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Primary Angle-Closure Glaucoma
5S2
AMERICAN JOURNAL OF OPHTHALMOLOGY
Glaucoma. Philadelphia, Lea and Febiger, 1965, p. 174. 10. Forbes, M. and Becker, B.: Iridectomy in ad vanced angle-closure glaucoma. Am. J. Ophth. 57 :S7,1964. 11. Gills, J. P.: Iridectomy for close angle glau coma. EENT Monthly 1967. (In press.)
12. Hall, G. A. and Lawrence, C.: The treatment of angle-closure glaucoma. Presented at Spring meeting of Wilmer Ophthalmological Institute April, 1963. 13. Leopold, I. H.: Fistulizing operations for glaucoma: their complications. J. Internat. Coll. Surg. 33 :171,1960.
PRIMARY ANGLE-CLOSURE
GLAUCOMA
POSTOPERATIVE ACUTE GLAUCOMA AFTER P H E N Y L E P H R I N E RONALD F.
APRIL, 1968
LOWE,
EYEDROPS
M.D.
Melbourne, Australia Posterior synechias may occur following peripheral iridectomy for the treatment or prophylaxis of angle-closure glaucoma. 1 They may be caused by traumatic iritis, by the pupil resting too closely against the rela tively forward anterior lens surface, or b y the iris not being lifted by the forward flow of aqueous, 2 which is impeded less by pass ing through the peripheral iridectomy than by way of the pupil. Daily postoperative pupil dilation greatly reduces posterior synechias. T h e recom mended mydriatic is 1 0 % phenylephrine. Weaker epinephrine-type eyedrops are usually poor pupil dilators, and the tropine drugs, such as atropine, cyclopentilate or homatropine are likely to cause the iris to fold into the angle, occluding it 3 and possibly causing peripheral anterior synechias. I n a series of 60 tests using 1 0 % phenylephrine for pupil dilatation following peripheral iri dectomy for angle-closure glaucoma, no an gles closed and many eyes showed increased facility of outflow. 4 Prior to this series of tests, one of our pa tients developed postoperative acute glau coma during the use of 1 0 % phenylephrine eyedrops; this case was briefly reported.* T h e eye went from bad to worse and was ul timately lost. T h e case was particularly tragic since the original surgery was prophy lactic on an uninvolved eye. From the Glaucoma Unit, the Royal Victorian Eye and Ear Hospital, and the Ophthalmic Research In stitute of Australia
Seven years later, another patient was to have acute glaucoma percipitated by 1 0 % phenylephrine, this time after a wide basal peripheral iridectomy and without uveitis. CASE
REPORT
A 69-year-old woman reported on February 21, 1967, with right acute angle-closure glaucoma of three days' duration. However, the attack was rela tively mild and right ocular tension was only 40 mm H g (Schijftz). One percent eserine eyedrops and a 500 mg Diamox Sequel reduced the tension to 6 mm Hg within six hours. The right pupil was constricted except in the one o'clock meridian where it remained dilated. Gonioscopy showed the angle to be narrow but open, except in the segment of pupil dilatation where the iris remained pushed into the angle. Anterior chamber depth was 1.85 mm in the right eye and 1.95 mm in the left." Miotics and acetazolamide were continued. Two days later, bilateral peripheral iridectomies were performed under local anesthesia, using Chan dler's technique." The pupils dilated readily with 10% Neo-Synephrine instilled each day. Convales cence was uneventful and four days later the pa tient was discharged from the hospital. Five days after discharge she telephoned to say that her right vision was blurred, and on the 11th postoperative day she returned to the hospital with a painful right eye. The right cornea was edematous and the pupil dilated. The left eye showed no unexpected abnormality. Tensions were 50 mm Hg in the right eye and 8 mm Hg in the left (Schipftz). She was given 500 mg of oral Diamox three times on the day of her return to the hospital. The following day her right cornea was clear, and her tensions were 10 mm Hg in the right eye and 6 mm Hg in the left (Schijrftz), but her best correctable vision was 2/60 in the right eye and 6/18 in the left. Both eyes showed clear an terior chambers which, although shallow, were probably re-formed to their preoperative depths. On gonioscopic examination, the right angle appeared to be closed all around but the peripheral iridectomy
