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Case #8 (03-21-2004)

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Andrew_Doan

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CC: 65 y.o. man with complaints of painless, gradual loss of vision OS.

HPI: Patient complained of a painless, gradual loss of vision OS over several months. He saw an eye doctor and was diagnosed with angle closure glaucoma. He was sent to the U of Iowa for evaluation, treatment, and possible laser peripheral iridotomy (LPI).

PMH: healthy, no medications, and no FH of glaucoma.

Exam:
mRx: PLANO OU
Best corrected visual acuities: 20/20 OD, barely hand motion vision OS.
Pupils: >3.0 LU RAPD OS (very large).
EOM: full OU
VF (see below)
IOP: 19 mmHg OD, 71 mmHg OS
DFE: retina exam notable for normal macula, vessels, and periphery OU. Optic nerves: 0.4 C/D OD, almost complete cup OS (see photos below).
SLE: OD notable for 1-2+ nuclear sclerosis cataract, OS see photos below.
Gonioscopy: moderately open angles OU. Not occludable OU. (+) Sampolesi line OS.

GVF OD - Full Field
GVFOD_03172004.jpg



GVF OS with severe VF loss
GVFOS_03172004.jpg



Slit Lamp OS: moderate injection, no cells seen in anterior chamber
OS_03172004.jpg



Slit Lamp OS: moderate corneal edema, and moderately deep anterior chamber
OS2_03172004.jpg



Slit Lamp OS: undilated pupil exam notable for white, fluffy material around pupil margin.
pupil_03172004.jpg



Slit Lamp OS: dilated exam notable for ground glass appearance of anterior lens capsule
pupil2_03172004.jpg



Right Optic Nerve: normal
ON_OD_03172004.jpg



Left Optic Nerve: almost complete cup
ON_OS_03172004.jpg



Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?
 

TomOD

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I agree. Recommend LPI or filtration surgery.
 

SnapperK

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Originally posted by TomOD
I agree. Recommend LPI or filtration surgery.

LPI? What would you do that for? Do you mean ALT?
 

Andrew_Doan

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Originally posted by TomOD
Recommend LPI or filtration surgery.

Without pupil block, LPI is not helpful here.

I'd try drops before filtration surgery. In addition, the left eye had a huge RAPD with only a small temporal island of vision. Doing intraocular surgery on an almost blind eye may put the other eye at risk for sympathetic ophthalmia. Taking the conservative route with the left eye may be better for the patient.
 

TomOD

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Originally posted by SnapperK
LPI? What would you do that for? Do you mean ALT?

Sorry. Yes, meant to write ALT....actually perhaps SLT. Our local glaucoma MD would probably do SLT first but I really think he'd be more aggressive. In my experience, this eye is too far gone to help at this point, but I'd sure try. It takes a very disciplined and motivated person to use drops 4-6 times per day, every day, for life. Apparantly this person was not concerned enough to seek help earlier (I could be wrong) as he/she watched their vision slowly fade away. So I'd be really surprised if they adapted well to aggressive topical treatment.

Also, I believe that studies have shown that this syndrome is typically bilateral, although asymmetric. I'd watch the other eye carefully.
 

TomOD

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Originally posted by Andrew_Doan
Without pupil block, LPI is not helpful here.

I'd try drops before filtration surgery. In addition, the left eye had a huge RAPD with only a small temporal island of vision. Doing intraocular surgery on an almost blind eye may put the other eye at risk for sympathetic ophthalmia. Taking the conservative route with the left eye may be better for the patient.

Good point. What combination of drops would you suggest? With a pressure of 71, there would have to be a very big drop in IOP. Even with a cocktail of betablockers, CAI, and prostagladins analogs, do you think it would be enough to lower the pressure THAT much?
 

Andrew_Doan

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Originally posted by TomOD
Good point. What combination of drops would you suggest? With a pressure of 71, there would have to be a very big drop in IOP. Even with a cocktail of betablockers, CAI, and prostagladins analogs, do you think it would be enough to lower the pressure THAT much?

We did that and the pressure decreased to the mid 30's-low 40's. The prostaglandins will decrease IOPs by 20-30%, and with the addition of each medication, there's less of an effect. Some patients respond and some won't. This patient responded well.

For instance, 70 -> 49 (30% reduction) -> 41 (15% reduction) -> 37 -> (10% reduction) -> 35 (5% reduction)

I think it's always good to try maximum medical therapy and document it before proceeding with an invasive procedure.

With the pressure under control, we can proceed with an ALT, CPC, or filtering surgery after discussing the risks and benefits of each procedure. With the level of vision OS, it may be best to do the CPC vs ALT..
 

golgi

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Hi,

Andrew, I really appreciate these cases. However, as a novice I am ignorant of the abbreviations. Would someone please tell me what PLANO, RAPD, DFE,SLE,ALT,CPC,SLT, and LPI stand for? Thanks for your time!
 

Andrew_Doan

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golgi said:
Hi,

Andrew, I really appreciate these cases. However, as a novice I am ignorant of the abbreviations. Would someone please tell me what PLANO, RAPD, DFE,SLE,ALT,CPC,SLT, and LPI stand for? Thanks for your time!

I'll post an abbreviation template later but here are your answers:

PLANO = no refractive error (plane glass)
RAPD = relative pupillary afferent defect
DFE = dilated fundus exam
SLE = slit lamp exam
ALT = argon laser trabeculoplasty
CPC = cyclophotocoagulation
SLT = selective laser trabeculoplasty
LPI = laser peripheral iridotomy

I welcome any forum members to make an abbreviation cheat sheet. I remember how difficult it was to rotate through ophthalmology as a medical student without knowing the "lingo". ;)
 
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