Page 60 - 21st Century Perspective - Glaucoma Supplement

Clinical Pearls

Any optic nerve head that looks abnormal, yet not glaucomatous, likely merits a 30-2 visual field test,
especially if there is generalized or sectoral pallor of the optic nerve. Most patients with glaucoma

have pink, well-perfused neuroretinal rim tissues and no pallor. Optic nerve tissue pallor more
commonly results from nonglaucomatous processes such as compressive lesions. We like the 30-2
test pattern because it tests more targets along the vertical midline, which would be a more sensitive
screen for neurological defects, as they almost invariably respect the vertical midline.

Optometrists should meticulously analyze and obsessively study the details of the optic nerve head
tissues. Do not let subtle parapapillary atrophy wrongfully skew the assessment of the cup-to-disc
anatomic relationship. Furthermore, in mostly older patients with presumed normal-tension

glaucoma, the glaucomatous cupping can be incredibly subtle. One must really study the peripheral
neuroretinal rim anatomy to search for a 0.8 or 0.9 cup that, at casual glance, may appear to be 0.3
to 0.5 cup.

Remember that patients with highly advanced cupping usually maintain normal vision, so if vision is
inexplicably reduced, then consider one or more of the following:

● visual field testing;
● subtle epithelial basement membrane dystrophy in the visual axis;
● macular OCT to rule out subtle maculopathy;

● potential acuity visometry to rule out the elusive “clear cataract”; and/or
● corneal topography to rule out subtle anatomical variations on the corneal surface.

Of course, you must have requisite diagnostic instrumentation available to provide these
evaluations. If you do not have the necessary diagnostic workup instrumentation, then please refer
the patient to an optometric colleague who does. Do consider the great virtue of intraprofessional

consultation and cooperation.

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