Reversal of Cupping
AAO Grand rounds 2011
I. A pseudoaphakic 68 year old Caucasian male artist was seen at our office for a
glaucoma follow up. He was diagnosed with POAG approximately 20 years ago
and was treated with topical medications until 6 years ago when, because of his
upcoming cataract surgeries and history of profound non adherence to
prescribed topical medicines, the decision was made between the patient and his
eye surgeon to proceed with combined trabulectomy – phacoemulsification with
posterior chamber lens implantation in each eye.
II. His corrected acuities were 20/25 in each eye. Dynamic contour intraocular
pressures were OD = 18.5 mmHg, OS 5.9 mmHg. Gonioscopy showed grade 3+
open angles with trace trabecular pigmentation in each eye. Trabulectomies in
each eye appeared to be normal, without signs of infection, ischemia or Siedels
sign for leakage. Cup to disc ratios were OD .5 H/.7 V and OS = .35H/.35V.
There was no evidence of Drance hemorrhage or nerve fiber wedge defect in
either eye. There was no evidence of a repeatable threshold visual field defect
(30-2 white on white) in either eye.
HRT progression analyses were as follows:
What’s your Dx??
III. The HRT progression analysis appears to show reversal in cupping in the left
eye and no significant change in the right. While, at first glance, the left optic
nerve appears to be healthy and to have full rim tissue, the unfortunate reality in
the apparent reduction in cupping of the left eye is the result of axonal edema
secondary to a chronically borderline hypotonous state.
IV. There are three major points that are brought to our attention with this case.
The first deals with the decision to choose pressure lowering surgery as an
alternative to medication in select individuals. While there is no doubt that
surgery is the only reasonable alternative for some patients, it bears significant
risk that must be acknowledged and respected. One has to wonder if better presurgical management of this intelligent patient could have caused him to develop
better adherence and then avoid the necessity for high risk fistulating surgeries.
Secondly, this case heightens our attention of the nature of hypotony and risk of
associated axonal edema, which can cause unusual and deceptive nerve
appearance. With hypotony, edema can be more extensive and cause folds in
the papillomacular bundle accompanied by severe irreversible vision loss.
V. Lastly, this case demonstrates and unusual type of glaucomatous progression
that is documented by the HRT. While we typically use instruments like the HRT
to watch for increased cupping which translates into glaucomatous progression,
here we see cupping that is apparently decreased over time and, with that
decrease, an ominous sign that the eye may be at great risk. Treatment options
in this case are conservative observation vs. topical steroids to increase IOP.
Elliot M Kirstein, OD, FAAO
8211 Cornell Rd
Cincinnati, Ohio 452249
drkirstein@drkirstein.com
Pics, etc available upon request