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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.