Table of Contents  
Year : 2018  |  Volume : 26  |  Issue : 2  |  Page : 121-127

The relationship between vertical cup–disc ratio and body mass index in a population of adult Saudi females

College of Medicine, King Faisal University, Al Hasa, Saudi Arabia

Date of Web Publication13-Feb-2019

Correspondence Address:
Dr. Fahad Al Wadani
College of Medicine, King Faisal University, Al Hasa
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_6_18

Rights and Permissions

Purpose: The vertical cup–disc (C/D) ratio is useful clinically in optic-disc assessment in glaucoma suspects and diagnosing glaucomas and is thought to also be influenced by many ocular and systemic factors. The body mass index (BMI) is said to be an important parameter which influences vertical C/D ratio and different studies have shown different correlation between these two variables. The aim of the study was to assess the relationship of vertical C/D ratio with BMI in a population of Saudi adult females. Methods: One hundred and one female participants in the age group 18 to 40 years were included in a cross-sectional study after obtaining information regarding demographic data, ocular/systemic diseases, and surgeries by an oral interview. The BMI was calculated as ratio of body weight divided by the square of the body height. C/D ratio was recorded with direct ophthalmoscopic examination and examination with 90-D (Volk) lens. Analysis of variance was used to examine the BMI on vertical C/D ratio. A P-value <0.05 was considered to be statistically significant with confidence interval of 95%. Results: The mean BMI was 22.7 (±4.49) and the mean C/D ratio was 0.22 (±0.14). No significant relationship between increasing vertical C/D ratio and BMI P-value 0.154 was found. Conclusion: This study, conducted as a pilot study to investigate the relationship between C/D ratio and BMI in a young female Saudi population, found no significant relationship between vertical C/D ratio and BMI. This relationship is important as it helps to rule out effect of BMI on C/D ratio parameters in this population.

Keywords: Body mass index, glaucoma suspect, vertical cup–disc ratio

How to cite this article:
Al Wadani F, Feroze KB, Al Yahya R. The relationship between vertical cup–disc ratio and body mass index in a population of adult Saudi females. Niger J Ophthalmol 2018;26:121-7

How to cite this URL:
Al Wadani F, Feroze KB, Al Yahya R. The relationship between vertical cup–disc ratio and body mass index in a population of adult Saudi females. Niger J Ophthalmol [serial online] 2018 [cited 2023 Mar 22];26:121-7. Available from:

  Introduction Top

Optic-disc examination is a vital tool that gives clues to many ocular and systemic diseases. Different optic-nerve pathologies affect the appearance of the optic-nerve head.[1],[2] Optic-disc cupping greater than 0.7 usually points to the presence of glaucoma.[3] The cup–disc (C/D) ratio is useful clinically in optic-disc assessment in glaucoma suspects,[4] childhood glaucomas,[5] and glaucoma progression.[6] High myopia is another condition which demonstrates optic-disc changes.[7],[8],[9],[10],[11] C/D ratio assessment is also of concern to the neuro-ophthalmologists, in conditions such as congenital and acquired optic neuropathies,[12] raised intracranial pressure,[13] and also in nonarteritic ischemic optic neuropathy.[14] Diabetic patients with poor metabolic control, severe retinopathy, and those who have received laser treatments are prone to develop retinal nerve fiber layer atrophy and optic-disc changes.[15] Thus, evaluation of optic disc is of utmost importance in so many ocular conditions, especially glaucomas. Vertical C/D ratio is considered one of the best parameters to discriminate between healthy and glaucomatous eyes[2] and predicting future development of Glaucoma.[16],[17],[18],[19],[20],[21],[22],[23] Different population-based studies have found that vertical C/D ratio ranges from 0.43 to 0.56,[24],[25],[26],[27] whereas many other studies have mentioned an average vertical C/D ratio around or less than 0.3 in normal participants.[28],[29],[30],[31],[32]

