Case 9: Ophtho Exam

Case 9 Index

On exam, the ophthalmologist notes that the patient’s vision can be improved to 20/20 with refraction, which is strange because the patient had no history of refractive error. 

Vision with correction: with -5.50 sphere OU →  20/20 OU

Next, the ophthalmologist performs gonioscopy.  

What’s gonioscopy?

gonio lensA Gonioscopy lens (image on left) has mirrors which allows for the examiner to visualize the angle of the eye, or the area where the trabecular meshwork is located, and where aqueous outflow occurs. In an eye with an open angle, the trabecular meshwork should be visible, as seen below:

open gonio with labelAbove Image Credit License: CC-BY SA 3.0

However, on gonioscopy for this patient, the ophthalmologist sees this:

closed gonio horizontal

In this patient, the iris is pushed up against the angle occluding the view of the trabecular meshwork, and therefore obstructing aqueous from the leaving the eye.

Ultrasound Biomicroscopy (UBM), an ultrasound of the anterior chamber,  is also performed to better visualize the angle, and is shown below:

Note: Both images are the same. Image on right is labeled.

The UBM shows frank closure of the angle with iris pushed up against the cornea (area marked by circle). It also shows presence of fluid in the suprachoroidal space (indicated by arrow), which is abnormal, and referred to as a supraciliary effusion.

On undiltated fundus exam you see this:

As seen above, mild macular choroidal folds are visible OU.

A B-scan ultrasound, an ultrasound to visualize the posterior segment, is also performed, and an image from the right eye is shown below (Note: B-scan in fellow eye appeared similar):

topamax B-scan with labels

B-scan above shows shallow choroidal detachments.

What’s the most likely diagnosis?
Drug-induced, secondary angle closure glaucoma
Acute angle closure glaucoma
Neovascular glaucoma
Primary open angle glaucoma

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Case 9 Index

Case 9: Introduction
Case 9: Additional History and Physical Exam