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Originally published In Press as doi:10.1167/iovs.09-3837 on September 8, 2009
 (Investigative Ophthalmology and Visual Science. 2010;51:890-895.)
© 2010 by The Association for Research in Vision and Ophthalmology, Inc.
doi:10.1167/iovs.09-3837
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Violation of the ISNT Rule in Nonglaucomatous Pediatric Optic Disc Cupping

Alexander E. Pogrebniak,1 Ben Wehrung,2 Katherine L. Pogrebniak,2 Rajesh K. Shetty,3 and Pam Crawford2

From the 1Division of Pediatric Ophthalmology, Nemours Children's Clinic, Jacksonville, Florida; the 2Department of Mathematics, Jacksonville University, Jacksonville, Florida; and the 3Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida.

Corresponding author: Alexander E. Pogrebniak, Nemours Children's Clinic, 807 Children's Way, Jacksonville, FL 32207; apogrebn{at}nemours.org.

Purpose. To determine whether nonglaucomatous optic disc cupping in children violates the ISNT rule (which states that for normal optic discs the neuroretinal rim width is greatest in the order inferior ≥ superior ≥ nasal ≥ temporal).

Methods. Digital ocular fundus photographs from a random cohort of children with large optic disc cups of nonglaucomatous origin were analyzed in masked fashion by using computer graphic software. The diameter and perimeter of each optic disc and optic cup and the width of the neuroretinal rim were drawn and measured. Measurements were compared to a random cohort of normal pediatric optic discs.

Results. The ISNT rule was intact in 9 (16%) of 55 eyes of nonpremature children with nonglaucomatous cupping, in 6 (21%) of 28 eyes of children with a history of prematurity and nonglaucomatous cupping, and in 35 (73%) of 48 eyes with normal discs.

Conclusions. Violation of the ISNT rule occurs with greater frequency in the pediatric population with large optic disc cups of nonglaucomatous origin, compared with the pediatric population with normal optic discs. In discs with small cups, neuroretinal rim width conforms to the overall oval shape of the disc, which is usually greatest in vertical dimension, whereas discs with large cups possess greater variability of relative neuroretinal rim width around the disc, greater relative vertical cup/disc ratio versus horizontal cup/disc ratio, and lower predictability of the ISNT rule.






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