Intraocular Pressure Spike and Corneal Decompensation Following Selective Laser Trabeculoplasty in Patients With Exfoliation Glaucoma.

PURPOSE: To report 5 cases of intractable intraocular pressure (IOP) elevation and 2 cases of corneal failure in patients with exfoliation glaucoma after undergoing selective laser trabeculoplasty (SLT). METHODS: SLT was performed for the treatment of exfoliation glaucoma in 5 patients, all of whom subsequently developed significant IOP elevation within 1 to 5 weeks following treatment. Two patients went on to develop corneal endothelial failure requiring transplantation within 9 to 11 months. RESULTS: All 5 patients failed to respond adequately to topical antiglaucoma therapy and required trabeculectomy. Two patients required secondary implantation of a glaucoma drainage device. Two patients suffered significant endothelial injury requiring corneal transplantation (one receiving penetrating keratoplasty and another receiving Descemet stripping automated endothelial keratoplasty). CONCLUSIONS: Significant and persistent IOP spikes requiring surgical intervention following SLT are extremely rare, with only 1 other case series of 4 patients (all with heavily pigmented angles) reported in the literature. Exfoliation patients, and likely all patients with heavily pigmented angles, should be considered at higher risk for developing this complication. Corneal endothelial failure is similarly rare. Nine cases have been reported in the literature, none requiring corneal transplantation. Further clinical attention and research is needed to help elucidate what factors (both pressure-dependent and pressure-independent) may predispose patients to corneal changes following SLT.

Posner-Schlossman syndrome and nonarteritic anterior ischemic optic neuropathy.

A 41-year-old woman with acute OD pain and decreased visual acuity presented with anterior uveitis, an intraocular pressure of 56 mm Hg, an open angle, ipsilateral nerve fiber bundle visual field defects, and optic nerve edema. With control of intraocular pressure and uveitis, visual acuity improved to 20/25, visual field defects persisted, and optic disc pallor developed. She has remained stable over 23 months of follow-up. This case represents a concurrence of glaucomatocyclitic crisis (Posner-Schlossman syndrome, PSS) and nonarteritic ischemic optic neuropathy (NAION). Although this combination occurs rarely, patients with PSS and other risk factors for NAION, including an optic disc that lacks a physiologic cup, should be protected against NAION by prophylactic treatment with ocular antihypertensive medications.