VOL. 65, NO. 4
PRIMARY ANGLE-CLOSURE GLAUCOMA
was well open and basally situated. The left angle was narrow but well open. Eserine eyedrops were instilled frequently in her right eye. The pupil constricted except for the per manently dilated segment. The peripheral iridectomy widened further (fig. 1), but eserine absorp tion made the patient very weak. She was sent home with instructions to continue instillation of Eserine 0.25% eyedrops three times daily and to continue taking Diamox, one tablet three times daily. Two days later (the 14th postoperative day) her vision had improved to 6/12 in the right eye and 6/9 in the left. Her ocular tensions were lownormal but her right angle remained closed in depth. With the Haag-Streit equipment5 her anterior chamber depth measured 1.76 mm in the right eye and 2.00 mm in the left. These were almost the preoperative measurements, indicating that the right lens had not undergone any unexpected movement. The eserine eyedrops were replaced with 4% pilocarpine and the Diamox tablets were discontinued. A week later, corrected vision had improved to preoperative levels of right, 6/4 and left, 6/9; ocular tensions were normal. At the next visit three weeks later (six weeks postoperative) her tensions were right, 33 mm Hg and left, 13 mm Hg (Schi^tz). Her corneas were bright and clear, but the angle in the right eye re mained closed in depth. To reduce the increased ocular tension in the right eye the 4% pilocarpine eyedrops were continued three times daily and 1% 1-epinephrine-base eyedrops were ordered for night and morning use. She instilled the epinephrine eyedrops that eve ning but next morning awoke with blurred right vi sion and again instilled Eppy and pilocarpine. Her vision became worse and she returned for examina tion. Her right cornea was moderately edematous and applanation tonometry showed tension in the right eye of 60 mm Hg and in the left, 16 mm Hg. Following application of glycerin her right pupil was three-quarters dilated, her anterior chamber depth measurements were unchanged (allowing for slightly thickened right cornea), and gonioscopic examination showed the iris folded against the wall of the anterior chamber angle so that the angle was closed all around except for the basal peripheral iridectomy. She was admitted to the hospital, and given 500 mg of Diamox intravenously and Eserine eyedrops intensively. By evening tension in the right eye had fallen to 8 mm Hg and the right pupil was con stricted except for the segment that had remained dilated since the original attack of acute glaucoma. Gonioscopic examination showed the angle to be open in its anterior portions but closed in depth, with the functional trabecula mostly covered by iris adhesions. Within a few days the Diamox tablets were discontinued, and when she left the hospital she was using 4% pilocarpine and 3% carbachol eyedrops three times daily. Ocular tensions remained controlled for three weeks and the pilocarpine eyedrops were discontin-
553
