Glaucoma as a systemic disease: when we have to look beyond the eye

Introduction: Growing evidence suggests an association between Glaucoma and changes in the immune system. Particularly in those with Normal Tension Glaucoma (NTG), an autoimmune or vascular mechanism may be responsible for optic nerve head damage. Case Report: A 67-year-old woman presented for a routine eye exam at our office visit. About her past medical history, she only mentioned Raynaud’s Disease. Her best-corrected visual acuity was 20/20 on both eyes, and slit-lamp examination was normal. Intraocular pressure was 10 mmHg in both eyes and fundoscopy revealed cup to disc ratio 0.8 bilaterally. On physical examination, we found microstomy and puffy hands with pitting scars. Optical Coherence Tomography (OCT) demonstrated an inferotemporal decrease of the peripapillary Retinal Nerve Fiber Layer (RFNLpp) on the RE and in the inferotemporal and superotemporal sectors of the LE. OCT-Angiography was also performed to complement the study. Computerized Static Perimetry (CSP) revealed pericentral scotomas on both eyes. Water Drinking Test (WDT) and Diurnal IOP curve were performed with a significant fluctuation. A 24-hour ambulatory blood pressure monitoring demonstrated nocturnal hypotension. After a clinical process review, we found the diagnostic of PSS. The patient initiated hypotensive drugs and was oriented for adjustment of therapy. Conclusion: If we do not look beyond the eye to observe patient phenotype and past medical history we can miss important clues for the correct diagnosis and treatment, often with complementary multidisciplinary approaches.