Glaucoma triad under controversy

 Raised IOP

✍ >21 mmhg

 Abnormal disc

✍ C/D ratio asymmetry > 0.2

✍ Large vertical C/D ratio for disc size > 0.5

✍ NRR notch or thinning (ISNT rule)

✍ Disc haemorrhage

✍ Vessel bayoneting and nasally displaced

✍ PPA (B-zone)

 VF defect

✍ Nasal step

✍ Paracentral scotoma

✍ Arcuate scotoma

✍ Altitudinal scotoma

✍ residual temporal

✍ central island of vision

🛑 ‘ISNt rule’ describes

☝ the normal contour of the disc rim

☝ thickest inferiorly, thinner superiorly, then nasally, and thinnest temporally.

☝ this rule often fails to apply when the optic discs have an anomalous configuration.

✍ Never forget 🚨 🚨 IOP does not need to be >21 mmhg to develop glaucomatous optic neuropathy.

✍ Anomalous optic discs are difficult to assess.

✍ raised IOP + normal disc + normal VF consider OHT

✍ raised IOP + suspicious disc + normal VF consider glaucoma suspect or preperimetric glaucoma

✍ raised IOP + suspicious disc + consistent VF defect consider highly suspicious and treated as glaucoma

✍ raised IOP + abnormal disc + consistent VF defect consider well established glaucoma

✍ Normal IOP+ normal disc + normal VF consider Normal

✍ normal IOP + suspicious disc + normal VF consider physiological cupping

✍ normal IOP + stable abnormal disc + stable VF defect consider congenital disc anomaly or previous disc insult

✍ normal IOP + evolving abnormal disc + evolving VF defect consider NTG.