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  • Glaucoma, Neuro-Ophthalmology/Orbit

    Review of: Glaucoma as a cause of optic nerve abnormalities on magnetic resonance imaging

    Mosleh R, Álvarez F, Bouthour W, et al. Eye (London), February 2024

    An analysis of MRI scans from patients with isolated glaucoma found that optic nerve T2 hyperintensity and optic nerve atrophy were relatively common, especially in eyes with more advanced disease, which suggests that such findings may not warrant further investigation.

    Study Design

    This was a single-center retrospective study of patients with any type of glaucoma and an abnormal optic nerve finding on MRI in at least 1 eye. Most patients (91%) underwent MRI after presenting with asymmetric or atypical glaucoma to rule out alternative causes of optic neuropathy. After excluding 32 patients who were found to have other medical conditions that could have associated optic nerve findings, data from 56 patients (112 eyes) with isolated glaucoma were reviewed.


    Thirty percent of eyes had optic nerve atrophy on MRI, 20% had optic nerve T2 hyperintensity, and 29% had both optic nerve atrophy and optic nerve T2 hyperintensity; the remaining eyes had neither of these findings. No patients had optic nerve enhancement. Not surprisingly, positive MRI findings were correlated with signs of increased glaucoma severity (e.g., visual field loss, decreased retinal nerve fiber layer thickness, and increased C:D ratio).


    The goal of this study was to report on MRI findings among patients with isolated glaucoma. Therefore, it does not reflect patients who carried a diagnosis of glaucoma but in whom MRI findings ultimately led to an alternative diagnosis.

    Clinical Significance

    Atypical presentations of glaucoma often prompt neuroimaging to exclude alternative optic neuropathies. However, many ophthalmologists and radiologists are not aware of common radiologic findings of glaucomatous optic neuropathy and incorrectly believe that abnormal T2 signal of the optic nerve is specific for optic neuritis. This study highlights two important points: 1) T2 hyperintensity and optic atrophy are nonspecific markers of optic nerve damage that can extend to the chiasm; they should not automatically prompt extensive investigations (i.e., for an underlying demyelinating/inflammatory disorder); 2) Optic nerve enhancement is abnormal (a sign of active breakdown of the blood–brain barrier) and is not seen in isolated glaucoma.

    Financial Disclosures: Dr. Hetal Ray discloses no financial relationships.