Kids with big optic cups make me leery. They always have. I will say that, like most ODs, I have seen far more cases of pediatric physiologic cupping than I have of pediatric glaucoma.
For this reason, I feel better when I see a large optic cup in the presence of a large optic disc. A big disc should have a big cup because the number of ganglion cells (a million or so) that converge to the optic nerve head is not governed by the size of the disc.
In other words, a larger donut equates to a larger donut hole.
I had an experience as a young clinician at a school screening that drove home this concept.
I was a fourth-year student working at an ophthalmoscopy station of an elementary school screening with my binocular indirect ophthalmoscope (BIO) in hand.
To note: I am more comfortable with a BIO and 20.00 D lens at a school screening than I am using a handheld ophthalmoscope because I do not really have to direct gaze all that much.
Even if the pediatric patients just want to follow the light around with their eyes, I can still get a decent view of the optic nerve head, arcade vessels, and macula all in one go.
During this particular screening, I had, for the first time, an opportunity to look at a number of optic nerve heads consecutively in a short period of time.
The concept of vast difference between optic nerve head sizes became readily apparent that day. Even now, I make a note of optic nerve size in a patient’s chart. I do not take exact measurements, but I do make a qualitative remark of the size: small, normal, or large.
With this notion in mind, a new patient was referred to me a few weeks ago for suspicion of glaucoma.
Accompanied by his grandfather, this 14-year-old white male presented with no other complaints. His medical history was remarkable for attention-deficit/hyperactivity disorder (ADHD), which was managed with a methylphenidate extended-release tablet every morning.
His family history was remarkable for cataracts. There was no frank family history of glaucoma, although the grandfather could not be entirely sure.
Visual acuity through his conventional spectacles was 20/20 in each eye (he wore a low hyperopic correction on an as-needed basis). Pupil function was unremarkable for each eye, and confrontational visual fields were intact for each eye.