The usefulness of routine photography in a myopic patient treated for glaucoma: 36‐year follow‐up

In 1960 when the patient was 22 years old, she had been diagnosed in Helsinki with pigmentary glaucoma (Krukenberg spindle without iris transillumination) after a positive water drinking test and had been treated with pilocarpine until 1979. In 1980–1986, the patient had been followed without treatment in two other towns in Finland at 6-month intervals. Thereafter, the patient moved to the Oulu area where she has been cared for by ophthalmologists in both public and private sectors. At the University Hospital, Oulu, routine black-and-white photography of the optic nerve head (ONH) and retinal nerve fibre layer (RNFL) for the diagnosis and follow-up of glaucoma were introduced by Professor Henrik Forsius and photographer Heikki Nieminen in the early 1970s. Based on progressive ONH changes in 1986–1993, treatment was re-started. The highest IOP up to 30 mmHg was measured on treatment in 1995. The patient was followed in Tays Eye Centre, Tampere University Hospital, Finland, in 2013–18, and thereafter in Oulu. She has no family history of glaucoma, has been treated for systemic hypertension since 2009 and was diagnosed with atrial fibrillation and hyperthyroidism in September 2020. In 1986, the patient's refraction was −1.75D (dioptre), cyl (cylinder) +0.75D axe (axis) 100° in the right eye (RE) and −5.0D, cyl +0.75D axe 80° in the left eye (LE). In addition to slow long-term progression detected in the ONH as well as optic disc haemorrhages in both eyes, the patient developed nuclear and posterior pole cataracts. She had cataract surgeries in both eyes in 2003 with preoperative refractions of −3.75D (RE) and −7.5D (LE). The one-month postoperative refractions were −0.25 D in both eyes. The latest refractions were −0.75D, cyl +0.75D axe 70° (RE) and −2.25D, cyl +0.5D axe 140° (LE) with Snellen visual acuities of 0.9 and 1.0, respectively. At the time of the cataract surgeries in 2003, the axial lengths were 25.4 mm (RE) and 27.2 mm (LE). In 1991, the axial lengths of 24.8 mm (RE) and 26.8 mm (LE) were measured for manual planimetry with disc sizes of 2.5 mm2 in RE and 2.4 mm2 LE. The neuroretinal rim areas were 1.3 mm2 and 1.5 mm2, respectively. When comparing digital ONH photographs to the first paper prints taken in 1986 in Oulu, they looked dramatically so different and therefore raised a doubt about whether the photographs had been taken from the same patient. However, organizing the pictures in chronological order revealed uncommon longitudinal ONH and peripapillary changes in both eyes during the 36-year follow-up (Figure 1a,b). Changes in the photographs of both eyes taken in 1986–2000 had been interpreted as glaucomatous progression in the upper and lower parts of the ONH, as indicated by the increased bending of the vessels towards the clinical disc margin. However, the subsequent images reveal that these changes actually continued further into profound progressive peripapillary scleral bowings, that is, bending of vessels along the cupping outside the disc margins in both eyes (Figure 1a,b). No patient charts had reported on the shifting of these changes outside the disc margins over the years. In the more myopic LE, optic disc shape appeared to change from circular to vertically oval configuration, as reported to be common in highly myopic eyes (Jonas et al., 2020). In the right eye, in spite of significant long-term changes in and around the ONH, the overall neuroretinal rim in the first and latest photographs look remarkably similar. While the early RNFL photographs were informative, for example, showing normal RNFL in the paper prints in 1986, the progressive myopia reduced the visibility of the RNFL hampering its evaluation later on (Figure 2). Figure 3 of the right eye, using Enhanced Depth Imaging (EDI) with optical coherence tomography (OCT) (Spectralis, Heidelberg Engineering GmbH, Heidelberg, Germany) (Spaide et al., 2008) demonstrates how the ONH has sunk posteriorly into peripapillary staphyloma. The scleral changes appear to be the main cause of the peripapillary deformation resulting in the intrachoroidal cavitation (Ehongo et al., 2023), also known as choroidal schisis around the termination of Bruch's Membrane Opening. Figure 4 presents an overview of the patient's clinical data: intraocular pressure, treatments, disc haemorrhages, procedures, mean deviation of visual fields and Snellen visual acuity. In conclusion, this essay demonstrates that routine photographic documentation of the fundus stands the test of time and promotes the continuous development of both clinical skills and deep learning algorithms. All authors fulfil all four criteria for authorship by International Committee of Medical Journal Editors (ICMJE). The study was supported by the Competitive Research Funding of the Pirkanmaa Wellbeing Services County (grant no. 21519). The governmental organization Business Finland (1346/31/2019) supported Tays Eye Centre to bid the development of tailormade real-world data collection and analysis tool package in collaboration with all university eye clinics in Finland (Figure 4). The bid was won by Optomed Plc, Finland.

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