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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 685-687

Pseudo-reversal of optic disc cupping in a case of pseudo-exfoliation glaucoma following trabeculectomy


Department of Ophthalmology, S. S. Institute of Medical Sciences and Research Centre, Davangere, Karnataka, India

Date of Submission27-Jan-2022
Date of Acceptance22-Apr-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Deepakakumar Dodamani
Department of Ophthalmology, S. S. Institute of Medical Sciences and Research Centre, NH-4, Davangere - 577 005, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_275_22

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  Abstract 


Reversal of glaucomatous cupping is rare in adults. A case of pseudo-reversal of total cupping in an elderly gentleman with pseudo-exfoliation glaucoma who underwent combined trabeculectomy with cataract surgery is reported. Early laser suture lysis to control high post-operative intra-ocular pressure (IOP) led to sudden lowering of IOP with subsequent optic disc edema, which manifested as reversal of cupping, albeit temporarily. Eight months later, the visual field was stable, but the macula had developed an epiretinal membrane, probably secondary to hypotony-associated inflammation, thus highlighting the importance of timing the suture lysis and aggressive control of intra-ocular inflammation.

Keywords: Hypotony, pseudo-exfoliation glaucoma, reversal of cupping, trabeculectomy


How to cite this article:
Dodamani D. Pseudo-reversal of optic disc cupping in a case of pseudo-exfoliation glaucoma following trabeculectomy. Indian J Ophthalmol Case Rep 2022;2:685-7

How to cite this URL:
Dodamani D. Pseudo-reversal of optic disc cupping in a case of pseudo-exfoliation glaucoma following trabeculectomy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 19];2:685-7. Available from: https://www.ijoreports.in/text.asp?2022/2/3/685/351148



True reversal of cupping is rare, mainly occurring in childhood glaucoma following surgical reduction of intra-ocular pressure (IOP). Profound reduction of IOP can lead to hypotony and optic disc tissue swelling, which can mimic reversal of cupping. This phenomenon is temporary with re-appearance of cupping as IOP normalizes.

We hereby describe such a case of pseudo-reversal of cupping in a patient with pseudo-exfoliation (PXF) glaucoma.


  Case Report Top


A 71-year-old gentleman presented with blurring of vision in his right eye (counting fingers one meter). He had a history of undergoing combined trabeculectomy with cataract surgery in his left eye a year ago and using timolol maleate and brimonidine topical drops in both the eyes. The IOP was 26 mmHg and 15 mmHg in the right and left eyes, respectively. Both the eyes had advanced glaucomatous cupping (0.9) and advanced glaucomatous field defects [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Considering dense cataract with high IOP, he underwent combined cataract and trabeculectomy with mitomycin–C in the right eye. Surgery was uneventful, but on the first post-operative day, the IOP was high (40 mmHg) with corneal edema. The patient was put on bimatoprost, timolol, and brinzolamide drops with oral acetazolamide. A week later, the IOP was still 23 mmHg, but the vision had improved to 6/6. To prevent further disc damage, laser suture lysis was performed with resultant hypotony. Because the anterior chamber was well maintained, he was managed conservatively with topical steroids and anti-glaucoma medications were discontinued. Four weeks later, the patient was seen again; his IOP had dropped to 8 mmHg, and there was reversal of cupping of the right optic disc to 0.6 with a stable visual field [Figure 2]a and [Figure 2]b. On further follow-up, 2 weeks later, cupping had again increased to 0.9 and a few hard exudates had appeared in the macula [Figure 2]c.
Figure 1: Advanced optic disc cupping (a and b) and visual field defect (HFA 10-2) (c and d)

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Figure 2: Reversal of optic disc cupping and the preserved central visual field (HFA 10-2) (a and b). Re-reversal of optic disc cupping and hard exudates in the macula (c)

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The patient was lost to follow-up for 8 months and presented with blurring of vision in the same eye (6/18). Examination revealed an elevated bleb with 0.9 cupping of the disc. The IOP was 12 mmHg. The macula had developed an epiretinal membrane (ERM) [Figure 3]a, which on optical coherence tomography showed loss of foveal contour and thickening [Figure 3]b. The visual field has remained stable [Figure 3]c.
Figure 3: Fundus finding at the last visit showing 0.9 cupping of the disc and ERM in the macula (a and b). The visual field has remained stable (c)

