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GLA06 03 Section IV Cable Car Next Stop Open Angle Glaucoma With Low Pressures Normal Pressure G

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Thank you so much it’s an honor to speak with you about normal pressure masqueraders i practice both in the divisions of glaucoma and neuro-ophthalmology at penn i have some commercial and intellectual disclosures none of which are relevant to this talk my first slide is an audience response question which of the following clinical findings are most indicative of

The need for neuroimaging we have decreased vision a questionable apd dis chroma top sia or an asymmetric visual field defect so it looks like we’re pretty spread which means the talk will be very relevant for this audience can we go back to my slides thank you so i’m going to present two case presentations and i’m going to deconstruct some red flags that i use

For the diagnosis of alternative diagnoses of inpatients that are presenting with presumed normal tension glaucoma i want to take a little bit of time to discuss the clinical that the process of clinical reasoning for me really fits into two systems when i’m in glaucoma practice i have to get through large sums of patients so there’s the quick recognizable patient

Symptoms and clinical presentation that leads to a diagnosis but there’s also the system too that requires slower thinking slowing down and collecting a few a little bit more information to arrive at the diagnosis so hopefully i’ll give some red flags that allow you to shift from one system one to system to patients first case is a 57 year old male with decreased

Vision in both eyes it was more prominent than the right eye he had been seen by two providers one of which diagnosed him with a arterial occlusion and then the other was a glaucoma specialist that had placed him on a tan acrost he continued to progress so he saw me he had pretty significantly decreased vision in the right eye the pressures off the latina procced

Were 18 and 17 he did have an apd and he had a super temporal defect in presumably the unaffected eye his gonio exam was wide open and no signs of recession these were his visual fields they were read previously as unremarkable the patient english wasn’t their first language and they were concerned about the visual fields and these were the oct s which showed thin

Areas in the right nerve i did a goldmann visual field and confirmed that in the right eye he had a small island of vision in the left eye he had a super temporal defect which is consistent with an anterior chiasma junctional scotoma seen on visual field analysis subsequent imaging studies revealed this to be a optic nerve sheath meningioma and i still remember

The day i was dropping my kid off at child care i got a call from the radiologist that said your patient has a midline shift what should i do so he went right to the emergency room so i knew this was a great case to present so there are key parts of the history that are important early glaucoma doesn’t typically present with acute visual symptoms the quality of

Their systems tend to not be a dimming or a decreased visual acuity in this patient despite the language barrier did complain of that and then i’m always very leery of a typical open-angle glaucoma z’ but what in the clinical exam kind of gave me a red flag was the visual acuity most non glaucoma this optic neuropathy unless the patient has snuffed has not poor

Visual acuity and count fingers is pretty poor most non glaucoma this optic neuropathies will have significantly reduced color testing whereas glaucoma patients because that their defects tend to be more triteness aren’t necessarily picked up in this common is she hara color plates that we use in the clinic and then the apd rare and mild or early disease and

Then i’m always very skeptical of temporal defects or nasal thinning on oct the final um case i’m gonna talk about is a 48 year old female she was given glasses to correct her complaint of dimming vision she had a mild history of mixed connective tissue disease and no other family history her exam showed pretty preserved vision her pressures were normal i will

Tell you that her color she did have a questionable apd in the left eye her colors were down in the left eye and she was slow in the right eye again gonio exam was normal those were her visual fields from 2016 consistent with some atra superior thin areas in the left eye and then they came to me because she progressed in a short period of time to that so the next

Audience response question is what’s the next course of management that you would select for this patient would you add vermont adine would you select an mri brain with contrast just to rule everything out would you add natasha dell and book the patient for surgery for rapid progression of visual fields or would you use an mri order an mri with special attention to

A particular location good so bd that’s exactly what i expected with the audience hopefully i’ll unveil why d is the correct answer can we go back to my slides so i ended up getting a dedicated orbital imaging study and what you can see here is in the left eye she’s got a classic doughnut sign for involvement of the optic nerve sheath because of the presentation

It was diagnosed as an optic nerve sheath meningioma and if you look in the right eye she has a small involvement at the right eye as well which is why her color testing was so slow i want to stop here and say if you do see this because of the way the patient presented there you wouldn’t be wrong to order blood test to rule out any other causes of peri neuritis

Then i’ll do the following repeat audience response questions to make sure there’s been some progress which of the following clinical findings are most in dicta of the need for neuro imaging is it decreased vision a questionable apd dis chroma top sia or an asymmetric visual field defect good so it looks like there’s a great learning curve i really do rely on

Those color plates especially in my glaucoma clinic and my patients with normal tension glaucoma all my technicians know that i need them to not only test it but identify whether they’re slow with their responses to the questions you would not have been wrong to pick decreased vision but again that’s not as sensitive as the color plates for optic neuropathy can we

Go back to my slides in conclusion i want to highlight optic nerve cupping is going to occur regardless of the insult the hint will be a careful examination of the optic nerve usually optic neuropathies the rim is involved and then normal tension glaucoma for me is a diagnosis of exclusion i’m always very very leery of this diagnosis altogether and start to think

Of other causes particularly in the complex patients and then the red flags we went over thank you

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GLA06 03 Section IV Cable Car Next Stop Open Angle Glaucoma With Low Pressures Normal Pressure G By BS Đoàn Lương Hiền