Age/Sex/Race
57 years old African American female
Chief Complaint
“I’m here for an annual eye examination. I have little blur at distance and near. Sometimes, my eyes itch and burn.”
Medical History
Hypertension, acid reflux, depression, mild heart attack and seasonal rhinitis
Aspirin, Amlodipine, Omeprazole, Lisinopril, Visine, Carvedelol and Aripiprazole
Allergic to Ibuprofen
Family History
Mother – cataracts
Maternal grandmother – glaucoma
Ocular history
1st visit to the clinic in 2010 when she did not have insurance
2nd visit to the clinic in 2012: was diagnosed with anterior bowing of iris, tried laser peripheral iridotomy in both eyes but could not do it in the left eye.
Diagnosis and initial plan of action
From her chief complaint and history, I knew she had some refractive error, possible dry eyes and plateau iris.
Applicable Testing & Results of Testing
Distance visual acuity (corrected):
OD: +0.75-0.25X098, 20/20-2
OS: +0.75-0.50X072, 20/25
Cover test: ortho at distance and near
Extraocular muscles: Full
Pupils: PERRLA OU, (-) APD
Confrontation fields: FTFC OU
Manifest refraction:
OD: +1.25-0.75X090, 20/20-
OS: +0.75-0.75X090, 20/20-
Add: +2.25, 20/20 at near
Intraocular pressure: 18mm Hg OU
Slit lamp examination:
Anterior segment: 1+ meibomian gland dysnfunction OU, racial melanosis OU
OD: non-patent peripheral iridotomy superior temporal
Lens: trace nuclear sclerosis OU
Van Harrick angles: grade 1 to almost closed angles OU
Gonioscopy: narrowed angles OU (OS>OD), convex iris (OS>OD) with iris and ciliary body seen in some of the angles (TM not observed due to convex of the iris)
No dilation due to narrow angles.
Posterior pole examination was not done due to miotic pupils.
(photo courtesy of Kanski Clinical Ophthalmology, A Systemic Approach, 6th Edition)
Assessment and Plan
We diagnosed the patient with plateau iris. She was referred to glaucoma specialist for peripheral iridotomy evaluation.
Through her chart, I found that she had peripheral iridotomy (PI) done in both eyes in 2010. In 2012, she was told to return for undilated gonioscopy, visual field, OCT and peripheral iridotomy. At this visit, both PI were almost non-patent. She did not return for a follow up appointment.
Patient education was very important in this case. She was very nervous about the procedure because she mentioned that last time they had to try it three times and couldn’t make a hole through her iris. She told them to stop since she got scared. We educated her on symptoms of angle closure attack and to return to clinic ASAP. She had scheduled an appointment with a glaucoma specialist on April 28th, 2014.
Here’s little more information on plateau iris:
Plateau iris is due to an anatomic configuration of the angle. It is caused by a narrow anterior chamber angle due to insertion of the iris anteriorly on the ciliary body or displacement of the ciliary body anteriorly.
Plateau iris syndrome occurs due to persistent narrow angle capable of angle closure despite having a patent peripheral iridotomy (PI).3 Females of ages 30 to 50 are most common to have plateau iris, and they usually have hyperopic eyes and family history of angle closure glaucoma.
References:
- Eyewiki. Plateau iris. http://eyewiki.aao.org/Plateau_Iris
- Lally, D. Eye pain and high IOP are troubling signs for this patient. http://www.revophth.com/content/d/wills_eye_resident_case_series/i/1370/c/30562
-featured photo courtesy of Pacific University
