Case presentation- Phacomorphic glaucoma

Patient presented to OPD on 29th July with chief complaint of

Ocular pain
Headache
Sudden dimination of vision
since 1 days in left eye
Apparently well 1 day back when she started having pain in her left eye which was acute in onset, throbbing in nature, localized to the left eye and radiating to the ipsilateral side of the temporal and occipital region.
Pain was severe enough to disturb her daily routine and was associated with one episode of vomiting
According to the patient, redness was noted around cornea which was associated with watering and photophobia with haloes around the light

Vision in the left eye was gradually decreasing over the past 1 year. However, since 1 day, she noticed a sudden marked reduction of vision, to the extent that she could only perceive light.

1. Case Presentation Dr Sambandha Khati 3 rd year resident LEIRC, NAMS

2. Patient’s details Name : XYZ Age/ Sex : 60 years/ female Occupation : Housewife Address : Butwal Sub MP-6, R upandehi Date of presentation : 2025/ 07/ 29 MR no : 2503000

3. Chief complaint Patient presented to OPD on 29 th J uly with chief complaint of Ocular pain Headache Sudden diminution of vision LE Since 1 day

4. History of presenting illness Apparently well 1 day back when she started having pain in her left eye which was acute in onset, throbbing in nature, localized to the left eye and radiating to the ipsilateral side of the temporal and occipital region. Pain was severe enough to disturb her daily routine and was associated with one episode of vomiting According to the patient, redness was noted around cornea which was associated with watering and photophobia with haloes around the light

5. Vision in the left eye was gradually decreasing over the past 1 year. However, since 1 day, she noticed a sudden marked reduction of vision, to the extent that she could only perceive light.

6. No h/o of trauma No h/o of intermittent ocular pain, coloured halos No h/o of purulent discharge or foreign body sensation No h/o similar complain in the fellow eye

7. History of past illness No h/o similar illness in the past

8. Medical/ surgical history No h/o any ocular surgery in the past H /o of use of anti-thyroid medication for hypethyroidism Tab Methimazole 5mg X 1 tab X PO X OD

9. Allergic history No known h/o any allergy to food or medication known till date

10. Personal history Housewife Mixed dietary habits Normal bladder habit

11. Family history No h/o similar illness in the family

12. General examination Average built, well nourished and co-operative Well oriented to time, place and person Body weight : 46 kg Height : 1.37m BMI = 24.5 kg/m2 No evidence of pallor, cyanosis, clubbing, icterus, lymphadenopathy, edema or dehydration

13. Vitals Temperature : 37.5°C ( afebrile) Blood pressure : 110/90 mm of hg Pulse : 78 beats/min and regular Respiratory rate : 20 breaths /min

14. Systemic examination CVS - S1S2M0 Respiratory system – normal v esicular breath sound, no added sound Gastrointestinal system - abdomen was soft, non-tender, no organomegaly , BS (+) CNS - grossly normal Musculoskeletal- No swelling or any deformity Integumentar y- No skin rashes, vesicles

15. Ocular examination Visual acuity : (UCVA) Pin hole : RE – 5/60 RE – 6/36 LE – PL Accurate PR LE – PL Glow not seen Glow not seen Working distance = 66cm 1/0.66m = +1.50D RE = -5.00 / -1.00 X 180 – 6/36 -4.50 D -3.50 D

16. General examination OD OS Symmetrical Head position :erect Symmetrical Symmetrical Forehead Symmetrical Symmetrically aligned Eyebrows Symmetrically aligned No forward or backward bulging Globe No forward or backward bulging

17. Extraocular movement √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ OS OD

18. Slit lamp examination RE LE Normal overlying skin Well opposed to globe Normal arrangement and direction of eyelashes No lagophthalmos No ptosis Lids & adnexa Normal overlying skin Well opposed to globe Normal arrangement and direction of eyelashes No lagophthalmos No ptosis

19. Slit lamp examination RE LE No redness, swelling or fistula over lacrimal sac area Puncta : normal without any eversion, stenosis or discharge ROPLAS : Negative Tear film height : Normal Lacrimal apparatus No redness, swelling or fistula over lacrimal sac area Puncta : normal without any eversion, stenosis or discharge ROPLAS : Negative Tear film height : Normal

20. Slit lamp examination RE LE No evidence of bulbar and palpebral congestion Conjunctiva Diffuse conjunctival and circumciliary congestion No discoloration, thinning, bulging or nodules Sclera No discoloration, thinning, bulging or nodules

21. Cornea (OD) Clear transparent Smooth with normal size and curvature No DM folds, KP’s Sensation intact

22. Cornea (OS) Normal size and shape Diffuse epithelial edema + Intact corneal sensation

23. Slit lamp examination OD OS Van Herrick's grade IV, quiet Anterior Chamber Van Herrick's grade II AC cells 2+ Normal colour and pattern, no synechia appreciated Iris Normal colour and pattern, no synechia appreciated Round regular and reactive Pupil Fixed mid-dilated pupil

