GlaucomaLearn 3 (Right 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: Colour photograph of fundus of right eye showed vertical cup disc ratio 0.9, inferior rim thinning (green arrow), scleral ring (black arrow), bayoneting of vessels (red arrow). Large inferior wedge-shaped defect of RNFL (yellow arrow). Macula appears normal.

Figure 1B: Colour photograph of fundus with magnified view of the disc. Arrows are marked similar as in Fig 1A.

Figure 2: Right eye OCT (Optical coherence tomography) showed significant thinning of retinal nerve fiber layer in temporo inferior and nasal inferior quadrants, with flooring effect (white arrow) (Fig.2b) and (black arrow) (Fig.2d). Thinning  of RNFL in  nasal superior and supero-temporal  quadrants was  noted (red arrow) (Fig.2b)  (blue arrow) (Fig.2d).
Figure 3: Right eye posterior pole deviation map showed significant reduction in ganglion cell layer thickness (yellow arrows) (Fig.3 A and B) in  inferior and inferior temporal quadrants. GCL segmental measurements in the macula showed thinning of inferotemporal and inferior sectors  (< 1 percentile) and global thinning of  < 5th percentile of healthy reference population (Fig.3 D).
Figure 4: Right eye Hood’s report showed reduction in retinal nerve fiber cell layer thickness in temporo-inferior quadrant (Fig.4 A  white arrow) and (Fig.4 B black arrow). There is a significant reduction of 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 inferior macular GCL shown by the heat map (Fig. 4 E red arrow) and the deviation map, field view (Fig. 4 G yellow arrow).

Impression: The intraocular pressure in right eye was borderline with two anti-glaucoma medications. Fundus showed cup disc ratio of 0.90, with classical wedge shaped defect of RNFL inferiorly. On OCT,  patient has significant retinal nerve fiber layer and ganglion cell layer thinning in right eye.  In view of the significant glaucomatous damage and for better control of intraocular pressure, patient was advised right eye trabeculectomy with mitomycin-C. It is also important to note  the axial length, which was ­­24.48 mm and 24.35 mm in the left eye, which is considered to be on the higher side and therefore the patient was considered to be myopic. This is important because the risk of developing primary open angle glaucoma tends to increase  with increasing axial length. Therefore  patients that have increased axial length should be assessed carefully and  all subjects who are glaucoma suspects or  have glaucoma should  ideally have their axial lengths measured.


Dr. Vinay Nangia
Suraj Eye Institute
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