Case history
Case history
A 50-year-old man presents for a routine eye examination with no symptoms. He has elevated intra-ocular pressure of 25 mmHg in the right eye and 30 mmHg in the left eye. On dilated examination, the cup-to-disc ratio is 0.5 in the right eye and 0.8 in the left eye. Corneal thickness and gonioscopy are normal. Subsequent automated visual field testing demonstrates blind spots in the nasal visual fields that are larger in the left eye than in the right. Repeated automated visual field testing shows that the visual field defects are reproducible. Optical coherence tomography images of the nerve fibre layer show corresponding thinning at the inferior and superior poles of the optic nerves.
Other presentations
Primary open-angle glaucoma is usually asymptomatic, and if it does cause symptoms, the disease is often quite advanced. However, even when pressures are elevated, they typically climb so gradually that the patient does not experience discomfort. Symptoms include painless visual loss in the form of visual field defects or a more vague description of weak or dim vision. Open-angle glaucoma may present with symptoms of unilateral vision loss with normal bilateral intra-ocular pressures: for example, walking into objects only on the right side. Corneal thickness measurements and gonioscopy may be normal and, on dilated examination, the cup-to-disc ratio in the affected eye may be borderline to ≥0.4. Patients may also show focal or diffuse thinning of the optic disc rim. Although flame-shaped haemorrhages can be seen less frequently, their presence is highly suggestive of glaucoma. Automated testing of visual fields shows reproducible visual field defects in the affected eye.
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