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Abstract #5343 Published in IGR 1-2
Cases in Controversy: Recurrent angle-closure glaucoma
Palmberg P; Gupta N; Wang T-HJournal of Glaucoma 1999; 8: 208-211
In this 'Cases in Controversy' series, a 56-year-old Chinese woman is presented who had a recurrence of an attack of angle closure after bilateral iridotomy in 1994. Her most recent intraocular pressures were 16 mmHg in both eyes without treatment. She had a typical attack in the left eye with pressures of 47 mmHg. On gonioscopy, a moderately narrow approach in the right eye was seen. The left eye could not be visualized. On B-scan ultrasound , there was a normal posterior segment and anatomy in both eyes. What is the cause of this attack? Are there any tests that add the diagnosis? What is the treatment? The first comment in this case is by Gupta, who offers the differential diagnosis of plateau iris syndrome, malignant glaucoma and secondary angle closure mechanisms, such as lens intumescence or anterior dislocation. Some secondary glaucomas may also mimic angle-closure glaucoma. These include neovascular, uveitic, phacolytic or iridocorneo endothelial syndrome, ciliary body cysts and posterior segment abnormalities. As usual a detailed history is important. Careful slit-lamp examination is necessary to see signs as keratic precipitates and lens swelling. Extremely helpful in these cases is ultrasound biomicroscopy. This author is happy with dark-room gonioscopy and a mydriatic provocative test to provide evidence of a plateau-iris configuration. In this case a plateau-iris syndrome seems to be the diagnosis. Management of the acute phase includes miotics. Also, argon laser peripheral iridoplasty is important. If this does not help a trabeculectomy with mitomycin-C is the procedure of choice. The other comment comes from Wang who states that chronic angle-closure glaucoma must be extinguished from open angle glaucoma with an anatomically narrow angle. If indentation gonioscopy reveals peripheral anterior synechiae, iridotrabecular apposition, or irregular and granular pigmentation of the trabecular meshwork the diagnosis is more likely to be angle-closure. He also believes in provocative testing. He also would use pilocarpine in this case. The editor of this series, Paul Palmberg, also discusses the differential diagnosis. He describes a method for decompressing the anterior chamber. In this case aqueous misdirection appears to be ruled out and plateau-iris syndrome seems to be present. He also found that plateau-iris syndrome occurs in 2.6% of patients with angle-closure who were undergoing initial iridotomy. Angle-closure occurs solely on the basis of the ciliary processes lifting the iris against the angle or as a result of iris crowding. Note that similar forward rotation of the ciliary processes can occur due to uveal congestion of any cause. Indentation gonioscopy can always make the diagnosis. Also, ultrasound biomicroscopy is very helpful. Miotic agents and peripheral iridoplasty can well be used for the treatment. This author would also do filtration surgery is everything fails.
P. Palmberg, Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101-6880; USA
Classification:
9.3.3 Plateau iris syndrome (Part of: 9 Clinical forms of glaucomas > 9.3 Primary angle closure glaucomas)
