Eye (2009) 23, 56–62

& 2009 Macmillan Publishers Limited All rights reserved 0950-222X/09 $32.00
www.nature.com/eye

The relationship MJ Hawker1, MR Edmunds1, SA Vernon1,

CLINICAL STUDY

JG Hillman2 and HK MacNab2

between central
corneal thickness
and the optic disc
in an elderly
population: the
Bridlington Eye
Assessment Project

Abstract correlation was found between any global

optic disc parameter and CCT in the 690 eyes
Purpose To determine population-based
analysed.
normative CCT data for elderly white subjects,
Conclusion Elderly white eyes with normal
with and without diabetes, and to explore the
fields have CCTs that are normally distributed,
relationship between CCT and IOP and HRT2
with those from diabetic persons having
measurements in such subjects with normal
greater CCTs. No clear evidence of a
visual fields.
relationship between CCT and HRT2 optic
Methods All eligible subjects were
disc parameters used in glaucoma diagnosis
consecutive in a population screened for eye
was found.
disease. CCT was measured by ultrasound
1
Department of Eye (2009) 23, 56–62; doi:10.1038/sj.eye.6703001;
pachymetry, and the optic disc was
Ophthalmology, Queen’s published online 19 October 2007
Medical Centre, University morphometrically defined using Heidelberg
Hospital, Nottingham, UK retinal tomography (HRT2). Inclusion criteria
Keywords: central corneal thickness; intraocular
were: (1) normal visual field on suprathreshold
2
The Medical Centre,
pressure; elderly; confocal scanning laser
testing and (2) corrected logMAR acuity of at
Station Road, Bridlington, ophthalmoscopy; Heidelberg retina tomograph;
least 0.3 in both eyes. Subjects with significant
UK glaucoma
corneal pathology, previous corneal surgery, or
known history of glaucoma or treatment for
Correspondence:
SA Vernon, raised intraocular pressure were excluded.
Department of One eye was randomly selected from each
Ophthalmology, Queen’s Introduction
subject for analysis.
Medical Centre, Results In all, 983 eyes of 983 subjects were Thin central corneal thickness (CCT) has been
University Hospital,
included with 690 HRT images deemed shown to be a powerful risk factor for the
Nottingham NG7 2UH, UK.
Tel: þ 0115 924 9924 acceptable for the analysis. The mean age progression of ocular hypertension (OHT) and
x63200. (414 men and 569 women) was 73.3 years preperimetric glaucomatous optic neuropathy
E-mail: stephen.vernon@ (minimum 65 years). Mean (SD) CCT was 544.1 to primary open-angle glaucoma (POAG).1,2
nuh.nhs.uk (36.5) lm, with a normally distributed range of Patients with a CCT of p555 mm in the ocular
429–633 lm. There was no significant hypertension treatment study (OHTS) had a
Received: 29 March 2007
difference in CCT between men and women three-fold increase in the risk of glaucoma
Accepted in revised form:
12 September 2007 (mean CCT 546.1 and 542.7 lm, respectively, development compared with those having CCT
Published online: P ¼ 0.15, Student’s t-test), though CCT was of X588 mm.3 In addition, thinner CCT is
19 October 2007 correlated weakly and negatively with age associated with more severe glaucoma
(Pearson’s r ¼ 0.063, P ¼ 0.047). Diabetic progression, both at first presentation to the
This study was presented as
patients (n ¼ 103) had a greater mean CCT than ophthalmologist,4 and during follow-up.5
a free paper at the Royal
College of Ophthalmologists non-diabetic patients (551.9 and 543.0 lm However, the mechanism by which CCT is
Annual Congress 2006. respectively, P ¼ 0.02). No significant related to glaucoma risk remains, as yet, unclear.
 CCT and HRT parameters in an elderly population
MJ Hawker et al
57

