In patients who present with very high IOP, he advised that ophthalmologists seek out secondary causes of glaucoma, such as steroid use or exfoliation.
Dr. Pasquale also alerted physicians to a careful annual follow-up of patients with physiologic cupping for development of POAG. Genome-wide association studies of the cup-to-disc ratio have found many genes associated with physiologic cupping, and several of those genes are associated with POAG.
The hope is that the future will see the development of a risk calculator with all genes that determine the optic nerve cupping and shape and predict who will develop POAG, he noted.
Returning to the initial case of the patient with apoplectic inferior altitudinal visual field loss in the left eye, Dr. Pasquale said the loss developed as the result of a 6-decibel loss annually.
“This rapid progression is a cause for great concern,” he said. “The ophthalmologist should seek alternative explanations for this loss, such as steroid use, eye rubbing, or some practice that might cause this degree of visual loss.”
Dr. Pasquale advised performing a diurnal curve to identify an IOP spike and possibly neuroimaging.