Melissa Valdellon

Patient case for August 18, 2023

Recently, we worked with a 55 year old black female who came in for her annual eye exam with no new complaints except she wanted to check on her eyes and get refills for her eye drops. She has been diagnosed with mild POAG both eyes and was scheduled to return for a visual field last year but no showed, so this is her first visit in about 1.5 years.

Systemically, she has a chronic hepatitis C infection with cirrhosis, arthritis, chronic back pain, and insomnia. She is taking latanoprost, timolol, cyclobenzaprine, diclofenac, melatonin, and trazodone.

The patient is correctable to 20/20 in each eye. Pupils, EOMs, and FDT visual field screener were clear today. She has some mild nuclear sclerosis and otherwise clear anterior segment. Posterior segment is also clear except for nerves with a C/D of 0.75 round in both eyes.

Historically, her max IOP was 16/18. In office today, IOP was 15/15.

Pachymetry is 517/518, gonioscopy showed open angles 360 OU.

An HVF 24-2 was last performed in 2021, which showed possible superior and inferior nasal steps both eyes after clear visual fields in 2019.

OCT of the RNFL both eyes showed thinning in the inferior-nasal quadrant for the right eye, thinning in the superior-temporal quadrant of the left eye.

Looking back at her visit history, she has had quite a few visits where she had cancelled them or no showed. At the end of the exam, she mentions she is always traveling and that’s why she can’t always come in. She also mentions that she skips a couple days’ worth of using her eyedrops when she’s waiting to pick up her new bottles from the pharmacy.

Given her appointment history and her IOPs, what would be your course of managing this patient next? I know I want to repeat her visual field for sure and check her IOP again. Is it worth it to consider adding another drop or change to a combo drop at the next visit? Is it worth it to refer her over to glaucoma to consider other interventions if her IOP still doesn’t go down?

What would you want to do for this patient?

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