Glaucoma and the shape of globe
Introducing the shape of globe
as a predisposing factor for
glaucoma
Hoseinzadeh A, Mehdizadeh AR, Fazelzadeh A
Sadra–Sina Interdisciplinary Research Group
Mashad University of Medical Sciences
Abstract
Glaucoma is a common blinding disease
worldwide with a number of risk factors
such as intraocular pressure, myopia,
gender, race and hyperopia. Glaucoma
screening program for early detection of
high risk individuals is very important.
Recognizing glaucoma predisposing
factors guides screening toward specific
populations.
Here we introduce eyeball′s shape as a
predisposing factor for glaucoma. If the
eyeball is a sphere, the stress
distribution is homogenous. We assume
the eyeball as a non sphere. Then, the
distribution of stress will not be
homogenous. Different individuals have
different eyeball’s shapes and different
patterns of stress distribution in their
eyes. So based on the eyeball’s shape
6
deviation from a sphere they will have
more or less stress load in the site of
glaucoma injury. Based on stress theory
for glaucoma, mechanical stress is the
main responsible for glaucomatous
damage. Therefore, risk of glaucoma
varies among the population.
The eyeball is routinely considered as a
sphere, but some evidences such as the
existence of anterior and posterior
projections of the eye show that the
globe is not a sphere. The other
evidence obtained from eyeball imaging
shows that the plane sections of the
globe are not definite circle. Two
empirical observations are consistent
with the hypothesis. The first is that
different races and two sexes have
different risks for glaucoma. On the
other hand there are several
morphological differences in the body
1386 ‫ زﻣﺴﺘﺎن‬- 38 ‫ﺷﻤﺎره‬
structure among individuals. According
to theses anatomical differences, eye′s
shape is different among different races
and between two sexes. Secondly, there
are some conditions such as myopia and
hyperopia in them the shape of the
globe has been changed. These
conditions are risk factors for glaucoma
too. Current diagnostic procedures of
glaucoma do not take the shape of
eyeball into account. We suggest using
eyeball′s shape for early glaucoma
detection. There are three other factors
in addition to eyeball’s shape, including
thickness of the globe’s wall,
intraocular pressure, and inner radius
that should be measured together for
each individual and stress load should
be calculated in different points of the
globe. Then eyes with more stress load
in site of injury are more prone for
glaucoma. More accurate measurements
of the factors which are contributing in
stress value for each case, lead us
toward better glaucoma screening.
Keywords: glaucoma, stress,
predisposing factor, strain,
biomechanics, shape of globe, spatial
configuration.
Introduction
The term glaucoma refers to a group of
diseases that have in common a
characteristic optic neuropathy with
associated visual field loss (1).
Glaucoma is a complex disease with a
number of risk factors such as
intraocular pressure (IOP), myopia,
gender, race, genetic predisposition (2)
and hyperopia (3).
Two principal theories for the
pathogenesis of glaucoma have been
described: a mechanical and an
ischemic theory (2). We introduced a
new theory for glaucoma (4), in which
mechanical stress is the main
responsible factor for glaucomatous
damage. According to the stress theory,
stress develops glaucomatous damage
by two ways:
1. Stress generates strain (tissue
deformation) within tissues that
experience load. Strain can deform and
interrupt the retinal layers, which end in
glaucoma. The magnitude of strain is
based on the material properties of the
tissues, including how well the tissues
are able to resist deformations induced
by the applied stress (5).
2. Also, stress pressurizes vessels leads
to obstruction of retinal vessels and
decreased perfusion of the optic nerve
cells and finally cell death (5).
The biomechanical model for the eye:
From a geometrical standpoint, a sphere
is the set of all points in three-
dimensional (3D) space which are at
distance of “r” from a fixed point of that
space, where “r” is a positive real
number called the radius of the sphere.
The sphere is the only complete
symmetrical spatial configuration while
a spheroid is a quadric surface obtained
by rotating an ellipse about one of its
principal axes and in spite of sphere; it
is not completely symmetric (6).
Stress (σ) is an applied force and strain
is the deformation in the material to
which stress has been applied (7).
Analysis of the eye as an idealized
spherical shell is considered. Within the
wall of any pressurized spherical shell,
the two principal stresses reside within
the plane of the sphere wall (the third
stress is radial in direction and minimal
in magnitude; Figure 1).
In the eyeball, linear elasticity theory
predicts that the planar wall stresses are
equal and orthogonal, and that each
stress can be approximated by the
equation:
σ = PR/2t (Eq.1)
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 Glaucoma and the shape of globe

Figure 1. Depiction of principal stresses within a thin-walled spherical pressure vessel of radius R. The
two largest principal stresses, σ1 and σ2, are equal, at right angles to each other, and reside within the
plane of the wall. The third principal stress, σr, is minimal in magnitude and directed toward the center
of the sphere. (From: Bellezza AJ, Hart RT, Burgoyne CF. The optic nerve head as a biomechanical
structure: initial finite element modeling. Invest Ophthalmol Vis Sci 2000;41:2991–3000.)

