Is this glaucoma? Leo Semes, OD Michael Chaglasian, OD Danica Marrelli, OD. Optometry s Meeting 2015 Seattle, WA
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1 Is this glaucoma? Leo Semes, OD Michael Chaglasian, OD Danica Marrelli, OD Optometry s Meeting 2015 Seattle, WA Case WM Engineer is referred to UAB Eye Care as a glaucoma suspect. Mild myopic refractive correction Lattice retinal degeneration (OD, OS) Former smoker (x 3 yrs) Family history of cataract (M & F) Exam findings BSCVA 20/20, 20/20 IOP (OD), (OS) Pachymetry o 587u, 586u Gonioscopically open angles Lens evaluation (LOCS II): NO 1 / NC2 CS 0 PSC 0 (OD = OS) Optic disc evaluation: o Small in each eye with inferior rim thinning (narrowing) OD > OS) o Some PPA consistent with rim configuration o Apparently well perfused with distinct margins o Appearance consistent with myopic refractive error Visual field analysis o Reliable in each eye o No blind spot on GS o PSD not flagged in either eye o Sporadic depressions OS Digital imaging (Cirrus OCT) o IT RNFL thinning statistically (OD > OS) o Statistically thin GCC temporal OD
2 Reviewing the data Good VA ( ) family history of glaucoma? SAS / (+) heart murmur // no beta blocker meds. Normal IOP Apparently clean VF Evidence of ONH / RNFL damage Case AA M ONH appearance changes over several visits suggesting progressive atrophy VF shows superior attitudinal defect OD with masked nasal step To treat or not to treat? (in the immortal words of Hamlet) Case YO Asian male presents for routine refractive care o Serving a neurology fellowship at UAB Hospital o Ophthalmic history is remarkable for refractive correction since an early age o Non contributory medical and family histories o BSCVA 20/20 (OD, OS) ( 7.50 OD, OS) o Anterior segment unremarkable (OD, OS) o IOP 16, 17 mmhg, (OD, OS); (Pachymetry not obtained) o ST RNFL defect OD < OS o Corresponding VF depression OD
3 Case WF Nurse referred for glaucoma evaluation from a community screening. Medical history non contributory Family history positive for glaucoma Ocular history: refractive correction and mention of amblyopia. Findings BSCVA 20/20 OD, OS. Minimal hyperopic refractive correction IOP: 16 mm Hg OD and 18 mm Hg OS Pachymetry: 567 microns OD and 562 microns OS Angles open with visible CB 360 OS, OS Anterior segment unremarkable ONH evaluation reveals asymmetry (C/D: OS > OD), good margins, no hemes no PPA VF reveals Left Inferior quadrantanopsia with emerging nasal step Digital imaging (Cirrus OCT) RNFL thinning ST: OD > OS) GCC statistically thin in regions corresponding to VF depressions. Case AM has been diagnosed and treated for MS for > 5 years. BSCVA: 20/40, 20/40+ ONH reveals temporal pallor Digital imaging reveals statistically significant GCC thinning
4 Case WM contact lens wearer referred for second opinion on ONH appearance OS. Non contributory medical and family histories BSCVA 20/20 in each eye IOP: 16, 16 Gonioscopically open angles Pachymetry 528u, 530u ONH appearance unremarkable OD but shows apparent cupping OS Visual Field reaulst are reliable in each eye and show sporadic depressions OD and paracentral depressions OS. Digital Imaging (Cirrus OCT) shows optic nerve profile. Case YO WM referred for glaucoma evaluation. Healthy pt with vision complaints Noncontributory personal medical and family histories (ex., father with HTn) No medications, no chronic diseases VA 20/25+ // 20/30 BAT: 20/50 // 20/40 Superpinhole 20/20 // 20/20 IOP 17/15 Pachymetry 601/606 Keratometry: / Refractive correction: OD X 050, OS X 130 BSCVA = 20/25+ // 20/30 ONH appearance is suspicious but photographs suffer resolution secondary to media opacity.
5 Visual field is reliable and clean in each eye. Digital imaging (Cirrus OCT) shows statistically thin RNFL ST and IT in each eye. Case WM presents for follow up care following diagnosis and treatment by community ophthalmic practitioner. Non contributory medical history Currently treated with 3 topcial drops in each eye; IOP mid teens over several visits. BSCVA 20/20 OD ( 5.25); 5/350 ( 9.50) OS VF is reliable and clean OD, no VF possible OS ONH appearance is suspicious OS Digital Imaging (Cirrus OCT) normal Followed X several years and continued on medications, with modification to only PGA in each eye. IOP maintained in mid teens. A decision was made to offer a vacation from medication. IOP stable X 2 and 4 weeks but elevated OS> OD at week 6! Gonioscopy reveals angle abnormalities....
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