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Abstract #6107 Published in IGR 2-2
Disc hemorrhages and glaucoma management
Piltz-Seymour J; Nicolela M; Jonas JBJournal of Glaucoma 2000; 9: 273-277
In this cases in controversy series, the editor Jody Piltz asks questions after presenting a case to Marcelo Nicolela and Jost Jonas. She presented a 45-year-old with woman with progressive glaucoma. Her medical history was notable for migraine headaches. Visual acuity was good in each eye with corrections of -2.75 and ?4.0 D. She had IOP of around 15 mmHg and deep anterior chambers and open angles. Ophthalmoscopy showed a moderate temporal sloping and thin inferior rim in the right eye and an inferior focal notch with superior and inferior flame hemorrhages at the disc border in the left eye. She had a typical dense arcuate scotoma in the right eye and a new superior paracentral defect in the left. The questions asked were: Do you agree with the diagnosis of progressive glaucoma? What diagnostic procedures would you do? Describe your management of this patient. One year later there was no evidence of progression apart from the disc hemorrhage. How did you manage that? Marcelo Nicolela called this NTG and stated that it is not unusual to see rather young patients with myopia who have this type of focal disc damage. These patients frequently have headaches, suggesting the association of vasospasm. In this case, the presence of optic disc hemorrhages suggested that the disease is progressive. This expert will start treatment with the aim of reaching a 20-30% reduction of IOP, after having made good baseline IOP measurements. Blood flow measurements are only considered as research techniques. Nicolela would start with betaxolol based on in vitro data. If the IOP lowering effect was minimal, the next choice would be latanoprost, followed by brimonidine or topical carbonicanhydrase inhibitors. Non-selective beta-blockers would be avoided. He likes monocular trials. His next stage would be laser trabeculoplasty. After one year with a hemorrhage in the good eye, he would take a conservative approach. Trabeculectomy with mitomycin may eventually be considered. Jost Jonas would first make a diurnal pressure curve and perform neuro-imaging. To him this is NPG. He would classify this as the progressive focal type of NPG. He would start medical therapy with a prostaglandin analogue or a topical carbonic anhydrase inhibitor. The use of a calcium channel blocker may be considered. He would perform a whole battery of tests to determine the effectiveness of treatment. If medical treatment is not effective, he would consider argon laser trabeculoplasty or filtering surgery without mitomycin. Jody Piltz added to this that she would ask the patient a number of questions regarding diet, excessive water drinking, family history, sleeping habits, etc. Contrary to the two preceding authors, she does not believe in a separate diagnosis of NPG. She would also carry out a whole set of examinations, but would reserve neurological examination for cases in which the diagnosis is unclear. She would also perform pachymetry and ambulatory blood pressure evaluation could be useful. She agreed with the treatment modalities proposed by the other authors, except that she would perform filtering surgery with mitomycin immediately after medical treatment. She also mentioned the issue of the quality of life.
Dr. Jody Piltz-Seymour, Department of Ophthalmology, Scheie Institute, 51 North 39th Street, Philadelphia, PA 19104, USA
Classification:
9.2.2 Other risk factors for glaucoma (Part of: 9 Clinical forms of glaucomas > 9.2 Primary open angle glaucomas)
9.2.4 Normal pressure glaucoma (Part of: 9 Clinical forms of glaucomas > 9.2 Primary open angle glaucomas)
