OPTOMETRIC EDUCATION CONSULTANTS CLINICAL CASE CHALLENGE

Case Challenge 05 – September 2018

A 65 year old woman previously diagnosed with primary open angle glaucoma presented for ongoing care. She was using latanoprost in each eye and had bilateral selective laser trabeculoplasty performed two years earlier. Her medical history was significant for hypertension, elevated cholesterol, and arthritis.  Her vision was 20/20 OD and 20/25 OS. She had an inferior retinal nerve fiber layer defect in the right eye and significant superior rim damage in the left eye. Threshold perimetry showed the above corresponding visual field defects.

However, there was no anatomical correlate to explain the inferior defect in the right eye. Particularly troubling was the fact that on the Greyscale, the inferior defect on the right eye broke from the blind spot and stopped at the vertical. Upon inspecting the left inferior arcuate defect, it was seen that there was a deeper scotoma underlying inferior nasally, also seemingly stopping at the vertical. It appeared that there was a right inferior quadrantanopia underlying the glaucomatous fields. Threshold perimetry was repeated and these patterns persisted. She was referred for neuroimaging. Interestingly, while awaiting the MRI results, the patient called in to report that she remembered a transient period of inability to speak 8 years earlier that had been attributed to a “mini-stroke”. MRI revealed past ischemic changes and the patient’s internist is intervening to attempt to prevent future cerebrovascular events.

This case underscores the importance of recognizing potential neurogenic fields which may be lost among glaucomatous vision loss. While historically disregarded, remember that the Greyscale on the visual field does impart valuable information.

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READ MORE CASE CHALLENGES

Click on the toggles below to read previous case challenges.

Case Challenge 04 – August 2018

The first patient is a 16 year old male whose vision has been fluctuating for 6 weeks. He also complains about headaches. His primary care physician feels it’s a normal growth spurt and Mom feels it’s migraines as there is a strong family history, but she still wants...

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Case Challenge 03 – July 2018

A 35 year old man presents wanting another opinion due to “blood on my right eye”. He says that everything happened 3 days ago after violently vomiting, reportedly due to food poisoning from chicken Caesar salad. He still feels a little nauseated and somewhat “not...

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Case Challenge 02 – June 2018

A 13 year old female was referred for painless reduced vision (20/40) in her left eye with a concurrent abnormal screening visual field, reportedly elevated intraocular pressure (IOP), and an afferent pupillary defect. Her previous exam was 3 weeks earlier and she had...

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Case Challenge 01 – June 2018

Case 1: A 27 year old woman presents urgently complaining of painful vision loss in her right eye. She has no known medical history and this has never occurred before. She has an edematous optic nerve with hemorrhaging, an afferent pupil...

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August 31-September 2, 2018