Glaucomatocylitic crisis is an acute secondary open angle glaucoma, and refers to the association of glaucoma with cyclitis. Typically there is a mild anterior uveitis associated with a marked elevation in intraocular pressure (IOP). The condition is usually unilateral and is typically seen in young adult to middle aged patients. It may be recurrent, always afflicting the same eye, with further episodes occurring within a few months or several years after the initial attack, although recurrences are uncommon in elderly patients. The duration of attacks may be several hours or weeks and treatment seems to neither shorten each episode nor prevent recurrences. The pathology of the disease is not well understood and it has been suggested that the rise in IOP is due to trabeculitis.
There may be diminished vision and disproportionately mild discomfort considering the degree to which IOP can be elevated. Photophobia and rainbow haloes around lights are often present.
IOP is frequently very high, perhaps reaching 60mmHg. Conjunctival hyperaemia is minimal although ciliary injection may be present. Gonioscopy reveals open angles. The corneal epithelium may be edematous and there is a slight anterior chamber reaction with a few cells and trace flare. Small, fine keratic precipitates are few in number and typically disposed inferiorly on the corneal endothelium (sentinel KP). There is an absence of synechiae, either posterior or peripheral anterior. Repeated attacks can lead to pathological cupping of the optic disc and visual field loss. The other eye remains normal.
Glaucomatocyclitic crisis is rare.
The condition should be distinguished from acute closed angle glaucoma and other glaucomas of inflammatory origin such as inflammatory open angle glaucoma and that seen as a sequela to Fuchs’ heterochromic iridocyclitis. Glaucoma in pigmentary dispersion syndrome and neovascular glaucoma are other differential diagnoses.
The idiopathic recurrent nongranulomatous anterior uveitis and acute ocular hypertension occur in self-limiting episodes, lasting hours to weeks. Treatment is aimed at protecting the optic nerve and visual fields.
Threshold visual field assessment is indicated.
Topical and Oral Medication
A topical corticosteroid such as prednisolone acetate 1% q.i.d. or a non-steroidal anti-inflammatory (NSAID) can be used to control the anterior uveitis, together with a topical cycloplegic in the symptomatic patient, although some consider the latter to be unnecessary. An oral non-steroidal anti-inflammatory (indomethacin) may also help control the inflammation and IOP. Topical aqueous suppressants such as beta blockers (e.g timolol 0.5% b.i.d.), alpha agonists (e.g. apraclonidine 0.5% t.i.d.) and carbonic anhydrase inhibitors are often required for the marked elevation of IOP. If IOP increase is persistent, systemic carbonic anhydrase inhibitors and hyperosmotic preparations may be considered. Topical miotics, prostaglandins and argon laser trabeculoplasty are contraindicated.
Cases that are refractory to medical management may require a filtering procedure.
Initially, the patient should be reviewed every few days until the condition is under control. Careful follow up with serial optic nerve head and threshold visual field evaluations is important, not only in terms of glaucomatocyclitic crisis, but also because both eyes are at an increased risk of developing primary open angle glaucoma.
Corneal epithelial edema and fine keratic precipitates in glaucomatocyclitic crisis. Figure courtesy of Kanski JJ. Clinical ophthalmology, 5th edition, Elsevier, Oxford 2003.