Bilateral acute angle closure glaucoma as a presentation of isolated microspherophakia in an adult: case report
© Kaushik et al; licensee BioMed Central Ltd. 2006
Received: 12 May 2006
Accepted: 07 July 2006
Published: 07 July 2006
Bilateral simultaneous angle closure glaucoma is a rare entity. To our knowledge this is the first reported case of bilateral acute angle-closure glaucoma secondary to isolated microspherophakia in an adult.
A 45-year-old woman presented with bilateral acute angle closure glaucoma, with a patent iridotomy in one eye. Prolonged miotic use prior to presentation had worsened the pupillary block. The diagnosis was not initially suspected, and the patient was subjected to pars-plana lensectomy and anterior vitrectomy for a presumed ciliary block glaucoma. The small spherical lens was detected intraoperatively, and spherophakia was diagnosed in retrospect. She had no systemic features of any of the known conditions associated with spherophakia. Pars-plana lensectomy both eyes controlled the intraocular pressure successfully.
This case demonstrates the importance of considering the diagnosis of isolated microspherophakia in any case of bilateral acute angle closure glaucoma. Lensectomy appears to be an effective first-line strategy for managing these patients.
Bilateral simultaneous acute angle closure is a rare entity, infrequently reported after psychotropic drug intake, [1–3] general anesthesia,  or snake bite . Spherophakia is an uncommon condition in which the small, spherical lens may led to pupillary block and secondary angle closure glaucoma. We present a case of isolated microspherophakia presenting as bilateral acute angle-closure glaucoma in a middle-aged woman.
The patient was given Injection Mannitol 20% 350 ml stat. followed by systemic acetazolamide 250 mg four-times-a day, Syrup Glycerol 30 ml thrice-a-day, topical timolol maleate 0.5% twice-a-day and Brimonidine 0.15% twice-a-day. Pilocarpine was withheld since the iris-lens diaphragm was anteriorly displaced. The IOP reduced to 34 and 38 mmHg respectively.
This response to cycloplegic treatment strengthened the possibility of a ciliary block glaucoma, and the patient underwent a pars-plana lensectomy and anterior vitrectomy (PPL-AV) in the left eye. Intraoperatively, under pupillary dilatation, the lens was found to be small and spherical (Fig 4, top right), suggestive of microspherophakia. Following surgery (Fig 4, bottom left), the IOP reduced to 12 mm Hg without medication with total relief of symptoms.
The right eye was re-examined under dilatation. The lens was small and spherical with the lens edge seen within the pupillary margin (Fig 4, bottom right). Microspherophakia was diagnosed in retrospect, with prolonged inverse angle closure glaucoma. We assessed the patient with particular reference to systemic conditions associated with spherophakia, such as Weill-Marchesani's syndrome, Marfan's syndrome and homocystinemia. She was of average height (155 cm), and moderately built. She had normal skeletal proportions with no evidence of arachnodactyly, short and stubby fingers or reduced joint mobility. There was no anterior chest deformity or scoliosis. The cardiovascular examination was within normal limits. Urine chromatography for homocystinuria was negative.
Despite our best efforts, the patient could not be contacted in rural Nepal for subsequent follow-ups. This also resulted in our inability to obtain informed consent from the patient for publication of this case report.
This is the first reported case of microspherophakia presenting as bilateral simultaneous acute angle closure glaucoma in an adult. The condition has been reported in a child,  where the underlying cause was unsuspected, and Pilocarpine aggravated the pupillary block, as was probably the situation in our patient. Microspherophakia is usually associated with systemic disorders such as Weill-Marchesani's' syndrome, homocystinemia, Marfan's syndrome, Alport's syndrome and Klinefelter's syndrome [9–12]. Our patient had no features suggestive of any of these conditions. Glaucoma in isolated microspherophakia is less commonly described [11, 12]. It can result from several mechanisms: pupillary block by the spherical lens, irritation of the ciliary body by the dislocated lens , or by complete luxation of the lens in anterior chamber. Unrelieved pupillary block may lead to peripheral anterior synechiae (PAS) formation and irreversible trabecular damage. Chronic pupillary block without complete angle closure may lead to crowding of the trabeculae by the spherophakic lens .
Our patient presented with bilateral acute angle closure secondary to pupillary block, which was worsened by miotics and relieved to some extent by cycloplegic treatment. Urbanek  described this phenomenon as inverse glaucoma. We did not suspect spherophakia initially, given the age group (most patients present in adolescence or early adulthood), [8, 15–17] and her presentation as bilateral acute angle closure glaucoma with dilated iris vessels simulating iris neovascularization. The anteriorly displaced lens-iris diaphragm and the extensive irido-lenticular contact seen on the UBM prompted a consideration of malignant glaucoma following prolonged angle closure. Malignant glaucoma has been described without a history of laser or surgery [18, 19], and after prolonged miotic use for angle closure glaucoma [6, 7]. The partial resolution of her condition seen after atropine treatment for the presumed ciliary block further consolidated our suspicion. Inverse glaucoma would respond in an identical manner, which in fact was what happened in our patient. Spherophakia was diagnosed only in retrospect, once we visualized the lens edge within the dilated pupil during the lensectomy procedure.
The management of glaucoma in spherophakia is still debated. Willoughby et al  described a case of spherophakia with glaucoma whose IOP could be successfully controlled without additional medication following lensectomy. In contrast, Yasar  described a patient in whom lensectomy could control the IOP in the short-term, but who subsequently required mitomycin-C augmented trabeculectomy in both eyes. Kanamori et al  reported good IOP control with goniosynechiolysis and lensectomy in a patient of spherophakia and chronic angle closure glaucoma. Asaoka et al  reported trabeculectomy to control the IOP in a patient with spherophakia, but open angles.
The IOP in our patient remained controlled without medication for the six weeks that we could follow her up, before she went back and never returned. The angles did appear to have opened partially, but it must be kept in mind that although lensectomy will relieve a pupillary block, it may not suffice to control the IOP in case of the presence of extensive PAS. Only longer follow-up can indicate how effective this procedure would be for our patient.
It is important to include spherophakia in the differential diagnosis of bilateral narrow angle glaucoma in adults, and remember that prolonged miotic therapy may lead to worsening of the condition. Pars-plana lensectomy appears to be a reasonable first-line treatment strategy for the glaucoma. The possibility of uncontrolled IOP despite lensectomy must be kept in mind, especially in the presence of extensive peripheral anterior synechiae.
- 1. IOP:
- 2. PAS:
Peripheral Anterior Synechiae
- 3. UBM:
- 4. PPL-AV:
Pars-plana lensectomy and Anterior Vitrectomy
We acknowledge the help of the Dr. Pranab Das who helped in patient management while she was admitted with us, and the help rendered by the Secretarial staff of the Department of Ophthalmology for use of their computers to finalize this manuscript.
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