Case 12
Victor Tran
Learning Outcomes
● Consider the relevant diagnoses of this case
● Understand the management plan of OAG & post radial keratotomy (RK) surgical
complications
● Patient values & considerations
History
55 year old male ..
PC:
○ Reduced vision OU
POH:
○ Refractive surgery 20 years ago
○ No eye infections/injuries
FOH:
○ Family history of glaucoma
GH:
○ Tritace (Ramipril) – for high blood pressure
○ No DM/CHO
○ No allergies
Clinical Findings
RE
LE
Refraction (BCVA)
+3.00DS (6/24)
+1.75/-0.75 x 152 (6/19)
Pupils
No RAPD, PERRLA
No RAPD, PERRLA
Colour Vision
No dyschromatopsia
No dyschromatopsia
IOP (Perkins) @ 2:15pm
18 mmHg
24 mmHg
Slit lamp biomicroscopy
-
-
DFE
Clear eyelids, eyelashes & conjunctiva
8 large, linear & deep incisions arranged in a radial pattern
(evidence of previous radial keratotomy (RK) surgery) with
associated irregular corneal endothelial changes
VH 1:1
Mild nuclear sclerosis
- Large optic disc
- CDR 0.5
- No notching
- Moderate cupping
- Macula flat & clear
-
Clear eyelids, eyelashes & conjunctiva
8 large, linear & deep incisions arranged in a radial pattern
(evidence of previous RK surgery) with associated irregular
corneal endothelial changes
VH 1:1
Mild nuclear sclerosis
- Large optic disc
- CDR 0.8
- Visible inferior notching (violating ISNT rule)
- Deep cupping
- Macula flat & clear
http://www.precisionfamilyeyecare.
com/radial-keratotomy/
https://benthamopen.com/FULLTEXT/TOOPHTJ-3-54
VF Results
RE
LE
Likely Diagnosis
Relevant Findings
Family hx of glaucoma
High IOP (LE > RE)
ONH asymmetry (LE > RE)
PRIMARY OPEN ANGLE GLAUCOMA (POAG)
Large optic discs
LE inferior ONH notching + cupping
Superior arcuate defect (LE)
Relevant Findings
Reduced BCVA
Hyperopic shift
Irregular corneal
endothelial changes
POST RK SURGICAL COMPLICATIONS
PERK Study 10 years after RK surgery (Waring, Lynn, McDonnell, 1994).
Management Plan
Based on the NHMRC guidelines ..
● Assess risk factors
○ Age, family hx, IOP
● Physical assessment
○ Gonioscopy
■ Evaluation of the anterior chamber angle
NHMRC Guidelines for the Screening, Prognosis, Diagnosis, Management and
○ Pachymetry
■ Helps interpret IOP measurement & assess patient risk
○ OCT
■ Identify changes + establish baseline for RNFL, NRR & GCC
○ VF
■ Need at least two for reliability
Prevention of Glaucoma
Management Plan
Based on the NHMRC Guidelines ..
● Target IOP 30% reduction or 18 mmHg
○ First line of treatment: Prostaglandin analogue (PGA)
■ Latanoprost (Xalatan) 0.005% 1 gtt nocte
● Follow-up 6 weeks
● Follow up 3-12/12 if achieving target IOP
● Refer to ophthalmologist within four months of diagnosis (OBA
Guidelines)
○ IOPs, VF (x2), OCT @ each follow up
NHMRC Guidelines for the Screening, Prognosis, Diagnosis,
Management and Prevention of Glaucoma
Evidence
NHMRC Level II
PEDro: 9/10
Latanoprost shows preservation of VF in patients with OAG
NHMRC Level I
AMSTAR: 9/11
Compared to other PGAs, latanoprost has the most
favourable tolerability profile
Management Plan
Based on the NHMRC Guidelines ..
● If target IOP not reached ..
○ PGA alternative OR combo therapy
● Consider laser therapy/surgery
○ SLT, MIGS, PLI
NHMRC Guidelines for the Screening, Prognosis, Diagnosis,
Management and Prevention of Glaucoma
• IOP reduction similar between SLT & drug therapy
• SLT is safe & effective as initial treatment in OAG
NHMRC Level II
PEDro: 8/10
Management Plan
Post RK surgical complications
NHMRC Level II
PEDro: 9/10
• LASIK was safe & effective post RK
• Mean SE decreased by at least 2.00 D
NHMRC Level III-2
• VA improved on average 4 lines on the Snellen chart
• Empirical fitting based on post-operative
keratometry
Patient values, clinical expertise, practice context
Patient Values:
● Can no longer drive
● Discuss adverse effects of IOP lowering drugs
Clinical Expertise:
●
Make sure px understands how to intil drops & the importance of compliance
Practice Context:
●
Access to OCT & ophthalmologist
References
●
Waring, G.O., Lynn, M.J. and McDonnell, P.J., 1994. Results of the prospective evaluation of radial keratotomy (PERK) study 10 years after surgery. Archives of
Ophthalmology, 112(10), pp.1298-1308.
●
Garway-Heath, D.F., Crabb, D.P., Bunce, C., Lascaratos, G., Amalfitano, F., Anand, N., Azuara-Blanco, A., Bourne, R.R., Broadway, D.C., Cunliffe, I.A. and Diamond,
J.P., 2015. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. The Lancet, 385(9975), pp.1295-1304.
●
Lin, L., Zhao, Y.J., Chew, P.T., Sng, C.C., Wong, H.T., Yip, L.W., Wu, T.S., Bautista, D., Teng, M., Khoo, A.L. and Lim, B.P., 2014. Comparative efficacy and tolerability of
topical prostaglandin analogues for primary open-angle glaucoma and ocular hypertension. Annals of Pharmacotherapy, 48(12), pp.1585-1593.
●
Katz, L.J., Steinmann, W.C., Kabir, A., Molineaux, J., Wizov, S.S. and Marcellino, G., 2012. Selective laser trabeculoplasty versus medical therapy as initial treatment of
glaucoma: a prospective, randomized trial. Journal of glaucoma, 21(7), pp.460-468.
●
Oral, D., Awwad, S.T., Seward, M.S., Bowman, R.W., McCulley, J.P. and Cavanagh, H.D., 2005. Hyperopic laser in situ keratomileusis in eyes with previous radial
keratotomy. Journal of Cataract & Refractive Surgery, 31(8), pp.1561-1568.
●
Lee, A.M. and Kastl, P.R., 1998. Rigid gas permeable contact lens fitting after radial keratotomy. The CLAO journal: official publication of the Contact Lens Association
of Ophthalmologists, Inc, 24(1), pp.33-35.
●
National Health and Medical Research Council., (2010). NHMRC Guidelines for the Screening, Prognosis, Diagnosis, Management and Prevention of Glaucoma 2010.,
https://www.nhmrc.gov.au/about-us/publications/guidelines-screening-prognosis-diagnosis-management-and-prevention-glaucoma
●
Optometry Board of Australia., (2016). Clinical Practice Guide for the Diagnosis, Treatment and Management of Glaucoma.,
https://www.optometry.org.au/wp-content/uploads/Professional_support/Guidelines/optometry_australia_glaucoma_clinical_practice_guide__july_2016.pdf