A CASE OF DELAYED CORNEAL DECOMPENSATION AFTER ACUTE PRIMARY ANGLE CLOSURE WITH ARGON LASER PERIPHERAL IRIDOPLASTY AND LASER PERIPHERAL IRIDOTOMY

We report a case of delayed corneal decompensation after acute primary angle closure (APAC) treated with argon laser peripheral iridoplasty (ALPI) and laser peripheral iridotomy (LPI).

A case report in a regional secondary and tertiary eye referral centre.

This study was a case report.

A 74 year old Chinese gentleman, with a history of left APAC treated with ALPI  and LPI in 2002, presented to our clinic in 2022 with a gradual onset of left painful eye and blurring of vision for 3 months.

Patient first presented to a local hospital with left APAC in 2002. He had LPI performed on his left eye but failed to respond with a continue closed angle and an intraocular pressure (IOP) at 30mmHg, despite maximal medical therapy. Later that day, he presented to our hospital with an IOP at 63mmHg in his left eye. He received immediate left ALPI, followed by bilateral sequential argon and neodymium-doped yttrium aluminum garnet LPI.

Post iridotomy gonioscopy revealed bilateral angles Shaffer grade 1-2 over all quadrants. Other than a fixed, mid-dilated left pupil, both eyes’ angle remained opened with clear corneas, healthy optic discs and normal fundal examination in subsequent visits. Perimetry in 2014 and 2017 were normal in both eyes. On the last visit in 2018, his decimal visual acuity (VA) in both eyes were 0.7. IOP was 11mmHg and 8 mmHg in the right and left eye respectively. The left pupil remained fixed and mid-dilated. Slit lamp examination revealed bilateral clear cornea, patent iridotomies, angles remained open with mild cataract and left peripheral ALPI marks. Dilated fundal examination showed bilateral pink discs with cup-disc ratio of 0.5-0.6 and mild retinal pigment epithelium pigmentary changes. Patient was subsequently discharged from our clinic after 16 years of monitoring.

On presentation in 2022, his aided pinhole VA of the left eye was 2/36 and IOP was 8mmHg. The left pupil was fixed and mid-dilated as previously recorded. Slit lamp examination of the left eye showed corneal oedema with bullae, a shallow anterior chamber, peripheral ALPI marks with iris atrophy, patent peripheral iridotomy and nuclear sclerosis 2+. Gonioscopy was impossible with a poor fundal view due to corneal oedema. Specular microscopy showed endothelial cell density of 2826 cells/mm² in the right eye but failed measurements in the left eye. He underwent left eye phacoemulsification, intraocular lens implantation and aqueous tap in November 2022 with an improved decimal VA of 0.2 and a subsequent endothelial keratoplasty planned.

We reported a delayed corneal decompensation up to 20 years after acute primary angle closure who received argon laser peripheral iridoplasty and laser peripheral iridotomy. Ophthalmologists should be aware of this potential delayed complication that could occur decades after the attack and laser treatment. All patients should have subsequent specular microscopy to monitor their endothelial cell density during follow ups.