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Plateau iris syndrome associated with cysts and nocturnal elevation of intraocular pressure
Correspondence Plateau iris syndrome associated with cysts and nocturnal elevation of intraocular pressure
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e report the case of a 38-year-old woman with symptoms of nocturnal blurred vision and ocular pain in both eyes. Examination by her personal physician revealed a visual acuity of 20/10 OD and 20/10 OS, an intraocular pressure (IOP) of 17 mm Hg OD and 17 mm Hg OS, and peripheral anterior synechia in both eyes. Prophylactic laser iridotomy was performed in both eyes. Because the symptoms remained after laser iridotomy, she was referred to our hospital for further examination. At the initial visit, IOP was 14 mm Hg OD and 13 mm Hg OS, and slit-lamp examination showed iris perforations after argon laser iridotomy in both eyes. The vertical cup-to-disc ratio was 0.4 OD and 0.3 OS. Humphrey (30-2) visual fields showed no visual field defect in either eye. Gonioscopy showed extensive angle closure and a double-hump sign in the inferior quadrant of both eyes. Ultrasound biomicroscopy revealed multiple ciliary body cysts in the superior, temporal, and infe-
Fig. 1—Ultrasound biomicroscopy in the right eye revealed a ciliary body cyst in the inferior quadrant (left) and angle closure with anterior dislocation of the ciliary body in the nasal quadrant (right).
rior quadrants of both eyes and revealed angle closure with anterior dislocation of the ciliary body in the nasal quadrant without ciliary body cysts (Fig. 1). On the basis of these findings, we diagnosed plateau iris syndrome associated with multiple ciliary body cysts. Because her symptoms suggested nocturnal IOP elevation, diurnal variation of IOP was examined. IOP at midnight was 67 mm Hg OD and 70 mm Hg OS (Fig. 2). Both eyes were immediately treated with topical pilocarpine hydrochloride (Santen, Osaka, Japan). Thirty minutes after the treatment, IOP was reduced to 15 mm Hg in both eyes. Diurnal variation of IOP under pilocarpine treatment showed no IOP elevation during the whole day (Fig. 2), and the symptoms disappeared. Plateau iris syndrome and ciliary body cysts are equally major etiologies of angle-closure glaucoma in children and young adults.1 Plateau iris syndrome often causes acute angle-closure glaucoma.2,3 We found nocturnal elevation of IOP in a patient with plateau iris syndrome and ciliary body cysts who had nocturnal blurred vision and ocular pain. Plateau iris occurs secondary to anterior positioning of the ciliary processes,4 and angle closure is often increased when the pupil dilates spontaneously or in response to mydriatic agents.5 Although plateau iris syndrome theoretically can cause nocturnal elevation of IOP, to our knowledge, this is the first reported case of nocturnal IOP elevation associated with plateau iris syndrome. Because our patient with multiple ciliary body cysts had no glaucomatous damage in the ocular fundus and was already treated with laser iridotomy, topical pilocarpine therapy was chosen, and the nocturnal elevation of IOP disappeared. However, further follow-up examinations are needed to prevent the progression of angle closure. REFERENCES 1. Ritch R, Chang BM, Liebmann JM. Angle closure in younger patients. Ophthalmology 2003;110:1880–9. 2. Azuara-Blanco A, Spaeth GL, Araujo SV, Augsburger JJ, Terebuh AK. Plateau iris syndrome associated with multiple ciliary body cysts. Arch Ophthalmol 1996;114:666–8. 3. Crowston JG, Medeiros FA, Mosaed S, Weinreb RN. Argon laser iridoplasty in the treatment of plateau-like iris configuration as result of numerous ciliary body cysts. Am J Ophthalmol 2005;139:381–3. 4. Pavlin CJ, Ritch R, Foster S. Ultrasound biomicroscopy in plateau iris syndrome. Am J Ophthalmol 1992;113:390–5. 5. Stamper RL, Lieberman MF, Drake MV. Becker-Shaffer’s Diagnosis and Therapy of the Glaucomas. 7th ed. St. Louis, Mo.: Mosby; 1999;249–51.
Tetsuya Baba, Kazuyuki Hirooka, Mai Takagishi, Shino Sato, Fumio Shiraga Fig. 2—Diurnal variation of intraocular pressure (IOP) in both eyes showed nocturnal elevation of IOP before pilocarpine treatment (top) and no IOP elevation during the whole day under pilocarpine treatment (bottom).
