The optic nerve carries impulses for sight from the retina in the eye to the brain. It is composed of millions of retinal nerve fibers that bundle together and exit to the brain through the optic disc located at the back of the eye. The optic disc has a center portion called the "cup" which is normally quite small in comparison to the entire optic disc.

In people with glaucoma damage, because of increased pressure in the eye and/or loss of blood flow to the optic nerve, these nerve fibers begin to die. This causes the cup to become larger in comparison to the optic disc, since the support structure is not there. Optic nerve cupping progresses as the cup becomes larger in comparison to the optic disc.

Both people with and without optic nerve damage have optic nerve cupping, although those with glaucoma tend to have a greater cup-to-disc ratio. A cup to disc ratio greater than six-tenths is generally considered to be suspicious for glaucoma.

Through periodic photographs of the optic nerve, the ratio of the cup to the disc can be monitored. This helps the doctor determine whether or not damage is still occurring to the nerve fibers with current treatment and/or if treatment should be modified.

Optic Nerve Cupping

Development of optic nerve cupping: The optic nerve is responsible for carrying information from the retina to the brain. Millions of retinal fibers bundle together to form the optic nerve and exit at the optical disc which is seen at the back of the eye. Individuals with glaucoma have increased IOP or consequent loss of blood flow to some regions of the eye, resulting in the death of optic nerve cells. The center of the optic disc (known as the cup) becomes larger, and the cup to optic disc ratio increases alarmingly. This process is referred to as optic nerve cupping. Most individuals do show some optic nerve cupping, but those with glaucoma suffer from much more severe cupping because of the disease.

Treatment of Optic Nerve Cupping in Glaucoma: A standard treatment for optic nerve cupping is to start with medical therapy. This is succeeded by laser trabeculoplasty, and then filtration surgery if necessary. If optic nerve perfusion is the main cause of the optic nerve cupping, medical treatment to increase the perfusion pressure will help to minimize further damage. Using medical treatments to lower the IOP will also help to reduce further damage to the optic nerve fibers within the optical disc. Laser trabeculoplasty is a procedure that can lower the IOP in glaucoma patients. It activates the immune system, so that macrophages are recruited into the trabecular meshwork tissue to remove debris.

The Heterogeneity of Glaucoma: Glaucoma is a disease with many different causes. Its heterogeneous nature has led to its expression at many different levels of severity between individuals. There are many ways in which the optic nerves can be damaged in glaucoma, resulting in optic nerve cupping. This is very harmful as it leads to extreme loss of vision in the affected eye. Treatment for optic nerve cupping takes many different forms depending on the severity of the disease and the factors that originally caused the optic nerve damage. Research will lead to future improvements in glaucoma screening, diagnostics, and treatment. This will hopefully reduce the number of people with this condition who go undiagnosed. 

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