Health Primary Open Angle Glaucoma

Primary Open Angle Glaucoma

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Introduction:

Glaucoma is a leading cause of blindness in the world; the most common form for adult onset is primary open angle glaucoma (POAG).The term “open angle” refers to a lack of mechanical closure of the chamber angle by the iris in which the trabecular meshwork appears normal. Inspite of the open angle, POAG patients typically have obstructed aqueous humor outflow and elevated intraocular pressure. If untreated, this usually leads to damage of the optic nerve and loss of peripheral vision. The increase in IOP is termed “ocular hypertension” when It is consistently > 21mmHg in both eyes and may precede optic nerve damage by many years. Because the specific defect(s) leading to POAG is unknown, treatment is directed at lowering 1OP. [1] Implied incidence’ was estimated from the prevalence results, being 0.11% per year in people aged 55 to 74 years. [2]

Significant age-adjusted risk factors for development of at least possible POAG were past cigarette smokers, family history of glaucoma, the presence of age-related macular degeneration (AMD), the presence of pseudo-exfoliation, and a baseline CDR higher than 0.7.[3]

Case Presentation

We hereby present a case of bilateral primary open angle glaucoma leading to permanent visual impairement.

Patient, Al Shehhi Ahmed Mohammad, 40 years of age presented in the center on 18th December 2019 for the evaluation of his intraocular pressure as he has previous history of Open Angle Glaucoma (on Ganfort and Alphagon)

Refraction

Right eye:

Sphere:  -0.25    Cylinder: -0.50    Axis: 95

Left eye:

Sphere:  -0.50    Cylinder: -0.25    Axis: 100

On Slit Lamp Examination

  • No bilateral eyelid abnormality found.
  • Bilateral cornea and conjunctiva was clear.
  • There was no activity in Anterior chamber of both eyes and anterior chamber depth of both eyes was normal.
  • Lens of both eyes was clear
  • Both eyes got round regular reactive pupil.
  • Fundus of both eyes was clear
  • Cup disc ratio in the right eye was 0.5 while in the left it was 0.9

His intraocular pressure in the right was 19mmHg while in the left intraocular pressure is 16mmHg. OCT of right eye shows minimal defect while in the left eye there is severe retinal nerve fibre damage. Visual field examination is done as well. In the right eye, it shows peripheral damage of 23% while in the left 77% concentric damage is present. There is no history of use of any steroids and patient had never gone through any surgical procedure like cataract surgery, keratoplasty in the past. There is no history of previous glaucoma surgery. There was no history of trauma to the eye.

Upon examination, patient was diagnosed:

Bilateral Primary Open Angle Glaucoma

Bilateral myopia with regular astigmatism

He was prescribed topical medication in his both eyes to lower IOP.

  • Ganfort ( Lumigan and Timolol)
  • Brimonidine

 

He was also advised left Xen-Valve Implantation

                              Clinical Report

Patient name: Al Shehhi, Ahmad Mohammad

Age: 40 years

Best corrected visual acuity:

Bilateral > 20/20

UCVA: 20/25

IOP:

OD: 19mmHg

OS: 16mmHg

Type of Glaucoma:

Primary Open Angle Glaucoma

Secondary: x

No history of steroid use

No past surgical history of cataract and keratoplasty

No history of trauma

No history of Neovascular Glaucoma

Laterality:

Bilateral

Severity based on visual fields:

Severe

Topical medications: 3

Ganfort (Lumigan & Timolol)

Brimonidine

Any Laser procedure:

No Peripheral Iridotomy

No Gonioplasty

Lens status:

Phakic

Previous Glaucoma Surgeries if done and number of re-surgeries done

No Trabeculectomy

No express shunt

Surgical treatment:

Advised

History:

Open angle glaucoma for 1 year

History of working for long hours on desktop, laptop, IPAD and phone

General symptoms:

Loss of vision

Physical examination:

No orbital pathology

Functional Acuity score (FAS):

VOU = 20/25 = 95 x 3 = 285

VOD= 20/25 = 95 x1 = 95

VUS = 20/25 = 95 X 1 = 95

FAS = 475/5 = 95

 

Now if average radius loss is concentric 60 degree

Conversion of field radius to field score

60 degree = 10

 

Functional Field score (FFS):

FFS = (3 X VFSOD  + VFSOS ) / 5

=3 X 30 + 28 / 5 = 23.6

AS

VFSOD = 100 – Solid dots missed + open dots seen

= 100-18+52

=100-70

=30

VFSOS = 100-40+32

=100-72

=28

Functional vision score (FVS):

