A new patient presented to establish care with me after moving to North Carolina in February 2019. At the time, she was 75 years old and had a long-standing history of glaucoma—approximately 14 to 15 years.
At the initial visit, the patient reported that she underwent “laser surgery” in both eyes for her glaucoma at the outset of her diagnosis and had a second, “different surgical procedure” about 12 years prior in each eye.
As is often the case with glaucoma patients presenting to a new office for the first time, she did not come with any previous records. Presenting without records can make the initial visit challenging, but the goal of this visit is to simply get a feel for the severity of the glaucoma. The stability of the glaucoma is answered in subsequent visits.
The patient’s list of medications included Lipitor (atorvastatin, Pfizer) QD, Neurontin (gabapentin, Pfizer) 300mg BID, hydrochlorothiazide QD, omeprazole QD, Glucophage (metformin, Merck) QD, acetylsalicylic acid 81mg QD and multivitamins. She reported no allergies to medications.
|My best guess is that this patient was lasered due to narrow angles, but UBM evaluation shows a classic iris plateau configuration. This makes an angle appear narrower on slit lamp examination and gonioscopy. LPIs generally are not effective in opening the angle; an iris plateau configuration is the basis of narrow angles. Click image to enlarge.|
As far as I could tell, she had developed type 2 diabetes over 20 years ago. Her most recent A1c was 6.0, and she does not regularly check her glucose levels. She was not taking any glaucoma medications, though she did report diligence with bilateral digital ocular massage TID.
The patient’s best-corrected visual acuities were 20/30- OD and 20/50- OS. There was no pupillary defect noted, though her pupillary reactions were diminished in intensity bilaterally and ovoid in shape.
Slit lamp examination of her anterior segments was remarkable for bilateral dermatochalasis, but not significant enough to have a large effect on her visual acuities. Both corneas had mild inferior superficial punctate keratopathy. There were superiorly placed blebs OU, with adjacent surgical peripheral iridectomies. Both eyes also had laser peripheral iridotomies (LPIs) at 10 o’clock OD and 2 o’clock OS. Applanation tensions were 19mm Hg OD and 18mm Hg OS. Central corneal thickness measurements were 525μm OD and 497μm OS. Angles were open with no risk of angle closure.
Through dilated pupils, the patient’s crystalline lenses were characterized by moderate nuclear and cortical cataract formation OS>OD. I determined that her best-corrected acuities were consistent with the cataracts. A complete posterior vitreous detachment (PVD) was noted in the right eye, whereas the left had a partial PVD. Both maculae were characterized by bilateral retinal pigment epithelium granulation and fine drusen consistent with her age. Evaluation of the peripheral retina was essentially unremarkable.
The patient’s optic nerves, as viewed stereoscopically at the slit lamp, were characterized by moderate and advanced glaucomatous damage OD and OS, respectively. There were no noted disc hemorrhages, and the retinal vasculature was characterized by mild arteriolarsclerotic retinopathy. I judged her cup-to-disc ratios to be 0.65x0.75 OD and 0.8x0.9 OS. The optic nerves were of average size.
Given the patient’s relatively thin pachymetry values and the level of her glaucomatous damage, I was not convinced that her intraocular pressure (IOP) was at an adequate level. This brought on further questioning, primarily related to glaucoma medication use. The patient mentioned that when she was initially diagnosed, she was on topical medications, but her previous provider was not happy with their effect; thus, he had proceeded with the laser procedures that resulted in the LPIs.
Apparently, the patient’s previous provider then proceeded with bilateral trabeculectomies for reasons unknown and was pleased with her post-op IOPs, ultimately discontinuing her glaucoma medications. She did, however, have to initiate ocular massage OU TID. She reported that she saw her provider every six months, and had done so six months prior to her visit with me, and that he raised no concern regarding her IOPs.
I was also not convinced that the patient’s optic nerves were stable given her IOPs. The question of stability determined the frequency of our next few visits, which aimed to obtain baseline information about the structure and function of her optic nerves. I obtained OCT and HRT-3 images, visual field studies, gonioscopy evaluations and UBM images.
Subsequent IOP readings varied from 12mm Hg to 23mm Hg OD and from 10mm Hg to 20mm Hg OS. According to the patient, sometimes she performed ocular massage while in the waiting room prior to being seen. This may have played a role in the range of IOPs I measured. On the other hand, variations in IOP can simply occur in glaucoma patients who are not adequately controlled. Ultimately, once I determined she was not in an acute situation, we stretched our visits out somewhat, though I continued to question her seemingly stable disease state.
|Bruch’s membrane opening (left) and retinal nerve fiber layer (right) follow-up scans demonstrate significant neuroretinal rim and retinal nerve fiber layer damage, but with no progression from baseline. Click image to enlarge.|
Skeptical of Stability
In July 2020, the patient presented with complaints of decreased vision OS>OD. Not surprisingly, her cataracts had progressed gradually over the past year, accounting for some of the reduced acuity. Surprisingly, the decreased acuity OS was not due to worsening field loss affecting fixation but to vitreomacular adhesion (VMA) development in the left eye.
At this visit, the patient’s acuities were 20/50 OD and 20/150 OS. Though VMA can either release on its own or with surgical management, I did not feel it was appropriate to pursue surgery without addressing the progressing cataracts as well. She preferred to revisit the topic in October. At that visit, her acuities were essentially unchanged, and the VMA had been slightly reduced. She opted to proceed with cataract surgery at some point at the beginning of 2021.
But what about the patient’s glaucoma? Throughout the time I’ve been seeing her, her only daily intervention consisted of digital massage. Typically, this therapy is used following trabeculectomies once the eye is stabilized. Trabeculectomies are usually performed on patients who either have non-stable or advanced glaucoma with a long history of poorly controlled IOP. Digital massage can lower IOP, which is easy to do with a patent trabeculectomy. But, some trabeculectomies tend to lower IOP too much, while others fail to reduce IOP at all. On top of that, how much pressure should a patient apply when they massage the eye? Doesn’t massaging the eye actually increase IOP during the massage? Can this cause damage that the post-massage IOP reduction is trying to mitigate?
My clinical intuition told me that with IOPs as variable as this patient’s, coupled with her advanced disease, she was not stable. However, OCT imaging of the neuroretinal rims, circumpapillary retinal nerve fiber layer and macular ganglion cells all showed remarkable stability in the 22 months that I’ve seen her. While her angles had narrowed slightly due to the progressing cataracts and her acuity was decreased, neither had direct bearing on her glaucoma.
Accordingly, the patient is continuing with her daily digital ocular massage and preparing for cataract extraction OU. The surgery is certainly not without risk given her advanced glaucoma, but it is necessary to prevent further reductions in her quality of life. Remember that for many glaucoma patients, topical therapy can have a negative effect on their quality of life, even if they are compliant and the medications work well. The least amount of medications that get the job done is a good mantra in glaucoma care management. And sometimes, digital massage is enough.
Dr. Fanelli is in private practice in North Carolina and is the founder and director of the Cape Fear Eye Institute in Wilmington, NC. He is chairman of the EyeSki Optometric Conference and the CE in Italy/Europe Conference. He is an adjunct faculty member of PCO, Western U and UAB School of Optometry. He is on advisory boards for Heidelberg Engineering and Glaukos.