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Year : 2016 | Volume : 4 | Issue : 3 | Page : 177 - 178  


Case Reports
Posner Schlossman Syndrome - A Case Report

Arvind Rathod

Assistant Professor, Department of Ophthalmology, Prathima Institute of Medical Sciences, Karimnagar, Telangana

Corresponding Author:

Dr. Arvind Rathod,                                                                              Received: 14-12-2015

Email: arvind_kmc@yahoo.co.in                                                           Accepted: 08-05-16

Abstract:

A 23 year old female patient presented to Ophthalmology OPD with complaints of left sided headache since one month, it was sudden in onset and was associated with redness, watering, photophobia and blurring of vision. There were about 8-10 episodes, each lasted for 1-2 days with asymptomatic period between the attacks. Left eye showed fine keratic precipitates with grade 2 flare and cells in anterior chamber. Pupils were mid-dilated and sluggishly reacting. IOP in left eye was 38 mmHg. Patient was started on topical steroids, oral Acetazolamide and topical anti glaucoma medication. Patient was followed after 3 days, showed decrease in inflammation and IOP of 22.00mm Hg in left eye, Gonioscopy revealed open angles and Humphreys visual field test showed no obvious visual field defects. Dilated fundus examination showed normal optic discs. Patients were followed regularly for IOP and any obvious optic disc and visual field defects.

Key words: Posner Schlossman syndrome, Glaucomatocyclitis crisis, Intraocular pressure (IOP), Inflammation, Visual field

 

INTRODUCTION:

Posner and Schlossman first reported 9 patients who suffered from recurrent unilateral attacks of ocular hypertension with mild anterior chamber inflammation and coined the term Glaucomatocyclitis crisis in 1948.[1] [2]

It was characterized by unilateral recurrent attacks of mild discomfort and blurring of vision. Mild anterior chamber reaction or fine keratic precipitates with increased intraocular pressure and open angles on Gonioscopy. Crises lasting for several hours to weeks with normal intraocular pressure and no signs of inflammation between the attacks. Visual field and optic discs appear to be normal.

Treatment of Posner Schlossman syndrome is aimed at controlling intraocular pressure and decreasing inflammation. Topical Beta-blocker such as Timolol, Alpha- agonists such as Brimonidine, Apraclonidine and Carbonic anhydrase inhibitors such Dorzolamide and oral Acetazolamide can be used as first line agents.[3][4] Topical steroids are used to control the inflammation. Posner Schlossman syndrome was thought to be benign disease as most of the patients recover without long term sequelae, however a number of patients with repeated attacks, even on treatment showed glaucomatous changes of the optic disc and visual fields. [5] Trabeculectomy may be considered, if IOP cannot be controlled with maximum medical therapy or signs of glaucomatous optic nerve damage and visual field defects appear. [6]

CASE REPORT:

A 23 year old female patient presented to ophthalmology OPD with complaints of left sided headache since one month, it was sudden in onset and was associated with redness, watering, photophobia and blurring of vision. There were about 8-10 episodes, each lasted for 1-2 days with asymptomatic period between the attacks. Patient had consulted a .ophthalmologist who advised her oral analgesics and topical antiglaucoma drugs and referred to us for further management. On examination BCVA in RE was 6/6 and in LE was 6/9-. Slit lamp examination showed normal anterior segment findings in RE. In left eye there was mild lid edema, conjunctival congestion, mild corneal edema, fine keratic precipitates in inferior part of cornea. Peripheral anterior chamber depth was more than half of corneal thickness and anterior chamber showed grade 2 flare and cells. Pupil was middilated and sluggishly reacting. IOP in right eye was 18mmHg and in left eye was 38 mmHg. Patient was provisionally diagnosed as Posner Schlossman syndrome and started on oral Acetazolamide, 250mg 3 times a day, topical anti glaucoma medication Brimonidine eye drops 3 times a day, and topical steroids every 2 hourly in left eye and followed after 3 days. On follow up patient was symptomatically better and there was decrease in signs like lid edema, conjunctival congestion, corneal edema and anterior chamber inflammation. IOP was 14.00mmHg in right eye and 22.00mmHg in left eye. Gonioscopy revealed open angles and Humphrey’s visual field test showed no obvious visual field defects. Dilated fundus examination was done which showed clear media and normal optic disc, macula and peripheral retina. Patient was again followed after 1 week, on examination both eyes anterior segment were within normal limits. IOP was 14 and 16 mm of hg in right and left eye respectively. Patient was advised to continue topical antiglaucoma medication and topical steroids were tapered over a period of month. Patient was followed regularly for IOP measurement and any signs of inflammation. Gonioscopy, Humphrey’s visual field test and dilated fundus examination was repeated every 6 months for any glaucomatous optic disc changes and visual field defects. On repeated follow-ups patients IOP was within normal limits and there was no obvious optic disc and visual field defects.