It is generally accepted that an indirect relationship A relevant standardized medical history was obtained
between CCT and glaucoma risk operates via its (eg, diabetes, stroke, hypertension) together with the
relationship with intraocular pressure (IOP). CCT is patient’s drug and family history. Distance and reading
positively related to IOP with thinner corneas requiring spectacle requirements were recorded in addition to
less force than expected to achieve applanation by any history of amblyopia, ocular surgery, or any other
Goldmann applanation tonometry. Thus, true IOP, and ocular disease. Specifically, any history of glaucoma
therefore glaucoma risk, may be underestimated in these was noted.
eyes. This may explain the findings that mean CCT is Patients then underwent a comprehensive eye
thinner in patients with normal tension glaucoma examination, logMAR visual acuity testing (Bailey Lovie
compared with those having POAG,6,7 and thicker in #4 Chart, National Vision Research Institute of Australia)
patients with OHT.8,9 These findings are replicated and automated suprathreshold visual field testing with
among different racial groups.10 the Henson Pro 5000 perimeter (Tinsley Instruments,
In addition, in a multivariate analysis of baseline Croydon, UK). A single stimulus, suprathreshold central
factors predicting the conversion of OHT into POAG 26-point test was employed. This was automatically
within OHTS, CCT was retained as a risk factor extended to a 68-point test if a defect was detected.
independent of its relationship with IOP.3 Speculative Intraocular pressure (IOP) was measured by a calibrated
proposals on the mechanism of this IOP-independent Goldmann tonometer and CCT measurement was
interaction reflect the nature of the cornea as an extension performed by ultrasound pachymetry (Tomey SP-3000
of the sclera. They include an association with altered Pachymeter, Tomey Corporation, Nagoya, Japan). The
trabecular meshwork function and a relationship with pachymeter probe operates at a frequency of 20 MHz
optic nerve head morphometry, perhaps via the quality with a resolution of 1 mm. Each scan comprises 10
of lamina cribrosa support. One study found that at the individual measurements with the mean measurement
time of referral of OHT and POAG patients, CCT being recorded in micrometres (mm). After instillation of
correlated positively with optic nerve head rim area.11 tropicamide 1% into both eyes, systematic slit-lamp
Two other studies demonstrated the relationships biomicroscopy was performed and Heidelberg retina
between CCT and neuroretinal tissue measurements in tomograph II images (HRT2, Software Version 2.1,
OHT patients12 and normal subjects.13 However, none of Heidelberg Engineering GmbH, Dossenheim, Germany)
these studies were population based and so are prone to were obtained.
unpredictable sources of bias. Bridlington Eye Assessment Project saw its first patient
This study presents data obtained from subjects on 5 November 2002 and had seen 2434 patients (58%
screened by the Bridlington Eye Assessment Project acceptance rate) when this study commenced. Patients
(BEAP)14 effectively, a screening programme for ocular were invited in ascending numerical order of postcode.
disease in elderly white subjects. The aim of the current An informed written consent was obtained from all
study was to determine population-based normative participants and a Local Ethics Committee approved all
CCT data for elderly white subjects both with and methodology. All methods adhered to the tenets of the
without diabetes, and to explore the relationship between Declaration of Helsinki guidelines for research in human
CCT and IOP and HRT2 measurements in such subjects subjects.
with normal visual fields.

Patient selection
Methods
Normal individuals were selected for this study from the
Subjects: the Bridlington Eye Assessment Project
BEAP database, with one eye chosen at random from
The methodology of BEAP has been previously each subject. Normality was defined with the following
described.14 Briefly, the project is a screening exercise for criteria applied to both eyes: (1) normal visual field
eye disease in patients over 65 years of age. determined by suprathreshold automated examination
Approximately 6500 such subjects registered with the and (2) corrected logMAR acuity of at least 0.3 (Snellen
general practitioners in the town of Bridlington, England equivalent 6/12). Exclusion criteria were: (1) significant
were systematically invited to attend an extensive eye corneal pathology that might influence corneal thickness,
examination performed by one of four optometrists such as corneal ulcers or scars, endothelial guttata, or
trained specifically for the project. Patients registered keratic precipitates (2) previous corneal surgery (3)
blind or partially sighted, bed-bound or suffering known history of glaucoma or intraocular pressure-
dementia, and those moving into or out of the area lowering-treatment and (4) incomplete data relating to
during the study were excluded. the above criteria.

