John C Hagan III, MD, FACS, FAAO  
Kansas City, MO

Specialties: Ophthalmology

Interests: Eye-Medical Blog
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Explanation of optic nerve "cupping" and Cup to Disk Ration

Apr 07, 2010 - 9 comments

optic nerve cupping


cup to disk ratio

"cupping" is a term applied to the optic nerve on the back of the eye. The optic nerve generally has a "dimple" or "cup".  Ophthalmologists use a ratio called the cup to disk ration "C/D ration".  An estimate is made of the width of the cup to the width of the whole optic serve. It is usually expressed as a decimal tenth. A flat optic nerve with no cup would be C/D = .0  an optic nerve ravaged by glaucoma that is 'cupped out" would be C/D = 1.0   So the possibilies are: 0, .1,.2,.3.,.4,.5,.6,.7,.8,.9,1.0      Some physicians express two numbers one being the verticle C/D and the other being the horizontal C/D. It has been shown that these are not exact numbers. There are large variations from observer to observer and even from the same observer from visit to visit.

90% of the population without glaucoma have C/D ratios of .4 or less. So a larger C/D might indicate glaucoma. However it's very complicated. You can have glaucoma with a small C/D and not have glaucoma with a large C/D. Other factors need to be taken into account like family history of glaucoma, age, corneal thinness, intra ocular pressure (remeber you IOP varies from hour to hour just like your blood pressure and your blood sugars. Many patients with glaucoma have normal IOPs for some or even most of a 24 hour period, conversely patients without glaucoma may top out over 21 for part of the day). Another factor is if the C/D are different in each eye, usually they're the same size.

When I see a patient with a C/D ratio or .5 or more I always tell them and explain what it means so that the next ophthalmologist that examines the patient will know it's been noted before.

I would never tell a person they had "moderate cupping" without explaining what it meant and giving them "the number" to add to their medical records.  Sometimes I'll take a photograph of the optic nerves as a baseline. A new and wonderful instrument the OCT (optical coherence tomography) instrument has taken a lot of the guessing out of these issues and if there's any question at all that's the test I go to.


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1249939 tn?1313316943
by Gabs143, Apr 09, 2010
Thank you!!!  My daughter has been diagnosed with Pseudotumor Cerebri and her doctor never has explained this fact to us.  In fact, she sees so many patients, she is in and out of there.  I hold her up by asking her questions sometimes, but my main worry is she doesn't know if my daughter is over-producing Crebral Spinal Fluid or not re-absorbing it.  So I did some looking into this based off of credible research journals.  What is your opinion regarding adrenal insufficiency and renal tubule osmotic pressure increasing CSF due to maintaining homeostasis?   Also, if someone is aldosterone deficient how does that impact the pressure put on the C/D ratio?  My child's IOP flew to the top of measuring device after 1 mL of CSF was taken out through lumbar puncture. So it was extremely high but immeasurable.  In March the doctor said he took out 20 mLs this time and brought her pressure down to 30mmHG  .  Pressure is returning and Opthamoloist is tripling her dosage to 1500mg a day ( 2 X 250mg=500mgs)  So 3 times a day
now, I am very worried about my daughter, can you give any advice?

Needs to be under the care of a neurologist and neuroophthalmologist. Treatment is Diamox oral. If heavy lose weight. It some cases this does not help and surgery called optic nerve fenestration is needed. Very specialized procedure.


1249939 tn?1313316943
by Gabs143, Apr 13, 2010
Can thyroid disease cause her eye to bulge?

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by dondonaldo, Apr 13, 2010
What is your favorite of the new OCT instruments ?


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by minmtn, May 01, 2010
Dr. H, I need an opinion from the "Show Me" State.  About six weeks ago had beginning of 2nd vitreous detachment (this time left eye-- R eye happened about 3 yrs ago).  This started with intermittent eye pain, which I didn't connect with anything. . .then storm of lightning bolts in my eye for about 24 hrs and tornado of floaters.  Happened on weekend, and I was able to see the ophthalmologist on Monday.  He said it was another vitreous detachment.  He asked me to come back in 2 weeks.  During the two weeks my headaches much worse, which I thought might be ocular migraine.  When this started, I realized the headaches actually began about 6 wks earlier, but not so bad or frequent and I had no idea why I was having them.  (I had migraines from about age 18 until at age 36 w/o aura, but they diminished to practically never.)

