PUBLICATION EXCLUSIVE: Man presents with sudden bilateral angle closure and myopic shift

A 40-year-old male airline pilot with no significant medical or ocular history presented as an urgent walk-in to the Tufts New England Eye Center Comprehensive Ophthalmology Clinic with 18 hours of sudden onset bilateral blurry vision. One day before presentation, he had been flying a commercial airplane from Hong Kong to Los Angeles when his vision became acutely blurry, and he could no longer read the control panels on the airplane. His vision became so hazy that his co-pilot had to take over for the rest of the flight. He had no other ocular symptoms at that time, and his systemic review of symptoms was negative other than an upper respiratory infection 3 weeks prior for which he had taken 5 days of azithromycin.

When he landed in Los Angeles, he went to a local ophthalmologist who noted that his vision had decreased to 20/80 but corrected to 20/20 in both eyes with a refractive error of –5 D. His prior correction was –3 D in each eye. IOP was 28 mm Hg in the right eye and 32 mm Hg in the left eye, and his anterior chambers were very shallow bilaterally. The ophthalmologist recommended urgent bilateral laser peripheral iridotomies (LPIs), but the patient deferred, preferring to be treated in Boston where his family was based. He was started on acetazolamide, dorzolamide, brimonidine and pilocarpine with an adequate improvement in IOP, and the patient then boarded the next flight to Boston.

Examination

Upon examination at Tufts, the patient’s visual acuity was 20/400 in each eye but corrected to 20/25 with –10 D of correction. Pupils were small and pinpoint in either eye due to the pilocarpine. IOP was 16 mm Hg in the right eye and 15 mm Hg in the left eye. The conjunctiva was white and quiet, and the cornea was clear bilaterally. The anterior chamber was extremely shallow with iris-cornea touch peripherally. No angle structures were visible on gonioscopy. The view to the posterior chamber was limited by the very small size of his pupils, but the nerves appeared to have a cup-to-disc ratio of 0.3 bilaterally with pink, healthy nerve tissue and good rims. The macula appeared flat bilaterally.

Figure 1. Anterior segment OCT showing bilateral angle closure and the extent of iris-cornea apposition.

Figure 2. Posterior segment OCT revealing a thickened choroid.

Figure 3. UBM showing effusion extending to the ciliary body, causing ciliary body detachment and anterior dislocation of the lens-ciliary body apparatus.

Figure 4. B-scan with bilateral thickening of the choroid.

Anterior and posterior segment OCT, ultrasound biomicroscopy and B-scan are shown in Figures 1 to 4.

What is your diagnosis?

Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, November 25, 2016.