Spark ImageWise 32

The Petal of Sight

Dr. Rashmi Nagar, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559 New Colony, Nagpur 

Case Description

A male, 50 years of age came to our institute for a regular eye examination. His best corrected visual acuity was 6/6, N6 with a correction of -0.50 DS and presbyopic addition of +1.75D in both eyes. Slit lamp examination showed normal anterior segment. Intra-ocular pressure was 22 mmHg in both eyes. His central corneal thickness was measured to be 509 microns in the right eye (RE) and 513 microns in the left eye (LE). He was not on any treatment.
On dilated fundus examination vertical cup-disc ratio (VCDR) was noted to be 0.90 in the right eye and a VCDR of 0.8 in the left eye. A diffuse loss of retinal nerve fibre layer sparing only the macula was seen in both eyes. He was started on Levobunolol 0.5% eye drops in both eyes.

Figure 1(a) – Colour fundus photograph of RE shows vertical CDR of 0.9:1 and diffuse retinal nerve fibre layer (RNFL) loss with sparing of macular fibres.
Figure 1(b) – Colour fundus photograph of RE shows vertical CDR of 0.9:1. Diffuse retinal nerve fibre layer (RNFL) loss (red arrows) is seen with sparing of macular fibres in the shape of a petal (yellow dashed lines). The horizontal raphe is also seen (blue arrow).
Figure 2(a) – Colour fundus photograph of LE shows VCDR 0.9:1. Diffuse RNFL loss is seen with sparing of macular fibres in the shape of a petal.
Figure 2(b) – Colour fundus photograph of LE with diffuse RNFL loss (red arrows) with sparing of macular fibres (yellow dashed lines).
Figure 3- Spectral Domain OCT (SD-OCT) circumpapillary RNFL (pRNFL) scan of RE shows preserved macular fibres (B – yellow arrows mark the edges). Edges of the preserved RNFL are also seen on the graph (D – red arrows).
Figure 4- SD-OCT pRNFL scan of left eye (LE) shows preserved macular fibres (B – yellow arrows mark the edges). Edges of the preserved RNFL are also seen on the graph (D – red arrows).
Figure 5 – SD-OCT posterior pole deviation map of right eye shows ganglion cell layer (GCL) loss (B – blue arrows) supero-temporal, temporal and temporo-inferior to the fovea corresponding to the loss in macular ganglion cell layer classification graph (C – blue arrows). The GCL heat map between the inner and outer circles show a relatively small defect indicative of the preservation of the GCL (A – red arrow).
Figure 6 – SD-OCT posterior pole deviation map of left eye shows ganglion cell layer (GCL) loss (B – blue arrows) superior, supero-temporal, temporo-inferior and inferior to the fovea corresponding to the loss in macular ganglion cell layer classification graph (C – blue arrows). The GCL heat map between the inner and outer circles show a relatively small defect indicative of the preservation of the GCL (A – red arrow).
Figure 7- SD-OCT posterior pole RNFL deviation map of RE shows preserved RNFL in the macular area (black arrows).
Figure 8 – SD-OCT posterior pole RNFL deviation map of LE shows preserved RNFL in the macular area (black arrows).
Figure 9 – Hood report of the RE shows preservation of RNFL in the temporal macular segment, (A – yellow arrows), corresponding with the position from 0° to 30° and 320° to 360° (D – red arrows).
Figure 10 – Hood report of the LE shows preservation of RNFL (A – yellow arrows), corresponding with the position from 0° to 17° and 320° to 360° (D – red arrows).

Discussion

Our patient presented rather late with significant glaucomatous damage in both eyes. There was presence of significant loss of RNFL superiorly and inferiorly to the extent, that there was evidence of a flooring effect. One may have expected a significant degree of loss of the macular RNFL also. However, the macular fibers are relatively preserved. We would like to call this ‘Macular Sparing in Glaucoma’ in individuals who present with significant loss of RNFL superiorly and inferiorly with classical optic disc damage.

The color photographs Figure 1(a,b) and Figure 2(a,b) show the presence in the RE and LE of preserved macular retinal nerve fiber layer outlined with the yellow dashed lines. The appearance is that of a petal.  Let us call this the ‘Petal of Sight’, due to the preservation of the macular RNFL and also the relative preservation of the ganglion cell layer thickness in the heat maps. (Figure 5A and figure 6A). There is also associated preservation of the RNFL in the macula (Figure 3B- yellow arrows and Figure 4B- yellow arrows).

Figure 7 shows the edges of the preserved macular fibers in RE and Figure 8 shows the edges of the preserved macular fibers in the LE.  The Hood report, which brings the macular fibers in the center, using the Nasal Superior, Temporal, Inferior and Nasal (NSTIN) arrangement of the RNFL shows the preserved macular fibers in Figure 9(A-yellow arrows, D-red arrows) in RE and Figure 10(A-yellow arrows, D-red arrows) in LE.

The phenomena of relative but significant preservation of the macular fibers and the central ganglion cells in advanced glaucomatous damage may be found in some glaucoma subjects. This leads to the preservation of central vision even through the optic disc shows significant damage, which is a source of anxiety, because the appearance of glaucomatous damage may portend impending blindness.

The cause of the ‘Petal of Sight’ and ‘Macular Sparing in Glaucoma’ is not clear.  That is, we may not be able to predict which patient is relatively more protected through this phenomenon from visual impairment and or blindness. The phenomena are important, since there is a natural selection of patients who in spite of advanced glaucomatous damage may continue to preserve their central vision for a much longer period of time, allowing them to live  with a  reasonable quality of life.

ReadWise

  1. Hood, Donald C., et al. “The nature of macular damage in glaucoma as revealed by averaging optical coherence tomography data.” Translational vision science & technology 1.1 (2012) doi:https://doi.org/10.1167/tvst.1.1.3
  2. Kim, Ko Eun, and Ki Ho Park. “Macular imaging by optical coherence tomography in the diagnosis and management of glaucoma.” British Journal of Ophthalmology102.6(2018):718-724.DOI:10.1136/bjophthalmol-2017-310869

Correspondence 

Dr Vinay Nangia
MS, FRCS, FRCOphth
Director 
Suraj Eye Institute
Nagpur
Email –education@surajeye.org

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