Individual Assignment

Special Senses Module/2017/1nd Term/3st Grade

By Nabilla Merdika Putri Kusuma, 1406642385

PBL-GD1: Diagnosis and DDx of Cataracts and Glaucoma

Senile Cataract Clinical Presentation

I. History-taking
In diagnosing patient with senile cataract condition, thorough history taking is compulsory to
determine the disease progression and possible differential diagnosis and disease
concurrences. Inquiries regarding the conditions that are related with cataracts include age >65
years, diabetes mellitus, certain metabolic or hereditary conditions (e.g., Wilson disease,
galactosemia, myotonic dystrophy, Marfan syndrome), long-term use of ocular corticosteroids, a
family history of congenital cataract or congenital influences (e.g., toxins, infections such as
rubella), smoking, and long-term exposure to UV light. Details of previous trauma to the eyes
should be sought, as this could signal the possibility of a traumatic cataract.1
The followings are the common key diagnostic factors complained by the patient:
1. Decreased visual acuity, the most common complaint of patient and typically progress
gradually. It is considered to be clinically relevant if there is significant aberration of the
visual acuity. However, under certain circumstances, such as in a patient with diabetes
mellitus, a relatively sudden reduction in vision may be reported. Additionally, the different
types of cataracts may affect the visual acuity differently. Generally, cortical cataract is not
considered relevant until it starts to compromise the visual axis.
2. Blurry vision and Glare, predominantly found in posterior subcapsular cataracts and to a
lesser degree, in cortical cataracts. Less associated with nuclear sclerosis. The complain may
comprise broad spectrum of types, starting from decrease in contrast sensitivity in bright
surroundings, disabling glare during the day, to severe form with forth-coming headlights
which usually occurs during the night. In patient with progressing nuclear sclerotic
cataracts, the complain regarding inadequate glasses prescription is often reported. The
change in lens proteins occurring in nuclear cataracts often causes a yellowish hue to the
cataract, and patients will note a decreased richness in colors, especially blues.
3. Myopic shift, cataracts may progress up to the point where it alters the diopteric power of
the lens leading to a mild-to-moderate degree myopia or termed as myopic shift. Patient
with presbyopia may report improvement in their near vision, in which depicted by the
lesser need for using reading glasses. However, such condition is temporary and as the
disease progresses, this improvement will eventually cease. The myopic shift does not
typically occur in cortical and posterior subcapsular cataracts.
4. Monocular diplopia, when the defects are focused in the inner part of the lens, refractile area
in the center of the lens is formed. Consequently, monocular diplopia or double vision in
one eye occurs due to the disruption of the light reaching the retina. 2,3

II. Physical Examination

Starting with the entire body habitus to point out systemic illnesses which may contribute into the
development of the cataracts. Visual acuity test must be performed for both near and far distances.
Visual acuity should be tested with the patient's most-suited glasses correction. Distance vision
should be checked using the best-corrected spectacle prescription for distance and a formal eye
chart. A slit-lamp exam should be performed to evaluate the lens following pupillary dilation.
Furthermore, slit lamp examination should concentrate on other ocular structures as well. Corneal
thickness and the presence of corneal opacities, such as corneal guttata, must be checked carefully.
The appearance of the lens must be noted before and after pupillary dilatation. In cases of
significant cataract, opacification of the lens will be noted. In children, and in adults unable to
cooperate with slit-lamp exam, observation and comparison of the red reflex using direct
ophthalmoscopy can help quantify the severity of the cataract.
Glare stress is conducted using the brightness acuity tester, a hand-held instrument with an
illuminated field pierced with a viewing aperture.
This instrument allows the examiner to measure the
patient's visual acuity under the type of glare
conditions that the patient might experience in the
real life setting. Significant cataract may result in
reduced visual acuity in glare stress. An initial
ophthalmology assessment also includes examination
of intraocular pressure. The result might be normal or
slightly increased if associated with glaucoma. No
other tests are performed to make the diagnosis of
cataract other than a physical exam of the lens.1,3
Figure 1. Senile Cataracts Appearance (1)

