Título

ACUTE ANNULAR OUTER RETINOPATHY MISDIAGNOSED AS NORMAL TENSION GLAUCOMA: A CASE REPORT

Objetivo

To describe a patient with Acute Annular Outer Retinopathy (AAOR) treated as normal tension glaucoma (NTG) for ten years. Retrospective case report with fundus photography, standard automated perimetry and peripapillary and macular optical coherence tomography imaging. This case highlights the importance of establishing differential diagnosis in cases of presumed NTG and reinforces the the OCT angiography use in clinical practice.

Relato do Caso

A healthy 60 years-old man, treated during ten years with topical hypotensive agents, beta-blocker and adrenergic agonist, owing to previous glaucoma diagnosis, noted a spontaneous small blind spot in the temporal visual field of the right eye. His best corrected visual acuity was logMAR 0.0 and Jaeger 1 in both eyes. At the right eye, he had an absolute inferotemporal scotoma both to hand movements and on Amsler grid testing, and inferotemporal slight visual blur at the left eye. Intraocular pressure of 12 mmHg, and an open anterior chamber in both eyes. At the fundus exam patient presented increased optic nerve cupping, annular area of photopigment loss surrounded by orange demarcation line with white spots. Standard automated perimetry 24-2 (Figure 1) showed an incomplete annular scotoma. The findings pattern led us to investigate other diseases. After performing spectral domain (SD)-OCT B scans (Figure 2), showing the outer retinal layers integrity loss, we diagnosed AAOR, excluding the previous NTG diagnosis.

Conclusão

This case report emphasizes the value of performing differential diagnosis in presumed NTG cases. We reported a patient misdiagnosed with NTG, owing to typical findings from the disease - increased optic nerve cupping, RFNL loss associated with visual field defect. And, unnecessarily, using topical hypotensive agents, during the past 10 years. Although, during follow-up, specific findings from (SD)-OCT B scans enable us to distinguish structural loss patterns of AAOR and elucidate the correct diagnosis.