The vertical C/D ratio is influenced by many ocular and systemic factors including race,[1],[25],[28] genetic factors,[33] birth weight,[34] age,[18],[32],[35],[36], sex,[37] longer axial lengths,[38] and IOP (intraocular pressure) and disc area.[39],[40],[41] The body mass index (BMI) is thought to be an important parameter which influences vertical C/D ratio. Some studies have found a positive correlation between vertical C/D ratio and BMI,[40],[42] whereas many studies have found an association between lower BMI and vertical C/D ratio[28],[37],[43],[44],[45] and some were statistically insignificant.[46]

The BMI, given in units kg/m2, has the dimension of an area density, the average value of which, for normal, healthy participants, has so far been recommended as 21.7.[47] Higher BMI was found to be a risk factor for posterior subcapsular lens opacities,[48] age-related macular degeneration,[49] increased retinal venular diameter,[50] IOP,[51] and hyperopic refraction.[52]

This study attempts to assess the relationship of vertical C/D ratio with the height, weight, and BMI in a population of Saudi adult females. The age group of 18 to 40 years was selected in this study, because it is considered to be less than the average age group of glaucomas[53],[54],[55],[56] and could allow better analysis of factors affecting C/D ratio prior to initiation of glaucomatous damage. We selected a female population as some studies have shown a higher prevalence of glaucomas in females in Saudi Arabia,[56],[57] with the intention of conducting a further study involving all populations.

  Methods Top

This cross-sectional study was conducted in the College of Medicine and the University Health Centre, King Faisal University, Al Hasa, after getting the approval of the concerned authorities. Informed verbal consent was obtained from all participants. A convenience sample of 101 females was selected.

The study population was females in the age group 18 to 40 years. Both eyes were included in the study.

Inclusion criteria:
  1. Saudi females, age 18 to 40 years
  2. No history of systemic diseases
  3. No history of significant ocular diseases or ocular surgeries
  4. Visual acuity better than or equal to 6/9
  5. Refraction within ±0.5D
  6. IOP < 21 mmHg

Details such as age, occupation, history of systemic/ocular diseases, and history of surgeries/injuries were obtained by an oral interview with the candidates. The BMI was calculated as ratio of body weight (measured in kilograms) divided by the square of the body height (measured in meters). The BMI was classified as underweight (<18.5), normal (18.5–25), overweight (25–30), and obese (>30).

The visual acuity was recorded with a Snellen’s chart, and a streak retinoscope was used to rule out refractive errors greater than ±0.5. Slit lamp examination was used to rule out any anterior segment pathologies. Goldmann applanation tonometry was performed to check the IOP. The vertical C/D ratio was recorded with a direct ophthalmoscopic examination (Welch Allyn ophthalmoscope using the 5° aperture) and confirmed by examination with 90-D (Volk) lens (Volk Optical Inc., OH). The same was performed by two ophthalmologists, and the average value was taken. Patients with small pupils were assessed after pupillary dilatation with tropicamide drops. The vertical CDR was taken as the longest vertical cup diameter divided by the longest vertical disc diameter. The contour of the cup was considered as the margin of the cup. Slit lamp measurement of the CDR was taken, and the two ophthalmologist had previously worked together on glaucoma patients, helping to standardize their estimations of CDR. The same was performed by two ophthalmologists, who have worked together previously in the glaucoma unit, and the average value was taken.

Statistical analysis

SPSS (Statistical Package for the Social Sciences) 21 (IBM Corporation) for Mac was used to analyze the data. Descriptive statistics and frequencies of the data were measured. Factorial analysis of variance (ANOVA) was used to examine the BMI in relation to vertical C/D ratio. A P-value <0.05 was considered statistically significant with confidence interval of 95%.

  Results Top

Young adult female participants in the age group 18 to 40 years were included in the study. There were 101 participants included in the study. A total of 202 eyes were included in the study. The mean age of the study population was 21.8 ± 3.6 years [Figure 1].
Figure 1 Age distribution of study sample

Click here to view

The BMI in this study ranged from 15.2 to 44.9, with a mean BMI of 22.66 ± 4.49. A total of 72.3% of the participants were in the normal BMI range [Figure 2].
Figure 2 Distribution of BMI among study population

Click here to view

On comparing the age group of the participants with the BMI, it was noted that with increasing age, there was a tendency to develop a higher BMI [Figure 3].
Figure 3 Graph of Age by BMI

