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Managing a patient with open-angle glaucoma: a case study

Mr AA is a 48-year-old shop attendant who presented at the eye unit of a teaching hospital with a history of gradual, painless vision loss. His presenting (unaided) visual acuity was counting fingers at 1 metre in the right eye and 6/60 in the left eye. Both corneas were clear, and the pupils had a slow reaction to light. There was a right relative afferent pupillary defect (RAPD). The right eye had a nuclear sclerotic cataract which precluded a good view of the optic nerve head, and a vertical cup:disc ratio (VCDR) of about 0.9, barely visible through the dilated pupil with the binocular indirect ophthalmoscope. The left eye VCDR was 0.8. Intraocular pressure (IOP) was 32 mmHg (right eye) and 30 mmHg (left eye) by applanation tonometry. Gonioscopy showed open angles in both eyes. Visual field tests (standard automated perimetry [SAP]) could not be carried out.