Fig. 1 (Lowe). Involved eye showing segmental pupil dilatation from the initial acute angle-closure glaucoma, and the wide basal peripheral iridectomy performed in an area of open angle. ued. Two weeks later, ocular tensions were 30 mm Hg in the right eye and 12 mm Hg in the left. Treatment was augmented to 6% pilocarpine eyedrop four times daily, and 3% Carbachol three times daily. Four days later, ocular tensions were 26 mm Hg in the right eye and 15 mm Hg in the left Tonography gave outflow values of right eye, 0.08 and left eye, 0.15. One Diamox Sequel capsule was ordered to be taken at night. Two weeks later her ocular tensions were 17 mm Hg in the right eye and 15 mm Hg in the left; outflow values were right eye, 0.17, left eye, 0.18. One month later, ocular tensions were normal (with treatment), and corrected vision was 6/5 in the right eye and 6/9 in the left. The left vision was slightly amblyopic from hypermetropic anisometropia, her necessary refractive correction being R.E. +1.25 sph +0.75 cyl ax 130 and L.E.: +4.00 sph +0.50 cyl ax 175. Bjerrum screen field tests with 2/2,000 white targets gave 20-degree nor mal fields; the optic discs were normal in appear ance Findings with linear A-scan ultrasonography were as follows: anterior chamber depth, 1.8 mm in the right eye and 2.0 mm in the left; corrected lens thicknesses, 4.8 mm in the right eye, and 4.8 mm in the left; corrected axial lengths, 21.5 mm in the right eye and 21.1 ram in the left. Test results for the involved eye did not differ particularly from those of most angle-closure glaucomatous eyes, nor was there any suggestion of an unusual convales cence. DISCUSSION
A t the Royal Victorian E y e and E a r H o s pital approximately 50 cases of angle-closure glaucoma are treated annually. Routine man agement includes surgery of both eyes with postoperative pupil dilatation by 1 0 % phenylephrine eyedrops. Since in seven years only two eyes have developed acute glaucoma by phenylephrine pupil dilatation in the pres-
554
AMERICAN JOURNAL OF OPHTHALMOLOGY
ence of open peripheral iridectomies, such occurrences must be considered very rare; however, they emphasize the alertness and care that is always necessary in the manage ment of this apparently simple procedure. The involved eyes have postoperative pla teau irises,7 but these are commonly seen and show interesting pharmacologic effects. In the presence of an open iridectomy, angleclosure following pupil dilatation frequently can be induced by tropine eyedrops,3 in con trast to the very rare angle-closure that oc curs after epinephrine-type drops. In the above case report, one eye was seen to de velop angle-closure following the use of two separate epinephrine-type eyedrops (10% phenylephrine and 1-eptnephrine base). For clinical reasons, tropine eyedrops have not been tried. SUMMARY
Following peripheral iridectomy in eyes subject to angle-closure glaucoma, pupil dila tation with 10% phenylephrine eyedrops can, on rare occasions, cause acute angle-closure glaucoma. The mechanism is the folding of the iris into the angle, thus occluding it, and
APRIL, 1968
is similar to that seen after the instillation of tropine eyedrops. Urgent miotic treatment is required to prevent the formation of ante rior synechias and permanent occlusion of the anterior chamber angle. 82 Collins Street (3000) ACKNOWLEDGMENT
We wish to thank Dr. Magda Horvat for valuable assistance in this study. REFERENCES
1. Lowe, R. F.: Angle-closure, pupil dilatation and pupil block. Brit. J. Ophth. SO :385, 1966. 2. Kessler, J.: The resistance to deformation: Of the tissue of the peripheral iris and the space of the angle of the anterior chamber. Am. J. Ophth. 42 :734,1956. 3. Lowe, R. F.: Primary angle-closure glaucoma. Investigations after surgery for pupil block. Am. J. Ophth. 57:931,1964. 4. : Primary angle-closure glaucoma. In vestigations using 10% phenylephrine eyedrops. Am. J. Ophth. 60:415,1965. 5. : New instruments for measuring ante rior chamber depth and corneal thickness. Am. J. Ophth. 62:7,1966. 6. Chandler, P. A.: Narrow angle glaucoma. Mark J. Schoenberg Memorial Lecture. Arch. Ophth. 47:695, 1952. 7. Becker, B. and Shaffer, R. N.: Diagnosis and Therapy of the Glaucomas. St. Louis, Mosby, 1965, ed. 2, p. 160.
