A 75-year-old man comes to the office for an annual wellness visit. He feels healthy and has no bothersome symptoms. The patient is up to date on vaccines and cancer screening tests. History is notable for hypertension, for which he takes lisinopril and amlodipine, and type 2 diabetes mellitus, for which he takes metformin. The patient does not smoke and drinks alcohol only on social occasions. Blood pressure is 128/82 mm Hg. External ocular examination is normal; funduscopic examination shows an enlarged optic cup with an increased cup/disc ratio. Automated visual field testing reveals decreased peripheral vision in all axes. Which of the following is the most likely diagnosis?

Question

A 75-year-old man comes to the office for an annual wellness visit.  He feels healthy and has no bothersome symptoms.  The patient is up to date on vaccines and cancer screening tests.  History is notable for hypertension, for which he takes lisinopril and amlodipine, and type 2 diabetes mellitus, for which he takes metformin.  The patient does not smoke and drinks alcohol only on social occasions.  Blood pressure is 128/82 mm Hg.  External ocular examination is normal; funduscopic examination shows an enlarged optic cup with an increased cup/disc ratio.  Automated visual field testing reveals decreased peripheral vision in all axes.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d491_e208_bc81_bfbb28ef6b34_MD0003_00 This patient has primary open-angle glaucoma (OAG), manifesting as loss of peripheral vision in association with an enlarged optic cup and an increased cup/disc ratio (ie, "cupping" of the optic disc). OAG is a type of optic neuropathy characterized by atrophy of the optic nerve head. It is typically associated with increased intraocular pressure (IOP), as measured by tonometry, but this finding is not highly sensitive or specific. The prevalence of OAG is elevated in African Americans, patients with diabetes mellitus, and those with a family history of glaucoma. OAG usually has an insidious, slowly progressive course, and patients frequently are asymptomatic until the condition is advanced. Early symptoms, when present, typically include tripping over objects or being involved in near-miss motor vehicle collisions. Screening (eg, tonometry, peripheral vision testing, slit lamp examination) is not universally recommended but can be considered for older individuals and patients with risk factors. Initial treatment includes topical agents (eg, bimatoprost) to decrease the volume and pressure of aqueous humor or laser trabeculoplasty. topical agents (Choice A) Patients with diabetic retinopathy are commonly asymptomatic until late in the disease course. However, typical examination findings include microaneurysms, hard exudates, and retinal hemorrhages, sometimes with neovascularization. The disc is generally normal, and visual field defects (when present) are patchy, rather than peripheral. microaneurysms, hard exudates, and retinal hemorrhages neovascularization (Choice B) Hypertensive retinopathy presents with blurred vision, sometimes with limited visual field defects. Examination shows arteriovenous nicking, copper wiring, flame hemorrhages, cotton-wool spots, and optic disc edema. arteriovenous nicking (Choice C) Age-related macular degeneration presents with slowly progressive central (not peripheral) vision loss. Examination shows subretinal drusen and pigment anomalies. drusen (Choice D) Nonarteritic anterior ischemic optic neuropathy is characterized by ischemia in the optic nerve head. It presents acutely with painless, monocular vision loss. Typical examination findings include optic disc edema and an afferent pupillary defect. (Choice E) Optic neuritis presents with acute, monocular vision loss and pain with extraocular movement. Examination shows unilateral optic disc edema. The condition often occurs in young women with multiple sclerosis. optic disc edema Educational objective: Open-angle glaucoma (OAG) is a type of optic neuropathy characterized by loss of peripheral vision associated with an enlarged optic cup and an increased cup/disc ratio (ie, "cupping"). It is typically associated with increased intraocular pressure, but this finding is not highly sensitive or specific. OAG usually has an insidious course, and patients frequently are asymptomatic until the condition is advanced. References: Primary open-angle glaucoma. (http://www.ncbi.nlm.nih.gov/pubmed/27654570)

A 75-Year-Old Man Comes to the Office for an Annual