- —Case prepared by Douglas J. Rhee, MD Other forms of optic of forms Other How would you proceed? How can often coexist with or masquerade or with coexist often can to important is It . as presenting correlate to attempt testing diagnostic and symptoms If one. this as such case a in results , make to seem not do they to necessary is workup further why. discover neuropathy. Regardless of whetherof Regardless neuropathy. Ipresent, are symptoms these of any MRIan order to proceed still would forlook to orbits and brain the of gentleman’sthis of etiology another ancillarythe because neuropathy optic scans)OCT testing, field (visual tests offindings with inconsistent so are glaucoma. from neuropathy optic field testing and imaging of the retinal nerve fiber fiber of the retinal nerve imaging field testing and of each demonstrate abnormalities (RNFL) layer currently administer 2). The patient is (Figures 1 and at bedtime. each eye latanoprost in ing - - Figure 2. Imaging of the RNFL demonstrates abnormalities. I would ask the patient whetherpatient askthe would I Motility and pupillary examinations are normal. examinations are normal. and pupillary Motility in glaucoma and could be highly sug highly be could and glaucoma in optichis of cause another of gestive he has experienced rapid growth ofgrowth rapid experienced has he ofepisodes any or feet or hands his Patientsgalactorrhea. or impotence secreting hormone a have who canmacroadenoma pituitary wouldI symptoms. these experience extraocularpatient’s this assess also presenceThe vision. color and motility indicatecould palsy nerve cranial a of tumorpituitary a of growth lateral toleading sinus, cavernous the into motility.extraocular in deficits various uncommonis vision color Decreased for this patient’s bitemporal field loss field bitemporal patient’s this for explored. be should A slit-lamp examination shows an early in cataract in an early A slit-lamp examination shows each eye. Gonioscopy is D40r 3+ pigmented trabecular The IV (Shaeffer). meshwork (Spaeth) and grade eye with vertical elon in each cup-to-disc ratio is 0.8 The retinal nasal pallor. gation and a suggestion of examination is normal. Automatic achromatic visual - - 9 201

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THOMAS PATRIANAKOS, MD THOMAS PATRIANAKOS, MD Although this patient may have may patient this Although A 60-year-old man of European ancestry is is of European ancestry man 60-year-old A Figure 1. Automated achromatic testing with a Humphrey Field Humphrey Field Figure 1. Automated achromatic visual field testing with a Analyzer (Carl Zeiss Meditec) demonstrates abnormalities. CASE PRESENTATION

Physicians explore whether another form of optic neuropathy caused this patient’s visual field loss. caused this patient’s neuropathy of optic another form whether Physicians explore MD SHAREEF, MD; AND ARTHUR J. SIT, MD; THOMAS PATRIANAKOS, MD; SHAKEEL BY DOUGLAS J. RHEE, GLAUCOMA OR SOMETHING ELSE? SOMETHING OR GLAUCOMA causes other than glaucoma could be could glaucoma than other causes loss. field visual his to contributing OCT neither of results the Because field visual nor RNFL the of imaging glaucomatous classicfor are testing etiologies other neuropathy, optic glaucoma that is suboptimally con suboptimally is that glaucoma medication current his on trolled that concerned more am I regimen, OU, and central corneal thickness (CCT) is 515 µm 515 µm is (CCT) and central corneal thickness OU, IOP the maximum µm OS. Historically, OD and 505 eye is 26 mm Hg. each reading for referred for uncontrolled IOP and visual field progres IOP and visual field uncontrolled referred for OS, is 20/30 OD and 20/40 On examination, UCVA sion. mm Hg OU. IOP is 19 and pinhole visual acuity is 20/25 GLAUCOMA TODAY

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“IT IS UNCLEAR WHETHER THE PATIENT’S IOP INCREASED RECENTLY OR WHETHER SHAKEEL SHAREEF, MD

