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Janet Lee
Optometry Resident
VA Albuquerque
Resident Case Report 2015
Incidental Finding in a Normal Tension Glaucoma Patient
Abstract : This case demonstrates management of a patient with normal tension glaucoma confounded
by a concurrent BRAO causing an arcuate field defect. Differentiation was determined through serial
OCT and visual field testing.
I.
Case History
 69 year old Native American male
 Chief complaint of constant blurred vision at distance and near through habitual
spectacles, gradually onset over the last few months.
 Ocular history significant for normal tension glaucoma OU, dry eyes, non-visually
significant cataracts, and refractive error.
 No history of ocular surgeries, injuries, or family history
 Ocular medications include Latanoprost OU and artificial tears 6-7x/day.
 Medical history significant for atrial fibrillation, ventricular tachycardia, atrial flutter,
ventral hernia, congestive heart failure, obesity, hypothyroid, benign prostate
hyperplasia, prostate cancer, coronary artery disease, hypertension, hyperlipidemia,
PTSD, and osteoarthritis.
 Systemic medications include aspirin, carvedilol, cholecalciferol, clotrimazole,
finasteride, isosorbide mononitrate, levothyroxine, Lisinopril, nitroglycerin,
simvastatin, spironolactone, tamsulosin, multivitamins, and fish oils
 Other salient information: N/A
II. Pertinent Findings
 Clinical
 Best corrected VA: 20/25 OD, 20/25+ OS
 Entering tests: unremarkable
 Pupils: unremarkable, no APD
 EOM’s, confrontations: unremarkable
 Slit lamp: unremarkable
 IOP: 12/12 OU
 IOP’s ranging from mid to low teens since 2009 on Travatan and Xalatan
since 2011
 Gonioscopy:




OU: slight CBB / flat approach / 2+ even pigmentation / dense iris
processes 360 / (-)angle recession/NVA/PAS
 Posterior segment
 Lens: 1-2+ NS with posterior vacuoles involving visual axis OU
 C/D: 0.65 round OD with an inferior temporal notch, sloping rims, 0.75
round OS
 Discs: 2.1 mm OU (with 60D), rims pink and healthy
 RNFL: Wedge defect IT OD, longstanding
 Macula/posterior pole/periphery: unremarkable
Imaging (serial OCT RNFL/Pole, HVF 24-2, and HVF 10-2 available for comparison)
 OCT RNFL with global values of 79/78 (Spectralis) with inferior temporal
thinning OD, no thinning OS
 Slight decrease in global values OD since 2009, stable OS since 2009
 OCT Posterior Pole Asymmetry analysis: significant inter and intra eye (OD/OS)
asymmetry
 History of significant intra eye asymmetry OD/OS since 2013 with
relative stability
 OD: inferior temporal arcuate noted on hemisphere asymmetry map
 Inferior temporal wedge defect noted on retinal thickness color
map with no associated retinal thinning
 OS: superior temporal arcuate noted on hemisphere asymmetry map
 Marked superior temporal thinning noted on retinal thickness
color map with significant superior temporal thinning on retinal
thickness profiles, consistent with superior BRAO
 HVF 24-2
 OD: generalized decrease in sensitivity with mild superior nasal defect,
superior temporal paracentral defect
 Stable since 2010 with no progression
 OS: generalized decrease in sensitivity with moderate inferior nasal
defect extending to fixation
 Stable since 2010 with no progression
 Was believed to be a glaucomatous inferior arcuate until
posterior pole asymmetry analysis in 2013 showed it to be a
BRAO
 HVF 10-2
 OD: stable superior paracentral arcuate involving fixation x1
 OS: stable dense inferior nasal defect, fixation involved x4 (shallow, not
repeatable)
 OU: first performed in 2013 with relative stability
Physical: unremarkable
Laboratory studies: unremarkable

Radiology studies: unremarkable
III. Differential Diagnosis
 Primary/leading
 Arcuate loss secondary to glaucoma
 Branch retinal artery occlusion leading to visual field defects
 Others
 Demyelinating disease
 Sectoral photoreceptor disease/sectoral retinitis pigmentosa
 Diabetic papillopathy
IV. Diagnosis and Discussion
 BRAO
 Involves infarction secondary to acute ischemia of the inner retinal layers. The
infarction may spontaneously resolve with time; with resolution, there is a
normal appearing retina on clinical exam although inner retinal layers are
permanently destroyed and marked thinning can be noted on OCT.
 Especially after ischemic retinal whitening can no longer be seen on fundus
exam, OCT can be useful in the diagnosis of BRAO as well as CRAO.
 BRAO’s can resolve with possible residual disc pallor, vessel attenuation,
arteriolar sheathing, cherry red spots (rarely), or a normal retinal appearance.
 Patients may or may not notice unilateral upper or lower field defects or
changes in vision.
 Normal tension glaucoma
 Normal tension glaucoma can present in varying severities ranging from slow to
rapid progression.
 It is well known that there can be good correlation between thinning observed
on OCT and visual field defects.
 Unique features:
 Old BRAO’s may be difficult to see clinically after the initial onset.
 BRAO’s on visual fields in a patient with concurrent glaucoma may cause
increased difficulty in management; without OCT imaging or clinical signs of
previous BRAO, a visual field defect may be suspected to be secondary to
glaucoma with no progression over time.
V. Treatment, Management
 Treatment: on prostaglandin drop therapy, this patient demonstrated stable IOP control
and minimal progression since diagnosis.
 Bibliography
 Hayreh SS, Zimmerman MB. Fundus changes in branch retinal arteriolar
occlusion. Retina 2015; 0: 1-7.
 Hayreh SS, Podhajsky PA, Zimmerman MB. Branch retinal artery occlusion::
natural history of visual outcome. Ophthalmology 2009; 116:1188-1194.
 Horn FK, Mardin CY, Laemmer R, et al. Correlation between local glaucomatous
visual field deects and loss of nerve fiber layer thickness measured with
polarimetry and spectral domain OCT. Invst Opthalmol Vis Sci 2009; 50:19711977.
 Cornut PL, Bieber J, Beccat S, et al. Spectral domain OCT in eyes with retinal
artery occlusion [in French]. J Fr Ophthalmol 2012; 35:606-613.
 Takahashi H, Iijima H. Sectoral thinning of the retina after branch retinal artery
occlusion. Jpn J Opthalmol 2009; 53:494-500.
VI. Conclusion
 Clinical pearls: OCT posterior pole asymmetry analysis can greatly assist in management
of glaucoma patients in ruling out alternative etiologies.
 OCT analysis of the posterior pole can assist in detecting a history of BRAO in
patients who had a previous episode, as clinical observation is difficult after the
initial presentation.
 OCT can help detect BRAO’s in patients with concurrent glaucoma and can help
differentiate between previous vascular events and glaucomatous arcuate field
defects.
 This may alter the perception of severity of disease, treatment, and
future management of the patient.