Systemic diseases blurring diagnosis? Is glaucoma appearance due to tamoxifen, or to thyroid disease? Or maybe neither?(Glaucoma Grand Rounds)

A 63-year-old white female presented in the fall of 1998 for a routine primary eye care visit. She was taking Vaseretic (enalapril/hydrochlorothiazide, Merck), Synthroid (levothyroxine sodium, Abbott), and 20mg Nolvadex (tamoxifen, AstraZeneca) qd. She had a 10-year history of hypertension, and had abnormal thyroid studies for more than 20 years.

She also had breast cancer. About nine months before initial presentation, she underwent a complete right mastectomy followed by radiation therapy. She started on tamoxifen about four months prior to her initial presentation to me.

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Her chief complaint at that time was decreased vision at distance and near, which had become more noticeable since her mastectomy. In her family history, she reported that her mother has glaucoma.

Diagnostic Data

Pupils were equal, round and reactive to light and accommodation with no afferent pupillary defect. Extraocular motilities were full. Best-corrected visual acuities were 20/20 O.U. through hyperopic astigmatic presbyopic correction.

A slit lamp examination of her anterior segments was unremarkable other than for fine SPK over the inferior one-third of her cornea, apparently dry eye related. She said that both eyes had been feeling drier over the past year. Applanation tensions were 20mm Hg O.D. and 21mm Hg O.S. Pachymetry was not obtained in the early visits.