GlaucomaLearn 3 (Left eye)

Vinay Nangia, Ravi Daberao


A male, 65 years of age, came for a second opinion of glaucoma. There was no presenting complaint. His best corrected visual acuity was 6/6 in both eyes. Anterior segment examination showed early cataractous changes in both eyes. Intraocular pressure was 20 mm Hg on Travoprost (0.004%) and brimonidine tartrate (0.2%) in both eyes. Gonioscopy showed open angles in all quadrants in both eyes. His axial length in the right eye was 24.48 mm and 24.35 mm in the left eye.

Figure 1A: Left eye color fundus photograph showed vertical cup disc ratio of 0.9O %, inferior rim thinning with broad inferior notch ( green arrow), enlarged scleral ring ( black arrow), bayoneting of vessels (red arrow). Inferior and superior  wedge-shaped defect of RNFL (yellow arrows) also noted. Macula appears normal.

Figure 1B: Left eye color fundus photograph with the magnified view of the disc. Arrows are marked as in Fig 5A.

Figure 2: Left eye OCT showed marked thinning of retinal nerve fiber layer in temporo-superior and temporo-inferior quadrants (white arrows) (Fig.2b) and (black arrows) (Fig.2d).
Figure 3: Left eye posterior pole deviation map showed marked thinning of ganglion cell layer thickness (yellow arrows) (Fig.3 A and B). GCL segmental measurements in the macula, (Fig. 3D) showing  thinning of, supero-temporal, infero-temporal, inferior sectors  (< 1  percentile)  and of the superior sector (< 5th percentile of healthy reference population).
Figure 4: Left eye Hood’s report showed reduction in retinal nerve fiber cell layer thickness with preservation of macular fibers (Fig.4 A white arrow) and (Fig.4 B black arrow). There is a significant reduction of superior and inferior RNFL as shown by the heat map (Fig.4 D black arrows) and the field view (Fig.4 F white arrows). There is also significant reduction of macular GCL shown by the heat map (Fig.8 E red arrow) and the field view (Fig.4 G yellow arrow).

Impression: Patient presented to us with advanced glaucomatous damage in left eye with significant retinal nerve fiber layer and ganglion cell layer thinning in left eye. The intraocular pressure in left eye was border line with two anti-glaucoma medications. In view of the significant glaucomatous damage, the patient was advised left eye trabeculectomy with mitomycin C.  This is a fortunate patient, where the Temporal retinal nerve fiber layer and the ganglion cells are relatively well preserved, in the classical phenomenon of “ Petal of Sight’. The clinical implications are that this patient is more likely to preserve his central vision or in other words may not lose his central vision at an early stage. This phenomena  tells us that in some glaucoma patients, the temporal nerve fiber layer and by extension the ganglion cell layer is less prone to damage.  The exact reason for this resistance to glaucoma damage remains largely unknown


Dr. Vinay Nangia
Suraj Eye Institute
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