|UVEITIC GLAUCOMA & GLAUCOMATOCYCLITIC CRISIS
The patient with glaucomatocyclitic crisis will present with a recurrent, unilateral red eye with very mild discomfort, or possibly no discomfort at all. Acuity will be mildly reduced; this is often the chief complaint. The cornea will be mildly edematous, but the anterior chamber will be remarkably clear. Often, the only signs of anterior chamber inflammation will be a rare cell or two in the chamber or, more commonly, a few keratic precipitates on the endothelium. Intraocular pressure can range from 30 to 70mm Hg, but the patient will not be in acute distress.
Often, the inflammatory cells physically block the trabecular meshwork, decreasing aqueous outflow, with the angle remaining open. Occasionally, the inflammatory cells and fibrous protein will form a connective bridge between the peripheral iris and cornea, pulling these structures into apposition, and resulting in an angle closure with PAS formation.
Because the inflammatory cells and protein in the anterior chamber form adhesions between the posterior iris and anterior lens, posterior synechiae commonly form. This will lead to iris bombé, secondary angle closure and peripheral anterior synechiae formation. There may also be a combination of mechanisms that increases IOP. Untreated, the patient will eventually experience glaucomatous optic atrophy, or possibly central retinal artery occlusion.
In glaucomatocyclitic crisis, there is an idiopathic inflammation of the trabecular meshwork that reduces this structure's ability to actively drain aqueous. Due to prostaglandin release, it is theorized that there may also be a concurrent overproduction of aqueous. Despite the elevated IOP, this condition is only mildly symptomatic, and is usually self-limiting. However, the recurrent nature of the attacks predisposes the patient to developing glaucomatous optic atrophy.
If any posterior synechiae have formed, prescribe phenylephrine 10% BID. Quelling the inflammation will temporize the IOP rise. To further reduce the IOP, use a topical beta-blocker BID or the topical carbonic anhydrase inhibitor Trusopt TID, provided there are no medical contraindications to any of these drugs. Avoid pilocarpine and other miotics in these patients. Follow the patient every 24 hours and gradually taper the medications as the condition improves.
Management of glaucomatocyclitic crisis is nearly identical to that described above for uveitic glaucoma, with the following two exceptions:
(1) It is acceptable to use a slightly weaker cycloplegic such as scopolamine (hyoscine 0.25%) or homatropine 5% BID.
(2) The patient should instill a topical steroid hourly rather than every 15 minutes.
Other Reports in This Section
Eyelids & Eyelashes | Conjunctiva & Sclera | Cornea
Uvea | Vitreous & Retina | Optic Nerve & Brain | Oculosystemic Disease
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