Two simultaneous processes are PROGRESSION HAS OCCURRED AT AN occurring. First, bitemporal visual field loss respecting the vertical meridian indicates that a compres- IOP THAT WAS PREVIOUSLY CONSIDERED sive optic neuropathy such as a pituitary macroadenoma is enlarg- ACCEPTABLE.” —ARTHUR J. SIT, MD ing and impinging on the chiasm1 where nasal fibers decussate. This may account for the visual field pro- 0.8 cup-to-disc ratio, and the gression and nasal pallor. Second, patient’s ethnicity, I would be more an inferonasal arcuate aggressive about further lowering aligned with the x-axis in the left IOP by adding a second agent (ie, a eye correlates with the tempo- carbonic anhydrase inhibitor) for the ral RNFL respecting the temporal treatment of both . Based upon raphe. OCT shows a 50% reduction subsequent serial visual field testing, I ARTHUR J. SIT, MD in RNFL thickness superiorly in the would adjust the IOP with additional left eye compared to the right eye. medical, laser, or surgical treatment This patient has two apparent These findings are consistent with to retard progression. If he were problems: uncontrolled IOP and glaucoma. a candidate for cataract surgery, I visual field progression. In this case, Primary open-angle glaucoma would offer phacoemulsification com- it is clearly more important to start is prevalent among patients with bined with angle surgery for his left by considering the visual fields, European ancestry. Gonioscopy eye. Options could include implanta- which suggest a bitemporal hemi- demonstrated open angles. In the tion of a Hydrus Microstent (Ivantis) that is denser in the left eye. Treatment or ab interno canaloplasty (iTrack Although there is also an inferior Study (OHTS), decreasing IOP by surgery system, Ellex) combined with nasal step in the left eye, a neuro- 20% or more with ocular hypoten- goniotomy using a Kahook Dual Blade logic cause for the visual field defects sive medication reduced patients’ (New World Medical). should be considered, consistent risk of developing glaucoma by 50% at For the suspected compressive with the nasal pallor of the discs. 5 years.2 For those with a baseline IOP optic neuropathy, I would request Taking a careful medical history will higher than or equal to 25.75 mm Hg neuroimaging (MRI) and refer the help to determine if there is a known and a CCT of less than or equal to patient to neurosurgery as appro- cause for a bitemporal defect, par- 555 µm, the 5-year risk of developing priate. The degree of reversibility ticularly a chiasmal lesion such as a glaucoma was 36%.3 of visual dysfunction after surgical pituitary adenoma. Even then, the A maximum IOP of 26 mm Hg OU decompression has been shown to progressive visual field decline would and an average CCT measurement correlate with average loss of RNFL make the next step an MRI of the for the two eyes of 510 µm put this thickness as measured preopera- head and orbits to rule out a com- patient at high risk of developing tively with OCT.4 A value of more pressive lesion. If the MRI is positive, glaucoma in each eye. Assuming the than 80 µm was correlated with a the patient should be referred to presence of ocular hypertension in postdecompression improvement of neurosurgery for further evaluation the past, this patient’s current IOP greater than 10 dB mean deviation and management, and modifica- of 19 mm Hg on latanoprost in both in visual field defects and improved tion of glaucoma therapy should be eyes represents a reduction of 20% visual acuity. The average RNFL deferred. If the neuroimaging is nega- or more from baseline. However, thickness in this patient (71 µm OD, tive, it would then be reasonable to considering the inferior arcuate sco- 53 µm OS) suggests the prospect of focus on the uncontrolled IOP, with toma in the left eye, a thin pachym- a modest recovery of visual function the assumption that the visual field etry reading, a vertically elongated after surgery. progression is due to glaucoma.

MAY/JUNE 2019 | GLAUCOMA TODAY 27 ------In the 2 years following surgery, following years 2 the In I thought that the changes in changes the that thought I It is unclear whether the patient’s patient’s the whether unclear is It an MRI of the brain with and with and with brain the of MRI an subsequently and contrast out neurosurgery to patient this referred of findings on based treatment for He 3–5). (Figures mass pituitary a resection underwent subsequently 6). (Figure mass the of field visual patient’s this of most medication would also be reason be also would medication symptom is patient the If able. then , early the from atic surgery glaucoma microinvasive not would I considered. be could surgeryuntil filtering recommend were measures conservative more failed. and tried WHAT I DID: DOUGLAS J. RHEE, MD could acuity visual patient’s this cataracts. bilateral to attributed be left his in step nasal inferior The the to localized be to appeared eye changes field visual other The RNFL. meridian, horizontal the respected propor of out seemed and however, ordered I damage. RNFL the to tion IOP increased recently or whether whether or increasedrecently IOP an at occurred has progression consid previously was that IOP if Regardless, acceptable. ered occur is progression field visual target the then Hg, mm 19 at ring level, lower a at set be should IOP teens, middle to low the in likely field visual significant the given Because . thin and defects single a only using is patient the variety wide a is there medication, therapy. additive for options of trabeculoplasty laser Selective the given appropriate be would trabecu 3+ and angles wide-open second a Adding pigmentation. lar contrast. Blue arrow indicates the growing pituitary mass. the growing pituitary mass. contrast. Blue arrow indicates indicates the optic chiasm. Labeled elongated blue arrow Figure 4. T1-weighted MRI scan, coronal section, with coronal section, with Figure 4. T1-weighted MRI scan, Figure 6. T1-weighted MRI scan, coronal section, with Figure 6. T1-weighted MRI scan, coronal section, with contrast, after surgical resection. No mass is present. 9 201 MAY/JUNE |

