Description: I am shown two photographs of a patient’s fundus. The obvious finding is the enlarged optic nerve cup on the left fundus (Fig. 6.1B). The enlargement of optic cup to disk (C/D) ratio is consistent with a glaucomatous optic nerve on the left eye. The right eye’s optic nerve appears to be within normal limits. I do not see any hemorrhages on the retina or the optic nerve.

Differential Diagnosis: This case reveals some type of asymmetric optic neuropathy. The most common optic neuropathy that leads to an enlarged C/D ratio is glaucoma. Glaucoma in general affects both eyes but can be asymmetric. Some glaucomas are unilateral. My differential diagnosis for this case of unilateral glaucoma includes trauma, increased episcleral causes, systemic syndromes, and iridocorneal endothelial syndromes. My number one working diagnosis is traumatic glaucoma of the left eye secondary to angle recession.

History: A history of trauma to the eye, especially a history of a hyphema, would prompt me to consider traumatic angle recession glaucoma.

Exam: Examination of the visual acuity is an important test, but just as important are confrontational visual fields and the color desaturation test. The iris examination would help us rule out the iridocorneal endothelial syndrome (ICE) and previous iris damage from trauma. A binocular slit lamp examination of the nerve would help us gauge the asymmetry revealed in the photos.

Workup: The pupil examination is important because in this case, it would likely reveal an afferent pupillary defect. The gonioscopy examination would help us confirm angle recession. Angle recession would show up with increased width of the ciliary body band best when compared to the patient’s normal eye. As expected, the patient’s intraocular pressure is elevated. A visual field test would document the baseline visual field deficits that the patient reports on the left side. The optical coherence tomography (OCT) of the nerve would quantify the amount of nerve fiber layer abnormality.

Treatment: I would initiate treatment with topical glaucoma drops, in both eyes, and I would avoid laser trabeculoplasty and miotics. I would treat both eyes because these patients are at increased risk of open-angle glaucoma in the contralateral eye.

Advice: I would tell the patient that the cause of his poor visual field is traumatic glaucoma, and traumatic glaucoma is often asymptomatic until it is very advanced. I would also advise the patient that he needs regular ophthalmology examinations and that he is at a higher risk for developing complications from trauma such as a cataract and retinal detachment.

Follow-up: I would follow up the patient within 4 weeks to confirm that the medication has lowered the intraocular pressure (IOP) by at least 20%. I would follow the patient at least every 6 months.

Description: My attention is drawn to the left eye with a posterior intraocular lens (IOL). I do not see any corneal edema. The IOL implant appears to be properly placed in the capsular bag or sulcus. I do not see retained lens material, a shallow chamber, a hyphema, or a Krukenberg spindle. This photo gives me the impression that the patient underwent an uncomplicated cataract surgery.

Differential Diagnosis: Elevated IOP can be divided into two categories, either <2 weeks or >2 weeks. An elevated IOP within 1 week of cataract surgery is secondary to a wide range of causes such as inflammation, retained viscoelastic, pigment dispersion, aqueous misdirection glaucoma, and retained lens material. For this patient, my number one diagnosis is retained viscoelastic material. In the late postoperative phase, elevated IOP after 2 weeks has etiologies such as uveitis-hyphema-glaucoma syndrome, pupillary block glaucoma, ghost cell glaucoma, and steroid-induced glaucoma.

History: I would carefully look at her medical record and surgical report to determine if the patient had a previous history of elevated IOP, glaucoma, or a difficult cataract surgery the day before.

Exam: After obtaining visual acuity and confirming IOP, I would confirm that the wounds are intact and that the IOL is in the proper location. To determine the type of glaucoma, it is important to look at the anterior chamber with a gonioscopy lens, specifically to look for a shallow chamber, iris bowing, presence of vitreous or viscoelastic material, lens material, or blood.

Workup: Topical fluorescein staining can be helpful to perform a Seidel test. Gonioscopy is useful anytime the etiology of elevated IOP or glaucoma is considered. Pachymetry is useful to measure the corneal edema when present. The dilated examination is used to determine the health of the retina and optic nerve.