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A 58-year-old diabetic, hypertensive male presents with a 3 month history of painless, decreased vision in his left eye.  On exam, his vision is 20/25 in his right eye and counts fingers (CF) in his left eye.  His intraocular pressure (IOP) in the right eye is 18 mmHg and 28mmHg in his left eye. On gonioscopy, the above is seen.

The next most important step in managing this patient is:

d -- immediate dilated retinal exam and immediate PRP The patient most likely has had a vascular occlusion of the retina and now has neovascularization of the angle. Patients who have had a central retinal vein occlusion must be followed very closely for any neovascularization as they are at risk for neovascular glaucoma (the so-called “90 day glaucoma”).  Patients should have heavy PRP treatment to the ischemic peripheral retina and must be followed closely to monitor IOP and the response to the laser.