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Profile of retinal nerve fibre layer symmetry in a multiethnic Asian population: the Singapore Epidemiology of Eye Diseases study
  1. Yijin Tao1,2,
  2. Yih Chung Tham1,3,
  3. Miao Li Chee1,
  4. Shivani Majithia1,
  5. Sahil Thakur1,
  6. Zhi-Da Soh1,
  7. Carol Yim-Lui Cheung4,
  8. Charumathi Sabanayagam1,3,
  9. Tien Yin Wong1,3,5,
  10. Ching-Yu Cheng1,3,5
  1. 1 Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
  2. 2 Department of Ophthalmology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
  3. 3 Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
  4. 4 Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
  5. 5 Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  1. Correspondence to Dr Ching-Yu Cheng, Ocular Epidemiology Research Group, Singapore Eye Research Institute, Singapore, Singapore; chingyu.cheng{at}


Background To examine the normative profile and determinants of retinal nerve fibre layer (RNFL) symmetry in a non-glaucoma, multiethnic Asian population.

Methods Chinese, Malay and Indian adults aged ≥40 years were recruited from the Singapore Epidemiology of Eye Diseases study. Participants underwent standardised systemic and ocular examinations. RNFL thickness was obtained using a spectral-domain optical coherence tomography (Cirrus HD-OCT). RNFL symmetry (in %) was calculated based on Pearson correlation coefficient between the RNFL thickness profiles of the right and left eyes. Multivariable linear regression analysis was used to investigate the associations between ocular and systemic factors with RNFL symmetry.

Results 4211 participants (1227 Chinese, 1245 Malays, 1739 Indians) were included. The mean RNFL symmetry was 86.7%±8.5% in Chinese, 84.7%±10.2% in Malays and 84.0%±10.7% in Indians. The fifth percentile limit of RNFL symmetry was 71.2% in Chinese, 65.0% in Malays and 62.0% in Indians. In multivariable analysis adjusting for age, gender, ethnicity, hypertension, diabetes, hyperlipidaemia, intereye absolute differences in intraocular pressure (IOP), axial length and disc area, Malays (β=−0.9; p=0.03) and Indians (β=−1.76; p<0.001) were found to have lower RNFL symmetry compared with Chinese. Older age, greater intereye differences in IOP, axial length and disc area were significantly associated with lower RNFL symmetry (all p≤0.003).

Conclusions In non-glaucoma individuals, intereye RNFL profile is less symmetric in Malays and Indians than that in Chinese. This also suggests that current commercial optical coherence tomography’s deployment of a single, universal RNFL symmetry cut-off for glaucoma detection is flawed, and ethnic-specific cut-off is warranted.

  • retinal nerve fiber layer symmetry
  • optical coherence tomography

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  • YT and YCT contributed equally.

  • Contributors YT, YCT, CYLC, CS, TYW and CY-C conceived and designed the study. YT, YCT and MLC analysed and interpreted the data. YT, YCT, MLC, SM, ST and Z-DS wrote the manuscript.

  • Funding This study was funded by the National Medical Research Council of Singapore (NMRC/1249/2010; NMRC/CIRG/1371/2013; NMRC/CIRG/141; NMRC/CIRG/1488/2018, and NMRC/CSA-SI/0012/2017).

  • Competing interests None declared.

  • Ethics approval Obtained from SingHealth Centralised Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available

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