Plateau-iris Syndrome
Chat Highlights
March 27, 2002

Norma Devine, Editor

On Wednesday, March 27, 2002, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Plateau-iris Syndrome."

Dr. Elliot Werner:  Hello, everybody.  Happy Passover and Easter.

Moderator:  Hello, Dr. Werner.  Tonight we're discussing plateau-iris syndrome.

P:  What is plateau-iris syndrome?

Dr. Elliot Werner:  It is a type of closed-angle glaucoma that results from a particular anatomic abnormality of the iris and ciliary body.  It is different from the usual closed-angle glaucoma in that it does not respond to iridectomy.  In my experience, it is rather uncommon.

P:  I read that plateau-iris syndrome can only be diagnosed after laser or other surgery.  Is that true?  Does that mean the surgery caused it?  

Dr. Elliot Werner:  The laser iridectomy does not cause the condition.  Strictly speaking, the definitive diagnosis can only be made AFTER an iridectomy has been done, but the anatomic anomaly can be detected before iridectomy by doing gonioscopy.

P:  Mine was "suggested" before I had the laser surgery, but became more definitive after the laser surgery didn't open my angles.

P:  What are the symptoms?  

Dr. Elliot Werner:  The same as for angle-closure glaucoma.  The acute form presents with pain,  inflammation, and blurred vison.  The chronic form presents with slowly developing high pressure and visual field loss without pain.  Acute glaucomas usually have inflammation, because the sudden increase in intraocular pressure causes decreased blood flow to the iris and ciliary body.  That produces pain and inflammation.

P:  How is plateau-iris syndrome treated?

Dr. Elliot Werner:  Treatment is difficult.  Some patients respond to medication, but the response is variable.  Most patients do fairly well with filtering surgery.

P:  When I had my iridectomy, my eye was very sore for three weeks.  It felt as if it had lint in it, and sometimes I felt pain.  My doctors denied any problem, and just made me feel they never heard of anyone with problems before.  So thanks.  At least you've heard of this.

Dr. Elliot Werner:  Discomfort and inflammation are not uncommon after iridectomy.  It is unusual for that to continue for three weeks, but it happens.  Again, you need to consider the risk of blindness from your disease versus the inconvenience of treatment.  Most medical treatments are unpleasant to some degree, but the disease, untreated, is usually worse.

P:  Is myopia a risk factor for plateau-iris syndrome?

Dr. Elliot Werner:  I don't know.  You usually don't see the condition in myopes, so I doubt it.

P:  Are miotics used in the treatment of plateau-iris syndrome?

Dr. Elliot Werner:  Miotics will sometimes work, if the angle is not permanently closed.  The same is true of iridoplasty, which works quite well in some patients.

P:  I've been lucky so far -- no medications and I had iridotomies in both eyes and an iridoplasty in one eye.

P:  What kind of abnormality does the iris have?  Is it easy to detect?  

Dr. Elliot Werner:  Actually, the iris is normal.  It is the ciliary body that is abnormal and produces an alteration in the configuration of the iris.  The ciliary body is placed more anteriorly than normal.  This pushes the peripheral part of the iris up into the angle.  The appearance on gonioscopy is characteristic.  This is a very difficult topic to discuss without pictures.

P:  What is the ciliary body?  If you were to look right at the eye, does the abnormality go all the way around?

Dr. Elliot Werner:  That's what I mean about trying to explain this without pictures.  The ciliary body is a ring-like structure located just behind the peripheral part of the iris. It is not normally visible, even during an eye exam.  The ciliary body produces the aqueous humor, and the muscles of the ciliary body are responsible for accommodation, focusing the lens of the eye.

P:  Where is the actual plateau?  Around the periphery of the iris?  Does it face anteriorly or posteriorly?

Dr. Elliot Werner:  It is called "plateau" because on gonioscopy the central iris is flat, like a plateau, and the peripheral iris has a very steep curvature into the angle.

P:  Is there also a risk of the pupil coming into contact with the lens due to the plateau?

Dr. Elliot Werner:  The iris, whether plateau or not, is normally in contact with the lens.  That is not a problem.  In the usual type of angle-closure glaucoma, the problem is excessive iris-lens contact.  Iris-lens contact is not a problem in plateau-iris syndrome.

P:  If pilocarpine opens the angle from grade 1 to grade 2, would that be a good thing?

Dr. Elliot Werner:  Yes. Pilocarpine pulls the iris out of the angle and will open a plateau iris somewhat.  Unfortunately, pilocarpine has a lot of side effects and many patients cannot tolerate long-term use.

P:  What are the side effects of pilocarpine?

Dr. Elliot Werner:  Blurred vision, dim vision, eye and head pain, increased myopia (nearsightedness) and poor night vision.

P:  Despite the potential side effects of pilocarpine, would you agree it is the best medication for lowering intraocular pressure? 

Dr. Elliot Werner:  No.  Most studies have shown that Xalatan and the other prostaglandins are more effective than pilocarpine; timolol and other beta blockers are also effective.

P:  On the positive side regarding pilocarpine:  When I'm in a dimly lit restaurant, I can read the menu without putting on reading glasses!

P:  Have any long-term studies been done on plateau-iris syndrome?

Dr. Elliot Werner:  Not to my knowledge.  It is a rather uncommon condition, so it is tough to get a large series of patients.

