Glaucoma Consults: how would you manage these varied patients with strong Fam Hx, physiologic cupping, and OHT.

Friday October 23, 2009

Case 1:

#Glaucoma #consult 55 yo WM myope, darkly pigmented TM, flat irides, CCT 572ums, IOP 32 & 26 at 0920hrs; N VF. Will follow not Tx.

This 55 yo white male was referred due to high intraocular pressure readings from their Optometrist. These readings were 28 mmHg in each eye at 1245hrs which were confirmed when repeated 6 hours later. Refractive error measured approximately -1.50D in each eye with healthy optic nerves with 0.3 cup-to-disc ratio.

On examination, his eye pressure was 32 OD and 26 OS at 0920hrs by Goldmann applanation tonometry. There were two small peripheral transillumination defects in the right iris, one at 3:00 and the other at the 6:00 position. The iris contour was flat in both eyes and the angles were open for 360 degrees with markedly increased and even pigmentation both eyes.

Would you treat or just follow for now?

23Oct2009 Case 1 VF OS

23Oct2009 Case 1 VF OD

23Oct2009 Case 1 HRT OS

23Oct2009 Case 1 HRT OD

Case 2:

#Glaucoma #consult 34 yo WF, non-contact tonometry IOP elevated, N on applanation and all other tests normal too. No further f/u.

Actually, this was a typographic error as this patient is 47 years old but I'm sure she doesn't mind being mistaken for being 13 years younger! Her intraocular pressure as measured using non-contact tonometry by the referring Optometrist was 24 OU @1040hrs, CCT of 543 and 549 ums, with healthy optic nerves described as 0.20 OD and 0.03 OS vertically. The less cupped eye is two diopters more hyperopic than the fellow left eye.

What would your follow-up plan and what level of eye care professional needs to follow her? Optometrist, Comprehensive Ophthalmologist, Glaucoma sub-specialist?

23Oct2009 Case 2 VF OD

23Oct2009 Case 2 VF OS

23Oct2009 Case 2 HRT OS

23Oct2009 Case 2 HRT OD

Case 3:

#Glaucoma #consult 44 yo E European, strong FamHx glaucoma, on Cosopt & Travatan for OHT, disc asymmetry; agree keep Tx'ing

This patient was referred by an optometrist as having chronic angle closure glaucoma with eye pressures of 20 mmHg in both eyes  on Cosopt and Travatan with the concern that the pressure "may not be low enough in lieu of her history." She was already seeing a comprehensive ophthalmologist who was managering her but the optometrist was wondering if she needed to be followed by a glaucoma sub-specialist. The family history includes grandparents, aunts, uncles and cousins all with glaucoma.

On examination, eye pressure readings were 16 OD and 15 OS @1030hrs with CCT measurements of 516 ums OD and 513 ums OS. Visual acuity was 6/6 OU without correction. Optic nerve rims were intact with relative thinning of the superior rim in the right eye. Visual field was completely normal.

At what point is a very strong family history enough reason to treat patient for glaucoma (if any)?

Does this patient need to be treated?

23Oct2009 Case 3 VF OS

23Oct2009 Case 3 VF OD

23Oct2009 Case 3 HRT Stereo OS

23Oct2009 HRT Stereo OD

23Oct2009 Case 3 HRT GPS OS

23Oct2009 HRT GPS OD

Case 4:

#Glaucoma #consult 34 yo East European male deep cupping right optic nerve; all else normal, no convinced any risk glacuoma.

This gentleman had a physical examination at work and was noted at that time to have 'deep cup' in the right eye. He was referred to check for glaucoma. 

I have been referred patients before with 'deep cups' and have never been sure if there is any known correlation between how deep the cupping is and the chance of glaucoma being present. As far as I know, it is optic nerve rim loss that matters.

Visual acuity was 6/6 OU uncorrected, IOP 20 mmHg OU @0930hrs with CCT of 588 ums OD and 580 OS. 

Does this patient require longterm follow-up?

23Oct2009 Case 4 VF OS

23Oct2009 Case 4 VF OD

23Oct2009 Case 4 HRT GPS OS

23Oct2009 Case 4 HRT GPS OD

Case 5:

#Glaucoma #consult 29 yo WF IOP 20s & AbN FDT at optom & 22/21 at 1015 here, CCT 542 OU, N VF, left disc slope but wnl.

This patient was referred by an Optometrist with what was being referred to as borderline eye pressures and slightly high pachymetry readings. The IOP readings were 23 and 24 with the time of day blurred out on the incoming fax, with pachymetry readings of 555 and 550. Our readings were slightly lower for both the IOP @1015hrs and the CCT. 

The Frequency Doubling Technology results were not provided by the referring Optometrist. Although we work hard to assure all the necessary information is provided in advance of a patient's consult, and often try calling on the day of the visit if we still do not have all the necessary information, we do not have the FDT test for this patient. As I tend to dismiss the FDT test results anyway due to their high false positive rate (being abnormal even when no other findings are found to confirm glaucoma), it would still be good to have these results for completeness.

Heidelberg Retinal Tomogram (HRT) and Visual Field results are as follows.

What would your management plan be for this patient? Would you follow because of the slight disc asymmetry?

23Oct2009 Case 5 VF OS

23Oct2009 Case 5 VF OD

23Oct2009 Case 5 HRT GPS OS

23Oct2009 HRT GPS OD

Case 6:

#Glaucoma #consult 14 yo E Indian male, glaucoma suspect b/o large discs & cups; likely physiologic

Before dismissing this purely as physiological cupping, it should be noted that this referral was not based on a single visit for a routine eye exam, but rather for a 7D myope, followed by a paediatric ophthalmologist who has noted this patient to have disc asymmetry in the past and is wondering if this has progressed.

With his fully myopic correction, visual acuity was 6/6 OU. His IOP readings were just 8 OD and 9 OS @1100hrs. Pachymetry readings were 551 ums OD and 562 OS.

Risk factors are the moderately high degree of myopia and 'cupping.' However, visual fields are completely normal, corneas are of normal thickness, and IOP readings are well below 'normal.' Would anyone treat? 

23Oct2009 Case 6 VF OS

23Oct2009 Case 6 VF OD

23Oct2009 Case 6 HRT Stereo OS

23Oct2009 Case 6 HRT Stereo OD