Neuro-opthalmic Conditions Misdiagnosed as Glaucoma: A Retrospective Study of Cases and Contributing Factors in a Developing Setting

Recent studies confirm the role of multimodality imaging, including OCT-based RNFL and macular ganglion cell analysis, in differentiating glaucomatous from nonglaucomatous optic nerve damage. 13,14t is against this background that the present study was undertaken to evaluate the prevalence, reasons, and patterns of neuro-ophthalmic conditions misdiagnosed as glaucoma in a tertiary care setting.It further identifies diagnostic gaps contributing to such errors and thus proposes strategies to improve diagnostic accuracy, which is highly relevant for low-resource healthcare environments where early and accurate differentiation is a major challenge. IntroductIonGlaucoma is a chronic progressive optic neuropathy and remains one of the most important causes of irreversible blindness worldwide, including in India, with a prevalence of 1.2-3.68% in adults above 40 years. [1][2]2][3][4][5] It is often termed the "silent thief of sight" due to its insidious onset and irreversible visual loss if undetected.Though open-angle glaucoma (OAG) is the most common form, differentiation of OAG from other optic neuropathies continues to remain a challenge for clinicians, especially in community and secondary care settings. [1][2]][3][4][5] Compressive, ischemic, demyelinating, hereditary, nutritional, and toxic optic neuropathies are several neuro-ophthalmic disorders that may appear clinically similar to glaucoma, with signs of optic disk cupping, thinning of the retinal nerve fiber layer (RNFL), and visual field defects. 6,7Such an overlap in structural and functional changes may lead to misdiagnosis, particularly where advanced imaging or neuroimaging facilities are not available. 8,9n resource-constrained settings, limited access to advanced diagnostics such as optical coherence tomography (OCT), central corneal thickness (CCT) measurement, and neuroimaging, combined with overlapping clinical features between glaucomatous and nonglaucomatous optic neuropathies, increases the risk of misdiagnosis. 8,9This may result in inappropriate initiation of intraocular pressure (IOP)-lowering therapy and delayed recognition of potentially treatable conditions.