re: John F. LaBranche, d.o.b. 12-04-1944

Richard F. Lewis, M.D.
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston MA 02114

Dear Dr. Lewis:
.PP
When Mr. LaBranche came for a regular glaucoma check today,
he asked me to send you a report about the condition of his
eyes. He explained to me that the unsteadiness when walking
which he has been noticing for several years appears to be
progressing rapidly and Mr. LaBranche is concerned that by
next year, he might not be able to walk at all.
.PP
Mr. LaBranche has been coming to see me for severe bilateral
open angle glaucoma since 1983. In the left eye he had
cataract extraction combined with filtering surgery in
1995. He presently is taking pilocarpine 4% OD q.i.d.,
apraclonidine OD b.i.d., Alphagan OD b.i.d., Betoptic OD b.i.d.,
Xalatan OD h.s., and acetazolamide 125 mg. q.i.d. Mr. LaBranche
also uses Polysporin eye ointment OS q.d. Mr. LaBranche's 
bronchial asthma seems not to be aggravated by the beta-blocker.
Do you think it likely that any of the medications he is taking
might be contributing to Mr. LaBranche's unsteadiness?
.PP
Examination today demonstrates visual acuity OD 20/30, OD 20/50.
Applanation tension OD 10, OS 7. Visual fields show that the
right eye has a superior Bjerrum scotoma with constriction of
the upper nasal field. The left eye has only a small central field
remaining. Both eyes are white and quiet. The corneas are clear,
the anterior chambers, deep and clear. The pupil OD is constricted
to 2 mm. The pupil OS is 5 mm and fixed. On mydriatic exam, both
discs are seen to be atrophic and excavated, the left, which is
totally cupped, more so than the right. I could see no abnormalities
of vessels or maculas.
.PP
Much of the field loss in the right eye occurred three years ago
when Mr. LaBanche interrupted treatment for almost a year and
tension OD was markedly elevated. The field loss OS, however,
progressed markedly even after the pressure was lowered by
successful surgery. I had suggested to Mr. LaBranche the option
of obtaining neurological consultation and possibly imaging
studies of the anterior fossa to exclude disease other than
glaucoma that might be contributing to the field loss, a course
of action that was precluded at the time by financial considerations.
.nf


                                 Sincerely yours,


                                 Ernst J. Meyer, M.D.