Glaucoma Consults Round-up: Progression on Goldmann VFs but is it Glaucoma?...and more!

Wednesday October 21, 2009

Case 1:

robschertzer #Glaucoma #consult 65 yo WM referred fearing VF progression w/ IOP <18, thin CCT, bothered by drops side f/x

This patient was referred by an Ophthalmologist wondering whether Selective Laser Trabeculoplasty would be useful. He is on Travatan in both eyes and was recently given Alphagan to use in the left eye as well. The referring doctor is concerned about progressive damage based on the Goldmann Visual Field tests shown below. Pachymetry is reported as slightly thin but no values provided. The patient's understanding is that he is not responding well to his drops. There is also a strong family history of glaucoma and intolerance to topical beta-blockers and oral carbonic anyhdrase inhibitors. Family members effected with glaucoma include his mother, great aunt, brother and nephews.

VA is 6/7.5 OD and 6/9 OS without correction needed. Early cataracts are present in both eyes and IOP readings are 14 mmHg OD and 16 OS at 1315hrs. Gonioscopy reveals wide open angles in both eyes with the Ciliary Body band visible. His optic nerves show the most drusen I have ever seen in any patient in his left eye; less so in the right but still present.

21Oct2009 Case 1 GVF OS Oct 2007

21Oct2009 Case 1 GVF OD Oct2007

21Oct2009 Case 1 GVF OS Sep 2008

21Oct2009 Case 1 GVF OD Sep 2008

21Oct2009 Case 1 GVF OS Jun 2009

21Oct2009 Case 1 GVF OD Jun 2009

Reviewing the Goldmann VFs above, I am not convinced of progression. Different technicians performed the test which can be prone to some stylizing that could make one test look like it has changed. There is quite an art to Goldmann perimetry which can be a very useful test, often giving a better overall picture than automated (Standard Automated Perimetry) tests but they lack statistical analysis options to help decide whether there is progressive damage.

Overall, I am not 100% convinced that this patient even has glaucoma. Patients with disc drusen can present with defects similar to those seen in glaucoma and can even, at times, get worse over time. Given that there is a strong family history, the corneas are thinner than normal, and that it is hard to tell if glaucoma might be co-existing, it is reasonable to keep treating this patient with glaucoma meds but I would not be more aggressive. Furthermore, it turns out they are taking Alphagan, Azopt and Travatan in both eyes; the odds are close to 0% that the SLT laser would have any effect on pressure reduction though perhaps it could replace a single medication if tolerance or compliance is a problem.

As a follow-up, the referring ophthalmologist disputed my findings and has now provided additional older visual fields for me to review. 

21Oct2009 Case 1 GVF OS Aug 2001

21Oct2009 Case 1 GVF OD Aug  2001

21Oct2009 Case 1 GVF OS May 2002

21Oct2009 Case 1 GVF OD May 2002

Armed now with these older Visual Fields, should this change the proposed management? And, for those wondering, stereo disc photos have been ordered for this patient. 

Case 2:

robschertzer #Glaucoma #consult 59 yo Persian F, prior PRK for astigmatism; second opinion for narrow angles; agree needs LPI.

This patient was referred by her family doctor after being told by another Ophthalmologist that she has narrow angles at risk of occlusion if does not have laser iridotomies performed. Of note is that she had LASIK peformed 5 years ago.

This patient has 6/6 visual acuity without glasses in both eyes and IOP readings of 15 mmHg OD and 12 OS. CCT readings are 503 ums OD and 445 ums OS. (Remember, did have LASIK to thin corneas.) Optic nerves are devoid of any cupping. Her angles are appositionally closed inferiorly in both eyes and slit open superiorly. There is 1+ increased pigmentation OD angle and 2+ OS, both in a patchy distribution on the angle structures that could be seen as well as 1+ iris processes OU.

Comments on this one? What do people think of the pachymetry readings (CCT) for this patient and any implications on management? What about the description of the angle anatomy? Agree with suggestion of Laser Peripheral Iridotomy?

Case 3:

robschertzer #Glaucoma #consult 91 yo WF, definite optic nerve damage w/ advanced VF defect; IOP w/in N range. Tx'ing as could wipe out fix'n in life.

I know what you're thinking....treat a 91 yo lady who is at risk of dying before she would ever lose vision? Am I out of my mind? Let's review and discuss.

21Oct2009 Case 3 VF OS

21Oct2009 Case 3 VF OD

My apologies for the poor quality of the images. It should be noted that the tests were repeated several times by the referring doc with improving performance each time. These results do appear to be reliable and show quite constricted visual fields.

Intraocular pressure readings have been in the mid-teens and this is true at this visit as well: 16OD and 14 OS at 1400hrs. Posterior chamber lens implants are present in both eyes and Visual Acuity is 6/9 OD and 6/7.5 OS. Angles are wide open and optic nerves show thinning of the rims, especially inferiorly. These are shown to some degree on the HRT stereometric parameter printouts. Not the rim area at the bottom end of the normal range with the disc area closer to the upper limit.

21Oct2009 Case 3 HRT Stereo OS

21Oct2009 Case 3 HRT Stereo OD

Treat? Diurnal tension curve? What would you do? (Patient not on any glaucoma treatment prior to referral.)

Case 4:

robschertzer #Glaucoma #consult 40 yo Brazilian F, disc asymmetry, IOP 14 OU @1410hrs, N CCT; not convinced glaucoma at this time. See 6/12.

Case 5:

robschertzer #Glaucoma #consult 79 yo WF advanced COAG, Cataract OD, Dry AMD OU; IOP low but apparent progression better eye. Suggest cataract surgery.

The following comment was copied from original submission date and posted as a journal follow-up article in preparation for changing to DISQUS for future commenting on my blog.)

On Nov 7, 2009 our Optom/EyeMD co-editor commented:

Concerning Case #3, the 91 year old woman, in my experience, the rationale for treatment is also based not only on life expectancy but other morbidities present as well as the risk of polypharmacy.

Frequently, medical treatment must be tempered when the internists has maximum medical therapy for coronary and cardiovacular issues. I recommend treatment if the patient is taking less than 10 other medications and no treatment or suggesting surgery if there already >15 other prescription medications.

Depression and despair are real villains here and I have sat in conferences where the addition of even 1 drop nightly drove the patient to completely be non compliant on their other medication. Of course, after very careful consultation with the patient and family, medical or surgical treatment can be tolerated but only if the family and the patient are fully involved.

Richard Hom OD