Glaucoma Case Studies

1
Glaucoma Case Studies

• James C. Tsai, M.D.
• Associate Professor of Ophthalmology
• Director, Glaucoma Division
• Edward S. Harkness Eye Institute
• Columbia University

2
LD Clinical History Exam

• 78 y/o woman with glaucoma x 7 months
• PMHx hypothyroid Meds Synthroid, Premarin
• Ocular Hx negative on Xalatan qhs OU
• Va 20/40 OU, Ta 17 OD, 22 OS (925 AM)
• SLE 2 NSC OU ( PXE flakes), A/C DQ
• Gonio Grade II-III OU CCT 518 OD, 533 OS
• C/D ratio 0.75 OD, 0.85 OS thin temporally OU

3
LD Clinical Assessment

• HVF OD WNL, OS inf. arcuate defect/nasal step
• OCT3 OD 88.0 microns, OS 74.75 microns
• Imp PXF glaucoma w/ uncontrolled IOP (OSgtOD)
  ? Thin CCT OU a risk factor Target IOP
  mid-teens OU
• Treatment Plan ??

4
Patient J.D.

• 47 y.o. M w/ COAG recurrent erosions
• FHx of POAG, Myopia (-4 to -6 D)
• Va 20/20 OU IOP 18 OD, 16 OS
• cc grayer darker vision (OD gt OS)
• C/D 0.8 OD, 0.7 OS (cupped temporally)
• Meds Betaxolol, Propine

5
Patient J.D.

• Initial ALT OD, followed by ALT OS
• 1 year later c/o worse vision (OS gt OD)
• Va 20/20 OU IOP 10 OD, 11 OS
• Diurnal curve peak of 13 OU
• HVF worse OU
• C/D 0.9 OD 0.85 OS

6
Patient J.D.

• Neuro-ophthalmology consult B-12 and folate
  WNL CT of orbits WNL
• 3 months later IOP 16 OU cc OS dimmer
• TBX w/ MMC OS OD 2 months later
• 5 year F/U Va 20/20 OU IOP 10 OD, 9 OS HVF
  stable OU No visual loss

7
Visual Fields Pre-Surgery
8
Visual Fields Post-Surgery
9
Case Presentation

• 15 year old boy S/P trauma OD (tennis ball)
• Cc Blurred vision OD x 3 months
• PMHx negative
• Va 20/200 OD, 20/20 OS
• IOP 4 mm Hg OD, 15 mm OS
• SLE (OD) deep A/C, trace RBCs

10
Gonioscopy
11
Funduscopy
12
Anterior Ultrasound
13
Assessment

• Ocular hypotony OD (with maculopathy)
• Cyclodialysis cleft with concomitant angle
  recession
• Treatment1. Argon laser closure of cleft2.
  Surgical closure of cleft
• Need to monitor for post-op IOP spike(?
  Concurrent Stage 1 glaucoma tube)

14
74 Year Old Female

• Followed in glaucoma clinic for COAG
• Noted progressive ? in vision
• Referred to retina clinic to evaluate macula
• VA 20/50 OD
• 20/80 OS
• 0.6 log unit RAPD OS
• Color 1/15 OU

15
Optic Disc Exam
16
Humphrey Visual Fields
17
Neuroimaging
18
Neuroimaging
19
Neuroimaging