A 78-year-old man presented with gradual vision loss in both eyes over 3 years. Examination found elevated eye pressures of 28 mmHg and 24 mmHg, optic nerve damage, and visual field loss. He was diagnosed with primary open-angle glaucoma based on his age, symptoms, examination findings, and lack of other risk factors. He was started on glaucoma medication and planned for surgery to further lower his eye pressure and slow vision loss.

1. Long Case Presentation:
Primary Open
Angle Glaucoma
DR.MD.ASHFAKUR RAHAMAN
(RAYHAN)
DO STUDENT, RPMCH

2. Particulars of the patient:
 Name: Mr. Jakaria
 Age: 78 years
 Sex: Male
 Religion: Islam
 Marital status: Married
 Address: Keranipara, Rangpur
 Occupation: Retired from private job
 Date of admission:21032022
 Date of examination:27032022

3. Chief Complaints:
Gradual dimness of vision in both eye for about 3 years

4. History of Present Illness:
According to the statement of the patient he was reasonably well
3 years back. Now he came with the complaints of gradual
dimness of vision in both eye for about 3 years and frequent
stumbling with surrounding object for 2 years. According to the
patient, his visual problem was insidious onset and slowly
progressive in nature, painless, not associated with redness,
photophobia and lacrimation. He has no history of trauma, no
history of steroid intake. Now he admitted in this hospital for his
better management.

5. General History:
▪ Past ocular history: He has no history of ocular surgery.
▪ Past medical history: He has no history of diabetes,
hypertention, asthma and other systemic diseases.
▪ Drug history: He took travoprost eye drop for 3 months,
3years ago.

6. General history cont…..
 Family history: His parents and siblings did not suffered from
such kind of ocular problem. He has 4 sons and a daughter, all
are in good health.
 Allergy history: He has no significant history of drug and food
allergy.
 Personal history: He is non smoker and non alcoholic.
 Socio economic history: He belongs from a middle class family.

7. General Examination:
▪ Appearance: Normal
▪ Body built: Average
▪ Co-operation: Well Co operative
▪ Anemia: Absent
▪ Jaundice: Absent
▪ Cyanosis: Absent
▪ Edema: Absent
▪ Lymph node: Not palpable
▪ Blood pressure: 13080 mmHg
▪ Pulse: 74 beatsmin
▪ Respiratory rate: 18 breathsmin
▪ Temperature: 98F

8. Ocular Examination:
Visual acuity Right Left
Distant
Unaided Hand movement 624
With pin hole Not improved 618
Aided Not improved 618
Near
Unaided Could not be evaluated N10
Aided Could not be evaluated N8

9. Ocular examination cont….
Right Left
Color vision Trichromatic Trichromatic
Hirschburg reflex central central
Field of vision
(Confrontation)
Could not be evaluated Superior and inferior field
constriction
Pupil Round , regular, reacting Round , regular, reacting
Ocular motility Full in all gaze Full in all gaze

10. Slit lamp examination
Right Left
Eyelid and Eyelash Normal Normal
Conjunctiva Normal Normal
Cornea Transparent Transparent
Anterior chamber • Normal AC depth
• No pigment
• No PAS
• Normal AC depth
• No pigment
• No PAS
Iris Normal Normal

11. Slit lamp examination cont…..
Right Left
Lens Peripheral lental opacity Peripheral lental opacity
Vitreous Normal Normal

12. Fundus examination…
Fundus examination Right Left
Media Clear Clear
CD ratio 0.9:1 0.7:1
Color of disc Pale Mild pallor
NRR Generalized thinning Superior and inferior thinning
Blood vessel • Nasal shifting
• Bayoniting of BV
• Nasal shifting
• Bayoniting of BV
Macula Normal Normal
Peripheral retina Normal Normal

13. Ocular examination
Right Left
IOP(GAT) 28 mmHg 24 mmHg
Gonioscopy • Angle open
• No angle recession
• No neovascularization
• Angle open
• No angle recession
• No neovascularization

14. Systemic Examination:
▪ Nervous system: No significant abnormality found.
▪ Cardiovascular system : Blood pressure: 13080 mmHg
Pulse: 74 beatsmin
▪ Respiratory system : Respiratory rate: 18 breathsmin
Percussion: Resonance
Auscultation: No ronchi
▪ Renal system : No significant abnormality found.

15. Salient Feature:
Mr. Jakaria 78 years old hailing from Keranipara,Rangpur
with the complaints of gradual dimness of vision in both eye
for about 3 years and frequent stumbling with surrounding
object for 2 years. According to the patient, his visual
problem was insidious onset and slowly progressive in
nature, painless not associated with redness, photophobia
and lacrimation. He has no history of trauma, no history of
steroid intake. Patient is non diabetic, normotensive and he
has no history other systemic diseases. Patient took
travoprost eye drop for 3 months, 3 years ago but he did not
continue this drug. Patient did not give any history ocular
surgery. He is non smoker, non alcoholic and he has no drug
allergy.

16. Salient feature cont…..
On examination-Visual acuity for distance in right eye is hand
movement and no improvement in pin-hole or refraction.
Visual acuity in left eye is 624 and in pinhole and refraction it
is 618.Field of vision could be evaluated in right eye and
there is superior and inferior constriction in left eye through
confrontation test. IOP in GAT is 28mmHg in right eye,24
mmHg in left eye. Gonioscopy reveals angle is wide open in
both eye and there is no neovascularization.
On fundus examination- media is clear, size and shape of
optic disc is normal. CD ratio 0.91 in right eye and 0.71 in
left eye. NRR is thin but remaining rim is pink in color, ISNT
rule is not maintained.

17. Salient feature cont….
There is nasal shifting and bayoniting of blood vessel.
Macula and peripheral retina is normal.

18. Provisional diagnosis
Primary open angle glaucoma with age related cataract in
both eye.

19. Differential Diagnosis:
 Normotensive glaucoma
 Steroid induced glaucoma
 Primary angle closure glaucoma

20. Investigations:
 Ocular:
• Central corneal thickness
• Visual field analysis
• Color fundus photograph
• OCT glaucoma protocol
 Systemic:
• FBS and 2HABF
• Fasting lipid profile

21. Clinical Diagnosis:

22. Treatment:
▪ Medical treatment: Anti glaucoma drugs (Prostaglandin
analogs are the 1st line drug)
▪ Surgical treatment: Combined trabeculectomy with SICS
with PCIOL