University of Iowa Health Care

Ophthalmology and Visual Sciences

Iowa Glaucoma Curriculum

Supplementary Material

Chapter 17

Pupillary block cases from
Narrow Angles - Slit lamp only: This is a 51 year-old woman who presented with narrow angles diagnosed by her local ophthalmologist. She has no other known eye pathology. Her Van Herrick test shows extremely narrow angles with areas of apposition. Interestingly, this patient is myopic (-3.50 diopters). Primary pupillary block angle closure is quite uncommon in patients with myopia. This clip is filed under both Examples: Pupillary Block and Techniques for Difficult Angles: Van Herrick.

Narrow Angle, Pupillary Block: This 60 year-old man has a strong family history of glaucoma. He was referred because his local optometrist found his iridocorneal angles to be narrow. He has mild hyperopia with a spherical equivalent of +0.75 OD and +1.25 OS. His intraocular pressures are normal at 12 mmHg OD and 15 mmHg OS. His optic nerve heads are completely normal.

Narrow Angles w/ Indentation Gonio and Corneal Wedge: This 54 year-old woman was referred for narrow angles. She is mildly hyperopic (one diopter).

Pupillary Block - Narrow Angles PAS on Indentation: 80 year-old woman was found to have elevated IOP on routine examination at age 54. She was treated as a POAG patient. At age 77 she was found to have narrow angle with low PAS on indentation. She is hyperopic with a spherical equivalent of +3.25 D OU.

Glaukomflecken - slit lamp only: This 41 year-old man had undergone a trabeculectomy with mitomycin C and had chronic post-operative hypotony. He was symptomatic from the hypotony with macular striae. For this reason a blood patch was performed on the left eye and at the same time the anterior chamber was filled with viscoelastic. After this procedure the patient had an intraocular pressure that went as high as 60 mmHg. Over the next several hours he was given maximum medical therapy and had fluid released from his paracentesis intermittently. Despite this it took almost 6-hours to make the patient comfortable and to attain a steady, normal intraocular pressure. The following week the patient was found to have glaukomflecken. With time as can be seen in the video this dissipated. Note: While these glaukomflecken are not from primary pupillary block angle closure this seems to be the most appropriate place to file this video.

Indentation Broad PAS: This gentleman is moderately hyperopic patient (+1.00 diopters) who has had longstanding glaucoma. He was taking pilocarpine gel at the time that this video was taken. His intraocular pressure was 32 mmHg. On examination he has narrow angles with scattered peripheral anterior synechia that are seen on indentation. Note: This video is also located in the Techniques for Difficult Angles - Indentation Gonioscopy and Peripheral Anterior Synechiae categories.

Pupillary Block: This patient underwent a laser iridotomy and this video shows the very narrow angle before the iridotomy and the deeper angle post iridotomy using the Van Herick technique.

Pupillary Block - Indentation Gonioscopy showing PAS: This is a 64 year-old man who is moderately hyperopic (+1.50 diopter spheres). He was found by his optometrist that morning to have intraocular pressures of 36 mmHg OD and 37 mmHg OS. He was treated with laser iridotomies in both eyes but ultimately required medical therapy because his pressures continued to be elevated.

Sequelae from Acute Angle Closure Attack - slit lamp only: This patient had a bilateral attack of acute angle closure glaucoma with intraocular pressures of 58 mmHg OD and 63 mmHg OS. She is a hyperopic patient and was on no medications that might have induced bilateral angle closure. She had laser iridotomies and now has sequelae of an angle closure attack.

Nanophthalmos cases from
Nanophthalmos - 1: This 71-year old patient presented with narrow angles. Her local physician had attempted cataract extraction but found the anterior chamber too shallow and was unable to complete the surgery. She has a refractive error of +10.5 diopters sphere in both eyes. The patient was found to have axial eye length of 16.92 mm OD and 16.97 mm OS.

Nanophthalmos - 2: This patient was first seen at the University of Iowa in 1980 at the age of 32 with narrow angles in both eyes. He underwent laser iridotomies at that time. In 1986 he developed cystoid macular edema in the left eye that persisted over several years. Standardized echography was performed in 1990 that showed actual eye lengths of 19.3 mm OD and 19.1 mm OS with lens thicknesses of 5.1 mm OD and 5.2 mm OS. He had marked thickening of the retinal choroidal layer. In 1991 he developed spontaneous choroidal effusions in the left eye for which he underwent four quadrant scleral windows. The cystoid macular edema in the left eye left him with chronically decreased vision in that eye. In 2007 he was referred with a nearly completely flat anterior chamber in the left eye. He underwent lensectomy vitrectomy on that eye with subsequent control of his intraocular pressure. Viewed here is the right eye which has 20/20 vision and an intraocular pressure of 15 mmHg but a very shallow anterior chamber and a lens that has grown in thickness from 5.1 mm in 1990 to 5.6 mm in 2008.