Introduction The diagnosis of primary open angle glaucoma (POAG) implies a life long disease with irreversible visual loss for which regular medication and followup is needed for the rest of the life. The visual loss is painless and progressive, and thus may go undetected as it does not involve the central vision initially. With early detection techniques we can halt and prevent visual loss due to glaucoma by appropriate and timely management. At the same time it must be differentiated from other causes which present similarly but with subtle differences in clinical presentation where both the prognosis and management differ. The ‘glaucoma masqueraders’ mimick glaucoma in one or more ways. They may cause a painless visual loss, that involves the periphery earlier and more severely than central vision involvement, or some may have high intraocular pressure (IOP) e.g. Compressive optic neuropathy (CON),Ocular hypertension (OHT). Others may have optic nerve head (ONH) changes similar to glaucomatous optic neuropathy (e.g. Optic pit and isolated ONH coloboma). Still others may have visual field defects simulating or mimicking glaucoma. Superior arcuate scotoma may be seen in optic pit, anterior ischemic optic neuropathy (AION), compressive optic neuropathy. Glaucoma field loss affects the nasal quadrant initially and may mask an unusual visual field presentation of a pituitary tumor. Differentiating a case of normotensive glaucoma from OHT can be a diagnostic dilemma. Corresponding Author, Prof. Meenakshi Dhar, Professor of Ophthalmology, Amrita Institute of Medical Sciences& Research Centre,, Edapally, Cochin, 682026, Email [email protected]Glaucoma Masqueraders – Our Clinical Experience – Has OCT Made Diagnosis Easier? Prof. Meenakshi Dhar MS, Dr. Abhijeet S. Khake, Dr. Gopal S. Pillai MD DNB, Dr. H. Sujithra DO, Dr. S. Jisha, MS, Dr. Deepa P.A. Abstract Conditions mimicking glaucoma with field changes or optic nerve head changes similar to glaucoma can puzzle the clinician. We present a series of 17 patients with optic nerve head pit, optic nerve head drusen, ONH coloboma, ocular ischemic syndrome, compressive optic neuropathy, and ocular hypertensives with high cup disc ratio in myopic optic discs which appear glaucomatous but with no field loss. OCT helped us to differentiate some of these. The clinical presentation, visual field analysis, OCT picture and also features clinching the diagnosis in these patients is discussed in detail. Keywords: Optic pit, compressive optic neuropathy, Ocular ischaemic syndrome, OCT ORIGINAL ARTICLE
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22 Kerala Journal of Ophthalmology Vol. XX, No. 1
Introduction
The diagnosis of primary open angle glaucoma (POAG)
implies a life long disease with irreversible visual loss
for which regular medication and followup is needed
for the rest of the life. The visual loss is painless and
progressive, and thus may go undetected as it does not
involve the central vision initially. With early detection
techniques we can halt and prevent visual loss due to
glaucoma by appropriate and timely management. At
the same time it must be differentiated from other
causes which present similarly but with subtle
differences in clinical presentation where both the
prognosis and management differ.
The ‘glaucoma masqueraders’ mimick glaucoma in
one or more ways. They may cause a painless visual
loss, that involves the periphery earlier and more
severely than central vision involvement, or some may
have high intraocular pressure (IOP) e.g. Compressive
optic neuropathy (CON),Ocular hypertension (OHT).
Others may have optic nerve head (ONH) changes
similar to glaucomatous optic neuropathy
(e.g. Optic pit and isolated ONH coloboma). Still
others may have visual field defects simulating or
mimicking glaucoma. Superior arcuate scotoma may
be seen in optic pit, anterior ischemic optic neuropathy
(AION), compressive optic neuropathy. Glaucoma field
loss affects the nasal quadrant initially and may mask
an unusual visual field presentation of a pituitary tumor.
Differentiating a case of normotensive glaucoma from
OHT can be a diagnostic dilemma.
Corresponding Author, Prof. Meenakshi Dhar, Professor of Ophthalmology, Amrita
Institute of Medical Sciences& Research Centre,, Edapally, Cochin, 682026,
Fig. 1. (c,d,e) OCT of a case of Optic Pit showing (c)–RNFL, (d)–ONH, (e)–line scan[clockwise]
(d)(e)
(c)
March 2008 Meenakshi Dhar et al. - Glaucoma Masquerades 25
Fig. 2. (a) Fundus photograph showing an isolated optic disccoloboma with a white excavation on disc, decenteredinferiorly with a thin inferior rim and a normalsuperior rim
Fig. 2. (b) Red free fundus photograph of optic disc coloboma
Fig. 2 (c) HFA left eye showing a superior arcuatescotoma