OPHTHALMIC MINIATURE
An Audience Lends An Eye—Vienna
(AP)
American violinist Nathan Milstein was about to begin a performance Sunday when he noticed that he forgot his eyeglasses at his hotel. Ushers went out into the audience and collected glasses from patrons. He tried them on one after the other. The 12th pair was right. Milstein then started with the concert and got a standing ovation at the end. Associated Press notice June 20, 1965
AMERICAN JOURNAL OF OPHTHALMOLOGY
Glaucoma. Philadelphia, Lea and Febiger, 1965, p. 174. 10. Forbes, M. and Becker, B.: Iridectomy in ad vanced angle-closure glaucoma. Am. J. Ophth. 57 :S7,1964. 11. Gills, J. P.: Iridectomy for close angle glau coma. EENT Monthly 1967. (In press.)
12. Hall, G. A. and Lawrence, C.: The treatment of angle-closure glaucoma. Presented at Spring meeting of Wilmer Ophthalmological Institute April, 1963. 13. Leopold, I. H.: Fistulizing operations for glaucoma: their complications. J. Internat. Coll. Surg. 33 :171,1960.
PRIMARY ANGLE-CLOSURE
GLAUCOMA
POSTOPERATIVE ACUTE GLAUCOMA AFTER P H E N Y L E P H R I N E RONALD F.
APRIL, 1968
LOWE,
EYEDROPS
M.D.
Melbourne, Australia Posterior synechias may occur following peripheral iridectomy for the treatment or prophylaxis of angle-closure glaucoma. 1 They may be caused by traumatic iritis, by the pupil resting too closely against the rela tively forward anterior lens surface, or b y the iris not being lifted by the forward flow of aqueous, 2 which is impeded less by pass ing through the peripheral iridectomy than by way of the pupil. Daily postoperative pupil dilation greatly reduces posterior synechias. T h e recom mended mydriatic is 1 0 % phenylephrine. Weaker epinephrine-type eyedrops are usually poor pupil dilators, and the tropine drugs, such as atropine, cyclopentilate or homatropine are likely to cause the iris to fold into the angle, occluding it 3 and possibly causing peripheral anterior synechias. I n a series of 60 tests using 1 0 % phenylephrine for pupil dilatation following peripheral iri dectomy for angle-closure glaucoma, no an gles closed and many eyes showed increased facility of outflow. 4 Prior to this series of tests, one of our pa tients developed postoperative acute glau coma during the use of 1 0 % phenylephrine eyedrops; this case was briefly reported.* T h e eye went from bad to worse and was ul timately lost. T h e case was particularly tragic since the original surgery was prophy lactic on an uninvolved eye. From the Glaucoma Unit, the Royal Victorian Eye and Ear Hospital, and the Ophthalmic Research In stitute of Australia
Seven years later, another patient was to have acute glaucoma percipitated by 1 0 % phenylephrine, this time after a wide basal peripheral iridectomy and without uveitis. CASE
REPORT
A 69-year-old woman reported on February 21, 1967, with right acute angle-closure glaucoma of three days' duration. However, the attack was rela tively mild and right ocular tension was only 40 mm H g (Schijftz). One percent eserine eyedrops and a 500 mg Diamox Sequel reduced the tension to 6 mm Hg within six hours. The right pupil was constricted except in the one o'clock meridian where it remained dilated. Gonioscopy showed the angle to be narrow but open, except in the segment of pupil dilatation where the iris remained pushed into the angle. Anterior chamber depth was 1.85 mm in the right eye and 1.95 mm in the left." Miotics and acetazolamide were continued. Two days later, bilateral peripheral iridectomies were performed under local anesthesia, using Chan dler's technique." The pupils dilated readily with 10% Neo-Synephrine instilled each day. Convales cence was uneventful and four days later the pa tient was discharged from the hospital. Five days after discharge she telephoned to say that her right vision was blurred, and on the 11th postoperative day she returned to the hospital with a painful right eye. The right cornea was edematous and the pupil dilated. The left eye showed no unexpected abnormality. Tensions were 50 mm Hg in the right eye and 8 mm Hg in the left (Schipftz). She was given 500 mg of oral Diamox three times on the day of her return to the hospital. The following day her right cornea was clear, and her tensions were 10 mm Hg in the right eye and 6 mm Hg in the left (Schijrftz), but her best correctable vision was 2/60 in the right eye and 6/18 in the left. Both eyes showed clear an terior chambers which, although shallow, were probably re-formed to their preoperative depths. On gonioscopic examination, the right angle appeared to be closed all around but the peripheral iridectomy
