OPTOMETRIC EDUCATION CONSULTANTS CLINICAL CASE CHALLENGE

Case Challenge 12 – September 2019

A 37-year-old woman presented for a glaucoma evaluation and ongoing care. She had previously been diagnosed with glaucoma approximately 3 years earlier and was using bimatoprost 0.01% OU QHS. She had not had any care for the past year. Her visual acuity was 20/20 in each eye and pupils were normal without afferent defect. Her IOP was 28 mm Hg OD and 30 mm Hg OS. Her optic nerves were symmetrically cupped at 0.95/0.95 OD and OS with very little rim tissue remaining in either eye. Pachymetry revealed thin corneas at 480 microns OD and 495 microns OS. Gonioscopy demonstrated fully open angles with no abnormalities in either eye. The remainder of her retinal exam was normal save for her advanced glaucomatous optic discs. Threshold perimetry on 24-2 and 10-2 fields were remarkably similar in each eye with not much more than fixation remaining. Indeed, she tended to rely upon her school-aged children to ambulate in the office.

This woman most likely has juvenile open angle glaucoma (JOAG), a particularly aggressive form of open angle glaucoma that typically begins early in childhood between the ages of 3 and 16 years. This is a speculative diagnosis as the severity of her condition and her young age strongly suggests that she had the condition for half of her life already.  Regardless, the management is similar to other form of open angle glaucoma.

Her peak unmedicated IOP is unknown, but her current level with thin corneas at her stage of disease severity is unacceptable. While glaucoma surgery (trabeculectomy or tube implant) would be the surest way to lower IOP, she runs the risk of losing her remaining vision to surgical ‘snuff out’. Laser trabeculoplasty would have minimal impact in this case.

Her medical therapy was amplified to include generic latanoprost, brimonidine 0.2%, and dorzolamide/ timolol fixed combination. This brought her IOP consistently down to the 09-10 mm range in each eye. She was referred for low vision rehabilitation and mobility training but chose not to go. For over two years of medical management, her visual fields and acuity remained stable. Then her visits became sporadic and she ceased retuning altogether, but refill requests came in from her pharmacy on a regular basis for the next 4 years. All of her medications were refilled when requested due to the harm that would be caused by a denial, but she refrained from scheduling an office visit. She was finally lost to follow up 2 years ago.

When faced with very advanced glaucoma, it is important to remember that if you can significantly lower IOP (by any acceptable modality) and keep it down, patients are not necessarily condemned to blindness and can remain stable.

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Click on the toggles below to read previous case challenges.

Case Challenge 11 – July 2019

A 57 year old asymptomatic woman was referred for a glaucoma evaluation due to elevated intraocular pressure (IOP). Her visual acuity was 20/20 in each eye and pupils were normal without afferent defect. Her IOP was 25 mm Hg OD and 24 mm Hg OS. Her optic...

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Case Challenge 10 – May 2019

A 46-year-old woman presented for a scheduled IOP check and visual field as a glaucoma suspect. She had a history of breast cancer 5 years earlier and was using tamoxifen. She reported that she got some cleaning fluid in her right eye 4 weeks earlier. She...

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Case Challenge 09 – April 2019

An 84-year-old African-American man with a history of glaucoma presented for consultation and care. Review of past records indicated that he had also been diagnosed the previous year with dry age-related macular degeneration (AMD) OD and wet AMD...

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Case Challenge 08 – March 2019

A 53 year old man who had been treated for advanced glaucoma presented with slowly progressive, painless vision loss in his right eye. He had missed his visits for the past year, though he had been obtaining medication refills through his pharmacy. His...

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Case Challenge 07 – January 2019

A 25 year old woman was involved in a minor automobile accident where she was hit by another driver. The accident was reportedly minor, with no initial injury to either driver, and both cars were able to be driven away. She felt that she experienced only a...

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Case Challenge 06 – November 2018

Optometric Education Consultants Clinical Case Challenge A 21 year old male plumber called in requesting an urgent appointment. He was working on a job and trying to dislodge a drain coupling by hammering it with the blunt end of a screw driver. He missed,...

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Case Challenge 05, Explained – October 2018

  A 47-year-old man presented complaining of gradually decreasing vision and monocular diplopia in his right eye for approximately the past 18 months. He had undergone LASIK vision correction over 13 years earlier with an excellent...

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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.

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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 eyes checked. His vision is 20/20 OD/OS uncorrected and he has bilateral optic disc edema.

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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 himself”. He saw another practitioner 3 days ago, was told he had a ‘bruise’ on his eye and it should go away in 1-2 weeks. From the outward appearance, he seems to simply have just a subconjunctival hemorrhage…or does he?

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