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Photo Quiz: Peaked Pupil
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Clinical Questions
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A 76-year-old white man was referred to ophthalmology clinic for evaluation of a peaked pupil (Figure). He has no ocular or systemic complaints and no history of trauma. He has no past ocular history other than moderate myopia that corrects to 20/20 in each eye. His intraocular pressure is 16 to 17 mm Hg in each eye.
Diagnosis
This patient has pigment dispersion syndrome. The color photo from the back cover shows profound iris transillumination defects, and slit lamp examination of the corneal endothelium revealed a Krukenberg’s spindle. On gonioscopy, the patient had an extremely open angle with a heavily pigmented trabecular meshwork, also known as a “mascara line.”
Imaging
The imaging test of choice to assist in diagnosis is ultrasound biomicroscopy (UBM). The UBM shown in the figure to the right demonstrates the posterior bowing of the iris and illustrates how the pupil acts as a one-way valve, creating the reverse pupillary block seen in this condition. The posterior bowing of the iris combined with the posterior iris chafing (as illustrated by the iris transillumination defects on the color photograph that are most prominent at 12:00 and 6:00) are so severe in this patient that the pupillary contour is distorted, resulting in a peaked pupil.
Note the posterior bowing of the iris in this patient with pigmentary dispersion syndrome.
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