Supplementary Material

Chapter 21

Case from
Pigmentary Glaucoma: 24-year-old male with episodic haloes around lights and blurry vision

Pigment dispersion syndrome and pigmentary glaucoma cases from
Krukenberg Spindle: This middle-age woman has a long standing history of pigment dispersion syndrome in this eye.

Pigment Dispersion Syndrome: Pigment on Iris (slit lamp only) - 56 year old with a five year history of pigment dispersion syndrome. His referring physician had performed laser iridotomies in both eyes.

Pigmentary Glaucoma: This patient was diagnosed at age 32 with pigmentary glaucoma. He has had pressures as high as 42 mmHg in both eyes and has required trabeculectomies in both eyes.

Pigment Dispersion Synd. - Iris Pigment and TIDs: This 31 year-old man was found to have pigment dispersion syndrome on routine examination. His intraocular pressures are 22 mmHg OD and 23 mmHg OS. Patient of Young H. Kwon, M.D., Ph.D. University of Iowa, video by Edward Sung, M.D.

PDS Pre and Post LPI: This nice clip shows many features of pigment dispersion syndrome. It also shows the changes to the iris after iridotomy.
Courtesy of: Howard Cohn, MD, American Hospital of Paris

Pigment Dispersion Syndrome with Marked Back Bowing: This young man is in his 30’s. He has had intraocular pressures as high as 32 mmHg in the right eye and 25 mmHg in the left eye. He has never been on therapy for glaucoma and currently has pressures of 17 mmHg and healthy optic nerves. He has remarkable back bowing.

Pigment Dispersion Syndrome - Iris Backbowing: 33 year-old woman with pigment dispersion syndrome.

Pigmentary Glaucoma Scheie Stripe: This 23 year-old man was diagnosed with pigmentary glaucoma one year previously. At the time of this examination he had intraocular pressures of 49 mmHg in the right eye and 42 mmHg in the left eye despite taking a beta blocker and a prostaglandin analog.

Pigment Dispersion Syndome - Scheie Stripe: 40 year-old man with a five-year history of open angle glaucoma. Was found to have pigment dispersion syndrome with a Krukenberg spindle, transillumination defects, dense angle pigmentation and a Scheie stripe.

Pigmentary Glaucoma Scheie Stripe - slit lamp: This patient was diagnosed with pigment dispersion syndrome when she was 27 years old. One year later she was diagnosed as having pigmentary glaucoma.

Sampaolesi Line Visible on Slit Lamp Exam: This patient with pigmentary glaucoma has a Sampaolesi line that is visible on slit lamp examination. He also has an excellent Scheie stripe.

Pigment Glaucoma (Burned-out): This 75 year-old woman was found to have cup-to-disc asymmetry. Her intraocular pressures were normal at 13 mmHg OD and 11 mmHg OS. She was found to have evidence of pigment dispersion syndrome and it was presumed that the optic nerve head asymmetry was from pigmentary glaucoma when she was younger.

Secondary Pigment Dispersion Syndrome: This 53 year old man had undergone phacoemulsification 9-months prior to this examination. He developed an elevated intraocular pressure that was treated with a beta blocker and a carbonic anhydrase inhibitor. On examination he was found to have 4+ angle pigmentation and transillumination defects were felt to be secondary to an intraocular lens.
Courtesy A. Tim Johnson, M.D., Ph.D. University of Iowa.

Pigment Dispersion from Angle Recession: This is a 67 year old male who has elevated intraocular pressures in both eyes, the right greater than the left. At age 13 he had severe blunt trauma to the right eye and had a very slow recovery and then a gradual decline again during his childhood. He had been treated for elevated intraocular pressure for over 20 years at the time these videos were taken. The patient has extensive angle recession and has a secondary pigment dispersion syndrome in the right eye. While his axial eye lengths are symmetrical his anterior chamber depth on the right side is deeper than the left (3.52 mm OD and 2.30 mm OS). This patient has been published: McKinney, J. K. and W. L. Alward (1997). "Unilateral pigment dispersion and glaucoma caused by angle recession." Arch Ophthalmol 115(11): 1478-9. Asymmetric pigmentary glaucoma caused by unilateral angle recession: Ritch, R. and W. L. Alward (1993). "Asymmetric pigmentary glaucoma caused by unilateral angle recession." Am J Ophthalmol 116(6): 765-6.
NOTE: This clip is presented both under pigmentary and under angle recession.

PDS with Striking Krukenberg Spindle: At age 39 this woman was seen for her pigment dispersion syndrome. She has a refractive error of -5.50 diopters and had a best corrected visual acuity of 20/30. Her optic nerve head was normal and her intraocular pressure was in a normal range on three classes of medications. This patient has the densest Krukenberg spindle that I have seen and her dense spindle may account for her 20/30 vision because her lens is perfectly clear.

PDS from Iris Cysts - 1: This 42 year-old woman had elevated intraocular pressures with evidence of pigment dispersion. Rather than having the typical slit-like defects in the pigment epithelium that one would see in pigment dispersion syndrome she had large globular areas of pigment epithelial loss and on ultrasound biomicroscopy was found to have cysts of the iris pigment epithelium pushing the pigment epithelium against the zonules. The patient is seen 6-years later at which time one of the cysts has grown large enough to reach into the pupil. You can see that she has undergone a trabeculectomy for intractably elevated intraocular pressures. The video was taken not long after her trabeculectomy, which explains the blood subconjuctivally inferiorly. This patient was reported in the Archives of Ophthalmology volume 113, pages 1574-1575, 1995.

PDS from Iris Cysts - 2: This 47 year-old man presented with bilateral narrow angles. On examination he was found to have large iris cysts of the pigment epithelium. His intraocular pressures were normal in both eyes but there were portions of his iridocorneal angle that were closed and therefore an iridotomy was performed in the left eye. This video shows the patient before and after the iridotomy. This patient also had pigment dispersion caused by abrasion of the pigment epithelium against the lens zonules.

PDS - Reverse Pigmentation: This patient was being evaluated for normal tension glaucoma at age 59. On examination, he has intraocular pressures of 12 mmHg OD and 14 mmHg OS. He has trans illumination defects of the iris and marked angle pigmentation. Note that his pigmentation is more striking superiorly than inferiorly. Dr. Robert Ritch makes the point that people who are clearing the pigmentation from their angles often have this reverse pigmentation - where there is more pigment above them below. It is not uncommon to see this in patients who are being evaluated for normal tension glaucoma. They probably have had elevated intraocular pressures when they were young adults.

PDS OD, ICE OS: At 35 years old was diagnosed with both pigment dispersion OD and essential iris atrophy OS. Her essential iris atrophy prevented her development of PDS OS.

Pigment Dispersion from Intraocular Lens: This 66-year-old man had vitreous hemorrhage from a vascular occlusive event. He ultimately underwent vitrectomy and at the time also had a lensectomy. A secondary posterior chamber intraocular lens was inserted but became dislocated. Therefore the intraocular lens was sutured to his iris with Prolene sutures. He subsequently developed ocular hypertension and was found to have marked backbowing and pigmented dispersion syndrome. There is no pigment dispersion in the opposite eye.

Pigment Dispersion Syndrome: A 27-year-old Asian man found to have ocular hypertension at age 26 with intraocular pressures of 30 mmHg OD and 26 mmHg OS.

Asymmetric Pigment Dispersion Syndrome: This patient has markedly asymmetric pigment dispersion syndrome. There is no known cause for the asymmetry. He has no history of trauma and his refractive errors (-3.35 D) are symmetric. The left eye has a larger cup and has required trabeculectomy while the right eye has been easy to control.