CHALLENGING CASES Phacomorphic Glaucoma

CA SE PRE SENTATION A 72-year-old white woman was referred to us 9 days after she experienced an episode of acute angle-closure glaucoma in her right eye. She had presented to the referring ophthalmologist with a complaint of a rightsided periorbital headache, nausea, and blurry vision upon awakening. Her right eye’s IOP was in the 50s and could not be medically controlled. The referring ophthalmologist could not perform a laser iridotomy in the patient’s right eye due to corneal edema, but he successfully completed a prophylactic laser iridotomy in her left eye. The next day, he performed a surgical iridectomy in her right eye. Despite a patent iridectomy, the IOP in her right eye remained in the 40s on timolol 0.5% and acetazolamide 500 mg b.i.d. The ophthalmologist referred her to us at that point for further management. The patient had no other ocular history but had several medical problems, including diabetes mellitus, hypothyroidism, congestive heart failure, sleep apnea, chronic obstructive pulmonary disease, and osteoarthritis. Upon initial evaluation, the patient’s UCVA was 20/250 (pinhole correction, 20/100) OD and 20/60 (pinhole correction, 20/30) OS. She had never worn distance glasses. Her IOP measured 34 mm Hg OD and 9 mm Hg OS with applanation tonometry. Her right pupil was partially dilated and minimally reactive without an afferent pupillary defect. The slit-lamp examination of her right eye revealed a hazy cornea with mild microcystic edema, a shallow anterior chamber, a 1.7-mm layered hyphema, a patent superior iridectomy, and a dense nuclear sclerotic cataract (Figure 1). Nylon sutures from the surgical iridectomy were visible superiorly at the limbus. The slit-lamp examination of her left eye revealed a clear cornea, a patent superior iridotomy, a shallow anterior chamber, and a dense nuclear sclerotic cataract. Performing gonioscopy on her right eye was difficult due to the corneal edema. Even with compression, the angle appeared to be closed without any identifiable angular structures. Gonioscopy of her left eye revealed an appositionally closed angle, which opened to the anterior trabecular meshwork upon compression. The fundus examination showed a cup-to-disc ratio of 0.3 OD and 0.2 OS. The rest of the fundus examination was unremarkable, without evidence of a mass or choroidal hemorrhage. A-scan ultrasound biometry showed an axial length of 22.9 mm, an anterior chamber depth of 1.6 mm, and a lens thickness of 5.5 mm OD. The patient’s left eye had an axial eye length of 22.5 mm, an anterior chamber depth of 1.8 mm, and a lens thickness of 5.3 mm. A B-scan ultrasound of the anterior segment using an immersion chamber showed a thick lens pushing the iris