Eye
 CCT and HRT parameters in an elderly population
MJ Hawker et al
58

Confocal scanning laser ophthalmoscope assessment

120
Patients were imaged with HRT2, with the scanner’s
focus being adjusted according to the patient’s refraction,
and to obtain the best image. One mean topographic 100
image was acquired per eye. Much of the acquisition
process using HRT2 is automated. If the machine stated
80
that astigmatism was significantly impairing the image

Frequency
then the image was obtained through the patients’
spectacles. If the image acquired was subjectively 60
unacceptable then the process was repeated to obtain an
acceptable image, although this was not possible in a
minority of patients. The optic disc contour line was 40
drawn on all images by one investigator (MJH). The
HRT2 software then calculated disc area (mm2), reference
20
height (mm) and 12 further stereometric parameters, cup
area (mm2), rim area (mm2), cup/disc area ratio, rim/
disc area ratio, cup volume (mm3), rim volume (mm3), 0
mean cup depth (mm), maximum cup depth (mm),
450 500 550 600 650
height variation contour (mm), cup shape measure, mean
Central Corneal Thickness (microns)
retinal nerve fibre layer (RNFL) thickness (mm), and
RNFL cross-sectional area (mm2). Each of these Figure 1 Central corneal thickness (mm) in 983 elderly subjects
without visual field defect. The normal curve is shown for
parameters was expressed for the global disc, and for six
comparison.
individual disc sectors (temporal, temporal superior,
temporal inferior, nasal, nasal superior, and nasal
left eyes was 544.0 and 544.3 mm, respectively (P ¼ 0.92,
inferior). Images with a mean pixel height SD greater
Student’s t-test). There was no significant difference in
than 50 mm were excluded from further analysis.
CCT between men and women (mean CCT 546.1 and
Statistical analyses were conducted using SPSS for
542.7 mm, respectively, P ¼ 0.15, Student’s t-test). CCT
Windows version 12.0.2 (Statistical Package for Social
correlated negatively very weakly with age (Pearson’s
Sciences, SPSS Inc., Chicago, IL, USA). Two-tailed tests
r ¼ 0.063, P ¼ 0.047). Mean CCT was found to be
were used in all statistical analyses. Statistical
significantly greater in those with diabetes mellitus
significance was set at Po0.05.
(551.9 mm) compared with nondiabetics (543 mm; P ¼ 0.02,
Student’s t-test). There was no significant difference in
Results mean CCT between those reporting systemic
hypertension (542.3 mm) and normotensives (544.8 mm;
Demographics
P ¼ 0.29, Student’s t-test), or between those with previous
In all, 983 eyes of 983 consecutive subjects satisfying the intraocular surgery (545.7 mm) and those without such a
entry criteria were included from the 2434 people history (544.1 mm; P ¼ 0.76). There was no significant
examined. All subjects were white and of European difference in CCT between those with and without a
extraction; 42% were men, and 52% of eyes were right positive family history of glaucoma (mean CCT 543.3 and
sided. The mean (SD) age of the 983 subjects was 73.3 543.7 mm, respectively, P ¼ 0.62, Student’s t-test). No
(5.2) years (range 65.3–94.2 years). The mean age of men significant correlation was found between CCT and
and women was not significantly different (73.2 and 73.3 study number indicating no calibration drift with study
years, respectively, P ¼ 0.67, Mann–Whitney U-test). Of duration.
the 983 subjects, 103 (10.5%) had a history of diabetes, 453
(46%) had a history of hypertension, 66 (6.7%) reported
Intraocular pressure
previous cerebrovascular disease, and 131 (13%) reported
a family history of glaucoma. The mean (SD) IOP in the 983 eyes was 16.4. (3.0) mmHg,
with a range of 8–32 mmHg. The mean IOP in men and
women did not differ significantly (16.5 and 16.3 mmHg,
Central corneal thickness
respectively, P ¼ 0.19, Student’s t-test). In addition, there
Central corneal thickness was normally distributed in the was no difference in IOP between eyes, with a mean IOP
983 eyes (Figure 1). The mean (SD) CCT was 544.1 (36.5) of 16.3 mmHg in left eyes and 16.4 mmHg in right eyes.
mm (range 429–633 mm) and the mean CCT in right and There was no significant difference in mean IOP between

