This past week in Glaucoma Consults Sep 14-18, 2009

Here is a roundup of the tweets I posted this past week regarding glaucoma patients seen in consultation. Please read and add comments to turn this teachable moments into a many days of learning! I have added more details to each case beyond what was posted on Twitter.

It was an abbreviated week as my office was closed for everyone to attend the Optimed Software Users' Group Conference for Accuro in Kelowna. You can search for my glaucoma consult tweets using the following RSS feed as well:feed://search.twitter.com/search.atom?q=robschertzer+%23glaucoma+consult

These four cases were tweeted and I have added additional notes under each:

robschertzer #glaucoma consult 49 yo WF, abN FDT test 1 eye; big cup and disc, N CCT, neg Fam Hx; observe for now.

Patient referred by optometrist as a glaucoma suspect due to an abnormal Frequency Doubling Test. VA was 6/6 OU uncorrected, IOP readings 16 OD & 15 OS @ 1515hrs, angles were wide open to the ciliary body. Both optic nerves had overal increase in size rather than just increased cupping. Baseline HRT nerve scan was performed for future comparison and the patient will be re-assessed in 6 months with Standard Automated Perimetry instead of FDT along with repeat HRT testing.

robschertzer #glaucoma consult 78 yo WF, old CRVO, locum thought Neovascularization iris; none in angle, likely just dilated vessel.

Patient was referred by her family doctor after a locum tenens filling in for her medical retina ophthalmologist noted blood vessels on the iris in the eye that had a Central Retinal Vein Occlusion in the distant past. The eye has only Hand Motion vision (HM) with fellow eye VA of 6/7.5. Eye pressures were 15 OD and 16 OS @1445hrs. There were no dilated vessels noted in the angle on gonioscopy, the angle was wide open to the ciliary body. The blood vessel around the pupillary margin appeared to be just a prominent vessel as opposed to a leaky one from neovascularization. 

robschertzer #glaucoma consult 36 yo E Indian F, ACG needing Travatan despite LPI but non-compliant; explained need to take or have to operate

Referred by a general ophthalmologist to consider glaucoma filtration surgery due to poor compliance to medical therapy resulting in progressive optic nerve damage. Has been on Travatan for awhile and Cosopt was added 2 weeks prior to this consult when pressure was found to be 26 in eye of concern; patient never filled Rx for the Cosopt and was not given a sample.

On examination her IOP was just 10 OU @1400hrs as she had taken her Travatan the previous night, though not her Cosopt. Although the angles had a narrow approach, the post TM could be seen OU. There was extensive optic nerve damage OS with shunt vessel formation. Told her she will need surgery if she does not keep on taking the drops but that the drops are actually working when she takes them; just stick with the Travatan.

robschertzer #glaucoma consult 79 yo WF, ARMD, angle pushed closed by vitreous pushing iris, IOP 20 vs 14 fellow eye; Txing with PG analog as +++cup

Referred by vitreo-retinal surgeon to confirm glaucoma. Had prior complicated cataract surgery with vitreous pushing IOL and iris forward, clsoing off the angle. VA was 6/9 OD and 6/30 in effected eye; also has Age Related Macular Degeneration (ARMD.) IOP readings of 14 OD and 20 OS @1420hrs. Significant optic nerve pallor OU with increased cupping. 

This patient has already been through two anterior segment procedures and one vitreo-retinal procedure. A conservative approach starting her on Travatan-Z OS qHS was initiated and she will be seen in follow-up.

These two cases could not be retrieved by searching Twitter but were from same day:

73 yo East Indian male, increased cupping, Chronic Open Angle Glaucoma (COAG).

Referred by general ophthalmologist for second opinion. Has been on Timolol BID OU x 10 yrs and very anxious about his eyes but not aware of what his pressure readings have been. Recent Optometrist visit IOP was 13 OD and 8 OS. VA 6/7.5 OD, 6/12 OS w/ correction. IOP readings 18 OD and 10 OS at 1340hrs. PC IOLs OU. Angles open but completely covered in pigmented debris. Both optic nerves completely "cupped out." Visual fields consistent with extensive disc damage. 

Opted to switch Timolol to Travatan-Z with rationale that likely had long term drift of IOP from many years on Timolol, to keep simple as single medication per day, and applying AGIS findings loosely to not tolerate single IOP reading 18 or more.

62 yo white male, referred by Optometrists b/o suspicious left optic nerve.

Referred with Hx of recent optic nerve "Drance" haemmorhage and abnormal OCT nerve fibre layer. Uncorrected VA of 6/9 OD and 6/7.5 OS and IOP of 20 OD and 19 OS at 1325hrs. Anterior segment normal except for early NS cataracts. Wide open angles OU. Optic nerve examination confirmed some thinning of the rim OS with single missed spot on Visual Field testing.

After discussing the options with the patient, we decided to continue to follow with repeat HRT, VF and examination every 6 months and only treat if begin to confirm and change over time.