VOL. 65, NO. 4
PRIMARY ANGLE-CLOSURE GLAUCOMA
was well open and basally situated. The left angle was narrow but well open. Eserine eyedrops were instilled frequently in her right eye. The pupil constricted except for the per manently dilated segment. The peripheral iridectomy widened further (fig. 1), but eserine absorp tion made the patient very weak. She was sent home with instructions to continue instillation of Eserine 0.25% eyedrops three times daily and to continue taking Diamox, one tablet three times daily. Two days later (the 14th postoperative day) her vision had improved to 6/12 in the right eye and 6/9 in the left. Her ocular tensions were lownormal but her right angle remained closed in depth. With the Haag-Streit equipment5 her anterior chamber depth measured 1.76 mm in the right eye and 2.00 mm in the left. These were almost the preoperative measurements, indicating that the right lens had not undergone any unexpected movement. The eserine eyedrops were replaced with 4% pilocarpine and the Diamox tablets were discontinued. A week later, corrected vision had improved to preoperative levels of right, 6/4 and left, 6/9; ocular tensions were normal. At the next visit three weeks later (six weeks postoperative) her tensions were right, 33 mm Hg and left, 13 mm Hg (Schi^tz). Her corneas were bright and clear, but the angle in the right eye re mained closed in depth. To reduce the increased ocular tension in the right eye the 4% pilocarpine eyedrops were continued three times daily and 1% 1-epinephrine-base eyedrops were ordered for night and morning use. She instilled the epinephrine eyedrops that eve ning but next morning awoke with blurred right vi sion and again instilled Eppy and pilocarpine. Her vision became worse and she returned for examina tion. Her right cornea was moderately edematous and applanation tonometry showed tension in the right eye of 60 mm Hg and in the left, 16 mm Hg. Following application of glycerin her right pupil was three-quarters dilated, her anterior chamber depth measurements were unchanged (allowing for slightly thickened right cornea), and gonioscopic examination showed the iris folded against the wall of the anterior chamber angle so that the angle was closed all around except for the basal peripheral iridectomy. She was admitted to the hospital, and given 500 mg of Diamox intravenously and Eserine eyedrops intensively. By evening tension in the right eye had fallen to 8 mm Hg and the right pupil was con stricted except for the segment that had remained dilated since the original attack of acute glaucoma. Gonioscopic examination showed the angle to be open in its anterior portions but closed in depth, with the functional trabecula mostly covered by iris adhesions. Within a few days the Diamox tablets were discontinued, and when she left the hospital she was using 4% pilocarpine and 3% carbachol eyedrops three times daily. Ocular tensions remained controlled for three weeks and the pilocarpine eyedrops were discontin-
553