P:  Are you able to detect this condition by just looking at the eye without using instruments?

Dr. Elliot Werner:  Not really.  You have to use a gonioscope.

P:  Rather than using filtering surgery to correct plateau-iris syndrome, could the ciliary body be repositioned?

Dr. Elliot Werner:  No, the ciliary body is a large and vital structure that cannot be altered surgically. 

P:  Approximately how many patients do you see with this syndrome in a year?

Dr. Elliot Werner:  I have seen perhaps one or two in the past year with plateau-iris angle closure.

P:  How old were they?

Dr. Elliot Werner:  I don't remember exactly.  Probably 40 to 60 years old. 

P:  So it's pretty rare?  Were those patients Caucasian?  

Dr. Elliot Werner:  Plateau iris syndrome is uncommon, and I don't know of any information on frequency and different ethnic or racial groups.  Angle-closure of the typical type is more common in Asians and Inuit (Eskimo), and angle-closure is less common in African-Americans.  Whites fall in the middle. 

P:  Is plateau iris syndrome more common in younger patients?

Dr. Elliot Werner:  I'm not sure. It is an anatomic anomaly, so it is probably present from a young age.  But you rarely see the angle closure develop before adulthood.

P:  I had an iridectomy for narrow-angle glaucoma and now see a white horizontal line when in the light.  Have you ever heard of this?  I also see the line sometimes with headlights.  It is very narrow. 

Dr. Elliot Werner:  That's because of  the myopia and pinhole effect from the small pupil.  Not all side effects are harmful.

P:  I have an appointment at Wills Eye Institute next week for an opinion.  The doctors here have never heard of the white line I see.  It makes me feel better that you have.  The doctors I've seen make me feel that I am making it up. 

Dr. Elliot Werner:  Who are you seeing at Wills?

P:  I didn't know who to see, but decided on Dr. George Spaeth.  Any suggestions would be appreciated.  I have Personal Choice insurance, so I can see anyone.

Dr. Elliot Werner:  You made a good choice.  

P:  I'm afraid to have an iridectomy performed in my other eye.  Was it the angle of the hole?  Can anything be done?

Dr. Elliot Werner:  We usually try to make the iridectomy under the upper eyelid to avoid this problem, but sometimes it occurs anyway.  You need to weigh the risks of permanent blindness from your disease versus the inconvenience of the treatment.  

P:  How often should gonioscopy be performed on a patient with plateau-iris?

Dr. Elliot Werner:  If nothing is happening, probably once a year is adequate.  If there are problems controlling pressure, more frequent gonioscopy may be needed.

P:  Are women more prone to this type of syndrome?

Dr. Elliot Werner:  Not that I know of.  My two most recent cases were both men, one white, one black.

P:  Does the long-term use of the maximum number of glaucoma medications have any connection to this condition?

Dr. Elliot Werner:  Probably not.  This is a kind of deformity of some of the structures of the eye.  It is probably hereditary.

P:  Can a cyst on the iris or ciliary body cause this syndrome?  If so, can the cyst be drained?

Dr. Elliot Werner:  Iris cysts or tumors can rarely cause a similar picture, but they tend to be localized -- that is, around the entire circumference.  Cysts or tumors of the ciliary body can be surgically managed.

P:  Are iris cysts common with this type of glaucoma?  A doctor I went to for a second opinion about synechiae said he thought there could be iris cysts due to some scalloping he noticed during gonioscopy.  He didn't recommend any follow up, so I don't know if this is anything to be concerned about.

Dr. Elliot Werner:  Iris cysts are very rare as a cause of glaucoma.  The definitive diagnosis would be made with ultrasound or some form of imaging.

P:  I had UBM (ultrasound biomicroscopy) about four years ago when I was first diagnosed.  There was no mention then of cysts.  Should I have the test repeated?  

Dr. Elliot Werner:  It wouldn't hurt, but if it was negative the first time, you probably don't have anything to worry about.

P:  One time my eye was hurting so much I had to put ice on it.  They had attempted to blast through some scar tissue.

Dr. Elliot Werner:  I hate glaucoma and what it does to people.  There is good evidence that simply informing people that they have glaucoma has a significant deleterious effect on their quality of life and sense of well being.

P:  Doctor, thanks for your understanding of our problems with glaucoma.

Dr. Elliot Werner:  My mother had bad glaucoma, so I have a little insight, personally, into its effects on families.

Moderator:  Is that why you specialized in glaucoma?

Dr. Elliot Werner:  No.  I went into glaucoma before she developed the problem.  In fact, I made the diagnosis, but sent her to someone else for treatment.

P:  A young glaucoma specialist who is also a glaucoma patient used to join us occasionally in the chat room on Monday nights.  He specialized in glaucoma after he became a glaucoma patient.  We felt he empathized with us, too.

P:  Thanks for an informative chat.  As a Wills eye patient, I thank you for your expertise.

P:  Thanks for making me feel that I'm not insane for seeing lines.  Thanks for your understanding.

Dr. Elliot Werner:  You're welcome.  Well, it's 9:30 p.m.  Have a great holiday everybody.  See you at the end of April. 

Moderator:  Thank you, Dr. Werner.  We look forward to your next visit.

End of highlights for March 27, 2002.

On April 3, Dr. Wilson discussed "Ocular Hypertension" in the Chat room. Click here for highlights of that meeting.

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