FVS = FAS X FFS / 100

= 95 X 23.6 / 100 = 22.42

Impairment:

100-22.42 = 77 (approximately)

Diagnosis:

Bilateral Glaucoma more severe in the left than the right eye

Comment:

The impairment assessment/evaluation made for Mr. Ahmed Al Shehhi is in accordance with “AMA GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT” 6TH edition. Mr. Ahmed tells me that his work often requires him to strain extended hours on his work Desktop, Laptop, IPAD and phone due to the nature of his work operations, business unit and position. Also a lot of focus and concentration coupled with long duration of work is understood from talking to Al Shehhi, with such bilateral visual field defects especially in the left eye which has 77% concentric damage and 23% damage to the right eye. I support his application provided to the management. Due to severe damage to the left eye of the patient, I advised him to take long leave from his work.

 

Discussion:

In our case patient was also suffering from myopia with regular astigmatism. Myopic subjects had a twofold to threefold increased risk of glaucoma compared with that of non-myopic subjects. The risk was independent of other glaucoma risk factors and IOP.[4] Myopia increases the risk of serious disorders such as myopic macular degeneration, retinal detachment, glaucoma, and cataract and is a leading cause of visual impairment and blindness across many countries. The reduction in age of onset of myopia is of great concern since the earlier the onset, the more myopic the individual will become, with all the attendant increased risks of accompanying debilitating eye conditions.  Early contact lens and spectacle interventions that reduce the rate of progression of myopia are able to significantly reduce the burden of myopia.[5]

Open-angle glaucoma generally is a bilateral disease, although it often is asymmetric. Damage in one eye significantly increases the risk of subsequent damage in the other eye. Progressive optic nerve cupping is a manifestation of progressive optic nerve death and uncontrolled glaucoma. Definitive perimetric (visual field) evidence detailed ophthalmoscopic evidence, or both confirm the diagnosis of open-angle glaucoma. [6]

After loss of more than 40 percent of the nerve fibers, patients may notice a gradual loss of peripheral vision, or “tunnel vision”[6] In our case, patient suffered from 75% concentric damage to left eye ( severe retinal nerve fibre damage).

Initially topically anti-glaucoma drugs are used for POAG.  SLT is an effective method to lower IOP over an extended period of time.[7]. Trans-scleral diode laser cyclo photocoagulation is an effective and safe method not only in the treatment of refractive glaucoma, but also as a primary surgical procedure in primary open-angle and pseudoexfoliative glaucoma.[8]

 

Conclusion:

Keeping in view the history of straining on eyes of my patient due to long working hours on laptop and phone and also after slit lamp examination and visual field scoring according to AMA Guidelines, I hereby declare my patient to be suffering from bilateral primary open angle glaucoma with 77% concentric damage to left eye and 23% damage to right eye and myopia with regular astigmatism.

I advised Al Shehhi, Ahmed Mohammad to take a long leave from his work to avoid more visual complications in the future. Patient should avoid working on laptop, desktop etc as it may cause further stress and straining to his eyes.

 

 

 

 

 

 

 

  1. Wirtz, M., et al., Mapping a gene for adult-onset primary open-angle glaucoma to chromosome 3q. American journal of human genetics, 1997. 60(2): p. 296.
  2. Tuck, M.W. and R.P. Crick, The age distribution of primary open angle glaucoma. Ophthalmic epidemiology, 1998. 5(4): p. 173-183.
  3. Le, A., et al., Risk factors associated with the incidence of open-angle glaucoma: the visual impairment project. Investigative ophthalmology & visual science, 2003. 44(9): p. 3783-3789.
  4. Mitchell, P., et al., The relationship between glaucoma and myopia: the Blue Mountains Eye Study. Ophthalmology, 1999. 106(10): p. 2010-2015.
  5. Holden, B., et al., Myopia, an underrated global challenge to vision: where the current data takes us on myopia control. Eye, 2014. 28(2): p. 142-146.
  6. Distelhorst, J.S. and G.M. Hughes, Open-angle glaucoma. American family physician, 2003. 67(9): p. 1937-1944.
  7. Egbert, P.R., et al., Diode laser transscleral cyclophotocoagulation as a primary surgical treatment for primary open-angle glaucoma. Archives of ophthalmology, 2001. 119(3): p. 345-350.
  8. Grueb, M., et al., Transscleral diode laser cyclophotocoagulation as primary and secondary surgical treatment in primary open-angle and pseudoexfoliatve glaucoma. Graefe’s Archive for Clinical and Experimental Ophthalmology, 2006. 244(10): p. 1293-1299.

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