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 CCT and HRT parameters in an elderly population
MJ Hawker et al
59

Table 1 Correlation between global optic nerve head para-

meters and central corneal thickness in 690 elderly subjects
30 without visual field defect

Parameter Pearson’s r P-value

Intraocular Pressure (mmHg)

25 Disc area (mm2) 0.05 0.16

Cup area (mm2) 0.07* 0.07
Rim area (mm2) 0.01 0.71
Cup volume (mm3) 0.04* 0.28
20 Rim volume (mm3) 0.00 0.92
Mean RNFL thickness (mm) 0.01 0.83
RNFL cross-sectional area (mm2) 0.01 0.88
15 RNFL, retinal nerve fibre layer.
*Spearman’s rank correlation.

10

3.00
450 500 550 600 650
Central Corneal Thickness (microns)
2.50
Figure 2 Scatterplot to demonstrate the relationship between
central corneal thickness and intraocular pressure in 983 elderly
Rim Area (mm2)

subjects without visual field defect. 2.00

1.50
diabetic and non-diabetic patients (16.7 and 16.3 mmHg,
respectively; P ¼ 0.22, Student’s t-test). There was a small
but significant positive correlation between CCT and 1.00
measured IOP in our sample (Pearson’s r ¼ 0.13,
Po0.001; Figure 2). No significant correlation was found 0.50
between IOP and study number indicating no calibration
drift with study number.
0.00

Optic nerve head parameters 450 500 550 600 650 700
Central Corneal Thickness (microns)
In total, 690 of the 983 eyes had acceptable HRT2 image
Figure 3 Scatterplot of rim area (mm2) of the optic nerve head
quality for analysis. Subjects with acceptable images vs central corneal thickness (mm) in 690 elderly individuals
were on average younger than those with images of without visual field defect.
unacceptable quality (mean ages 72.6 and 75.3 years,
respectively; Po0.001, Mann–Whitney U-test). Mean
CCT tended to be greater in subjects with acceptable HRT2) in an elderly white population. The elderly are an
images, though of borderline statistical significance important group in the study of glaucoma since they
(mean CCT 544.8 and 537.3 mm, respectively; P ¼ 0.07, have the greatest prevalence of the disease.15 The study
Student’s t-test). group employed in this research represents a population
There was no significant correlation between any of elderly subjects without visual field defect or a
global optic nerve head parameter and CCT in this group diagnosis of glaucoma. As the only entry criteria were
of eyes (Table 1, Figure 3). The Spearman’s rank based on visual field and visual acuity, we included
correlation coefficients between CCT and HRT2 sectoral subjects with IOPs outside the normal range and optic
ONH parameters were all nonsignificant except for cup discs which might be determined as glaucomatous by
area in the temporal (rs ¼ 0.07, P ¼ 0.05) and temporal- some observers. Our sample of nearly 700 eyes from 700
superior sectors (rs ¼ 0.09, P ¼ 0.02). persons analysing CCT against HRT should therefore
include eyes that will be progressing towards
glaucomatous field loss. The number of ONHs in the
Discussion
sample has been sufficient to demonstrate systematic
To our knowledge this is the first study to simultaneously differences in HRT2 parameters between elderly men
report CCT data and objective ONH parameters (using and women in one of our previous publications,14 the

