Retinal “Sloping” Could Be Linked to Advanced POAG

In assessing stereo color images, a team of researchers from the University of Pennsylvania observed and graded a novel feature that they termed “sloping retina,” on a substantial number of optic discs. This measure differs from disc tilt, a rotation of the optic disc around the anterior-posterior axis of the optic nerve. The research team believes that tissue thinning likely contributes to retinal sloping.Their recent study analyzed demographic, phenotypic and ocular characteristics among primary open-angle glaucoma (POAG) eyes with and without sloping retinas to better understand this novel topographic feature and its connection with POAG risk factors in individuals of African ancestry. The team determined that sloping retina was present in 22% of eyes with POAG. Their results also suggest sloping may indicate more advanced disease, as it was associated with many features of advanced POAG, including a large cup-to-disc ratio. The association between eyes with sloping and larger cup-to-disc ratio suggests that sloping is associated with eyes with more severe glaucomatous damage. Photo: Di Rosa I, et al. BMJ Open Ophthalmol. 2025;10(1):e002224. Click image to enlarge. The researchers have defined sloping as a circumferential dip of the peripapillary retina, adjacent to the disc margin and below the level of the retinal plane. A sloping retina is one that appears to slope towards the optic disc margin instead of existing on the same plane as the margin. Trained non-physician graders graded digital stereo disc images from 1,770 POAG cases that were graded as part of the larger Primary Open-Angle African American Genetics study, which includes more than 10,200 subjects of African ancestry.In a multivariable analysis, compared with eyes without sloping, eyes with sloping were less likely to have disc hemorrhages and more likely to have a tilted disc, larger cup-to-disc ratio (defined as 0.7 to 1), gray crescent, nasalization of the vessels, moderate or deep cup depth and conical cup shape. Eyes with sloping were less likely to have disc hemorrhaging. Sloping was not significantly associated with IOP, indicating it is unlikely that the pressure-related disease process causes sloping. Sloping was not associated with any demographic characteristics in the multivariable analysis.The team speculated that the presence of sloping could indicate faster POAG progression by way of its interaction with the optic cup and other structural elements of the optic nerve head.Eyes with sloping were more likely than those without sloping to have tilted discs (27% of eyes with sloping vs 11.6% without sloping had tilted discs). However, because the majority (73%) of eyes with sloping did not present with disc tilt, the researchers speculated that sloping is its own distinct feature as opposed to a regional expression of disc tilt.“In support of this speculation is our finding that sloping, though associated with tilted disc, was not associated with refractive error in the univariable analysis, suggesting no significant relationship between myopia and sloping,” they wrote in their paper, which was published in BMJ Open Ophthalmology.In eyes with and without disc tilt, a quadrant-based analysis that compares the frequency of sloping in the superior, inferior, nasal and temporal sectors of the ONH could help to illuminate the relationship between sloping and disc tilt.“While our results suggest sloping may indicate more advanced disease, the absence of a non-POAG control group in our study cohort limits its diagnostic value and overall clinical utility,” the team noted. “The lack of a suspect cohort in this study may also introduce spectrum bias, as sloping’s prevalence and its association with POAG risk factors may differ in this group. Future studies that include both suspects and controls will help to elucidate whether sloping can be considered a marker of advanced disease.”These studies are key to understanding the mechanisms by which sloping develops and to understanding whether this development is the result of or a precursor to glaucomatous damage.Click here for the journal source. Di Rosa I, Edziah AA, Salowe R, et al. Sloping retina: a novel feature associated with primary open-angle glaucoma in an African ancestry cohort. BMJ Open Ophthalmol. 2025;10(1):e002224.  This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.