Bilateral pigment dispersion glaucoma

Patient presentation

• Eye examination date 26th April 2024 
• New patient. Female, aged 58 years 
• Myopic both eyes 
• The patient was recommended by her family Optometrist in the Republic of Ireland to visit me because of poor vision in new spectacles. 
• Last eye examination February 2024 
• Advised cataracts at last sight test Feb 2024 
• History of dry eyes and blepharitis – well controlled 
• General health good – suspect hyperglycaemia, under investigation with GP 
• No family history of eye disease including glaucoma 
• No flashes or floaters 
• No reported headaches or diplopia 
• Occupations: Driver, Office worker, art galleries, running and swimming 

Diagnosis and Management

VAs in current spectacles R +0.32 L +0.34 

Cover test Orthophoric in existing glasses at distance and near 

Todays refraction and VAs: 

R-5.50/+0.25×180 VA +0.30 

L-7.00/+0.25×180 VA +0.34 

Add +2.00 N6 both eyes 

Pupils normal – PERRLA 

Tonometry 

Pulsair IOPs at 12.25pm R 22 L 29 mmHg 

Goldmann IOPs at 12.30 R 23 L 30 mmHg 

Visual fields (Medmont Central 22A thresholded fields) 

Right superior ring defect (artefact, and poor reliability) 

Left eye normal – no local defects (good reliability) 

 Topcon Maestro OCT 

Maculae – normal profile and bright reflexes 

Central Corneal thickness scan R552 L 534 microns 

Optic Discs – RNFL asymmetry seen. Both eyes show inferior RNFL thinning. Relatively large cups for the smaller than average size of the optic nerves 

Slit lamp examination – anterior segment 

Anterior blepharitis grade 2 both eyes 

Anterior segment – anterior chamber wide grade 4 Van Herricks both eyes 

Posterior segment and slit lamp BIO with 0.5% tropicamide both eyes: 

Bilateral moderate cortical cataracts 

Vessels – normal crossings and no arteriosclerosis or hypertensive changes seen 

Maculae – Bright reflexes 

Fundus and periphery – Flat pink and healthy with no lesions tears holes or detachments 

Optic discs:

Right CD 0.4 Inferior pallor of NRR with well defined margins 

Left CD 0.6 Inferior pallor of NRR with well defined margins 

Discussed bilateral cataract and an inability to improve visual acuity using new spectacles. Patient was offered referral for cataract extraction and wished to go ahead. Discussed with patient that there was evidence of open angle glaucoma in the left eye (raised IOP) and possibly even some evidence of optic nerve damage in the right eye too despite normal IOPs 

I suggested that we have the eye pressure and suspect glaucoma checked by a glaucoma consultant, as well as having the cataracts evaluated for surgery by the same consultant. Since cataract surgery would impact on eye pressure I thought it prudent to discuss seeing a glaucoma consultant before cataract extraction, since the surgery options may potentially be altered to reduce eye pressure if appropriate (such as using iStents). 

The patient was offered an NHS hospital referral with a wait of approximately 6 months to be seen, alternatively to see a local glaucoma specialist privately within the next few weeks 

Patient chose the private option to expedite treatment. A referral was sent to the private clinic via email and the patient was seen 2 weeks later. 

Conclusion

The patient was diagnosed with bilateral pigment dispersion glaucoma by the glaucoma specialist and started on Latanoprost to both eyes noct., with a review in 6 weeks time. Patient declined private cataract surgery with iStents. The consultant confirmed that the patient was fine to proceed with cataract extraction without delay. 

 Following the appointment for glaucoma the patient asked me to refer her onwards to have bilateral cataract extraction with implants to correct her myopia. Again options were offered to go via the NHS hospital, or privately, or to an NHS funded private provider. One of the local private cataract providers offers NHS funded cataract extraction performed by a glaucoma specialist who also happens to work at the same NHS hospital as the glaucoma consultant that had diagnosed her glaucoma. She agreed that this may be a good option and consented to referral which was sent electronically to her GP surgery. 

I now await her return for post operative refraction in the coming month or two.