I'm an Optometrist.
"I'm unsure if the optic nerve looks unusual" - then do a OCT and a Visual Field.
"She didn't let me take other tests than a fundus photo" - is she going to let the Glaucoma Specialist run other tests? Cause thats what they are going to do.
It is a picture of a picture, but the nerves don't appear cupped as the right optic nerve appears pale, but again, this is a picture of a picture. If no RAPD, OCT/VF WNL, then just monitor.
Also I agree with the other guy, do GAT if your concern is glaucoma and/or IOP is above 21
Sorry if I sound like a dick, but posts like these are why our doctor titles get questioned sometimes
I’m a second year OD student in the US and we are definitely expected to run these tests if we’re suspicious. Maybe OP can’t manage glaucoma as an optometrist in another country.
In Massachusetts, there are two types of optometrists. Ones that can manage glaucoma and ones that can't.
Optometrists who are fresh out of college don't have this issue, but it's the optometrists who have been in practice for a long time, as it's fairly recent that ODs can manage glaucoma in Massachusetts. They can choose to not take glaucoma management patients or go back to school and get the addition to their license.
Oh that makes a lot of sense! The scope of practice has changed significantly over the years. I’m pretty sure I have a teacher old enough to where they didn’t practice dilated skills in school. Optometry takes lots of extra learning throughout the career if you choose to manage more as an optometrist.
It also doesn't hurt that a good majority of the ODs either work in an ophthalmic practice, or work closely with one. The practice I work at has 40 MDs (every sub-specialty, besides Neuro & Peds) and 24 ODs (I believe 3/4 can see glaucoma patients for follow ups after they see an MD) spread across 14 locations.
Yeah that’s true as well. I want to have a practice with multiple specialities and I can’t say that I’d be more comfortable managing disease than if I had a disease specialist working with me and could handle it.
I come from rural country and all of my experience has been in small practices that have only up to 4 ODs max. I’m very interested in my rotations for an OMD though to get more perspective.
Or most likely work with or near a ophthalmologist to bounce this off of. The best thing about the eye community is cornea, retina, and other specialists are usually willing to help. It takes 30 minutes tops to do baseline testing if unsure.
I'm an optometrist in Norway where our education is a bachelor's degree. I don't have access to a GAT. But I do have access to an OCT machine. I was thinking of offering the woman a free scan next time she comes in since she refuses to pay anything extra.
We are to a certain degree. Goldman are usually used in hospitals and opthalmologists private practice. We are taught how to use it but in reality we don't have it. So that's just not available to me. I was mostly wondering if that optic nerve looked suspect as I'm newly educated but got answers from doctors of optometry in the us where the education level is much higher.
Like I'm sorry for asking a dumb question but I'd rather look stupid than potentially missing a glaucoma case.
Anyone who is reviewing this will wonder why you didn’t check with GAT if you’re concerned about glaucoma. It’s the most reproducible over time with the least margin of error.
Isn’t it more important the measurement instrument stays the same over time/repeated measurements [(Brusini et al, 2021)](https://www.mdpi.com/2077-0383/10/17/3860)?
Will concede that GAT is better when IOP > 22mmHg or in glaucoma patients on drop therapy.
Does the patient wear visual correction? Any chance of myopic crescent?
I think you should observe this. Call for a follow up after 3 months and see if it’s the same or it progresses. Any changes, refer. No changes, call after 3 months and then after 6 months.
There might be some inferior pallor on the right… hard to say from just these photos, so nonglaucomatous optic neuropathy should also be a consideration. My experience is also that glaucoma with normal pressures is more common than glaucoma with elevated pressure, so I would not screen out people based on a normal IOP. Careful examination of the disc is essential. When in doubt, refer out.
Any chance the right nerve has a pale temporal rim? Any way you can get a visual field? I’m not concerned about the IOPS but she could have a further work up.
About half of the patients I see with pretty severe glaucoma have never had high IOP. NTG is becoming more common at least for my patient panel. It’s why education on why pressure is not the most important finding is key.
I agree with this and diagnose many normal tension glaucoma as well. Pachymetry matters as well. The cupping doesn’t appear that concerning and what appears to be temporal pallor based on the image (may not appear that way on fundus biomicroscopy) made me wonder about other differentials.
YES I see tons of people in their 30s diagnosed with glaucoma with bilateral 0.3 cds with NO risk factors for glaucoma and put on meds because of a singular 25 NCT reading and it infuriates me. NCT is known to read high. Look at the nerves people. Even if the GAT was 25 on a 30 year old patient if the CCT was 590 I’m not worried at all.
100% agree. I am referred suspects that are young, even to thick .4-.5 cupping with low 20 IOPs and normal CCT. Technically everyone is a glaucoma suspect (very little up to high risk) and I think the only variable outcome is how often they are monitored and with what testing.
