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Is it a fish …

Is it a fish …. or is it fishy?. OR When might a cupped disc be something else?. ד"ר תמר פדות קלויזמן בי"ח בני ציון ושרותי בריאות כללית - חיפה. Our Patients. Frequency. Up to 15-25% of patients with POAG experience NTG In the Baltimore Eye Study:

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Is it a fish …

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  1. Is it a fish… or is it fishy?

  2. ORWhen might a cupped disc be something else? ד"ר תמר פדות קלויזמן בי"ח בני ציון ושרותי בריאות כללית - חיפה

  3. Our Patients

  4. Frequency • Up to 15-25% of patients with POAG experience NTG • In the Baltimore Eye Study: • 50% of individuals with cupping and VF changes had an IOP < 21 on a single visit • 33% had an IOP < 21 mm Hg on 2 measurements

  5. NTG and compressive lesions • Both can cause ONH cupping • Both can produce VF changes • Compression of the ON may make the nerve susceptible to damage at normal Tension

  6. Do I need to image? • Yes – Occasional pathology found, Kasta”ch – difficult patients • No – Low cost effectiveness, unnecessary radiation (CT)

  7. Meningiomas Craniopharyngiomas Pituitary tumors Cysts Chordomas Compression by normal carotid artety Aneurysms affecting the prechiasmal and/or chiasmal visual pathways. Compressive lesions to consider in NTG

  8. Compression by ICA • Gutman and Melamed (Graefes 1993) studied by CT 62 patients with NTG • 90% had either calcification or dilation of the ICA adjacent to the opening of the optic canal • Only 21% of age matched controls had similar abnormalities

  9. N. Ogata - BJO 2005 • Retrospective, 103 eyes with NTG, 104 controls • Compressive optic neuropathy by ICA in 49.5% of NTG patients • 34.6% in age matched controls • Bilateral compression 40.7% of NTG • 21.2% in controls • C/D > 0.7 – higher frequency of ICA compression Neurosurgical decompression? – don’t rush

  10. Sheba Hospital (RHB) • 40 consecutive NTG suspects referred to the neuro-ophthalmology clinic • Complete neuro-ophthalmic exam • Review of scans by neuro-ophthalmologist (RHB)and neuro-radiolosist (MB)

  11. Results

  12. NTG - Suspected findings: > visual complaint > color vision defect > optic disc pallor > atypical visual field defect for glaucoma

  13. Greenfield - Oph 1998 • A retrospective case-controlled study : • Fifty-two eyes of 29 NTG patients • All had brain CT or MRI as part of a diagnostic evaluation between 1985- 1995 • Comparison group – • 44 eyes of 28 patients withcompressive lesions and increased C/D ratio

  14. RESULTS None of the patients diagnosed with glaucoma had radiologic evidence of a mass lesion in the anterior visual pathway

  15. Glaucoma patients Older 68.7 y Better VA Vertical cupping Disc hemorrhage (13%) Less NR pallor HVF – arcuate defects aligned horizontally Compressive lesions Younger <50 y VA < 20/40 No disc hemorrhage Mostly pallor Vertically aligned defects Group characteristics

  16. CONCLUSIONS • Anterior visual pathway compression is an uncommon finding in the neuroimaging of patients with suspected NTG. • Younger age, lower levels of visual acuity, vertically aligned visual field defects, and neuroretinal rim pallor may increase the likelihood of identifying an intracranial mass lesion.

  17. Ahmed - Methods • A prospective, comparative, observational case series, 1988-1998 • 62 consecutive NTG patients had MRI • 70 progressive POAG with controlled IOP . • The prevalence of intracranial compressive lesions, demographic data, and clinical characteristics were compared. J Glaucoma, 2002

  18. RESULTS • 4 of the 62 (6.5%) patients withNTG had clinically relevant intracranialcompressive lesions involving the anterior visual pathway • 2 pituitary macroadenoma, 1 meningioma, 1 arachnoid cyst • None of the 70 patients with POAG had a compressive lesion (P = 0.039)

  19. What is the diagnosis? 24-2 HVF of a patient with pituitary macroadenoma

  20. What is the diagnosis? HVF of a patient with an arachnoid cyst

  21. CONCLUSIONS: • Intracranial compressive lesions are an important diagnostic consideration in the workup of normal-pressure glaucoma • Ahmed: Neuroimaging is cost-effective Remember: • Compressive lesions can cause cupping and mimic glaucomatous VF defects!!! Trobe et al, Arch oph 1980

  22. “Red Flags” • Mismatch between the cupping and the visual field loss (C/D 0.5 but 10°- VF remaining). • An APD or visual acuity loss out of proportion to the VF loss or cupping. • Rapid progression of visual loss. • Glaucomatous-appearing visual field loss in a patient with an anomalous or hypoplastic optic nerve (where cupping is hard to judge).

  23. Indications for neurological workup • Unexplained reduction of visual acuity • Color vision loss w/o advanced VF loss • visual field loss out of proportion to cupping • VF loss atypical for glaucoma • Optic nerve pallor in excess of cupping • Neurological symptoms.

  24. I agree with the authors • If it looks like normal-tension glaucoma, you do not have to do neuroimaging to sleep at night. Richard Mills, Discussion on Greenfield

  25. Thank You

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