Treatment Plan

P-S: I Don't Love You

By Leo Semes, OD, FAAO

A 58-year-old African-American man was referred from a community health screening for evaluation of corneal edema and elevated intraocular pressure (IOP) in his left eye. His history was vague but included reduced vision OS (20/400). The right eye was uninvolved and correctable to 20/20.

Upon examination, I noted mild corneal edema, a significant posterior subscapular cataract, and endothelial deposits (keratic precipitates) OS. A mild anterior-chamber reaction noted at the screening was not present at this examination. IOPs were 16mmHg OD and 49mmHg OS. The anterior chamber angle of the left eye was open but copiously invested with pigment. Peripheral anterior synechiae were absent. The pupil of the left eye was minimally reactive, and the posterior pole was not visualized.

To reduce the IOP OS, I administered 500mg acetazolamide and two drops of 0.5% apraclonidine (Iopidine, Alcon). By the end of the examination, the IOP had decreased to 29mmHg. I diagnosed Posner-Schlossman (P-S) syndrome and asked the patient to return the next morning for follow up.

Posner-Schlossman Syndrome

Posner and Schlossman first described this syndrome in 1948. They reported the commonalities of increased IOP and an anterior chamber reaction, which normalized when treated. This was about 14 years before “PS: I Love You” appeared as the B side of the Beatles' single “Love Me Do,” which was released on Oct. 5, 1962.

Glaucomacyclitic crisis is a more clinically descriptive term for this constellation of findings— mild irritative symptoms, corneal edema of varying degrees, endothelial keratic precipitates, and elevated IOP—that recurs in patients between 20 and 50 years of age.

This case was somewhat unusual in that there was significant lenticular involvement, which may have been the result of previous episodes of the inflammatory glaucoma or treatment with topical steroids.

Treatment Recommendations

Various topical and oral agents may be used to treat P-S syndrome, including:

• topical steroids
• topical antiglaucoma drops (Avoid beta-blockers in patients who have asthma.)
• systemic carbonic anhydrase inhibitors
• topical or oral nonsteroidal anti-inflammatory drugs.

Acute presentations of elevated IOP respond better to topical apraclonidine than do cases of primary open-angle glaucoma (Hong and Song, 1993).

Some sources suggest that mild elevations of IOP for short durations do not pose a threat to vision (Darchuk et al 2001), but others have documented irreversible damage to the optic nerve head (Jap et al, 2001). The differences in these conclusions may be related to the number or frequency of the episodes, the duration of follow up, or the fact that more patients were studied in the latter study (n=55).

I decided to offer treatment to this patient because this was his first visit to the clinic in a context of reduced visual acuity and elevated IOP.

Long-Term Management

Although P-S syndrome is typically thought to be benign, repeated episodes or more frequent attacks may produce glaucomatous visual field loss and optic nerve damage. Reducing IOP is the primary treatment goal. Informing the patient of the symptoms is another important aspect of management. My patient has not been evaluated for optic disc or visual field damage because of the presence of significant lens opacity, but follow up is planned.

For further insights, I recommend an excellent review by Green (2007) and a paper by Kongyai et al (2012), which suggests a viral association. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #199.