Good Hope, Heartlands, and Solihull Eye Clinics

Glaucomatocyclitic crisis
(Posner-Schlossman syndrome)

David Kinshuck

Glaucomatocyclitic crisis

This is also termed Posner-Schlossman syndrome. We are learning more about this condition. There are episodes lasting days of a sudden eye pressure rise. This is caused by inflammation in the eye. The episodes occur now and again, perhaps once every 2 years, with no obvious trigger factor. The episodes do need treatment, as the high pressure that occurs may damage the optic nerve. Each episode tends to be similar, but it is likely that the earlier the treatment started, then the quicker the recovery will be.

On the slit lamp the ophthalmologist notes a mild uveitis (iritis), keratoprecipitates (inflammatory cells on the back of the cornea), may be some thinning of the iris (atrophy), and may be a different coloured iris (heterochromia). Details are explained here.

posner-schlossman

Key to diagram (enlarge)

  1. aqueous fluid is made in all eyes here in the ciliary body
  2. the aqueous passes through the anterior chamber
  3. the fluid leaves the eye (and enters veins around the eye) here in the trabecular meshwork
  4. inflammation may be in the cornea here (keratitis); or in the trabecular meshwork itself (4)
  5. or in the iris here (iritis/uveitis)
  6. if the trabecular meshwork blocks (3), the pressure in the eye builds up, and is transmitted to the back of the eye and presses on the optic nerve
  7. optic nerve

Mechanism of pressure rise

Inflammation in the cornea (4), or/and the iris (5) or trabecular meshwork (3) develops. This may be caused by a virus, sometimes the CMV (cytomegalovirus). The inflammatory cells circulate through the anterior chamber (2) and may block the trabecular meshwork (2). Alternatively, the trabecular meshwork may itself be inflamed (2) and block.

When the trabecular meshwork blocks, the aqueous fluid (2) gets trapped in the eye, and the pressure goes up (like a tyre being pumped up too much), and the pressure is transmitted to the optic nerve (7) which may become damaged.

Treatment

  1. An examination in the eye department with a slit lamp is needed to check the pressure, and visibly see the inflammation.
  2. The treatment itself:
    • First, the inflammation is treated with steroid eye drops such as dexamethasone (often Maxidex), or less often prednisolone such as Pred Forte.
    • Second the pressure is treated, with glaucoma drops, such as Latanoprost (see drops).
    • The virus may be treated, with acyclovir if herpes simplex or zoster suspected, or Valacyclovir if cytomegalovirus (CMV) suspected IO 87.    G 17...  can prevent recurrences.
    • there is no response to acyclovir.
  3. As the treatment is complicated and further attacks may occur in the years to come, it is important
    • to keep a record of the treatment used, noting successful treatment or side effects
    • bring the drops every visit
    • eventually glaucoma surgery is often needed