Glaucoma Case Studies

James C. Tsai, M.D.

Associate Professor of Ophthalmology Director, Glaucoma Division Edward S. Harkness Eye Institute Columbia University

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 (9:25 AM)

• SLE: 2+ NSC OU (+ PXE flakes), A/C D&Q

• Gonio: Grade II-III OU; CCT: 518 OD, 533 OS

• C/D ratio: 0.75 OD, 0.85 OS; thin temporally OU

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 (OS>OD) ? Thin CCT OU a risk factor

Target IOP: mid-teens OU

• Treatment Plan: ??

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 > OS)

• C/D = 0.8 OD, 0.7 OS (cupped temporally)

• Meds: Betaxolol, Propine

Patient: J.D.

• Initial ALT OD, followed by ALT OS

• 1 year later: c/o worse vision (OS > 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

Patient: J.D.

• Neuro-ophthalmology consult:B-12 and folate: WNLCT 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 OSHVF stable OU; No visual loss

Visual Fields Pre-Surgery

Visual Fields Post-Surgery

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

Gonioscopy

Funduscopy

Anterior Ultrasound

Assessment

• Ocular hypotony OD (with maculopathy)• Cyclodialysis cleft with concomitant

angle recession• Treatment:

1. Argon laser closure of cleft2. Surgical closure of cleft

• Need to monitor for post-op IOP spike(? Concurrent Stage 1 glaucoma tube)

74 Year Old Female

Followed in glaucoma clinic for COAGNoted progressive ↓ in visionReferred to retina clinic to evaluate macula

VA: 20/50 OD20/80 OS0.6 log unit RAPD OSColor 1/15 OU

Optic Disc Exam

Humphrey Visual Fields

Neuroimaging

Neuroimaging

Neuroimaging