Eye
 CCT and HRT parameters in an elderly population
MJ Hawker et al
60

former of which have twice the prevalence of the such as corneal rigidity. In addition to our study, other
disease.15 Thus, the absence of any relationship between researchers have found a significant thinning of the
global HRT2 parameters and CCT in this study suggests central cornea with age.8,10,19,20 Two studies which also
that if a larger study found a relationship, it would likely only recruited older participants, failed to detect a
be of little clinical significance (the finding of two significant relationship.21–24 The changes in structural
statistically significant associations in the 72 sectoral corneal biomechanics with subject age adds further
analyses of CCT vs HRT2 parameters would be expected complexity to the relationship between CCT and
by chance in a study with large numbers such as ours Goldmann IOP.26
and is also of no clinical significance). The diabetic patients in our study had significantly
Previous studies investigating the relationship greater CCTs than the non-diabetic patients, although
between CCT and ONH have produced varying results. only by a mean of 9 mm. Although the eyes of diabetics
One study found no relationship between CCT and (all type 2) had higher IOPs (a mean of 0.4 mmHg higher)
retinal nerve fibre layer thickness (measured by scanning in our study, this did not reach statistical significance in
laser polarimetry) in 44 eyes with normal visual fields contrast to the results of larger comparative studies that
and clinically normal optic discs.13 Additionally, included types 1 and 2 diabetics.27,28 Similar findings of
investigations into the relationship between CCT and an association between diabetes and thicker CCT have
scleral characteristics found no correlation with post- been found in the Barbados Eye Study,25 and in another
mortem lamina cribrosa or scleral thickness in normal study,29 whereas a Japanese study found no increase in
eyes,16 or with axial length in the clinic setting.17 Studies CCT in type 2 diabetic patients.30
which have found a relationship between CCT and ONH Potential sources of bias exist in our study. As BEAP
parameters did so only in ocular hypertensive and did not utilise a randomised sampling procedure, we
glaucomatous eyes.11,12 One of these studies found a cannot be sure that the study population is representative
significant relationship between CCT and ONH rim area of the whole population. However, using the Jarman
at the time of referral of glaucoma patients but found no Index (a measure of deprivation), those not attending did
relationship between CCT and risk of progression during not differ from attendees during the project. The
follow-up.11 In these samples, the substantial exclusion of 30% of subjects due to poor HRT2 image
confounding effects of IOP, as measured by applanation, quality is unfortunately an inevitable consequence of a
which may have a nonlinear relationship with CCT,18 study such as this. This issue has been discussed
and those of the glaucomatous process, may make previously,14 and represents the reduction in image
isolation of the relationship between CCT and ONH quality with increasing age, and is due to a number of
difficult. Age is a further confounding factor since CCT factors including lens clarity. However, there was no
decreases,10,19,20 and POAG prevalence increases, with significant difference in CCT and age between those
advancing years. In addition, limitations of the CCT included and excluded on the grounds of HRT quality. A
measurement protocol in the OHTS study3 may make the further potential limitation to the study is the fact that we
finding of a statistically independent relationship did not measure intra- and inter-observer repeatability of
between CCT and the risk of POAG development CCT during BEAP. This was for logistical reasons in such
unreliable.11 Our study adds weight to the evidence that, a large screening exercise with much data to collect from
in the white elderly population with normal fields, lower each individual. Some studies have shown significant
CCT values are not associated with reduced neuro-retinal variability in CCT measured by ultrasound pachymetry
rim measurements on the HRT2, and therefore probably on different occasions,31–33 although others have
not an important risk factor for future glaucomatous found a high degree of reproducibility.34,35 Finally, we
visual field loss. cannot be sure that those considered not to have diabetes
In our study with 983 eyes from 983 white persons of would all be deemed negative by strict criteria as it was
European extraction, CCT was normally distributed with impractical to perform glucose tolerance tests on all
a mean of 544.1 mm and a range of 429–633 mm, similar to subjects.
the findings of the Rotterdam Study.21 Our study found In conclusion, our study indicates that CCT is normally
that CCT was positively correlated with IOP in elderly distributed in the white elderly population with normal
white subjects without visual field defect. A similar visual fields, that diabetics have thicker corneas than
relationship has been found in various populations,21–24 nondiabetics within this population and that there is no
although it was not present in the black participants of significant association between CCT and optic nerve
the Barbados Eye Study.25 IOP measured by Goldmann characteristics used in glaucoma diagnosis on HRT
applanation tonometry should ideally be adjusted for scanning. This suggests that the measurement of CCT in
CCT, although a simple nomogram is unlikely to be white elderly people with normal fields is of no value in
accurate in all cases due to the influence of other factors predicting the ONH morphology as measured by the