Click here to view

Most of the participants had C/D ratios less than 0.5. C/D ratios ranged from no cup to 0.7. The mean C/D ratio in this study was found to be 0.219 ± 0.14 [Table 1].
Table 1 BMI by C/D ratio

Click here to view

Analysis of the BMI and C/D ratio was performed using ANOVA. Analysis of the data showed that the P-value was 0.154, which showed that there was no association between BMI and C/D ratio [Figure 4]. In addition, it was noted that there was no association between different BMI categories and C/D ratio.
Figure 4 Graph of C/D by BMI

Click here to view

  Discussion Top

The C/D ratio is one of the most important parameters in diagnosis and follow-up of glaucomas and is said to be influenced by many factors, which could lead to misinterpretation of glaucoma diagnosis. BMI has, long, been considered to be one of the important factors influencing C/D ratio.[28],[37],[40],[42],[43],[44],[45],[46] This study was conducted to find out the relationship between vertical C/D ratio and BMI in a population of young Saudi adults. This is probably the first time a study of this kind was conducted in this area of Saudi Arabia [Table 2].
Table 2 Comparison of results from other studies

Click here to view

The mean age of participants in our study was 21.8 ± 3.6 years. Other studies analyzing this relationship have a mean age of 35 ± 13.29 years,[46] with a much higher average age in other studies.[25],[26],[28],[38]

The mean BMI in our study was 22.66 ± 4.49, which was in the normal range. Most other studies also show majority of participants having normal BMI.[38],[46]

The mean vertical C/D ratio in our study was found to be 0.219 ± 0.14. Other studies show a mean C/D ratio of 0.38 ± 0.13,[46] 0.49 ± 0.14,[25] 0.48,[26] 0.34 ± 0.12,[28] 0.44 ± 0.17.[38]

The Nigerian Port Harcourt study found a positive correlation between overweight BMI ranges and larger C/D ratios.[46] Higher BMI was found to be associated with larger vertical disc diameter.[38] Other studies have reported an association between lower BMI and larger C/D ratios.[28],[37],[42]