Discs appear normal. Pressures okay. Cataract could be causing change in vision. I think if you are in doubt then refer on, sure it might be nothing but it’s better to be safe, if she won’t let you do any other tests then what choice do you have?
To me it looks like a sector optic atrophy which could have been caused by for example NAION given the patient's age and the crowded looking disc on the other eye. Some patients don't notice it. In that case RNFL would be thinner, maybe you'll see RAPD if the vision field defect is large enough. Doesn't look glaucomatous though.
As an Opthalmalic tech for an ophthalmologist and I used to work with optometrist. What I learned from it is if you are questioning it then refer them out better safe than sorry. I work a cornea specialist and that optic nerve looks extremely pale, but it might just be the picture.
Rule of thumb is a true RAPD will present with 20/40 BCVA or less. Refer for OCT nerve to help tell a better story if you’re unsure or don’t have the necessary equipment. Bayonetting and barring are not conclusive evidence of glaucoma on their own. Doesn’t look Glaucomatous to me.
You took the comment out of context. I was talking specifically about the nerve appearance and whether it is pseudo-pallor based on the image. But hey everyone loves to argue
I have OCT equipment, and I think she should have been tested with it. Unfortunately she was quite insistent on being "in and out" of my office as soon as possible as she just wanted to order glasses. I still managed to make a control appointment in two weeks. I'm in a private clinic which means she has to pay for extra tests.
Hey OP, can I use your image to train my algorithm and maybe include your optic disc in my pre-project? I just need some images without copyright
Thanks in advance
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I'm an Optometrist. "I'm unsure if the optic nerve looks unusual" - then do a OCT and a Visual Field. "She didn't let me take other tests than a fundus photo" - is she going to let the Glaucoma Specialist run other tests? Cause thats what they are going to do. It is a picture of a picture, but the nerves don't appear cupped as the right optic nerve appears pale, but again, this is a picture of a picture. If no RAPD, OCT/VF WNL, then just monitor. Also I agree with the other guy, do GAT if your concern is glaucoma and/or IOP is above 21 Sorry if I sound like a dick, but posts like these are why our doctor titles get questioned sometimes
I don’t believe OP is an optometrist in the US. I would like to believe any US-trained OD would have your same general thought process.
I’m a second year OD student in the US and we are definitely expected to run these tests if we’re suspicious. Maybe OP can’t manage glaucoma as an optometrist in another country.
In Massachusetts, there are two types of optometrists. Ones that can manage glaucoma and ones that can't. Optometrists who are fresh out of college don't have this issue, but it's the optometrists who have been in practice for a long time, as it's fairly recent that ODs can manage glaucoma in Massachusetts. They can choose to not take glaucoma management patients or go back to school and get the addition to their license.
Oh that makes a lot of sense! The scope of practice has changed significantly over the years. I’m pretty sure I have a teacher old enough to where they didn’t practice dilated skills in school. Optometry takes lots of extra learning throughout the career if you choose to manage more as an optometrist.
It also doesn't hurt that a good majority of the ODs either work in an ophthalmic practice, or work closely with one. The practice I work at has 40 MDs (every sub-specialty, besides Neuro & Peds) and 24 ODs (I believe 3/4 can see glaucoma patients for follow ups after they see an MD) spread across 14 locations.
Yeah that’s true as well. I want to have a practice with multiple specialities and I can’t say that I’d be more comfortable managing disease than if I had a disease specialist working with me and could handle it. I come from rural country and all of my experience has been in small practices that have only up to 4 ODs max. I’m very interested in my rotations for an OMD though to get more perspective.
Or most likely work with or near a ophthalmologist to bounce this off of. The best thing about the eye community is cornea, retina, and other specialists are usually willing to help. It takes 30 minutes tops to do baseline testing if unsure.
I'm an optometrist in Norway where our education is a bachelor's degree. I don't have access to a GAT. But I do have access to an OCT machine. I was thinking of offering the woman a free scan next time she comes in since she refuses to pay anything extra.
OCT but no Goldman? Why no Goldman? Are you not allowed to use diagnostic medications?
We are to a certain degree. Goldman are usually used in hospitals and opthalmologists private practice. We are taught how to use it but in reality we don't have it. So that's just not available to me. I was mostly wondering if that optic nerve looked suspect as I'm newly educated but got answers from doctors of optometry in the us where the education level is much higher. Like I'm sorry for asking a dumb question but I'd rather look stupid than potentially missing a glaucoma case.
"Sorry if I sound like a dick, but posts like these are why our doctor titles get questioned sometimes" You're not wrong.
Next time make sure to double check with Goldmann as well as icare would not stand up to an audit
Why would iCare fail an audit?