Figure 7. Serial automated achromatic visual field testing with a Humphrey Field Analyzer demonstrates reversal of vertical vertical Figure 7. Serial automated achromatic visual field testing with a Humphrey Field Analyzer demonstrates reversal of meridian respecting visual field defects. Most recent visual field is seen at the top. Figure 5. T1-weighted MRI scan, sagittal section. Blue arrow Figure 5. T1-weighted MRI scan, sagittal section. Blue arrow indicates the pituitary mass. Figure 3. T1-weighted MRI scan, coronal section, with contrast. coronal section, with contrast. Figure 3. T1-weighted MRI scan, pituitary mass. Blue arrow indicates the growing GLAUCOMA TODAY

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Figure 8. RNFL testing over the same date range as the visual fields shown in Figure 7. Stability of the RNFL defects is seen. defects resolved (Figure 7) even mol. 2002;120(6):714-720. THOMAS PATRIANAKOS, MD 4. Danesh-Meyer HV, Papchenko T, Savino PJ, Law A, Evans J, Gamble GD. n though his RNFL defects remained In vivo retinal nerve fiber layer thickness measured by optical coherence Chair of Ophthalmology, Cook County Health and stable (Figure 8). Given his history tomography predicts visual recovery after surgery for parachiasmal tumors. Hospitals System, Chicago of elevated IOP and a persistent Invest Ophthalmolol Vis Sci. 2008;49(5):1879-1885. n [email protected] RNFL-localizing inferior arcuate n Financial disclosure: None defect, he continued glaucoma medi- cal therapy. He recently underwent DOUGLAS J. RHEE, MD | SECTION EDITOR SHAKEEL SHAREEF, MD bilateral cataract surgery, after which n Chair, Department of Ophthalmology and n Professor, Flaum Eye Institute, University of IOP decreased in each eye. At his Visual Sciences, Case Western Reserve Rochester School of Medicine, Rochester, New York last follow-up visit, UCVA was 20/20 University, Cleveland n [email protected] OU, and IOP measured in the middle n Member, GT Editorial Advisory Board n Financial disclosure: None teens in each eye. n n [email protected] n Financial disclosure: Ad hoc consultant ARTHUR J. SIT, MD 1. Atan D. The visual impact of pituitary tumours. The Pituitary Foundation (Aerie Pharmaceuticals, Alcon, Allergan, n Professor of Ophthalmology, Mayo Clinic College of website. https://www.pituitary.org.uk/news/2017/08/the-visual-impact-of- Medicine, Rochester, Minnesota pituitary-tumours/. Published May 8, 2017. Accessed April 29, 2019. Ivantis); Data safety monitoring board (Ocular n 2. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treat- Therapeutix); Research (Allergan, Glaukos, [email protected] ment Study: a randomized trial determines that topical ocular hypotensive Ivantis); Speakers’ bureau (Aerie Pharmaceuticals, n Financial disclosure: Consultant (Aerie medication delays or prevents the onset of primary open-angle glaucoma. Arch Pharmaceuticals, Allergan, InjectionSense, Ophthalmol. 2002;120(6):701-713. Bausch + Lomb) 3. Gordon M, Beiser J, Brandt J, et al. The Ocular Hypertension Study: baseline PolyActiva); Research support (Aerie factors that predict the onset of primary open-angle glaucoma. Arch Ophthal- Pharmaceuticals)

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