Eyeworld

EW INTERNATIONAL 106 March 2016 by Matt Young and Gloria Gamat EyeWorld Contributing Writers appeared with unusual sectorial iris vessels. "The sectorial iris vessels were noted for 2 clock hours between 10 and 12 o'clock. He had a back- ground of left traumatic optic neuropathy," Dr. White reported. "Visual acuity was 6/6 in both eyes. Intraocular pressures were 18 and 20 [mm Hg]." These symptoms were alleviated with treatment of famciclovir for 10 days. Case 5: Pseudoexfoliative glaucoma A 76-year-old woman with pseudo- exfoliative glaucoma suffered from the complications of Descemet's membrane folds and cornea edema. "The patient did not improve despite achieving stable IOP of 18 [mm Hg] on glaucoma medications and post-SLT," Dr. White reported. "It was initially thought that the patient may have some flare, in additional to corneal signs, so she was switched to preservative-free glaucoma drops." However, her visual acuity kept worsening to 6/24. Six days of ste- roids were started. Slow improvement occurred to 6/12 in October 2014. Drops were tapered, and yet by mid-2015, IOP was at 24 mm Hg. Vision had Poster from the 2015 RANZCO scientific congress explores cases where glaucoma was the secondary issue A detailed case series can be fascinating to read. One such series popped up at the 2015 Royal Australian and New Zealand College of Ophthalmologists (RANZCO) scientific congress, in Wellington, New Zealand. In a scientific poster, researchers reported, "Herpes simplex virus/ cytomegalovirus masquerading as atypical glaucoma cases." The series was reported by Andrew White, FRANZO, Save Sight Institute, University of Sydney, and colleagues Chandra Balachandran and Linda Zheng. While there were only 5 cases, they reinforced the fact that glauco- ma may be intertwined with organ- ism-causing problems, as noted by an ocular microbiology expert. Case 1: Microaneurysms A 77-year-old man presented with open-angle glaucoma. He was found to suffer from recurrent spontaneous right anterior chamber hyphema as well as subconjunctival hemorrhages. In 2013, he reported right eye blurred vision with an irregular pupil and IOP of 38 mm Hg in his right eye; this was only 19 mm Hg in his left. Right iris atrophy and a dilated venule were found upon examination. Blood also was found in the inferior angle and open angles. Although confocal microscopy was normal, iridocorneal endothelial (ICE) syndrome and secondary glau- coma was suggested as the culprit. Iris angiography displayed mi- croaneurysms. "It was felt that the microaneu- rysms in his right iris were second- ary to an underlying infection with herpes simplex virus," Dr. White reported. "He was commenced on anti-viral therapy. Two months post anti-viral therapy commencement, HSV1 serology was detected and HSV2 was not detected. At the last clinic visit in 2015 the patient has remained on anti-viral therapy with no bleeds and a stable right IOP of 12." Case 2: Past CMV infection A 36-year-old man suffered from an- gle-closure glaucoma. It was believed to be occurring secondary to chronic uveitis, and he was treated as such. His vision improved and corneal edema decreased. His IOP continued to be difficult to control as there was 360 degrees of peripheral anterior synechiae, so he underwent right eye goniosynechialysis when the uveitis settled. During surgery, his right iris seemed to be unusually floppy. Despite having undergone the procedure, his right eye IOP was still 38 mm Hg and required medical management to bring it under con- trol. In February 2015, his peripheral synechiae seemed to be reforming and abutting the cornea for no apparent reason. The diagnosis was still uncertain. He saw a cornea specialist in April 2015 and was determined to have extensive peripheral anterior synechiae with progressive iris atro- phy, which suggested ICE syndrome. He started treatments including acyclovir and ganciclovir, and tested positive for CMV IgG, which alluded to the fact that he had past CMV in- fection. Repeat confocal microscopy demonstrated ICE syndrome. "At the last clinic visit in 2015, his vision and pachymetry has been improving on antiviral treatment, with a latest IOP of 15 mm Hg OD," the researchers reported. Case 3: "Owl's eye" A 63-year-old woman had left angle- closure glaucoma. A 360-degree iridoplasty was done, which opened up her angles. She was discovered to have evidence of iridocorneal con- tact and peripheral synechiae. Her visual acuity worsened. She had intermittent symptoms from pe- ripheral synechiae formation as well. Thus, cataract surgery was done in August 2013. Oddly, she developed uveitis afterward, which was treated. She had cataract surgery for her right eye in October 2013. Uveitis flared again at times. In April 2014, a left Baerveldt tube 250 (Abbott Medical Optics, Abbott Park, Ill.) was implanted for IOP lowering. In January 2015, left eye visual acuity worsened. Endothe- lial cells were found to be 603 cells/ mm 2 . After seeing a corneal specialist, she was found to have inferior cor- neal edema in her left cornea. This affected her visual axis, with a clear superior cornea. "The Baerveldt tube was noted super temporally without any surrounding corneal edema," Dr. White reported. "Confocal micros- copy showed 'owl's eye' appearance, which suggested a diagnosis of CMV endotheliitis. However, ICE syn- drome was a differential due to her triad of iris dysfunction, unilateral glaucoma and corneal decompensa- tion." She was started on ganciclovir gel and other treatment. "Blood was positive for CMV IgG suggesting past but not current infection," he reported. "Serology for HSV2 was positive, suggesting concurrent infection with HSV2. At the last clinic visit in 2015, the patient has been maintained on antivirals and is improving with no further vision loss." Case 4: Sectorial iris vessels In May 2015, a 50-year-old man Atypical glaucoma cases discussed at RANZCO Eye with confirmed iridocorneal endothelial (ICE) syndrome Source: Andrew White, MD

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