Traumatic glaucoma with features of unilateral pigment dispersion

Abstract

SummaryWe report a patient with traumatic glaucoma with features of unilateral pigment dispersion. This rare form of secondary glaucoma has only been reported twice previously, with both patients demonstrating angle recession, indicating associated damage to the trabecular meshwork. To our knowledge, this is the first such case reported in which angle recession was absent. Case ReportA 68-year-old white man presented at Conquest Hospital, Hastings, with a complaint of redness and discomfort in the left eye 2 days after suffering blunt trauma with the tip of a pool cue. Medical history was remarkable for myopia previously treated with radial keratotomies. On examination, the left eye had diffusely injected conjunctiva with anterior chamber cell, traumatic mydriasis, and an intraocular pressure (IOP) of 20 mm Hg, with no gonioscopic evidence of angle recession. Radial keratotomy scars were visible in both eyes. Neither eye had features of pigment dispersion. Fundus examination revealed cup:disc ratios of 0.3 in both eyes, with no disc features suggestive of glaucoma. He was treated as a case of traumatic iritis and started on a tapering course of topical 0.1% dexamethasone every 2 hours.At 4 weeks' follow-up, the left eye was found to have an IOP of 70 mm Hg and a quiet anterior chamber. Although the left eye was physiologically shorter than the right eye, it was noted to have a visibly asymmetric, deeper anterior chamber on examination. This finding was confirmed by measurements obtained from the IOLMaster (Carl Zeiss Meditec, Jena, Germany): axial length 26.44 mm in the right eye and 25.84 mm in the left eye, anterior chamber depth 3.21 mm in the right eye and 3.45 mm in the left eye. There were no features of pigment dispersion. The elevated IOP was believed to be secondary to steroid therapy, which was consequently discontinued. He was started on topical latanoprost once daily and dorzolamide/timolol twice daily. This had the effect of reducing his IOP to 18 mm Hg. At 22 weeks' follow-up, his IOP had risen to 54 mm Hg, and he was noted to have pigmented cells in the anterior chamber for which he was restarted on topical dexamethasone 3 times daily. A Humphrey visual field 24-2 test was performed, revealing a mean deviation of −12.32 dB and an inferior arcuate scotoma. His IOP increased to 67 mm Hg, and he was started on oral acetazolamide 250 mg twice daily and referred to a glaucoma specialist.On examination of the left eye by a specialist 3 days later, the IOP was 42 mm Hg, the anterior chamber was asymmetrically deep with peripheral iris concavity, and there were midperipheral iris transillumination defects without other signs of iris damage. Gonioscopy showed evidence of Sampaolesi's line and no clinical evidence of angle recession (Figures 1-2). The cup:disc ratio in the left eye was 0.65, with superior neuroretinal rim thinning.The patient was diagnosed with traumatic pigment dispersion syndrome without angle recession and was started on maximal topical IOP reduction therapy; other medications were disco...