What's intraocular pressue on both eyes????

Then - measure the corneal thickness and assess the result of pressure taken into acccount corneal value!

I think that is two reason should exist!

First-

It seems that is an early Glaucoma stage!

The earliest stage Glaucoma without morphological changes in optic nerve! The only is a visual field decreasing! (GHT - Borderline on OD with MD -5.21, GHT - Outside on OS with MD - 6.73 with decreasing in nasal side)

I could recommend make an additional investigation - Blue-Yellow Static Perimetry or Flicker Pereimetry or FDT Zeiss perimetry! Second - make the add OCT with internal retina layer analisys (Ganglion Cell Layer) - it's very significant for early detecting Glaucoma.

Second-

Make the MRT of the brain and get the neurological consultation (for excluding pathology of the neurological type like "descending optical neuropathy")

I suppose more neurological work up taken into account 1 week hystory

Thank you for your reply.

Non-contact IOP measurement: OD 14 mmHg, OS 15 mmHg.

Corneal thickness?

May be Glaucoma with normal or low pressue!

If neurologist has not found the problem, I would assign drops that lower the pressue! And observe this patient after 3 month in progress (all investigation will repeated)!

BR.O.

First opinion to do CT scan of brain and orbit.

Apart from the above mentioned tests, I would suggest to do contrast sensitivity test at different spatial frequency eg. FACT to look at her quality of vision as she complained of decrease vision. VA can't tell you much in terms of vision quality in this case. FACT can gives you some clues on where the problem is as well i.e. the eyes or impulse conduction problem.

the hypothesis of a normal tension glaucoma is unlikely. OCT optic disc is normal.

The visual field shows non-specific defects or of difficult interpretation if you dont analyse more than 30° (with a manual visual field).

Also useful to make an ERG or a mfERG to analyse retinal function.

Dear Xiaogang Wang !

I would like to understand better the case before giving my opnion.

I would like to know:

1- What does 12/20 and 16/20 mean in Snellen chart scale?

2- About this sentence: " female, 25 years old, complain vision decrease about one week " Vision decrease in Right Eye? Left Eye? Both?, Did it started in both eyes simultaneously? or sequencial?

3- I see that the visual-acuity didn´t change with the correction, in this moment, I ask you if the visual-acuity was better with the Pin Hole? Because, if it is better with Pin Hole, maybe the problem is in the lacrimal tear?, cornea ( Keratoconus), Lens and Vitreous. If the vision didn´t get better with the pin hole, then the problem is in then retina, or optic nerve and optic pathway.

4- To separate the optic nerve Disease and Macula disease:

It is important to know about:

Chromatic test( Hishiara) because in optic nerve disease will be deepper then in macula disease!, Amsler grid- metamorphopsia in macula disease and not in optic nerve disease, Pupil exame, are they full?, The photo stress test- in macula disease the patient will be slower in come back to read one line above the best line before the photostress test, and this test is normal in optic nerve disease.

Is there pain when the patient move her eyes?

After your answers, I will be able to go on!

5- About the Visual field , I think that it should be repeated for confirmation of the left Eye defects .

6- About the Macula Oct: Maybe there is a problem in the subfoveal IS/OS layer in the Left Eye, it seems to be interrupted?, But I would like to see more than one OCT image and Oct image in grey collor as well. Because maybe there is a macuolpathy as Cone Dystrophy or Central Serous retinopathy scar? in left eye. Maybe you could ask for fluorescein angiography.

7- About Neuro-ophthalmologic problems, we need to know about her pupils, because the optic nerve seems to be normal in both eyes and the RNFL is normal in the both eyes, although the retinography is a little difficult to see details of the optic nerve and retina.

8- About Neuro-ophthalmologic disease in the patient´s age, I will think in Multiple Sclerose( Retrobulbar optic neuritis in Left Eye? or , Pituitary tumor and if I think to these possibilities, if the pupils aren´t normal, then I will ask for MRI of the Brain and Orbits.

9- If the pupils is normal, We should think about the Covert Diffuse Retinal and macula disease- like: Cone dystrophy, Pigmentary Retinose without pigment, Leber Hereditary Optic Neuropathy, Cancer-associated Retinopathy( CAR), Melanoma- associated Retinopathy( MAR) and others.( Here, I will ask for a Multifocal ERG as Dr.Mario Messenio said!

P.S: There is a such good chapter called: Unexplained Visual Loss in the book Neuro-ophthalmology Problem Solving by Jesse Halpern, Steve B. Flynn and Scott Forman.

I am looking forward for your answers !

Romar

Dear all, I do not understand why to think about glaucoma, which is an asymptomatic disease and that certainly does not begin with a visual loss.

I suppose that the colleague did not observe abnormalities of the pupillary dynamics because he would have reported it and this would rule out neurological diseases.

I suppose also that the colleague has not found anomalies of the chromatic sense and this excludes maculopathies.

I think the explanation is much simpler: hysteria.

Maybe Visual Evocked Potential and Pattern Electroretinogram may be sufficient to resolve the case.

In hysteria there is field reduction. Campimetria with yellow background is needed. Although there is no disease, do not rule out masses near pituitary and vascular probes. Take into account what Romar Vallory and Alberto Mavilio say

I think glaucoma is excluded. This field (if reliable), points to neurological (visual pathway) problem, possibly optic radiation.

It may be more of a neurological cause. Sometimes functional vision loss also happens to be the case. A CT brain would be indicated therefore. Glaucoma also has degenerative islands beyond optic nerve, so it will be better to look into psychological and neurological issues. I think a 128 channel EEG would show changes in beta waves?

Also, sometimes glaucomatous vision loss may appear despite the optic cup being apparently normal. In that case RGCs are in a stage of apoptosis but have not yet died. Sometimes there are issues with optic nerve beyong the optic nerve head.

Intracranial pressure may also be one of the contributing factors.

Please update us about the diagnosis.