Glaucomatocyclitic Crisis & Other Inflammatory Glaucomas
Chat Highlights
January 2, 2008

On Wednesday, January 2, 2008, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucomatocyclitic Crisis & Other Inflammatory Glaucoma".

Moderator:  Before we begin, I'd like to announce that this is Dr. Wilson's last chat. He's been our chat host since the beginning of the chat room in 1998 and has provided a wonderful service all this time educating patients about glaucoma in this unique forum.

Dr. Wilson, we'll miss you. Thank you. We hope you'll return sometimes as a special guest.

Dr. Wilson:   Thank you. It has been my pleasure and I hope to support Dr. Mike Pro and the other members of the Glaucoma Service as we go forward.

Moderator:  Tonight our topic is “Glaucomatocyclitic Crisis & Other Inflammatory Glaucomas”. This topic was suggested by one of our chat participants via email.

First of all, what is glaucomatocyclitic crisis and what are its symptoms? It sounds like an emergency. Is it?

Dr. Wilson:  Glaucomatocyclitic crisis refers to a period of elevated IOP (IntraOcular Pressure) with mild inflammation of the anterior chamber. It is a rare condition and is also known as Posner-Schlossman Syndrome. The symptoms are related to the inflammation in the eye although pain may occur from pressure if it is in the 50's and 60's. Usually the external eye is red with the redness concentrated around the cornea. The vision is often slightly blurred or "glare-y" and the pupil may be small. The patient may be sensitive to light. It is usually not an emergency but should be addressed promptly. [Please note: light sensitivity is not related to the size of the pupil.]

More often than not, with glaucomatocyclitic crisis, the symptoms are minimal even though the IOP may be in the 50's. It's also not unusual for IOP to be lower, in the 30's or 40's.

An episode may last for several weeks but usually resolves on its own. The main treatment is to rid the eye of inflammation as quickly as possible and lower IOP to limit damage.

P:   What are possible causes of inflammation?

Dr. Wilson:  The most common causes are: herpetic 22%, Fuchs’ iridocyclitis 19% , Juvenile Rheumatoid Arthritis 16%, syphilis 14%, sarcoid 12% [ref: Christopher Girkin]

P:  Is glaucomatocyclic crisis diagnosed by tests, observation, or ruling out other ocular disease?

Dr. Wilson:  Glaucomatocyclitic crisis has the presentation I mentioned above, especially with the high pressure being in one eye only without much in the way of signs or symptoms. If we rule out the other causes of one-eyed glaucoma, especially inflammatory glaucoma, then we are left with glaucomatocyclitic crisis.

P:  Is the first course of action with any inflammation of the eye treating the inflammation?

Dr. Wilson:  One should start treatment for inflammation and IOP concurrently. But you are right in the sense that treating the IOP alone in almost all the inflammatory glaucomas except glaucomatocyclitic crisis means you are not treating the root cause of the disease, which will probably continue to fester.

P:  How do you treat the root cause of glaucomaticyclic crisis?

Dr. Wilson:  The root cause is not completely understood. When I retired, it was thought to be an inflammation of the trabecular meshwork that was usually self-limiting. We treated the inflammation as above.

P:  Does that mean glaucomatocyclitic crisis is inflammation of the trabecular meshwork? Didn't you say earlier that it involves the cornea??

Dr. Wilson:  There may be small deposits of inflammatory cells on the inferior cornea called keratitic precipitates but usually these are on the trabecular meshwork and hard to see in glaucomatocyclitic crisis.

P:  Can surgery help with inflammation or will that make the inflammation worse?

Dr. Wilson:  Unless the inflammation is due to a foreign body or lens material, etc. that can be removed, surgery has little effect on the inflammation.

P:  Can one have this inflammatory crisis and not have optic nerve damage?

Dr. Wilson:  Yes, especially if the episode is not very long. Remember however that a high IOP over a short term usually causes pallor of the optic nerve and not cupping so you cannot judge the damage by cupping, but only by a visual field that doesn't show damage until 35 to 50% of the nerve has been injured.

P:  What is pallor and how do you assess it?

Dr. Wilson:  Pallor is a paleness of the optic nerve head that is seen at the back of the eye. Assessment of it is totally subjective.

P:  What is "not very long" in this context?

Dr. Wilson:  3 to 6 weeks

P:  Could long-term dry eye be misdiagnosed as glaucomaticyclic crisis?

Dr. Wilson:  No.

P:  Dr., I was diagnosed with Opthalmic Herpes Zoster 6 years ago and it resolved after 6 weeks standard treatment including valtrex. Three months ago I was diagnosed with glaucomatocyclitic crisis. Could it be a reoccurrence of Zoster?

Dr. Wilson:  It certainly sounds as if it might be.

P:  How long will you let a patient with uveitic glaucoma go with pressures in the 25-35 mm range? I see halos in the morning and worry that this is due to high pressure, likewise with an astigmatism that has gotten worse.

Dr. Wilson:  With inflammatory glaucoma, the doctor doesn't know what pressure will be tolerated. An extraordinary amount of damage can be done more quickly than usual in people who are very susceptible to IOP but don't have a track record like someone with ocular hypertension moving over into glaucoma. Therefore most doctors will just get the IOP down into the normal range, i.e. under 22. I would not leave someone whose tolerance of elevated IOP I don't know in the upper 20s or lower 30s unless I could not control them with medication.

One would think that an elevated IOP might flatten out the astigmatism slightly so I am baffled why the astigmatism is worse. I worry that the halos are due to elevated IOP pushing fluid into the cornea.

P:  Are there other reasons for halos other than high pressure?

Dr. Wilson:  Contact lenses are a common cause usually due to wearing them too much or tightness. LASIK can also be a cause. Halos refer to colored rainbows around a point source of light - not radiating spokes of light.

P:  What's the next step if you can't get the pressure below 25 with medication?

Dr. Wilson:  If the IOP remains elevated and shows no signs of gradually decreasing, then surgery may be necessary. In patients with chronic inflammation, I find that an aqueous shunt provides the best long-term control.

P:  What medication would be used to reduce the inflammation.

Dr. Wilson:  Usually topical steroids possibly with non-steroidal anti-inflammatory drugs. Occasionally shots of steroids around the eye or in the eye possibly combined with systemic steroids may be necessary.

P:  What's the typical long-term prognosis for a patient diagnosed with uveitic glaucoma under age 40?

Dr. Wilson:  It depends dramatically upon the cause of the inflammation. Usually glaucomacyclitic crisis glaucoma has a more benign course than say a herpetic inflammatory glaucoma or a Fuchs heterochromic iridocyclitis.

P:  How do you differentiate between the glaucomacyclitic crisis and herpetic inflammatory glaucoma?

Dr. Wilson:  Usually glaucomacyclitic crisis is only in one eye whereas herpetic disease may be in both, but the main way is the patient generally has had a herpetic infection in the eye before the glaucoma develops.

Moderator:  That was the last question folks. And we bid Dr. Wilson a fond farewell and happy retirement. Hope to see him sometimes as a SPECIAL guest!

On January 16, Dr. Pro discussed "Glaucoma and Blepharitis" in the Chat room. Click here for highlights of that meeting.

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