findings has been published.8 When color Doppler imaging of the retrobulbar circulation was undertaken, all of these disc-based categories of glaucoma demonstrated circulatory abnormalities in the orbital vessels, without a discrete pattern being attributable to this particular focal variety.169 The inclusion of the term ‘ischemic’ is thus based on the clinical impression of frequent disc hemorrhages in these eyes, which rarely demonstrate highly elevated IOPs.

Age-related atrophic primary open-angle glaucoma pattern (senile sclerotic)

Eyes with age-related atrophic primary open-angle glaucoma (Fig. 13-18) are often associated with diffuse fundus changes described as both ‘choroidal sclerosis’ and ‘tessellated fundus’11 – findings that, in combination with the association with older age, account for the term ‘age-related’ or ‘senile sclerotic.’  The discs are of normal size and shape, but PPCA is a prominent finding,59 so the edges of the ONH must be carefully distinguished. The cupping is described as shallow and saucerized, even ‘moth-eaten.’11 As the concentric cupping progresses, the neural rim may nevertheless retain a pale but almost normal color.68 This anomaly results in a discrepancy between the ‘color cup,’ as estimated on the basis of pallor (often with the monocular view of the direct ophthalmoscope), and the actual geometric, larger shape of the cup, as determined by highmagnification stereoscopic disc evaluation.The clinical appreciation of such color/cup discrepancy is important and often explains why visual field loss appears to be greater than the optic disc changes. Overlooking the color/contour discrepancy is a common reason for clinicians to underdiagnose the extent of glaucomatous damage in elderly patients. Focal changes, such as polar notching, disc hemorrhages, or wedge RNFL defects, are uncommon in this form of age-related atrophic cupping.

Often the fundus appearance is striking in its mosaic, or tessellated, pattern of prominent choroidal vessels and mottled orange background. One study59 found that subgroups with the highest degree of fundus tessellation showed the most peripapillary atrophy and the lowest mean maximal IOP when compared with other subgroups with the same disc appearance. Other clinical associations have included a tendency toward lower IOPs;9 more generalized vascular disease (systemic hypertension and ischemic heart disease);11 visual field loss that was often diffuse;58 evidence

Fig. 13-19  Juvenile open-angle glaucoma pattern.

of pronounced disturbances of orbital blood vessel velocities as determined by color Doppler imaging;169 and visual field progression less marked than seen with other patterns of disc damage.174

Juvenile open-angle glaucoma pattern

Disc findings in younger patients with open angles, with or without discrete angle anomalies, share features in common with discs subjected to sustained elevated IOPs from secondary causes (Fig. 13-19).58 The nerves are of normal size and shape and thus differ from myopic discs. The cupping is often distinctively steep-edged and deep, exposing the laminar pores and struts, and it enlarges in a concentric pattern. Focal changes, such as disc hemorrhages, wedge RNFL defects, and signs of PPCA, are infrequent. One comparative study found virtually no distinctive morphologic features between high-IOP juvenile glaucomatous discs and those of older eyes with ‘normal-tension glaucoma.’175

Primary open-angle glaucoma pattern (generalized enlargement)

A distinctive category of disc appearance that is commonly seen in POAG with high IOPs includes a disc of normal size with ­diffusely enlarged round cups (Fig. 13-20).11 Localized rim defects