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Noga Harizman, MD; Cristiano Oliveira, MD; Allen Chiang, MD; Celso Tello, MD; Michael Marmor, PhD; Robert Ritch, MD; Jeffrey M. Liebmann, MD

Arch Ophthalmol. 2006;124:1579-1583.

Objective  To determine whether the ISNT rule (that normal eyes show a characteristic configuration for disc rim thickness of inferior  superior  nasal  temporal), widely used for clinical evaluation of the optic nerve head, can differentiate normal from glaucomatous eyes.

Methods  All subjects underwent complete eye examination, including achromatic automated perimetry, simultaneous stereoscopic disc photography, and confocal scanning laser ophthalmoscopy. Subjects with normal eyes had no evidence of glaucoma or ocular hypertension and had normal perimetry measurements. Subjects with glaucoma had a reproducible visual field defect. One eye from each subject was randomly enrolled. The ISNT rule was assessed by masked evaluation of disc photographs at the 3, 6, 9, and 12 o’clock positions.

Results  Sixty-six subjects with normal eyes (33 black and 33 white individuals) and 43 with open-angle glaucoma (15 black and 28 white individuals) were enrolled. The ISNT rule was intact in 52 (79%) of 66 normal eyes and 12 (28%) of 43 glaucomatous eyes (P<.001). Multiple logistic regression indicated that the odds ratio for glaucoma associated with violation of the ISNT rule was 6.04 (95% confidence interval, 1.74-20.95) after adjustment for age; race was not a confounder of this association.

Conclusion  The ISNT rule is useful in differentiating normal from glaucomatous optic nerves and is unaffected by race.

Author Affiliations: Departments of Ophthalmology, The New York Eye and Ear Infirmary (Drs Harizman, Oliveira, Tello, and Ritch), New York University School of Medicine (Drs Chiang, Marmor, and Liebmann), and Manhattan Eye, Ear, and Throat Hospital (Dr Liebmann), New York, NY, and Department of Ophthalmology, New York Medical College, Valhalla, NY (Drs Harizman, Oliveira, Tello, and Ritch).

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