Case 12-7, Superior and Inferior Nasal Step

Clinical Summary

A 43-year-old white man was referred for a second opinion regarding his diagnosis of glaucoma. He was taking betaxolol 0.25% and dipivefrin 0.1%, each twice daily, and pilocarpine 0.1%, four times a day in the right eye. On examination, the visual acuity was 20/20 in this eye and the intraocular pressure was 26 mm Hg. Slit-lamp examination was normal. Gonioscopy revealed that the angle was open to the ciliary body band except between 10:00 and 2:00, where only the posterior trabecular mesh-work was visible. Ophthalmoscopy (A,B) showed marked disc cupping with a severely attenuated neuroretinal rim between approximately 5:00 and 12:00. An advanced superior nasal step with an early inferior nasal step was identified on a Humphrey visual field (D).

Optical Coherence Tomography

The circular OCT section (E) revealed diffuse nerve fiber layer thinning throughout the image, which was considerably worse interiorly than superiorly. Only a local area of nerve fibers remained within the 12:00 hour, corresponding to the inferonasal area of relative visual preservation.

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