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 CCT and HRT parameters in an elderly population
MJ Hawker et al
61

HRT2, and may be of no value in predicting future field 8 Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal
loss from glaucoma in screening programmes. thickness in the ocular hypertension treatment study
(OHTS). Ophthalmology 2001; 108(10): 1779–1788.
9 Wu LL, Suzuki Y, Ideta R, Araie M. Central corneal
Acknowledgements thickness of normal tension glaucoma patients in Japan.
Jpn J Ophthalmol 2000; 44(6): 643–647.
We wish to thank Mrs S MacNab (Project Manager), 10 Aghaian E, Choe JE, Lin S, Stamper RL. Central corneal
Mr S Brown, Mrs J Button, Mr G Langton, and Mr M Kunz thickness of Caucasians, Chinese, Hispanics, Filipinos,
(Optometrists) for their work with the project. We thank African-Americans, and Japanese in a glaucoma clinic.
Ophthalmology 2004; 111(12): 2211–2219.
Mr J Bapty, Mr N Connell, Mr P Jay, and Mrs G Poole for
11 Jonas JB, Stroux A, Velten I, Juenemann A, Martus P, Budde
their work as the charity trustees of the Bridlington Eye WM. Central corneal thickness correlated with glaucoma
Assessment Project. Financial support: The Bridlington damage and rate of progression. Invest Ophthalmol Vis Sci
Eye Assessment Project was funded by an unrestricted 2005; 46(4): 1269–1274.
grant from Pfizer. We also thank the following 12 Henderson PA, Medeiros FA, Zangwill LM, Weinreb RN.
Relationship between central corneal thickness and retinal
organisations for financial support of the Project:
nerve fiber layer thickness in ocular hypertensive patients.
Pharmacia, Yorkshire Wolds & Coast Primary Care Trust, Ophthalmology 2005; 112(2): 251–256.
the Lords Feoffees of Bridlington, Bridlington Hospital 13 Iester M, Mermoud A. Retinal nerve fiber layer and physio-
League of Friends, the Hull & East Riding Charitable logical central corneal thickness. J Glaucoma 2001; 10(3): 158–162.
Trust, the National Eye Research Centre (Yorkshire), the 14 Vernon SA, Hawker MJ, Ainsworth G, Hillman JG, Macnab
HK, Dua HS. Laser scanning tomography of the optic nerve
Rotary Club of Bridlington, the Alexander Pigott
head in a normal elderly population: the Bridlington Eye
Wernher Memorial Trust, Bridlington Lions Club, the Assessment Project. Invest Ophthalmol Vis Sci 2005; 46(8):
Inner Wheel Club of Bridlington, Soroptimist 2823–2828.
International of Bridlington, and the Patricia and Donald 15 Wolfs RC, Borger PH, Ramrattan RS, Klaver CC, Hulsman
Shepherd Charitable Trust. CA, Hofman A et al. Changing views on open-angle
Competing interests: None. glaucoma: definitions and prevalencesFthe Rotterdam
study. Invest Ophthalmol Vis Sci 2000; 41(11): 3309–3321.
Conflict of Interest: None of the authors have any
16 Jonas JB, Holbach L. Central corneal thickness and thickness
financial interests to declare in relation to this of the lamina cribrosa in human eyes. Invest Ophthalmol Vis
manuscript. Sci 2005; 46(4): 1275–1279.
17 Shimmyo M, Orloff PN. Corneal thickness and axial length.
Am J Ophthalmol 2005; 139(3): 553–554.
18 Kniestedt C, Lin S, Choe J, Bostrom A, Nee M, Stamper RL.
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