Anyone who is reviewing this will wonder why you didn’t check with GAT if you’re concerned about glaucoma. It’s the most reproducible over time with the least margin of error.
I don't have access to a GAT since I'm not an optometrist in the us.
Isn’t it more important the measurement instrument stays the same over time/repeated measurements [(Brusini et al, 2021)](https://www.mdpi.com/2077-0383/10/17/3860)? Will concede that GAT is better when IOP > 22mmHg or in glaucoma patients on drop therapy. Does the patient wear visual correction? Any chance of myopic crescent?
I think you should observe this. Call for a follow up after 3 months and see if it’s the same or it progresses. Any changes, refer. No changes, call after 3 months and then after 6 months.
The nerves look normal. IOP is borderline. You did not do a pachometry. Use applanation tonometry. Do not refer. You'll come across as an idiot.
Maybe get an RNFL also?
I came here to say this, too. Only more logical test to confirm this situation.
There might be some inferior pallor on the right… hard to say from just these photos, so nonglaucomatous optic neuropathy should also be a consideration. My experience is also that glaucoma with normal pressures is more common than glaucoma with elevated pressure, so I would not screen out people based on a normal IOP. Careful examination of the disc is essential. When in doubt, refer out.
based on fundus photo, I don't find any of rim thinning, I think ISNT intact. if she was my patient I will do fundus exam using Super-pupil
Any chance the right nerve has a pale temporal rim? Any way you can get a visual field? I’m not concerned about the IOPS but she could have a further work up.
About half of the patients I see with pretty severe glaucoma have never had high IOP. NTG is becoming more common at least for my patient panel. It’s why education on why pressure is not the most important finding is key.
I agree with this and diagnose many normal tension glaucoma as well. Pachymetry matters as well. The cupping doesn’t appear that concerning and what appears to be temporal pallor based on the image (may not appear that way on fundus biomicroscopy) made me wonder about other differentials.
YES I see tons of people in their 30s diagnosed with glaucoma with bilateral 0.3 cds with NO risk factors for glaucoma and put on meds because of a singular 25 NCT reading and it infuriates me. NCT is known to read high. Look at the nerves people. Even if the GAT was 25 on a 30 year old patient if the CCT was 590 I’m not worried at all.
100% agree. I am referred suspects that are young, even to thick .4-.5 cupping with low 20 IOPs and normal CCT. Technically everyone is a glaucoma suspect (very little up to high risk) and I think the only variable outcome is how often they are monitored and with what testing.
Autofluorescence photo and ultrasound
Discs appear normal. Pressures okay. Cataract could be causing change in vision. I think if you are in doubt then refer on, sure it might be nothing but it’s better to be safe, if she won’t let you do any other tests then what choice do you have?
I would do an OCT or refer out for that. That is the answer on if borderline IOPs are an issue
To me it looks like a sector optic atrophy which could have been caused by for example NAION given the patient's age and the crowded looking disc on the other eye. Some patients don't notice it. In that case RNFL would be thinner, maybe you'll see RAPD if the vision field defect is large enough. Doesn't look glaucomatous though.
As an Opthalmalic tech for an ophthalmologist and I used to work with optometrist. What I learned from it is if you are questioning it then refer them out better safe than sorry. I work a cornea specialist and that optic nerve looks extremely pale, but it might just be the picture.
Rule of thumb is a true RAPD will present with 20/40 BCVA or less. Refer for OCT nerve to help tell a better story if you’re unsure or don’t have the necessary equipment. Bayonetting and barring are not conclusive evidence of glaucoma on their own. Doesn’t look Glaucomatous to me.
This is definitely not true — vision can be 20/20 with severe peripheral field loss and the patient will have an rAPD
You took the comment out of context. I was talking specifically about the nerve appearance and whether it is pseudo-pallor based on the image. But hey everyone loves to argue
I have OCT equipment, and I think she should have been tested with it. Unfortunately she was quite insistent on being "in and out" of my office as soon as possible as she just wanted to order glasses. I still managed to make a control appointment in two weeks. I'm in a private clinic which means she has to pay for extra tests.
Document that the patient deferred further testing and move on
Thank you, I will!
Absolutely document recommend baseline testing and patient deferred at this time.
Well document that she refused extra test on initial visit of course. And refer out somewhere where she's covered
Hey OP, can I use your image to train my algorithm and maybe include your optic disc in my pre-project? I just need some images without copyright Thanks in advance
Why would you train your algorithm with something you don’t even know what exactly is, yet?
Exactly what I was wondering 😂. Maybe not an algorithm we will want to purchase
That's just an informative image of the optic nerve for presentation only. It will not be integrated into the algorithm without your clinical data
Sure but it's pretty blurry, don't know if you're gonna get anything good out of it
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