This study was conducted as a pilot study to investigate the relationship between C/D ratio and BMI in a young female Saudi population. There was found to be no significant relationship between increasing vertical C/D ratio and BMI. This relationship is very important as it helps to rule out effect of BMI on C/D ratio parameters. This is the first time that this kind of study has been conducted in this area. So, the inferences of this study are thought to be important in optic-disc analysis for glaucoma diagnosis. The limitations of this study were thought to be the small sample size. Further studies are required in all age groups of both sexes to confirm a similar association, which would go a long way in helping glaucoma specialists to assess patient status, follow-up, and diagnose borderline cases.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Samarawickrama C, Hong T, Jonas JB, Mitchell P. Measurement of normal optic nerve head parameters. Surv Ophthalmol 2012;57:317-36.  Back to cited text no. 1
Calvo P, Ferreras A, Abadia B, Ara M, Figus M, Pablo LE et al. Assessment of the optic disc morphology using spectral-domain optical coherence tomography and scanning laser ophthalmoscopy. Bio Med Res Int 2014;2014:275654.  Back to cited text no. 2
Chiappe JP, Nahum P, Casiraghi J, Iribarren R. Prevalence of disc cupping in non-glaucomatous eyes Medicina 2015;75:6-10.  Back to cited text no. 3
Garway-Heath DF, Ruben ST, Viswanathan A, Hitchings RA. Vertical cup/disc ratio in relation to optic disc size: Its value in the assessment of the glaucoma suspect. Br J Ophthalmol 1998;82:1118-24.  Back to cited text no. 4
Amer S, Saif MY, Saif AT, Saif PS. Variations of cup-to-disc ratio in children. Open J Ophthalmol 2014;4:12-7.  Back to cited text no. 5
Kanakamedala P, Harris A, Siesky B, Tyring A, Muchnik M, Eckert G et al. Optic nerve head morphology in glaucoma patients of African descent is strongly correlated to retinal blood flow. Br J Ophthalmol 2014;98:1551-4.  Back to cited text no. 6
Chang L, Pan CW, Ohno-Matsui K, Lin X, Cheung GC, Gizzard G et al. Myopia-related fundus changes in Singapore adults with high myopia. Am J Ophthalmol 2013;155:991-9.  Back to cited text no. 7
Park HY, Kim SE, Park CK. Optic disc change during childhood myopic shift: Comparison between eyes with an enlarged cup-to-disc ratio and childhood glaucoma compared to normal myopic eyes. PLoS ONE 2015;10:e0131781.  Back to cited text no. 8
Kim TW, Kim M, Weinreb RN, Woo SJ, Park KH, Hwang JM. Optic disc change with incipient myopia of childhood. Ophthalmology 2012;119:21-6.e1-3.  Back to cited text no. 9
Samarawickrama C, Mitchell P, Tong L, Gazzard G, Lim L, Wong TY et al. Myopia-related optic disc and retinal changes in adolescent children from Singapore. Ophthalmology 2011;118:2050-7.  Back to cited text no. 10
Gvozdenović R, Risović D, Marjanović I, Vuković D, Stanković B. Morphometric characteristics of optic disc in patients with myopia and primary open-angle glaucoma. Vojnosanit Pregl 2013;70:51-6.  Back to cited text no. 11
Fraser CL, White AJ, Plant GT, Martin KR. Optic nerve cupping and the neuro-ophthalmologist J Neuro- Ophthalmol 2013;33:377-89.  Back to cited text no. 12
Golshani K, Zadeh ME, Farajzadegan Z, Khorvash F. Diagnostic accuracy of optic nerve ultrasonography and ophthalmoscopy in prediction of elevated intracranial pressure. Emergency 2015;3:54-8.  Back to cited text no. 13
Hayreh SS, Zimmerman MB. Nonarteritic anterior ischemic optic neuropathy: Refractive error and its relationship to cup/disc ratio. Ophthalmology 2008;115:2275-81.  Back to cited text no. 14
Toprak I, Yildirim C, Yaylali V. Optic disc topographic analysis in diabetic patients. Int Ophthalmol 2012;32:559-64.  Back to cited text no. 15
Hart WA, Yablonski M, Kass MA, Becker B. Multivariate analysis of the risk of glaucomatous visual field loss. Arch Ophthalmol 1979;97:1455-8.  Back to cited text no. 16
Drance SM, Schulzer M, Thomas B, Douglas GR. Multivariate analysis in glaucoma. Use of discriminant analysis in predicting glaucomatous visual field damage. Arch Ophthalmol 1981;99:1019-22.  Back to cited text no. 17
