Five rules to evaluate the optic disc and retinal nerve fiber layer for glaucoma Murray Fingeret, O.D., a,b Felipe A. Medeiros, M.D., c Remo Susanna, Jr, M.D., d and Robert N. Weinreb, M.D. c a Department of Veterans Affairs, New York Harbor Health Care System, Brooklyn, New York; b State University of New York, State College of Optometry, New York, New York; c Hamilton Glaucoma Center and the Department of Ophthalmology, University of California, San Diego, California; and d Department of Ophthalmology, University of São Paulo, São Paulo, Brazil A systematic approach for the examination of the optic disc and retinal nerve fiber layer is described that will aid in the detection of glaucoma. This approach encompasses 5 rules: evaluation of optic disc size, neuroretinal rim size and shape, retinal nerve fiber layer, presence of parapapillary atrophy, and presence of retinal or optic disc hemorrhages. A system- atic process enhances the ability to detect glaucomatous damage as well as the detection of progression, and facili- tates appropriate management. Key Words: Glaucoma, optic nerve, optic disc, retinal nerve fiber layer, optic disc hemorrhages T he evaluation of the optic nerve and retinal nerve fiber layer (RNFL) is essential to the recognition of glaucomatous damage. An optic nerve or RNFL ab- normality is often, but not always, the first sign of glauco- matous damage. 1,2 In the earliest stages of the disease, optic nerve and RNFL damage may be present, while standard automated perimetry is still within normal lim- its. 3-6 Early glaucomatous damage can be difficult to detect, requiring careful observation of the optic nerve and RNFL. Optic disc photography or optic nerve and RNFL imaging should be performed at the initial visit and yearly thereaf- ter to document the optic nerve and RNFL status. In situations in which stability is in question, photography and imaging may be done at earlier intervals. Recent studies have found the difficulty clinicians have in following guidelines proposed by professional organiza- tions. 7,8 These guidelines recommend documentation of the optic disc appearance at the time of diagnosis and at periodic intervals during followup. In one study utilizing a chart re- view, 193 primary open-angle glaucoma (POAG) patients were followed up in 8 private practices in the Los Angeles area for at least 2 years. 8 Almost all patients had a photograph or drawing at the initial examination, but, at the final fol- lowup visit, 33.2% had not had an optic nerve drawing or photograph taken within the previous 2 years. Another 37.8% had not had optic disc photography since the initial examina- tion. A more recent chart review evaluated records from 395 POAG patients in 6 managed care plans. 7 Only 53% had optic disc photographs or drawings at the initial examination. Although several textbooks and articles describe the char- acteristic signs of glaucomatous damage to the optic disc, Fingeret M, Medeiros FA, Susanna Jr R, Weinreb RN. Five rules to evaluate the optic disc and retinal nerve fiber layer for glaucoma. Optometry 2005;76:661-8. REVIEW ARTICLE 661 VOLUME 76 / NUMBER 11 / NOVEMBER 2005 OPTOMETRY