Diagnostic dilemma in a case of normal tension glaucoma in crowded optic disc

A 47-year-old Asian woman with myopia presented with a recent onset of blurred near vision, initially attributed to presbyopia. Best-corrected visual acuity was 6/6 bilaterally, with intraocular pressures (IOPs) of 15 mmHg (right) and 12 mmHg (left), and open angles on gonioscopy. Fundus examination revealed crowded optic discs and a wedge-shaped retinal nerve fiber layer defect in the right eye. Standard optical coherence tomography (OCT) appeared normal, but OCT angiography demonstrated loss of superior temporal radial peripapillary capillaries. Automated perimetry confirmed an inferior hemifield defect, consistent with moderate normal tension glaucoma (NTG) in the right eye. Treatment with once-daily omidenepag isopropyl 0.002% reduced IOP by 33% to 10 mmHg, sustained at 1 year without progression or adverse effects. This case underscores the diagnostic challenges of NTG in crowded discs, highlights the value of multimodal imaging, and supports selective EP2 receptor agonists as effective therapy.