Leske MC, Connell AMS, Wu S-Y., Nemesure B, Li X, Schachat A et al. Barbados Eye Studies Group. Incidence of open-angle glaucoma. The Barbados Eye Studies. Arch Ophthalmol 2001;119:89-95.  Back to cited text no. 18
Gordon MO, Beiser JA, Brandt JD, Heuer DK, Higginbotham EJ, Johnson CA et al. The ocular hypertension treatment study: Baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120:714-20.  Back to cited text no. 19
Le A, Mukesh BN, McCarty CA, Taylor HR. Risk factors associated with the incidence of open-angle glaucoma: The visual impairment project. Invest Ophthalmol Vis Sci 2003;44:3783-9.  Back to cited text no. 20
Medeiros FA, Weinreb RN, Sample PA, Gomi CF, Bowd C, Crowston JG et al. Validation of a predictive model to estimate the risk of conversion from ocular hypertension to glaucoma. Arch Ophthalmol 2005;123:1351-60.  Back to cited text no. 21
Bengtsson B, Heijl A. A long-term prospective study of risk factors for glaucomatous visual field loss in patients with ocular hypertension. J Glaucoma 2005;14:135-8.  Back to cited text no. 22
Gordon MO, Torri V, Miglior S, Ocular Hypertension Treatment Study Group, European Glaucoma Prevention Study Group, European Glaucoma Prevention Study Group. Validated prediction model for the development of primary open-angle glaucoma in individuals with ocular hypertension. Ophthalmology 2007;114:10-9.  Back to cited text no. 23
Bourne RR, Foster PJ, Bunce C, Peto T, Hitchings RA, Khaw PT et al. The morphology of the optic nerve head in the Singaporean Chinese population (the Tanjong Pagar study): Part 1—Optic nerve head morphology. Br J Ophthalmol 2008;92:303-9.  Back to cited text no. 24
Ramrattan RS, Wolfs RC, Jonas JB, Hofman A, de Jong PT. Determinants of optic disc characteristics in a general population: The Rotterdam Study. Ophthalmology 1999;106:1588-96.  Back to cited text no. 25
Varma R, Tielsch JM, Quigley HA, Hilton SC, Katz J, Spaeth GL et al. Race-, age-, gender-, and refractive error-related differences in the normal optic disc. Arch Ophthalmol 1994;112:1068-76.  Back to cited text no. 26
Crowston JG, Hopley CR, Healey PR, Lee A, Mitchell P. The effect of optic disc diameter on vertical cup to disc ratio percentiles in a population based cohort: The Blue Mountains Eye Study. Br J Ophthalmol 2004;88:766-70.  Back to cited text no. 27
Kim YJ, Kim JM, Shim SH, Bae JH, Park KH, Epidemiologic Survey Committee of the Korean Ophthalmological Society. Associations between optic cup-to-disc ratio and systemic factors in the healthy Korean population. Korean J Ophthalmol 2015;29:336-43.  Back to cited text no. 28
Hrynchak P, Hutchings N, Jones D, Simpson T. A comparison of cup-to-disc ratio evaluation in normal subjects using stereo biomicroscopy and a digital image of the optic nerve head. Ophthalmic Physiol Opt 2003;23:51-9.  Back to cited text no. 29
Carpel EF, Engstrom PF. The normal cup-disk ratio. Am J Ophthalmol 1981;91:588-97.  Back to cited text no. 30
Khalil H, Saif MY, Abd El-Khalek M, Makar A. Variations of cup-to-disc ratio in age group (18-40) years old. Res Ophthalmol 2013;2:4-9.  Back to cited text no. 31
Tariq YM, Li H, Burlutsky G, Mitchell P. Retinal nerve fiber layer and optic disc measurements by spectral domain OCT: Normative values and associations in young adults. Eye 2012;26:1563-70.  Back to cited text no. 32
Healey P, Carbonaro F, Taylor B, Spector TD, Mitchell P, Hammond CJ. The heritability of optic disc parameters: A classic twin study. Invest Ophthalmol Vis Sci 2008;49:77-80.  Back to cited text no. 33
Samarawickrama C, Huynh SC, Liew G, Burlutsky G, Mitchell P. Birth weight and optic nerve head parameters. Ophthalmology 2009;116:1112-8.  Back to cited text no. 34
Garway-Heath DF, Wollstein G, Hitchings RA. Aging changes of the optic nerve head in relation to open angle glaucoma. Br J Ophthalmol 1997;81:840-5.  Back to cited text no. 35
Jonas JB, Thomas R, George R, Berenshtein E, Muliyil J. Optic disc morphology in South India: The Vellore Eye Study. Br J Ophthalmol 2003;87:189-96.  Back to cited text no. 36
Amerasinghe N, Wong TY, Wong WL, Mitchell P, Shen SY, Loon SC et al. Determinants of the optic cup to disc ratio in an Asian population: The Singapore Malay Eye Study (SiMES). Arch Ophthalmol 2008;126:1101-8.  Back to cited text no. 37