Differential Diagnosis of Cataracts

1. Refractive error,might be differentiated using correct spectacle prescription which may
improve patient’s vision. Usage of pinhole is useful to indicate whether the change in
glasses is adequate to improve vision without the need of surgery
2. Dry eye, abnormal tear film may appear and a drop of fluorescein and tear break-up time
calculation may provide the guide for diagnosis. The results with dry eye are likely to be
abnormal (<7seconds)
3. Glaucoma, peripheral vision may be decreased. An increased in intra-ocular pressure
measurement, abnormal visual field testing, and a large cup-to-disc ratio upon
opthalmoscopy examination may aid in establishing the diagnosis of glaucoma.
4. Retinal Detachment, marked by flashes of light and numerous floaters visible by the patient.
The patient should be examined for an afferent pupillary defects. In fundus examination it is
revealed that there are evidence of tears, vitreous haemorrhage, or detachment.
5. Optic neuritis, signs include decreased or patchy vision occuring monoocularly, eye-pain
during movement, and decreased colour vision. Closely associated with multiple sclerosis.
Administration of several tests including MRI, visual acuity, and colour vision may aid in
diagnosis. MRI results provide the evaluation for optic nerve, white matters alteration in the
brain, despite the normal appearance of fundus.
6. Age-related macular degeneration, differentiating symptoms include wavy vision or a
central blurry vision. Fundus examination reveals wet or dry macular degeneration, for
instances, drusen (retinal metabolic by-products) or sub-retinal fluid
7. Infectious or inflammatory causes, signs and symptoms depend on each invidual diagnosis.
A complete examination including fundus inspection should be conducted to investigate the
underlying causes
8. Epiretinal membrane, marked by distorted and wavy vision, fundus examination shows
epiretinal membrane or puckering of the macula.
9. Macular oedema, patient may have blurred and distorted vision, there is evidence of oedema
upon fundus examination
10. Vitreous haemorrhage, history of trauma or uncontrolled diabetes mellitus. Marked by
sudden decrease in vision or large patchy areas of blurry vision. Reduced visual acuity and
 the findings of blod in the vitrous during dilated fundus examination may aid in the
diagnosis.3
Primary Open-angle Glaucoma Clinical Presentation
Glaucoma is the second leading cause of blindness in the world, with open-angle accounting for
two-thirds of those affected. Frequently presents asymptomatically and can be identified on routine
ophthalmic examination. Intraocular pressure may or may not be elevated in this type of glaucoma.
Optic disk cupping serves as the most important diagnostic parameter. This disease may lead to
irreversible loss of peripheral vision and, later, of central vision if untreated.1
I. History-taking
Patients will most likely have no complaints. The cornea appears clear. The patient may or may not
notice a decrease in peripheral vision, for instances, manifested as bumping into objects the patient
could not see. Attention towards certain aspects including past ocular history and previous eye
surgery, head trauma, medical history (systemic cardiovascular disease, diabetes mellitus, migraine,
hypertension and vasospasm), and current medications (systemic corticosteroid or hypertensive
agents) used by the patient must be given during the process of history-taking. Risk factors for
glaucomatous optic neuropathy such as history of elevated IOP (advanced age, family history, and
myopia) must also be taken into consideration. Other risk factors include obesity, smoking, alcohol,
history of stress, anxiety, and sleep apnea.2,4

II. Physical Examination

1. Measuring intraocular pressure (tonometry) and gonioscopy
IOP varies from hour-to-hour in any individual. The circadian rhythm of IOP usually causes it to
rise most in the early hours of the morning; IOP also rises with a supine posture. The most common
method is Goldmann tonometry, widely considered the gold standard of tonometry. Intraocular
pressure measurement is not sufficient to determine the presence of glaucoma because patients can
have glaucoma with normal pressure. The normal range of intraocular pressure is 11–21 mm Hg,
with upper limit of 24 mmHg in elderly. A difference between the 2 eyes of 3 mmHg or more
indicates greater suspicion of glaucoma. An average of 10% difference between individual
measurements is considered normal. The measurements should be repeated on at least 2-3 occasions
before deciding on a treatment plan. If it is possible, measurement should be completed in the
morning and at night to check the diurnal variation (A diurnal variation of more than 5-6 mmHg
may be suggestive of increased risk for POAG). Early POAG is suspected strongly when a steadily
increasing IOP is present. The corneal thickness may alter the result of tonometry, in which case
pascal dynamic contour tonometer might become useful. Gonioscopy should be performed as well.
This examination is performed during slit-lamp examination in which a lens is placed in front of the
eye, allowing visualization of the anterior chamber angle between the cornea and iris. Typically, no
obstruction is seen. In contrast, an occludable angle exists with closed-angle glaucoma: this
differentiates between open-angle and closed-angle disease.

2. Retinal and optic disk visualization

The retina and optic disk should be visualized, and this can be done through use of a direct and/or
indirect ophthalmoscope: both portable, useful devices. The examination is optimal if the pupils are
dilated with eye drops. The direct ophthalmoscope shines and reflects light onto the eye interior,
providing clear visualization of the retina and optic disk, with high magnification. This is the usual
method of disk examination by nonophthalmologists. The indirect ophthalmoscope is useful in
providing the 3-dimensional appearance of the retina and diagnostic optic disk cupping or
indentation, but with limited magnification. Both instruments, used together, provide optimal
information.The slit lamp examination of the anterior segment is done to rule out non-glaucomatous
visual field defects. During the examination, it is compulsory to examine optic nerve according to
the following: cup-to-disc ratio in horizontal and vertical meridians, appearance of disc, progressive
enlargement of the cup, evidence of nerve fiber layer damage with red-free filter, notching or
thinning of disc rim, pallor. presence of hemorrhage (most common inferotemporally), asymmetry
between discs, parapapillary atrophy (possible association with development of glaucoma), or
congenital nerve abnormalities.
The “cup–disk ratio” is a useful way of recording the size of the optic disk in glaucoma patients. It
is the ratio of cup size to disk diameter, for example, a small cup is 0.1 and a large cup 0.9. In the
presence of visual field loss or elevated intraocular pressure, a cup–disk ratio greater than 0.5 or
significant asymmetry between the two eyes is highly suggestive of glaucomatous atrophy.

