- 1.
A 72-year-old man presents for a routine exam. He states that vision in the left eye is getting bad. On exam, he has vision of 20/30 in the right and counts fingers at 3 feet in the left. The intraocular pressure in the right eye is 25 mmHg, in the left eye, 42 mmHg. The optic nerve appears somewhat cupped on the right, severely so on the left. Visual fields reveal a significant nasal step in the right eye and a temporal island on the left. He does not have pseudoexfoliation syndrome or a Krukenberg spindle in either eye. His angles are deep. What do you suspect?
A history of trauma. The patient had been a boxer, and he was often hit in his eyes. Angle-recession glaucoma can be asymptomatic until many years later when visual loss occurs. On gonioscopy, the angle recession is determined by torn iris processes and posteriorly recessed iris, revealing a widened ciliary body band. Comparison with the other eye may help to identify this condition. Any patient with traumatic iritis or hyphema needs to be warned of this complication, which may occur many years later. Treatment is the same as with open-angle glaucoma except that miotic agents are ineffective and may even increase the intraocular pressure. Argon laser trabeculoplasty (ALT) is rarely effective.
- 2.
What should you look for to make a diagnosis of pseudoexfoliation glaucoma?
Fibrillar, “dandruff-like” material is deposited on the anterior lens capsule in a characteristic bull’s eye pattern, most easily seen after pupillary dilation. This material is also seen clinically in the angle and on the iris. Gonioscopy reveals a heavily pigmented trabecular meshwork and a Sampaolesi’s line, which is pigment deposited anterior to the Schwalbe’s line ( Fig. 17-1 ).
Figure 17-1
The Sampaolesi’s line is a scalloped band of pigmentation anterior to the Schwalbe’s line.
(From Alward WLM: Color Atlas of Gonioscopy. St. Louis, Mosby, 1994.)
Pseudoexfoliation syndrome is thought to be part of generalized basement membrane disorder, because it can be found histologically in other parts of the body. It may be unilateral or bilateral with asymmetry. Although pseudoexfoliation is infrequent in the United States, it accounts for more than 50% of open-angle glaucoma in Scandinavia. The condition is often more resistant to medical therapy than primary open-angle glaucoma and may require ALT, selective laser trabeculoplasty (SLT), or surgical therapy.
- 3.
Is the condition cured after cataract extraction?
No. The deposits continue, and cataract surgery has a higher risk in such patients. The zonules are weak, and synechiae are often present between the iris and the anterior lens capsule. There is an increased risk of posterior capsular rupture and zonular dialysis.
- 4.
What is true exfoliative glaucoma?
True exfoliative glaucoma is a capsular delamination caused typically by exposure to intense heat, as seen in glassblowers.
- 1.
Bull’s-eye deposits on anterior lens capsule.
- 2.
Sampaolesi’s line on gonioscopy.
- 3.
Less responsive to medical therapy.
- 4.
Higher risk for complications in cataract surgery.
- 5.
A 24-year-old man with sarcoidosis presents with an intraocular pressure of 35 mmHg in the right eye and 32 mmHg in the left eye. He notes mild pain and some decreased vision but is otherwise asymptomatic. On examination, you notice 2+ cell and flare in both eyes as well as significant posterior synechiae and mutton-fat keratic precipitates. Gonioscopy reveals an open angle with no peripheral anterior synechiae. A dilated exam reveals no significant cupping of either optic nerve. What do you do?
Most likely, the inflammatory cells have clogged the trabecular meshwork. Intensive topical steroids and a cycloplegic should decrease the inflammatory load and break the synechiae to prevent angle closure from becoming an issue in the future. Antiglaucoma medications are also appropriate until the pressure decreases. However, miotics are contraindicated because they may cause further synechiae and precipitate angle closure. They also increase the permeability of blood vessels and may contribute to an increase in inflammation. Prostaglandin agonists or analogs may also increase inflammation and should be avoided. The aggressiveness with which the pressure is lowered depends a great deal on optic nerve cupping.
- 6.
The same patient returns 14 days later with pressures of 40 and 45 mmHg in the right and left eye, respectively. Exam reveals minimal cell and flare in each eye as well as a significant decrease in the keratic precipitates. He has been using prednisolone acetate 1% every hour and atropine 1% three times/day. What should you do?
A gonioscopy should be performed. The differential of increased intraocular pressure in this situation includes:
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Steroid response. Decreasing steroids lowers the pressure if this is the cause.
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Cellular blockage of the trabecular meshwork from the inflammatory cells. Increasing the steroids lowers the pressure if this is the cause.
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Synechiae formation causing an element of secondary angle closure or blocking of the meshwork. Gonioscopy determines whether the angle is open. Increased steroids may melt the synechiae.
Provided the angle is open and without neovascularization, the most likely cause is response to steroids. The increased intraocular pressure may occur anywhere from a few days to years after initiating therapy. Raised intraocular pressure has been seen with topical steroids in or around the eye, after oral and intravenous administration of steroids, and even with inhalers. Patients with Cushing’s syndrome with excessive levels of endogenous steroids are also at risk. Optic nerve evaluation is crucial to determine the risks of damage. Decrease the steroid concentration or dosage and start antiglaucoma therapy. A topical nonsteroidal agent may help decrease inflammation without increasing intraocular pressure. Fluorometholone and loteprednol (Alrex, Lotemax) are also less likely to increase intraocular pressure than other formulations of steroids; however, they have less potency to decrease inflammation.
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- 7.
What does a Krukenberg spindle look like? What does it mean?
A Krukenberg spindle is a vertical pigment band on the corneal endothelium ( Fig. 17-2 ). It is typically found in patients with pigmentary dispersion syndrome. The iris is often bowed posteriorly and rubs against the lens zonules. This process causes midperipheral spokelike iris transillumination defects. Gonioscopy reveals a densely pigmented trabecular meshwork for 360 degrees. The patient is often asymptomatic but may notice blurred vision, eye pain, and halos around lights after exercise or pupillary dilation. Pigmentary dispersion syndrome is more common in young adults and white, myopic males. It is usually bilateral.
