OPTOMETRIC EDUCATION CONSULTANTS CLINICAL CASE CHALLENGE

Case Challenge 14 – February 2020

An 82 year old man presented complaining of a moderately painful left eye of approximately 2-week duration. He was both diabetic and hypertensive.  He was 20/25 OD and bare light perception OS. His intraocular pressure (IOP) was 23 mm Hg OD and 62 mm Hg OS. His left eye manifested central microcystic corneal edema, florid iris neovascularization, and hyphema. Gonioscopically, his right angle was open to at least scleral spur while his left angle was closed with peripheral anterior synechiae (PAS) for 1800 with hyphema and angle neovascularization for the remaining part of the angle. The corneal edema, circulating hyphema, and poor dilation prevent fundus examination.

Clearly this was an acutely urgent case of neovascular glaucoma (NVG). Patients with NVG typically present with a chronically red, painful eye, which often has significant vision loss.  There frequently is an antecedent history of a retinal vessel occlusion, carotid artery disease, chronic retinal detachment, or advanced diabetic retinopathy. There will be visible neovascularization of the iris (NVI) and angle (NVA).  The patient will typically have significant corneal edema, anterior segment inflammation, anterior chamber cell and flare reaction, and elevated intraocular pressure due to synechial angle closure, often exceeding 60 mm Hg.

Retinal hypoxia induces vascular endothelial growth factor (VEGF) to act upon healthy endothelial cells of viable capillaries to stimulate the formation of a fragile new plexus of vessels (neovascularization). VEGF diffuses forward to the nearest area of viable capillaries, namely the posterior iris.  Neovascularization buds off of the capillaries of the posterior iris, grows along the posterior iris, through the pupil, along the anterior surface of the iris, and then into the angle.  Once in the angle, the neovascularization, along with attendant fibrovascular support membrane will block the trabecular meshwork with progressive PAS.

Neovascular glaucoma requires prompt and aggressive therapy. This involves control of the intraocular pressure and inflammation as well as management of the retinal ischemia as well as any precipitating conditions. Upon first presentation, a strong cycloplegic such as atropine 1% BID as well as a topical steroid such as prednisolone acetate 1% or difluprednate 0.05% QID should be prescribed.  The fact that the angle may be closed with PAS does not preclude pharmacologic mydriasis from atropine. Neither does the elevated IOP disqualify steroid use. This will greatly add to patient comfort.  Aqueous suppressants in the form of beta blockers, carbonic anhydrase inhibitors, and alpha adrenergic agonists may be used in order to temporarily reduce IOP. Definitive treatment is best accomplished with pan-retinal photocoagulation (PRP) to destroy ischemic retina, minimize oxygen demand of the eye, and reduce the amount of VEGF being released. While PRP is the most definitive treatment for the neovascularization causing NVG, the advent and use of antiangiogenic drugs has proven to be a valuable adjunct. 

The patient presenting here was prescribed atropine 1% BID, prednisolone acetate 1% QID, and brinzolamide/brimonidine fixed combination TID in the left eye. Upon meeting with the retinal specialist approximately 2 weeks later, his eye pain had disappeared, his IOP was now lowered to 24 mm Hg OS, and his cornea had clear enough to allow fundus examination. There was still iris neovascularization, but the hyphema had cleared. Fundus examination of the left eye revealed combined central retinal artery and vein occlusion. He received an intravitreal injection of an anti-VEGF agent and was scheduled for PRP.

Attend & Earn 15-20 COPE Continuing Education Hours

MID-WINTER EDUCATION GETAWAY

Scottsdale, AZ
February 14-16, 2020

Twin Cities Power Hours

St. Paul/Twin Cities
April 18-19, 2020

READ MORE CASE CHALLENGES

Click on the toggles below to read previous case challenges.

Case Challenge 13 – November 2019

A case of very high pressure A 21-year-old woman was referred for assessment of elevated intraocular pressure (IOP). She did not recall the IOP level, nor did she bring any referral form from her previous doctor. She presented in no acute...

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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...

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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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