It is important to see the bigger picture when evaluating and diagnosing a patient as there are many ocular conditions that can masquerade as glaucoma. By evaluating a comprehensive medical history, case history, and utilizing different multimodal ophthalmic imaging, we will be better equipped to diagnose and manage our patients accordingly. This article will walk through different cases to construct a thought process with which to tackle these diseases.
- 57 yo BF referred by PCP for glaucoma evaluation.
- POHx: Latanoprost qhs OU, poor compliance. Pt self discontinued since “she did not feel it was helping”.
- MHx: HIV (+), unknown viral load
- BCVA: 20/40 OD/OS
- Pupils: PERRL (+) Grade 2 RAPD OS
- IOP: 19/20
- PACHY OD: 530, OS: 534
- Gonioscopy: Open (-) neovascularization of the angle, angle recession, peripheral anterior synechiae
- Additional findings: Anterior Uveitis OS; asymptomatic. Tritan color vision defect, OS
Figure 1.0: Fundus photos (blur due to cataract) and pachymetry (OD 533um, OS 534um)
Figure 1.1: Left: OCT RNFL - notice the asymmetry between the RNFL layer of the eyes. Right: Ganglion Cell Analysis - OS shows asymmetry between the superior and inferior portion, respecting the horizontal raphe.
Figure 1.2: Top: 30-2 SITA, OS - dense inferior arcuate defect, and superior nasal step. Bottom: 10-2 SITA, OS - corresponds well with the ganglion cell loss as seen in Figure 1.2. Note: OD visual field not shown, but full without glaucomatous defects.
Conclusion: Still in the gray area, and glaucoma should be put on the differential list. The patient has some outlying data: asymmetry and APD that warrant a closer look at imaging.
Figure 1.3 Left: Fundus photography, OS. Right: Red-free fundus photography OS - distinct pallor temporal.
Case 1 Discussion
The patient was diagnosed with neurosyphilis. Remember that if you have a puzzling diagnosis that does not look quite right, consider blood work, as well as, neurosyphilis. The ocular manifestations of neurosyphilis are quite diverse:
- Interstitial keratitis
- Papillary conjunctivitis
- Granulomatous or non-granulomatous uveitis
- Multifocal choroiditis
- Optic atrophy
- Ocular hypertension
- Argyll-Robertson pupil
- Cranial nerve palsies
- 52 yo WM
- BCVA: 20/25 OD, 20/20 OS
- Pupils: PERRL (-) RAPD
- IOP: 18/19, Pachymetry: 560/553
- MHx: unremarkable, + smoking (cigarettes)
Figure 2.0: OCT RNFL and ganglion cell analysis. Notice the asymmetry in the RNFL thickness from OD to OS.
Figure 2.1: VF 24-2 absolute defect inferior nasal, OD. Recall that glaucoma starts as a relative defect.
Figure 2.2: Before and after resolution of BRVO.
Case 2 Discussion
This patient had a branch retinal vein occlusion (BRVO) of the right eye. The occlusion starts very close to the optic nerve head (Figure 2.2), and branches off to the peripheral retina with damage to capillary beds as seen by the deeper hemorrhages. Due to the size and extent of damage, there’s been a lot of retinal ischemia.
Cases like this one can be glaucoma masqueraders when the patient walks into your office after resolution of the condition. You want to be able to pick up a history of retinal vein occlusion so the patient doesn’t get misdiagnosed with a different condition. With careful analysis of the fundus photo post-resolution, you can see the arterials were attenuated. A fundus autofluorescence image (Figure 2.3) also makes the tiny collateral vessels pop out. It is important to use different imaging techniques to assess the overall picture, and to evaluate from quadrant to quadrant to pick up on subtle signs.
Figure 2.3: Fundus autofluorescence, OD. Cursor is pointed at collateral vessels.