Although I’ve been in practice for a while, I haven’t seen that many patients with glaucoma.  As my pre-reg was in a multiple with a patient base skewed towards the young, I saw relatively few patients with either diagnosed glaucoma or dodgy looking discs.

In my last practice, I saw a lot of AMD (both wet and dry), some weird and wonderful corneal dystrophies and a surprising number of retinal detachments.  I did have a few patients with suspicious discs and raised pressure and/or visual field defects but, although I referred these on, I didn’t hear back from the ophthalmology department so I don’t know if I was right.

One of my lecturers said that you have glaucoma when an ophthalmologist tells you that you do.  It’s always on our minds when we are looking at discs, checking pressures and telling them to stop looking around for the lights and just focus on the red dot in the centre.  I assumed that, like AMD and cataracts, if I saw it, I’d know it.  The problem was that the glaucoma patients I’ve seen, the ones with the actual diagnosis, all had very pronounced disc damage.  They were the ones with a 0.9 cup to disc ratio and a field defect that was so obvious it could be picked up by even the most haphazard confrontation test.

Up until recently, I’d never looked at an optic disc in a routine eye test and known instinctively that it was glaucomatous.

So, that brings me to last week, when I had a patient attend for a routine eye exam complaining of reduced vision at near.  Considering he was in his late forties and his last pair of reading specs had a +1.00DS add, it seemed like an open and shut case.  Refraction revealed almost perfect distance vision with a +1.75 add at near.  I moved onto Volk and, as soon as I focused on the disc, my heart sank.  The C:D was recorded, 2 years previously, as 0.5 in both eyes.  In the right eye, it was now closer to 0.7 with pronounced inferior thinning and in the left, I would say it was 0.8.

On the fundus photo, I could see that one of the blood vessels at the lower left of the disc appeared stretched in today’s photo when compared to the 2014 one – the vessel was drooping into the notch instead of sitting against the inferior margin as it was in the previous photo.

Now, the left disc also showed inferior thinning but it was a bit more subtle – I had to bring the two fundus photos up on the screen simultaneously to really convince myself.

The patient’s IOPs in 2014 were R & L 18mmHg. He had no visual field defects and no family history of glaucoma.

I’d taken the patient straight into the room as there was someone else using our fields machine (which is on the same table as the NCT) so I waited until the end of the test to do pressures.  They were R & L 26mmHg.

As part of my referral, I’m having the patient return for pachymetry, Goldmann and a full threshold visual fields test (he didn’t have time for this on the day of the eye test so we’re doing a supplementary exam when he picks up his new glasses).  I’ve explained to him about the raised pressure and that I would like to do some more tests before referring him, just so I can give the ophthalmologist as much information as possible.

Those of you practising in Scotland may have noticed a pachymeter appearing in your practice (a little gift from NHS Scotland).  It’ll be the twin of mine:

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This arrived yesterday and I’ve already tried it on myself (without anaesthetic but wearing my daily disposable contacts because I’m hardcore like that) and I can’t wait to try it on a real patient.

It comes with a lanyard so you can wear it around your neck in preparation for any corneal thickness emergencies that crop up.  It’s very weird, like wearing a Perkins on a string.  I honestly have no idea why Accutome have included this feature.

Anyway, I’ll post the second part of this blog post when my patient returns next week.

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