PILOCARPINE INDUCED ACUTE ANGLE CLOSURE GLAUCOMA

Published 2022 - 26th ESCRS Winter Meeting

Reference: P235 | Type: Abstracts | DOI: 10.82333/nrhk-nq09

Authors: Abbas Fahem* ¹ , Irena Serov Volach ¹ , Aby Jacob ¹ , Parwez Hossain ¹

¹Ophthalmology,Southampton General Hospital,Southampton,United Kingdom

Purpose

To highlight the paradoxical effect of pilocarpine as a potential trigger for acute angle closure glaucoma when used in patients with secondary angle closure glaucoma.

Setting

85 year old presented to the eye casualty with acute pain, redness, blurred vision and raised intraocular pressure of 60mmHg in his right eye two days after he had been started on pilocarpine to control his intraocular pressure. He has 3 year history of secondary angle closure glaucoma developed after implantation of secondary sulcoflex toric IOL for residual astigmatism following a routine cataract surgery. Examination showed corneal haziness, raiased IOP of 60 and 360 angle closure with iris bombe and PAS. IOP normalised after administering intravenous acetazolamide and then IV mannitol followed by YAG peripheral iridotomy 24 hours later. The fellow eye is pseudophakic with wide open angle and normal IOP.

Methods

This is a case report of what we think a rare cause for inducing an acute angle closure glaucoma in a pseudophakic patient. Acute rise in IOP with shallowing of the anterior chamber can be due to several causes depending on the lens status, past ocular history, past medical and drug history. In this case, as patient is pseudophakic, the most important differential was secondary acute angle closure glaucoma and aqueous misdirection. As the patient has had no peripheral iridotomy on presentation and the fact that anterior chamber has widened after performing YAG PI, secondary acute angle closure glaucoma induced by pilocarpine use was the most likely explanation.

Results

Pilocarpine is a muscarinic agonist that can lower the IOP by inducing miosis which pulls the iris away increasing the angle width and also by inducing ciliary body contraction that stretch the trabecular meshwork and Schlemm canal thereby increasing aqueous outflow. However, ciliary body contraction can also induce forward movement of iris-lens diaphragm which can lead to pupillary block and subsequent angle closure. In this case, the pupillary block was further potentiated by the presence of the secondary sulcus toric IOL.

Conclusion

Whilst pilocarpine is a well-established treatment for various types of glaucoma especially in acute angle closure situation or as pre-laser treatment. It can itself causes paradoxical pupillary block glaucoma. Therefore, it should be used in caution especially in patients with secondary angle closure glaucoma.