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  Discussion Top


Reversal of glaucomatous cupping was first reported in 1869 by Von Jaeger.[1] It is well known to occur after IOP reduction following glaucoma surgery in childhood glaucoma but to a lesser degree in adult glaucoma.[2],[3] Park et al.[4] described short-term reversal of disc cupping in adult glaucoma patients following trabeculectomy. Five-year results of a collaborative initial glaucoma treatment study concluded that reversal occurred more frequently following surgery but without significant improvement in fields.[5]

True reversal of cupping is a result of forward movement of lamina cribrosa, a decrease in the diameter of the sclera canal, which is elastic in nature during the younger age. Thus, in the older age, as elasticity decreases, mechanical support of the optic nerve head stiffens and reversal of cupping becomes a rare event.[6] Furthermore, in adults, reversal in cupping is subtle and is often over-looked because of observer variability.[7]

Spaeth et al.[8] reported that disc edema that develops after sudden IOP reduction (hypotony) could mimic true reversal, but this phenomenon lasts for a maximum of 2 months post-operatively. These eyes with hypotony show engorged veins, whereas the eyes with true reversal have veins of normal caliber.[2]

In our present case, reversal of cupping occurred after sudden IOP reduction following laser suture lysis and disappeared within 2 months. Visual fields were stable with no improvement. Appearance of hard exudates in macula in our patient suggests the presence of a subtle sub-retinal fluid because of hypotony, thus strengthening the notion that this was pseudo-reversal of cupping because of transient disc edema, although veins retained normal caliber during the follow-up period.

Our patient developed ERM on the macula with an increased foveal thickness and loss of foveal contour. The role of cytokines and growth factors involved in ERM formation is not completely understood.[9] Whether hypotony-associated inflammation caused or accelerated ERM formation in our case is an open question.


  Conclusion Top


It is important to time the suture removal and anticipate the hypotony-related changes in fundus and aggressive control of inflammation related to it. Pseudo-reversal of cupping because of transient disc edema in our patient is one such sign of hypotony and needs to be differentiated from true reversal of cupping.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Von Jaeger E. Ophthalmoskopischer Hand Atlas. Vienna, Austria: Druck und Verlag der K.K. Hofund Staatsdruckerei; 1869. p. 76-8.  Back to cited text no. 1
    
2.
Pederson JE, Herschler J. Reversal of glaucomatous cupping adults. Arch Ophthalmol 1982;100:426-31.  Back to cited text no. 2
    
3.
Parrow KA, Shin DH, Tsai CS, Hong YI, Juzych MS, Shi DX. Intraocular pressure-dependent dynamic changes of optic disc cupping in adult glaucoma patients. Ophthalmology 1992;99:36-40.  Back to cited text no. 3
    
4.
Park KH, Kim DM, Youn DH. Short-term change of optic nerve head topography after trabeculectomy in adult glaucoma patients as measured by Heidelberg retina tomography. Korean J Ophthalmol 1997;11:1-6. doi: 10.3341/kjo.1997.11.1.1.  Back to cited text no. 4
    
5.
Parrish II RK, Feuer WJ, Schiffman JC, Lichter PR, Musch DC. Five-year follow-up optic disc findings of the collaborative initial glaucoma treatment study. Am J Ophthalmol 2009;147:717-24.  Back to cited text no. 5
    
6.
Zeimer RC, Ogura Y. The relation between glaucomatous damage and optic nerve head mechanical compliance. Arch Ophthalmol 1989;107:1232-4.  Back to cited text no. 6
    
7.
Lichter PR. Variability of expert observers in evaluating the optic disc. Trans Am Ophthalmol Soc 1976;74:532-72.  Back to cited text no. 7
    
8.
Spaeth GL, Fernandes E, Hitchings RA. The pathogenesis of transient or permanent improvement in the appearance of the optic disc following glaucoma surgery. Doc Opthalmol Proc 1979;22:111-26.  Back to cited text no. 8
    
9.
Joshi M, Agrawal S, Christoforidis JB. Inflammatory mechanisms of idiopathic epiretinal membrane formation. Mediators Inflamm2013;2013:192582. doi: 10.1155/2013/192582.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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