A 65-year-old man is found to have an abnormal reading during screening tonometry. The patient has no visual symptoms or headache. Medical history is significant for asthma, for which he takes inhaled fluticasone/salmeterol routinely and inhaled albuterol on most days to control the symptoms. Vital signs are within normal limits. Eye examination shows normal conjunctivae, corneas, and lenses. Intraocular pressure is 28 mm Hg (normal: 8-21). Funduscopy reveals thinning of the optic disc rim and asymmetry of the cup/disc ratio between the eyes. Which of the following is the most appropriate next step in management of this patient's ocular condition?

Question

A 65-year-old man is found to have an abnormal reading during screening tonometry.  The patient has no visual symptoms or headache.  Medical history is significant for asthma, for which he takes inhaled fluticasone/salmeterol routinely and inhaled albuterol on most days to control the symptoms.  Vital signs are within normal limits.  Eye examination shows normal conjunctivae, corneas, and lenses.  Intraocular pressure is 28 mm Hg (normal: 8-21).  Funduscopy reveals thinning of the optic disc rim and asymmetry of the cup/disc ratio between the eyes.  Which of the following is the most appropriate next step in management of this patient's ocular condition?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d08a_d90e_bc81_415f8431ed39_MD0003_00 This patient has open-angle glaucoma (OAG), a form of optic neuropathy typically (but not always) associated with elevated intraocular pressure (IOP) and characterized by atrophy of the optic nerve head (eg, optic disc rim thinning, increased cup/disc ratio [ie, "cupping"]). OAG is usually asymptomatic in the early stages, but patients can develop gradual loss of peripheral vision. Because vision loss from OAG is generally irreversible, treatment should be initiated before the patient develops significant symptoms (Choice D). OAG can be treated with a number of topical agents that lower IOP by decreasing the formation of aqueous humor or increasing its outflow from the anterior chamber. The first-line agent for most patients is a topical prostaglandin (eg, latanoprost, bimatoprost), which acts by increasing drainage of aqueous humor through the uveoscleral pathway. If prostaglandins are ineffective, topical beta blockers (eg, timolol) can be added, although they should be used with caution in patients with comorbid asthma. If topical agents are ineffective or not tolerated, surgical intervention (eg, laser trabeculoplasty) can be considered. (Choice A) Systemic or ophthalmic glucocorticoids (eg, prednisone and prednisolone eye drops, respectively) can worsen OAG by decreasing the outflow of aqueous humor from the anterior chamber. However, this adverse effect is much rarer with inhaled glucocorticoids and is unlikely to have caused this patient's elevated IOP. Discontinuing the inhaled glucocorticoid would increase the risk of asthma exacerbation and is not recommended. (Choice B) Ophthalmic atropine is used to dilate the pupil to facilitate examination of the retina. It is contraindicated in patients with OAG because the dilation can lead to angle narrowing, which results in decreased outflow of aqueous humor from the anterior chamber, leading to acute angle-closure glaucoma. (Choice C) Systemic (ie, oral, intravenous) carbonic anhydrase inhibitors (eg, acetazolamide) are used acutely for angle-closure glaucoma, which presents with headache, ocular pain, vomiting, and a fixed, middilated pupil. For OAG, topical carbonic anhydrase inhibitors (eg, dorzolamide) are preferred. Educational objective: Open-angle glaucoma can be treated with topical agents that lower intraocular pressure. The first-line agent for most patients is a topical prostaglandin (eg, latanoprost, bimatoprost), which increases drainage of aqueous humor in the anterior chamber. If prostaglandins are ineffective, topical beta blockers (eg, timolol) can be added. References: Therapy for open-angle glaucoma. (http://www.ncbi.nlm.nih.gov/pubmed/30068436)

A 65-Year-Old Man Is Found to Have an Abnormal Reading