Where P is the inner pressure (IOP), R
is the inner radius of the sphere
(approximately one half of the axial
length), and t is the thickness of the
sphere wall (sclera thickness) (8).
Today, the Goldmann applanation
tonometer provides the gold standard
for the clinical measurement of IOP (9).
Axial length and sclera thickness were
measured ultrasonically using A–scan
ultrasonography and ultrasound
biomicroscopy (UBM), respectively
(10).
Hypothesis
IOP-related force has a predictable
distribution and leads to predictable
levels of IOP-related stress (11). Stress
distribution is homogenous in all points
of a sphere (Figure 2-A). In a non
sphere configuration for example a
spheroid, there is not complete
symmetry (3D); then stress distribution
is not homogenous and stress is less at
some points and more at the others (Fig
2-B).
If the eyeball is a sphere, then the stress
distribution is homogenous in all its
points.
Here we assume the eyeball as a non
sphere. So, the distribution of IOP-
related stress won’t be homogenous and
stress magnitude would be less at some
points and more at the others.
Different individuals have different
eyeball’s shapes and different patterns
of stress distribution in their eyes. So
based on the eyeball’s shape deviation
from a sphere, they will have more or
less stress load in the site of glaucoma
injury.
In other words, distribution and
magnitude of IOP-related stress within
the site of glaucoma injury for a given
level of IOP is primarily determined by
the 3D shape of the eye. Since stress is
the main responsible factor for
glaucoma, risk of glaucoma varies
among different populations.
So, we introduce eyeball′s shape as a
predisposing factor for glaucoma.

8
1386 ‫ زﻣﺴﺘﺎن‬- 38 ‫ﺷﻤﺎره‬
Figure 2. Stress distribution is homogenous over a sphere section; σ1 = σ2 (A). Stress distribution is not
homogenous over a spheroid section; σ1′ ≠ σ2′ (B). Stress distribution has also two different patterns in
two shapes; σ1 ≠ σ1′ and σ2 ≠ σ2′.
Discussion
Like all other events in nature,
Glaucomatous damage has specific
causes and glaucoma presents with
specific patterns and does not occur at
random (3).
Recognizing glaucoma predisposing
factors helps us understand the
mechanism of disease and guides
screening and treatment toward specific
populations and subpopulations.
The eyeball is routinely considered as a
sphere, but there are some evidences
show that the globe is not a sphere. One
of them is the existence of anterior
(corneal curvature) and posterior (optic
disk cupping) projections of the eye.
The other evidence obtained from
eyeball imaging shows that the contours
and the plane sections of the globe are
not definite circle.
Two empirical observations are
consistent with the hypothesis. The first
is that ethnicity and sex are established
risk factors for glaucoma. For example,
the prevalence of glaucoma is 20 to 40
times higher in Eskimos than in
Caucasians (12). Congdon et al. (12)
and the Rotterdam study (13) in their
studies found different prevalence of
glaucoma between men and women.
There are several morphological
differences in the body structure among
individuals. The false pelvis is shallow
in the female and deep in the male. The
pelvis inlet is transversely oval in the
female but hurt shaped in the male. The
pelvis cavity is roomier in the female
than in the male, and the distance
between the inlet and the outlet is much
shorter. The pelvic outlet is larger, the
sacrum is shorter, wider and flatter and
the pubic arch is more rounded and
wider in the female than in the male
(14). The angle of the elbow is more
valgus in the female than in the male
(15).
Tallness varies among different races.
Pelvic inlet shape is different among
women of different races and is
classified into four groups: gynecoid,
android, anthropoid and platypelloid
according to its shape (16).
In the eye we can see structural
differences among different ethnicities
and sexes; for example axial length and
optic disc area is bigger in blacks than
whites (17). Anterior chamber depth
and eye size is smaller in women than
men (18).
9

According to these anatomical
differences that exist in body structure,
variation in shape of the eyeball is also
possible.
Secondly, there are some conditions
such as myopia and hyperopia in which,
the shape of the globe, for example its
axial length has been changed (16).
These conditions are considered as risk
factors for glaucoma (3,19) and the
current explanation of this relationship
is that anatomical alterations of the
eyeball’s shape in such conditions may
involve trabecular meshwork (20) but in
our theory this anatomical alteration
directly leads to increasing the risk of
glaucoma by changing the distribution
of IOP related stress load.
Since glaucoma has no clinical
manifestation until the last stages and is
one of the leading causes of irreversible
blindness throughout the world (21),
glaucoma screening program for early
detection of high risk individuals and
their management is very important.
Current glaucoma screening methods
include IOP measurement, optic nerve
head (ONH) and peripapillary retinal
evaluation and visual function tests
(22).
Current diagnostic procedures of
glaucoma do not take the shape of
eyeball or oculometric measurements
into account.
We suggest using eyeball′s shape for
early detection of glaucoma. There are
three other factors in addition to
eyeball’s shape, including thickness of
the globe’s wall which was shown
previously by authors to be related with
central corneal thickness (CCT) (23),
pressure (IOP), and inner radius that
should be measured together for each
individual and stress load should be
calculated in different points of the
globe. Then eyes with more stress load
10
Glaucoma and the shape of globe
in the site of glaucoma injury are more
prone to glaucoma.
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