Kagawa University Faculty of Medicine, Kagawa, Japan Correspondence to Tetsuya Baba, MD: [email protected] Can J Ophthalmol 2008;43:725 doi:10.3129/i08-129 CAN J OPHTHALMOL—VOL. 43, NO. 6, 2008
725
W
e report the case of a 38-year-old woman with symptoms of nocturnal blurred vision and ocular pain in both eyes. Examination by her personal physician revealed a visual acuity of 20/10 OD and 20/10 OS, an intraocular pressure (IOP) of 17 mm Hg OD and 17 mm Hg OS, and peripheral anterior synechia in both eyes. Prophylactic laser iridotomy was performed in both eyes. Because the symptoms remained after laser iridotomy, she was referred to our hospital for further examination. At the initial visit, IOP was 14 mm Hg OD and 13 mm Hg OS, and slit-lamp examination showed iris perforations after argon laser iridotomy in both eyes. The vertical cup-to-disc ratio was 0.4 OD and 0.3 OS. Humphrey (30-2) visual fields showed no visual field defect in either eye. Gonioscopy showed extensive angle closure and a double-hump sign in the inferior quadrant of both eyes. Ultrasound biomicroscopy revealed multiple ciliary body cysts in the superior, temporal, and infe-
Fig. 1—Ultrasound biomicroscopy in the right eye revealed a ciliary body cyst in the inferior quadrant (left) and angle closure with anterior dislocation of the ciliary body in the nasal quadrant (right).
rior quadrants of both eyes and revealed angle closure with anterior dislocation of the ciliary body in the nasal quadrant without ciliary body cysts (Fig. 1). On the basis of these findings, we diagnosed plateau iris syndrome associated with multiple ciliary body cysts. Because her symptoms suggested nocturnal IOP elevation, diurnal variation of IOP was examined. IOP at midnight was 67 mm Hg OD and 70 mm Hg OS (Fig. 2). Both eyes were immediately treated with topical pilocarpine hydrochloride (Santen, Osaka, Japan). Thirty minutes after the treatment, IOP was reduced to 15 mm Hg in both eyes. Diurnal variation of IOP under pilocarpine treatment showed no IOP elevation during the whole day (Fig. 2), and the symptoms disappeared. Plateau iris syndrome and ciliary body cysts are equally major etiologies of angle-closure glaucoma in children and young adults.1 Plateau iris syndrome often causes acute angle-closure glaucoma.2,3 We found nocturnal elevation of IOP in a patient with plateau iris syndrome and ciliary body cysts who had nocturnal blurred vision and ocular pain. Plateau iris occurs secondary to anterior positioning of the ciliary processes,4 and angle closure is often increased when the pupil dilates spontaneously or in response to mydriatic agents.5 Although plateau iris syndrome theoretically can cause nocturnal elevation of IOP, to our knowledge, this is the first reported case of nocturnal IOP elevation associated with plateau iris syndrome. Because our patient with multiple ciliary body cysts had no glaucomatous damage in the ocular fundus and was already treated with laser iridotomy, topical pilocarpine therapy was chosen, and the nocturnal elevation of IOP disappeared. However, further follow-up examinations are needed to prevent the progression of angle closure. REFERENCES 1. Ritch R, Chang BM, Liebmann JM. Angle closure in younger patients. Ophthalmology 2003;110:1880–9. 2. Azuara-Blanco A, Spaeth GL, Araujo SV, Augsburger JJ, Terebuh AK. Plateau iris syndrome associated with multiple ciliary body cysts. Arch Ophthalmol 1996;114:666–8. 3. Crowston JG, Medeiros FA, Mosaed S, Weinreb RN. Argon laser iridoplasty in the treatment of plateau-like iris configuration as result of numerous ciliary body cysts. Am J Ophthalmol 2005;139:381–3. 4. Pavlin CJ, Ritch R, Foster S. Ultrasound biomicroscopy in plateau iris syndrome. Am J Ophthalmol 1992;113:390–5. 5. Stamper RL, Lieberman MF, Drake MV. Becker-Shaffer’s Diagnosis and Therapy of the Glaucomas. 7th ed. St. Louis, Mo.: Mosby; 1999;249–51.
Tetsuya Baba, Kazuyuki Hirooka, Mai Takagishi, Shino Sato, Fumio Shiraga Fig. 2—Diurnal variation of intraocular pressure (IOP) in both eyes showed nocturnal elevation of IOP before pilocarpine treatment (top) and no IOP elevation during the whole day under pilocarpine treatment (bottom).
Kagawa University Faculty of Medicine, Kagawa, Japan Correspondence to Tetsuya Baba, MD: [email protected] Can J Ophthalmol 2008;43:725 doi:10.3129/i08-129 CAN J OPHTHALMOL—VOL. 43, NO. 6, 2008
725