Went back in 2 weeks and asked about ocular migraine.  The doctor said he wanted to run some lab work and mentioned a condition called Giant Cell Arteritis, which I'd never heard of, but it scared me because he said it can cause blindness.  (My mother has wet mac degeneration in both eyes).  The labwork was neg for CRP, and the other two tests.  When I went home and read about the symptoms, I realized I had most of them -- neck pain, sore scalp, jaw pain, pain over temple (mostly one or the other but not at the same time), intermittent shart pain in my calves and feeling slightly nauseated.  Also retaining a lot of fluid in my eyelids, abdomen and lower extremities.

My Raynaud's has been acting up and my pinky finger keeps "dying".  Since the WPW ablation, I rarely have bad Raynaud's episodes except while taking antibiotics, then it stop, but I'm still having attacks.    

The headaches have been even worse the past few days and my appt with opthalmology is in a week.   The floaters are pretty bad but don't look like a curtain or snow.  My head feels bad but I cannot tell if it is my sinus, teeth, neck or what is causing my head pain.  It is worse after I eat anything.  Hard to find comfortable way to lay on a pillow.

I also have a congenital anomaly -- a pit at the optic nerve R eye.  With the first VT, I ended up with retinopexy because they thought it looked as if a tear was starting at this location.

1.   The first one happened 3 hrs ago while on 3rd round of nitrofurantoin for UTI and I have had chronic UTI since then and my doctors cannot figure out why.   Diagnosed with Vit D deficiency nearly two years ago but that is normal now.  My temp is always subnormal.  Is there a medically recognized connection between antibiotics and vitreous detachment or inflammation of blood vessels?

2.  I had ablation for WPW Heart Syndrome slightly over a year ago.  Have Raynaud's.  Was told I had some venous insufficiency in legs.  Is it possible to have this arteritis w/ neg lab work?  My CRP was 0.04 a year ago and now it is .50, so that's higher I think, but still not what the doctor would consider high.  The sed rate was 16.  Hemogram, no flags.  My primary doctor was talking about doing some immunological testing.

I currently have UTI, >100,000 staph plus vaginal infection after taking 500 mg/4xday  Tetracycline, which I think knocked out my lactobacillis and caused the vag infection.  

3. I saw my primary doctor and asked about the possibility of Giant Cell Arteritis and he quickly dismissed the possibility.

Should I be concerned about this condition or just wait and see? MO legacy.

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by tkvinod, Nov 16, 2010
test comment http://www.yahoo.com

1642011 tn?1305182379
by Vinnie11, Mar 22, 2011
Dr John C Hagan, I just want your opinion regarding my cataract surgery. I am a juvenile Diabetic and my right eye was operated in April 2008 but I am not satisfied with my surgery because I am not been able to achieve 100% vision and still its very hard for me to recognize people at a  distance. Even during night hours, its hard for me to walk on a road.
Even I am not been able to read from my operated eye and at times I saw black lines moving up & down in my operated eye. I told all these things to my doc but he consider it normal  .He told me that lens takes time for adjustments and he don't have any answer for that black line.
I am really scared that whether everything is all right with my eyes or not. Also, I just wanted to know that how much time do the new lens takes for adjustments and is there any way by which I can check the accuracy or success of my cataract surgery.
waiting for your reply...

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by napasa, Jun 28, 2011
Dear Doctor,

My father has glaucoma and his optic nerve severly damaged on one eye, the other one has the fuchs spot. So he hardly see. Can something be done for his optic nerve? Is there a solution or treatment? Thank you

Avatar universal
by jackymac21, Oct 26, 2012
Dr. Hagan,
I have a few questions/concerns. I have Third nerve palsy along with a complicated strabismus, which came from a car wreck when I was 9. All the damage was to the left side of my face. I under went 5 muscle repair surgeries trying to fix the strabismus. CT scans showed a mass on my third nerve up until the scan I had earlier this year, and it was gone. This week I have started noticing some rather questionable things that I haven't experienced in multiple years. My left eye feels as though its trying to move/work?!?! I am excited and scared because I don't want to get my hopes up. Is it possible to "fix" itself or begin healing? I would love to know any possibilities as I have had a hard time dealing with this all these years. any insight you can give me would be great.

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