DISCUSSION:

Posner Schlossman syndrome is a rare disease with recurrent, acute, unilateral raised intraocular pressure and mild intraocular inflammation. It typically affects patients between second and fourth decades.

Patient presented here was a 23 year old female with typical history of recurrent attacks with asymptomatic period between the attacks. Typical clinical signs of increased IOP, mild anterior chamber reaction and response to topical steroids and antiglaucoma medications helped in clinching the diagnosis of Posner Schlossman syndrome.

Diagnosis of Posner Schlossman syndrome can be easily missed because of the mild inflammatory nature of the disease. [7] Posner Schlossman syndrome should be differentiated from Acute angle closure glaucoma, Primary open angle glaucoma and Fuchs heterochromic uveitis. Acute angle closure glaucoma was ruled out as Gonioscopy revealed open angles. Primary open angle glaucoma was ruled as signs of inflammation are usually absent and it is typically a bilateral disease with raised IOP, open angles, optic disc and visual field changes. Primary open angle glaucoma is commonly seen in older age group patients. Fuchs heterochromic uveitis can be ruled out due to absence of heterochromia and stellate keratic precipitates.

Posner Schlossman syndrome responds well to topical steroids and antiglaucoma medications. Systemic antiglaucoma agents like Hyperosmotic agents and Carbonic anhydrase inhibitors can be used to reduce IOP in acute attacks. [8] Trabeculectomy may be done, if IOP is not under control with maximum medical therapy and patient developing glaucomatous optic disc damage and visual field defects. Jap A reported that patients with Posner Schlossman syndrome may develop secondary chronic open angle glaucoma. 26.4% of 53 cases of Posner Schlossman syndrome developed secondary chronic open angle glaucoma. Patients with more than 10 years of repeated attacks have 2.8 times more risk of developing glaucoma.

CONCLUSION:

Presenting here is a rare case of Posner Schlossman syndrome in a young female and the need of follow up regularly to check for any glaucomatous changes.

REFERENCES:

  1. Posner Schlossman syndrome A. “Syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms.” Archieves of Ophthalmology.1948 Apr: 39(4):517-35.
  2. Posner Schlossman syndrome A. “Further observation on the syndrome of glaucomatocyclitis crisis.” Trans Am Acad Ophthalmol Otolaryngol.1953:57:531.
  3. Muthusamy P.”Apraclonidine in the management of glaucomatocyclitic crisis”. Eye. 1994:8(Pt3):367-8.
  4. Hong C, Song KY. “Effect of apraclonidine hydrochloride on the attack of Posner Schlossman syndrome.” Korean Journal of Ophthalmol.1993 Jun: 7(1):28-33.
  5. Jap A, Sivakumar M, Chee SP. “Is Posner Schlossman syndrome benign?” Ophthalmology. May 2001:108(5):913-8.
  6. Hung PT, Chang JM. “Treatment of glaucomatocyclitic crises.” American journal of ophthalmology. 1974:77:169-172.
  7. Green RJ. Posner Schlossman syndrome. Clinical Experimental optometry 2007; 9053-56
  8. Kanski J. Clinical ophthalmology. A Systematic Approach 6th Edition London Butterworth Heinemann Elseiver. 2007.





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