Case Study 1

Patient: Caucasian Female, age 65, with mixed color irises

Medical History: Post menopausal; mild osteopenia; no history of cardiovascular or pulmonary disease; mother had glaucoma

Diagnosis: Open-angle glaucoma in one eye

IOP: OD 28 mmHg; OS 23 mmHg

CCT: 557.0

Vertical C/D: 0.8 OD, 0.5 OS

Visual Field: OD—Superior arcuate defect; OS—Full

Ophthalmic History: Myopia in both eyes; complains of burning and stinging at administration of any ocular drops

History/Chief Complaint: On a routine check-up, mentions occasional ocular irritation and the feeling that her eyes are “sensitive” and that she needs to use over-the-counter eye drops occasionally to relieve redness and dryness. Upon review of her medical history, she reported that her mother suffered from glaucoma.

Clinical Findings: Diagnosis of open-angle glaucoma: Upon examination, IOP was found to be elevated in her right eye at 28 mmHg, while ocular fundus examination revealed significant cupping (.8) of the disc. Visual fields were conducted, with results in the same eye showing early superior arcuate defects. Central cornea thickness was measured to be 557 μ.

click to enlarge

OD = 0.8	OS = 0.5
Used with permission of Craig Blackwell, MD.

Considerations for Management

• Treatment to be initiated with IOP-lowering medication in both eyes
• Patient is conscious of appearance and has been wearing contact lenses for 10 years for her myopia
• She is concerned about side effects, and considers herself susceptible
• The patient has no comorbidities that would result in a contraindication for a beta blocker

Questions

1. Why would you consider a beta blocker for this patient? Potential eye color change with prostaglandin analogs Patient sensitivity/concern about ocular side effects that affect appearances, like hyperemia Early stage, mild glaucoma No cardiovascular or pulmonary comorbidities All of the above None of the above—would not consider a beta blocker

2. Why would you consider a preservative-free eye drop for this patient? Patient concern about side effects Patient wants to continue wearing contact lenses Patient complains of burning and stinging, foreign sensation when applying any eye drops All of the above Would not consider preservative-free drop

References: 1. Pisella PJ, Pouliquen P, Baudouin C. Prevalence of ocular symptoms and signs with preserved and preservative free glaucoma medication. Br J Ophthalmol. 2002;86:418-423. 2. Miyake K, Ota I, Akura J, et al. Enhanced disruption of the blood-aqueous barrier and the incidence of angiographic cystoid macular edema by topical timolol and its preservative in early postoperative pseudophakia. Arch Ophthalmol. 2001;119:387-394. 3. Zimmerman TJ, Hahn SR, Gelb L, Tan H, Kim E. The impact of ocular adverse events on patients treated with topical prostaglandin analogs: changes in prescription medicine. J Ocul Pharmacol Ther. 2009;25:145-152. 4. Nordmann JP, Auzanneau N, Ricard S, Berdeaux G. Vision related quality of life and topical glaucoma treatment side effects. Health Qual Life Outcomes. 2003;10:75. 5. Kahook MY, Noecker RJ. Comparison of corneal and conjuctival changes after dosing of Travoprost preserved with sofZia, Latanoprost with 0.02% benzalkonium chloride, and preservative-free artificial tears. Cornea. 2008;27:339-343. 6. Baudouin C. Detrimental effect of preservatives in eyedrops: implications for the treatment of glaucoma. Acta Ophtahlmol. 2008;86:716-726. 7. Noecker R, Herrygers L, Anwaruddin R. Corneal and conjuctival changes caused by commonly used glaucoma medications. Cornea. 2004;23:490-496.