Figure 2a-b. Inferior Focal Notching & Typical Disk-cupping in Glaucoma (1)

3. Photographs of the optic nerve head

When glaucoma is suspected, photographs of the optic nerve head should be done. A high-quality
35-mm photograph allows detailed comparison with ophthalmologic examination. Cup-to-disk
ratios of >0.5 carry greater risk. However, a cup-to-disk ratio of 0.7 may be a normal anatomic
variant, while a ratio of 0.3 may indicate glaucoma if, for example, the ratio started out at 0.1.
Photographs should be repeated and compared each time a change is detected.

4. Pachymetry
Pachymetry provides measurement of corneal thickness, rigidity, curvature, which is predictive of
high intraocular pressures proceeding to glaucoma. A thick cornea can falsely increase the
intraocular pressure reading. In addition, a thin central corneal thickness can underestimate the
intraocular pressure as well as predict progression from high IOP to glaucoma.

5. Visual field examination

Regular visual field examination is essential to the diagnosis and
follow-up of glaucoma. Glaucomatous field loss is not in itself
specific, since it consists of nerve fiber bundle defects that may
be seen in other forms of optic nerve disease; but the pattern of
field loss, the nature of its progression, and the correlation with
changes in the optic disk are characteristic of the disease. The
field loss is peripheral with initial sparing of central vision.
Glaucomatous field loss involves mainly the central 30 of
field. It will usually correspond with the optic nerve head
appearance. If a visual field test is needed but cannot be ordered,
an ophthalmology referral is indicated, or Goldmann testing
might be used to be the substitute. The temporal peripheral field
and the central 5–10 degree are affected late in the disease.
Figure 3. Basic VIsual Field Loss in
Central visual acuity is not a reliable index of progress of the Glaucoma (1)
disease. In end-stage disease, there may be normal central acuity
but only 5 degree of visual field in each eye. The patient may have 20/20 visual acuity but be
legally blind. Examination results must take into account that visual field defects may not be
apparent until over 40% loss of the nerve fiber layer has occurred.1,2,4

Other tests:

Nerve fiber layer analysis, using scanning laser polarimetry or confocal scanning laser
ophthalmoscopy, is available, as well as optical coherence tomography scans of the optic disk.
Scanning laser polarimetry is used to scan the nerve fiber layer thickness. Confocal scanning laser
ophthalmoscopy scans the optic nerve head and can indirectly detect the nerve fiber layer thickness.
The thicker the tissue, the healthier it is. All of these methods, if performed serially, create a record
of serial scans that can be compared. Optical coherence tomography scanning should also be done
when glaucoma is suspected. Scanning of the optic nerve head may be ordered initially and for
follow-up examinations for comparison. It provides a low-resolution digital image but uses the
information for several calculations.4

Differential Diagnosis of Glaucoma

1. Ocular hypertension, marked by elevated IOP but no definite signs of glaucomatous optic
neuropathy
2. Normal tension glaucoma, includes all the features of POAG but IOP always measured
within normal limits
3. Primary angle closure glaucoma, characterized by narrow drainage angle on gonioscopy
4. Pigment dispersion glaucoma, signs include Krukenberg spindle, iris transillumination,
heavily pigmented angle in all 360 degrees
5. Pseudoexfoliation glaucoma, shown with pseudoexfoliative material seen on pupil margin
and lens
6. Steroid-induced glaucoma, history-taking reveals topical or systemic steroid usage)
7. Posner-Schlossman Syndrome, indicated by unilateral mild inflammation
8. Physiological cupping, normal large optic disc with large cup:disc ratio; should be
symmetric between both eyes
9. Myopia, optic discs can be very difficult to assess, and may be associated visual field
defects which are not generally progressive4
Conclusion
The diagnosis of cataracts is done mainly through the history-taking and physical examination. The
diagnosis of primary open-angle glaucoma is established when glaucomatous optic disk or field
changes are found with elevated intraocular pressures, a normal-appearing open anterior chamber
angle, and no other reason for intraocular pressure elevation. At least one-third of patients with
primary open-angle glaucoma have a normal intraocular pressure when first examined, so repeated
tonometry can be helpful.1

References
1. Vaughan D, Asbury T, Riordan-Eva P, Whitcher J. Vaughan & Ashbury's general
ophthalmology -17th ed. 1st ed. New York: McGraw-Hill; 2008.
2. Sehu K, Lee W. Ophthalmic Pathology. 1st ed. New York, NY: John Wiley & Sons; 2012.
3. Olson R, Braga-Mele R, Chen S, Miller K, Pineda R, Tweeten J et al. Cataract in the Adult
Eye Preferred Practice Pattern®. Americans Journal of Ophthalmology. 2017;124(2):P1-
P119.
4. Prum B, Rosenberg L, Gedde S, Mansberger S, Stein J, Moroi S et al. Primary Open-Angle
Glaucoma Preferred Practice Pattern® Guidelines. Americans Journal of Ophthalmology.
2016;123(1):P41-P111.