Angle closure glaucoma – misleading causes, delayed treatment

Abstract

We present the clinical case of a 43 years old female patient, referred to our clinic for a red, painful left eye. Multiple bilateral similar attacks were reported by the patient in the last 2 years, for which a diagnosis of conjunctivitis or anterior uveitis was established. At current presentation we found bilateral marked inflammatory reaction in the anterior segment (extensive peripheral iris synechiae, inflammatory membrane in the pupillary area, iris “bombe”, pigment dispersion, but no keratic precipitates or cells in the anterior chamber. Intraocular pressure (IOP) was 12 mmHg in OD and 40 mmHg in OS, under topical treatment, started 24 before the current visit. Gonioscopy showed closed angle in both eyes, “openable” in various grades after indentation in all quadrants. Anterior segment ocular coherence tomography (AS-OCT) and ultrasonic biomicroscopy (UBM) suggested anatomical causes for acute angle closure, revealing multiple rolling folds on the iris surface, high insertion onto the scleral wall. Multiple laboratory investigations excluded any potential cause of uveitis, therefore the anatomical theory remained in discussion related to a disproportion between anterior structures leading to angle closure attacks. We performed laser peripheral iridotomy, in this patient with positive outcome: IOP decrease, deepening of the AC, open angle in gonioscopy. Misleading issues in this case confused the initial diagnosis and delayed the adequate treatment.