feature
Applying the Most Recent Clinical Data To Improve Glaucoma Treatment
The
following case study will give clinicians new ideas on how to use travopost
0.004% (TRAVATAN® solution) in their daily practice to better manage
glaucoma patients.
By Murray Fingeret, O.D.
|
|
|
Figure
1 |
|
|
|
Figure
2
|
As
demonstrated in this case study, travoprost 0.004% (TRAVATAN® solution) lowered
IOP significantly in one of my patients with early, open-angle glaucoma (OAG) when
it was given alone.
Success in the early stages
A 66-year-old white man presented with blurred
near vision. His medical history included hypertension. He wasn't using any systemic
medications, although he was being managed on a low-salt diet.
Uncorrected visual acuity was 20/20
in each eye at distance. A frequency doubling technology (FDT) perimetry N30-5
screening field, performed at the beginning of the examination, revealed a repeatable
defect in the left eye.
IOPs were 22 mm Hg OD and 23 mm Hg
OS at 9 a.m. A dilated fundus examination in the right eye showed that the optic
nerve was slightly smaller than average, with the inferior-superior-nasal-temporal
(ISNT) rule noted as questionable (Figure 1).
The left eye failed the ISNT rule with
the neuroretinal rim tissue thin, especially inferiorly (Figure 2). The cup in the
left eye had a vertical shape with zone beta peripapillary atrophy noted temporally.
There were no signs of disc hemorrhage or retinal nerve fiber layer (RNFL) defects
in either eye.
Glaucomatous
damage was suspected in the left eye, so we performed pachymetry. The corneal thickness
measured at 495 μm OD and 497 μm OS. Optic nerve imaging performed with
the Heidelberg Retinal Tomograph (HRT) (Figure 3) showed a smaller-than-average
disc, thin rim tissue and a large cup — especially OS. Moorfields Regression
Analysis (MRA) failed in each eye, though more sectors were flagged OS.
The
GDx VCC printout (Figure 4) showed that each eye had thin RNFL, with the nerve fiber
indicator (NFI) being higher OS. The temporal-superior-nasal-inferior-temporal
(TSNIT) curves of the RNFL were thin in each eye, although they remained within
the so-called normal range (5% to 95% confidence levels). Optical coherence tomography
(OCT) with the Stratus OCT showed loss, although it was greater OD (Figure
5).
|
|
|
Figure 3
|
The
patient returned in a few weeks, at which time his IOPs were 21 mm Hg OD and 24
mm Hg OS at 10 a.m. SITA Standard 24-2 visual fields were full and reliable in each
eye (Figures 6, 7). Gonioscopy showed wide-open angles in each eye.
FDT 24-2 threshold testing,
using the Matrix perimeter, found defects in each eye (Figures 8, 9). The defect
in the right eye extended inferiorly from the blind spot (inferior partial arcuate).
The left eye's defect extended both inferiorly and superiorly from the blind spot
(double partial arcuate scotoma).
The
FDT Matrix 24-2 defects repeated in each eye; 24-2 SITA SWAP showed a defect extending
inferiorly from the blind spot in the right eye, but the left eye was full and did
not replicate the defect seen with the FDT.
This is a case of early, primary
open-angle glaucoma, with optic-nerve damage present. But functional loss was seen
only with one of the newer forms of perimetry.
We prescribed travoprost 0.004% (TRAVATAN®
solution) OU q.h.s. to meet a target IOP goal of 15 mm Hg to 17 mm Hg.
One month later, we learned the patient
tolerated the drug well and achieved IOPs of 16 mm Hg OD and 17 mm Hg OS.
Given these good results, the patient
will continue using travoprost and return for follow-up in 3 months.
 |
 |
 |
|
Figure 4 |
Figure
5 |
Figure 6 |
 |
 |
 |
|
Figure 7 |
Figure
8 |
Figure
9 |
Optometric Management, Issue: August 2006