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    Managing functional visual field loss with low IOP

    San Francisco—When visual field defects progress despite good IOP control, clinicians should look for other factors, according to Malik Y. Kahook, MD.

    Dr. Kahook, chief of glaucoma services at the University of Colorado in Aurora, CO, discussed strategies for addressing normal or low-tension glaucoma here at the Glaucoma Symposium CME.

    He defined low-tension glaucoma as chronic, progressive optic neuropathy with characteristic optic nerve head cupping, retinal nerve fiber layer thinning and functional visual field loss with an IOP of less than 22 mm Hg.

    Related: Tracking glaucoma progression with precision medicine

    Clinicians should still focus on lowering IOP in these patients, but also investigate other factors, Dr. Kahook said. These include vascular dysregulation, hypotension (particularly nocturnal), lamina cribrosa abnormalities, and autoimmune disorders.

    Compared with patients with primary open-angle glaucoma, patients with low-tension glaucoma are more likely to have paracentral defects, nerve fiber layer hemorrhages, focal notches and peripapillary atrophy, he said.

    The big question to answer in these patients is whether they have glaucoma or some other condition that mimics it, Dr. Kahook said.

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    “When we have low-tension glaucoma, we have certain features that we look for to guide us toward imaging,” he said.

    He listed the following glaucomatous etiologies: primary open-angle glaucoma with diurnal fluctuation of IOP; intermittent acute angle-closure glaucoma; underestimation of actual IOP; resolved corticosteroid-induced glaucoma; uveitic glaucoma; traumatic glaucoma; uveitic glaucoma/glaucomatocyclitic crisis (Posner-Schlossman); “burned out” pigmentary glaucoma, myopia with peripapillary atrophy, optic nerve coloboma or pits; and congenital disc anomalies/cupping.

    More: Check out a recap from the 2016 Glaucoma 360 gala!

    Dr. Kahook said compressive, metabolic, toxic, inflammatory or infectious optic neuropathy can mimic glaucoma. This includes pituitary adenoma, meningioma, empty sella syndrome, Leber heriditary optic atrophy, methanol optic neuropathy, optic neuritis, and syphilis.

    What to rule out

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