Kuang TM, Liu CJ, Ko YC, Lee SM, Cheng C, Chou P. Distribution and associated factors of optic disc diameter and cup-to-disc ratio in an elderly Chinese population. J Chin Med Assoc 2014;77:203-8.  Back to cited text no. 38
Tsutsumi T, Tomidokoro A, Araie M, Iwase A, Hiroshi Sakai H, Sawaguchi S. Planimetrically determined vertical cup/disc and rim width/disc diameter ratios and related factors. Invest Ophthalmol Vis Sci 2013;53:1332-40.  Back to cited text no. 39
Kashiwagi K, Tamura M, Abe K, Kogure S, Tsukahara S. The influence of age, gender, refractive error, and optic disc size on the optic disc configuration in Japanese normal eyes. Acta Ophthalmol Scand 2000;78:200-3.  Back to cited text no. 40
Caprioli J, Miller JM. Optic disc rim area is related to disc size in normal subjects. Arch Ophthalmol 1987;105:1683-5.  Back to cited text no. 41
Zheng Y, Cheung CY, Wong TY, Mitchell P, Aung T. Influence of height, weight, and body mass index on optic disc parameters. Invest Ophthalmol Vis Sci 2010;51:2998-3002.  Back to cited text no. 42
Xu L, Wang YX, Wang S, Jonas JB. Neuroretinal rim area and body mass index. PLoS ONE 2012;7:e 30104.  Back to cited text no. 43
Cheung N, Wong TY. Obesity and eye diseases. Surv Ophthalmol 2007;52:180-95.  Back to cited text no. 44
Mori K, Ando F, Nomura H, Sato Y, Shimokata H. Relationship between intraocular pressure and obesity in Japan. Int J Epidemiol 2000;29:661-6.  Back to cited text no. 45
Pedro-Egbe CN, Awoyesuku EA. The relationship between vertical cup-disc ratio and body mass index in Port Harcourt, Nigeria. Niger J Clin Pract 2013;16:517-20.  Back to cited text no. 46
[PUBMED]  [Full text]  
Kuczmarski RJ, Flegal KM. Criteria for definition of overweight in transition: Background and recommendations for the United States. Am J Clin Nutr 2000;72:1074-81.  Back to cited text no. 47
Hiller R, Podgor MJ, Sperduto RD, Nowroozi L, Wilson PW, D’Agostino RB et al. A longitudinal study of body mass index and lens opacities. The Framingham Studies. Ophthalmology 1998;105:1244-50.  Back to cited text no. 48
Seddon JM, Reynolds R, Rosner B. Associations of smoking, body mass index, dietary lutein, and the LIPC genetic variant rs10468017 with advanced age-related macular degeneration. Mol Vis 2010;16:2412-24.  Back to cited text no. 49
Ikram MK, de Jong FJ, Vingerling JR, Witteman JC, Hofman A, Breteler MM et al. Are retinal arteriolar or venular diameters associated with markers for cardiovascular disorders? The Rotterdam Study. Invest Ophthalmol Vis Sci 2004;45:2129-34.  Back to cited text no. 50
Lee JS, Lee SH, Oum BS, Chung JS, Cho BM, Hong JW. Relationship between intraocular pressure and systemic health parameters in a Korean population. Clin Exp Ophthalmol 2002;30:37-41.  Back to cited text no. 51
Roy A, Kar M, Mandal D, Ray RS, Kar C. Variation of axial ocular dimensions with age, sex, height, BMI and their relation to refractive status. J Clin Diagn Res 2015;9:ACO1-4.  Back to cited text no. 52
Andeev RV, Alexandrov AS, Bakunina NA, Basinsky AS, Blyum EA, Brezhnev AY et al. A model of primary open-angle glaucoma: Manifestations and outcomes. Klin Med 2014;92:64-72.  Back to cited text no. 53
Kolko M, Horwitz A, Thygesen J, Jeppesen J, Torp-Pedersen C. The prevalence and incidence of glaucoma in Denmark in a fifteen year period: A nationwide study. PLoS ONE 2015;10:e0132048.  Back to cited text no. 54
Coleman AL, Miglior S. Risk factors for glaucoma onset and progression. Surv Ophthalmol 2008;53:S3-10.  Back to cited text no. 55
Al Obeidan SA, Dewedar A, Osman EA, Mousaa A. The profile of glaucoma in a Tertiary Ophthalmic University Center in Riyadh, Saudi Arabia. Saudi J Ophthalmol 2011;25:373-9.  Back to cited text no. 56
Abu-Amero KK, González AM, Osman EA, Larruga JM, Cabrera VM, Al-Obeidan SA. Susceptibility to primary angle closure glaucoma in Saudi Arabia: The possible role of mitochondrial DNA ancestry informative haplogroups. Mol Vis 2011;17:2171-6.  Back to cited text no. 57


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded301    
    Comments [Add]    

Recommend this journal