Abstract
A patient with longstanding bilateral glaucoma, worse in the left eye, was followed over nearly two decades with serial structural and functional testing. Her ocular history was notable for thin central corneas, prior keratorefractive surgery, medication intolerance, and multiple glaucoma procedures, including trabeculectomy in both eyes and a Baerveldt glaucoma implant in the left eye. Despite mean intraocular pressures of approximately 10 mmHg in the right eye and further reduction to single-digit levels in the left eye following tube implantation, longitudinal visual field testing demonstrated continued progression. In the right eye, 24-2 mean deviation declined from -10.9 dB in 2007 to -15.5 dB in 2026, with corresponding worsening on 10-2 testing indicating central involvement. The left eye exhibited earlier advanced disease, with mean deviation approaching -20 dB by 2023, after which further assessment was limited by corneal graft failure and significant visual decline. Optical coherence tomography demonstrated generalized retinal nerve fiber layer and ganglion cell complex thinning in both eyes, largely stable in later stages, consistent with floor effects. This case underscores that intraocular pressure reduction, while beneficial, may be insufficient to halt progression in some patients. The findings support a multifactorial pathophysiology involving pressure-independent mechanisms such as vascular dysregulation and reduced ocular perfusion. Management focused on maximizing tolerated medical therapy and maintaining intraocular pressure in the low range, with close monitoring of functional progression in the better-seeing eye.
Presentation Date: 03/26/2026
Issue Date: 04/03/2026