24. Gonioscopy : TM TM TM TM

25. OD OS NS III , CC II, PSCC I Lens Mature Senile Cataract Clear Media No view Pink, round, well defined margins CD ratio : 0.3 :1 Optic disc No view 2:3 A:V ratio No View Foveal reflex : present Macula No view

26. Intraocular pressure GAT : at 2:56 pm 10 mm of HG 32 mm of HG

27. Provisional diagnosis Left Eye Phacomorphic glaucoma Differential Diagnosis Left eye primary angle closure glaucoma Left eye phacolytic glaucoma

28. Phacomorphic glaucoma Points in favour Age 60 years Acute onset of pain, redness and watering Headache radiating to I/L side with vomiting Corneal edema + haloes around light Shallow Anterior Chamber Mid –dilated fixed pupil Points against

29. Primary angle- closure glaucoma (PACG) Points in favor Sudden pain, redness, D ecrease vision, haloes, H eadache, vomiting Shallow anterior chamber Narrow angle on gonioscopy Points against Matured senile cataract Fellow eye normal anterior chamber

30. Phacolytic glaucoma Points In favour Age 60 Matured senile cataract Acute onset of pain, redness and watering Corneal edema, conjunctival congestion, raised IOP Points against Shallow Anterior chamber Absence of white flocculent lens protein Closed angle in gonioscopy

31. Treatment Tab Acetazolamide 250mg X PO X TDS for 3 day Gtt. Prednisolone acetate 1% X 1 Drop X QID Gtt Brimonidine tartarate (0.15%) and Timolol maleate (0.5%)X 1 drop X BD Gtt Dorzolamide 2% X 1 drop X TDS Patient was asked to review in 3 days LE

32. On follow up : 2025 / 08/02 Patient was symptomatically better GAT @ 10:15 am VA – RE – 5/60 LE – PL with accurate PR 10 mm of HG 8 mm of HG

33. Final diagnosis RE – Immature senile cataract with LE- Phacomorphic glaucoma with mature senile cataract

34. Patient was advised for Left Eye Cataract Surgery ( Small incision cataract surgery with PCIOL ) under guarded visual prognosis

35. Gonioscopy : TM TM TM TM

36. Investigation HIV : Non- reactive HBsAG : Non- reactive HCV : Non- reactive RBS - 90 mg/dl Blood pressure : 110/80 mm of hg

37. Biometry Axial length : 22.62mm Anterior chamber depth : 2.1mm Keratometric value : K1 : 47.0 at 180° K2 : 45.75 at 90 ° IOL power : 20.50 D

38. 1 st POD 2025/08/03 V/A – UCVA RE – 5/60 LE – 6/24 Pinhole – RE - 6/36 LE – 6/24

39. Slit lamp examination RE LE Normal overlying skin Well opposed to globe Normal arrangement and direction of eyelashes No lagophthalmos No ptosis Lids & adnexa Normal overlying skin Well opposed to globe Normal arrangement and direction of eyelashes No lagophthalmos No ptosis

40. Slit lamp examination RE LE No redness, swelling or fistula over lacrimal sac area Puncta : normal without any eversion, stenosis or discharge ROPLAS : Negative Tear film height : Normal Lacrimal apparatus No redness, swelling or fistula over lacrimal sac area Puncta : normal without any eversion, stenosis or discharge ROPLAS : Negative Tear film height : Normal

41. Slit lamp examination RE LE No evidence of bulbar and palpebral congestion Conjunctiva Sub Conjunctival hemorrhage No discoloration, thinning, bulging or nodules Sclera No discoloration, thinning, bulging or nodules Tunnel Wound opposed

42. Cornea (OD) Clear transparent Smooth with normal size and curvature No DM folds, KP’s Sensation intact

43. Cornea (OS) Normal size and shape Striae

44. Slit lamp examination OD OS Van Herrick's grade IV, quiet Anterior Chamber AC formed Van Herrick's grade IV Ac cells 2+ Normal colour and pattern, no synechia appreciated Iris Normal colour and pattern, no synechia appreciated Round regular and reactive Pupil Fixed mid-dilated pupil

45. Posterior segment OD OS NS III , CC II, PSCC I Lens PCIOL Clear Media Clear Pink, round, well defined margins CD ratio : 0.3 :1 Optic disc Pink, round, well defined margins CD ratio : 0.4 :1 2:3 A:V ratio 2:3 Foveal reflex : present Macula Foveal reflex : Dull

46. Intraocular pressure GAT : at 9:30 am 10 mm of HG 9 mm of HG

47. Treatment Gtt. Prednisolone acetate 1% X 1 Drop X 12 times (2hourly) Oint Chloramphenicol, Polymyxin -B Sulphate and Dexamethasone Sodium Phosphate X LA X HS Patient asked to follow up in 1 week /SOS