May be very mild early in course. Moderate pain, red eye, and photophobia may develop. Classically follows incisional (e.g., cataract, glaucoma, retinal) or laser surgery in eyes with small anterior segments (e.g., hyperopia, nanophthalmos) or with primary angle closure glaucoma. May occur spontaneously or be induced by miotics.
Critical
Diffusely shallow or flat anterior chamber and increased IOP in the presence of a patent PI and in the absence of both a choroidal detachment and iris bombé. IOP may not be significantly elevated, especially early in the presentation.
Believed to result from anterior rotation of the ciliary body with posterior misdirection of the aqueous; aqueous then accumulates in the vitreous resulting in forward displacement of the ciliary processes, crystalline lens, intraocular implant, or the anterior vitreous face, causing secondary angle closure. Newer theories point toward choroidal expansion, reduced conductivity of fluid through vitreous, and reduced trans-scleral fluid movement as factors in development.
If the attack is broken (anterior chamber deepens and IOP normalizes), continue atropine 1% daily, indefinitely. At a later date, perform PI in the contralateral eye if the angle is occludable.
If steps 1 through 6 are unsuccessful, consider one or more of the following surgical interventions to disrupt the anterior hyaloid face in an attempt to restore the normal anatomic flow of aqueous. Ultimately, the goal is to create a unicameral eye:
NOTE: |
An undetected anterior choroidal detachment may be present. Therefore, a sclerotomy to drain a choroidal detachment may be considered before vitrectomy. |