CrossRefPubMedGoogle Scholar
  10. Lankaranian D, Altangerel U, Spaeth GL, Leavitt JA, Steinmann WC. The usefulness of a new method of testing for a relative afferent pupillary defect in patients with ocular hypertension and glaucoma. Trans Am Ophthalmol Soc. 2005;103:200-208.PubMedGoogle Scholar
  11. Levatin P. Pupillary escape in disease of the retina or optic nerve. Arch Ophthalmol. 1959;62:768-779.PubMedGoogle Scholar
  12. Nakanishi Y, Nakamura M, Tatsusmi Y, et al. Quantification of retinal nerve fiber layer thickness reduction associated with a relative afferent pupillary defect. Graefe’s Arch Clin Exp Ophthalmol. 2006;244:1480-1484.CrossRefGoogle Scholar
  13. Rosenberg ML, Oliva A. The use of crossed polarized filters in the measurement of the relative afferent pupillary defect. Am J Ophthalmol. 1990;110:62-65.PubMedGoogle Scholar
  14. Tatsumi Y, Nakamura M, Fujioka M, Nakanishi Y, Kushuara A, Maeda H, Negi A. Quantification of retinal nerve fiber layer thickness reduction associated with a relative afferent pupillary defect in asymmetric glaucoma. Br J Ophthalmol. 2007;91:633-637.CrossRefPubMedGoogle Scholar
  15. Thompson HS, Corbett JJ, Cox TA. How to measure the relative afferent pupillary defect. Surv Ophthalmol. 1981;26:39-42.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Scott J. Fudemberg
    • 1
  • Yuanjun Zhao
    • 2
  • Jonathan S. Myers
    • 3
  • L. Jay Katz
    • 4
  1. 1.Glaucoma DepartmentWills Eye Institute, Jefferson Medical CollegePhiladelphiaUSA
  2. 2.Wills Eye InstitutePhiladelphiaUSA
  3. 3.Spaeth/Katz/Myers, P.C., Wills Eye InstitutePhiladelphiaUSA
  4. 4.Jefferson Medical College, Wills Eye InstitutePhiladelphiaUSA

Personalised recommendations