A 72-Year-Old with Fluctuating Vision and a Family History of Glaucoma
A 72-year-old woman reports gradually worsening vision, especially glare and haloes at night, and says her glasses 'never seem right.' She has a family history of glaucoma in her mother. Examination: best-corrected acuity 20/40 OD and 20/30 OS; IOP 22 mmHg OD and 21 mmHg OS by Goldmann tonometry; central corneal thickness 545 µm OD and 550 µm OS; gonioscopy shows open angles with mild pigment; optic discs show a cup-to-disc ratio of 0.6 OD and 0.55 OS with healthy neuroretinal rims. Slit lamp shows 3+ nuclear sclerosis and 2+ cortical spoke-like lens opacities OU. Macula and periphery are normal. She asks whether she needs glaucoma drops and whether cataract surgery is worthwhile.
1. How do you interpret the IOP, disc, and gonioscopy findings, and what would you do before deciding on glaucoma treatment?
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The findings are borderline, not diagnostic of glaucoma:
- IOP 21-22 mmHg is above the population mean but within the normal range; with central corneal thickness near average (545-550 µm), the readings are not meaningfully corrected up or down.
- Cup-to-disc 0.55-0.6 with healthy rims and no asymmetry or hemorrhage is not glaucomatous; a positive family history raises risk but is not itself a diagnosis.
- Open angles with mild pigment are normal for age; no synechiae or narrow configuration.
The correct next step is not to start drops but to establish a baseline and look for functional or structural glaucomatous change:
- Visual field testing (and repeat if unreliable) to look for a defect consistent with the disc.
- OCT retinal nerve fiber layer as a structural baseline.
- Serial IOP and disc photos for comparison.
Only if there is reproducible field loss, progressive cupping, or documented high-risk features would treatment be indicated. Ocular hypertension without damage is a risk factor, not a disease, and treating it commits her to lifelong therapy and cost. The cataract is the more likely cause of her symptoms.
2. How would you counsel her about cataract surgery, and how does the glaucoma question interact with that decision?
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Cataract surgery is reasonable and likely beneficial: she has visually significant nuclear and cortical opacities with glare, haloes, and fluctuating refraction consistent with lens changes; acuity of 20/40 and 20/30 understates the disability from glare and contrast loss.
Counseling points:
- Set realistic expectations: improved clarity and glare, but reading glasses will still be needed unless she chooses a multifocal or monovision strategy, and those have trade-offs (haloes, reduced contrast).
- Discuss IOL choice in light of her night-driving and glare complaints.
- Explain typical recovery and the small risks of surgery.
Interaction with the glaucoma question:
- Cataract surgery alone often lowers IOP modestly, and removing the lens can deepen the anterior chamber - relevant if she later needs glaucoma surgery.
- If she truly has glaucoma, the surgical plan may change (e.g., combined procedures or MIGS at the time of cataract surgery).
- Therefore, complete the glaucoma workup (fields, OCT) before scheduling surgery, so a single combined plan can be made rather than discovering progressive glaucoma afterward. This sequencing is the key judgment call.