Jean Marie Pagani, OD


February 25, 2016

Clinical Presentation

A 44-year-old black man presented for a comprehensive eye examination. He noted blurred vision in his right eye that had been worse in the morning for more than a year. At his previous ocular examination, which was 2 years ago, he was given a bottle of eye drops that he used until they were finished. He did not return to that doctor for follow-up care.

His health history was significant for hypertension (5 months) and diabetes (6 years), both of which were being properly treated. His blood pressure at this examination was 110/75 mm Hg.

On ocular examination, best-corrected visual acuity was 20/30 for the right eye and 20/20 for the left eye. Pupils were isocoric, round, and reactive to light, with an afferent pupillary defect in the right eye. Extraocular muscles were full for both eyes. Confrontation visual fields were restricted in the right eye and full in the left eye.

Intraocular pressures by Goldmann tonometry were 31 mm Hg in the right eye and 19 mm Hg in the left eye. Pachymetry was measured at 569 µm in the right eye and 565 µm in the left eye.

Slit-lamp examination revealed an irregular appearance of the corneal endothelium of the right eye with an abnormal iris surface. The left eye demonstrated normal structure (Figure 1).

On dilated fundus examination, cup-to-disc ratios were 0.95/0.95 in the right eye and 0.6/0.6 in the left eye, with no pallor noted (Figure 2). Mild nonproliferative diabetic retinopathy was noted in both eyes. No retinal holes, tears, or detachments were seen in either eye.

Figure 1. Photograph of the anterior segment of the right eye, showing an irregular corneal endothelium and abnormal surface of the iris. Anterior segment photograph of the left eye was unremarkable.

Figure 2. Fundus images of the optic nerves,showing cup-to-disc ratios of 0.95/0.95 in the right eye and 0.6/0.6 in the left eye.

Four-mirror gonioscopy revealed broad-based anterior synechiae in the right eye and relatively normal structures in the left eye (D-40-F).

On optical coherence tomography, the retinal nerve fiber layer thickness was significantly reduced in the right eye, with superior and inferior thinning of the nerve fiber layer; in contrast, the retinal nerve fiber layer was normal in the left eye (Figure 3). 24-2 Humphrey visual fields showed end-stage glaucomatous loss, and a small central island of vision noted with a 10-2 field in the right eye; borderline abnormal findings were seen in the left eye (Figures 4-6).

Figure 3. Cirrus optical coherence tomography, showing a reduced retinal nerve fiber layer in the right eye and a normal retinal nerve fiber layer in the left eye.

Figure 4. Humphrey visual field 24-2 OD, showing end-stage glaucomatous loss.

Figure 5. Humphrey visual field 10-2 OD, showing a small central island of vision.

Figure 6. Humphrey visual field 24-2 OS, showing scattered points with an inferior nasal pattern defect and breakout from a blind spot.


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