Fig. 1 (Lowe). Involved eye showing segmental pupil dilatation from the initial acute angle-closure glaucoma, and the wide basal peripheral iridectomy performed in an area of open angle. ued. Two weeks later, ocular tensions were 30 mm Hg in the right eye and 12 mm Hg in the left. Treatment was augmented to 6% pilocarpine eyedrop four times daily, and 3% Carbachol three times daily. Four days later, ocular tensions were 26 mm Hg in the right eye and 15 mm Hg in the left Tonography gave outflow values of right eye, 0.08 and left eye, 0.15. One Diamox Sequel capsule was ordered to be taken at night. Two weeks later her ocular tensions were 17 mm Hg in the right eye and 15 mm Hg in the left; outflow values were right eye, 0.17, left eye, 0.18. One month later, ocular tensions were normal (with treatment), and corrected vision was 6/5 in the right eye and 6/9 in the left. The left vision was slightly amblyopic from hypermetropic anisometropia, her necessary refractive correction being R.E. +1.25 sph +0.75 cyl ax 130 and L.E.: +4.00 sph +0.50 cyl ax 175. Bjerrum screen field tests with 2/2,000 white targets gave 20-degree nor mal fields; the optic discs were normal in appear ance Findings with linear A-scan ultrasonography were as follows: anterior chamber depth, 1.8 mm in the right eye and 2.0 mm in the left; corrected lens thicknesses, 4.8 mm in the right eye, and 4.8 mm in the left; corrected axial lengths, 21.5 mm in the right eye and 21.1 ram in the left. Test results for the involved eye did not differ particularly from those of most angle-closure glaucomatous eyes, nor was there any suggestion of an unusual convales cence. DISCUSSION
A t the Royal Victorian E y e and E a r H o s pital approximately 50 cases of angle-closure glaucoma are treated annually. Routine man agement includes surgery of both eyes with postoperative pupil dilatation by 1 0 % phenylephrine eyedrops. Since in seven years only two eyes have developed acute glaucoma by phenylephrine pupil dilatation in the pres-
554
AMERICAN JOURNAL OF OPHTHALMOLOGY
ence of open peripheral iridectomies, such occurrences must be considered very rare; however, they emphasize the alertness and care that is always necessary in the manage ment of this apparently simple procedure. The involved eyes have postoperative pla teau irises,7 but these are commonly seen and show interesting pharmacologic effects. In the presence of an open iridectomy, angleclosure following pupil dilatation frequently can be induced by tropine eyedrops,3 in con trast to the very rare angle-closure that oc curs after epinephrine-type drops. In the above case report, one eye was seen to de velop angle-closure following the use of two separate epinephrine-type eyedrops (10% phenylephrine and 1-eptnephrine base). For clinical reasons, tropine eyedrops have not been tried. SUMMARY
Following peripheral iridectomy in eyes subject to angle-closure glaucoma, pupil dila tation with 10% phenylephrine eyedrops can, on rare occasions, cause acute angle-closure glaucoma. The mechanism is the folding of the iris into the angle, thus occluding it, and
APRIL, 1968
is similar to that seen after the instillation of tropine eyedrops. Urgent miotic treatment is required to prevent the formation of ante rior synechias and permanent occlusion of the anterior chamber angle. 82 Collins Street (3000) ACKNOWLEDGMENT
We wish to thank Dr. Magda Horvat for valuable assistance in this study. REFERENCES
1. Lowe, R. F.: Angle-closure, pupil dilatation and pupil block. Brit. J. Ophth. SO :385, 1966. 2. Kessler, J.: The resistance to deformation: Of the tissue of the peripheral iris and the space of the angle of the anterior chamber. Am. J. Ophth. 42 :734,1956. 3. Lowe, R. F.: Primary angle-closure glaucoma. Investigations after surgery for pupil block. Am. J. Ophth. 57:931,1964. 4. : Primary angle-closure glaucoma. In vestigations using 10% phenylephrine eyedrops. Am. J. Ophth. 60:415,1965. 5. : New instruments for measuring ante rior chamber depth and corneal thickness. Am. J. Ophth. 62:7,1966. 6. Chandler, P. A.: Narrow angle glaucoma. Mark J. Schoenberg Memorial Lecture. Arch. Ophth. 47:695, 1952. 7. Becker, B. and Shaffer, R. N.: Diagnosis and Therapy of the Glaucomas. St. Louis, Mosby, 1965, ed. 2, p. 160.
OPHTHALMIC MINIATURE
An Audience Lends An Eye—Vienna
(AP)
American violinist Nathan Milstein was about to begin a performance Sunday when he noticed that he forgot his eyeglasses at his hotel. Ushers went out into the audience and collected glasses from patrons. He tried them on one after the other. The 12th pair was right. Milstein then started with the concert and got a standing ovation at the end. Associated Press notice June 20, 1965