Shayan Soomro

Posner-Schlossman syndrome, also known as glaucomatocyclitic crisis, is a rare condition characterised by recurrent transient elevations in intraocular pressure (IOP) concomitant with anterior chamber inflammation (1). It principally affects young to middle-aged adults, chiefly males, within the age range of 20 to 50 years (2). While the exact aetiology remains equivocal, several factors have been implicated, including possible viral triggers, autoimmune processes and genetic predilection (2).

Pathophysiology and aetiology

The pathophysiology of Posner-Schlossman syndrome is proposed to involve an immune-mediated response triggered by infectious agents, such as the herpes simplex virus (HSV-1) (2,3). Viral particles have been recognised in the trabecular meshwork and anterior chamber, suggesting a potential viral aetiology (1). Autoimmune mechanisms, activated by viral antigens or other stimuli, may lead to the release of inflammatory mediators, resulting in episodic elevation of IOP (2,3).

Clinical presentation and diagnosis

Patients classically present with sudden-onset blurred vision, haloes surrounding lights, mild ocular discomfort, and conjunctival injection (4,5). During acute episodes, anterior chamber inflammation and elevated IOP are evident (1,2). Gonioscopy can reveal an open angle with inflammation of the trabecular meshwork (4). Ancillary tests, including anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM), can provide comprehensive anatomical information, assisting in the diagnosis and management (5).

Management and Treatment

The management of Posner-Schlossman syndrome involves addressing both the inflammation and elevated IOP. Topical corticosteroids, such as prednisolone acetate, are the mainstay for controlling inflammation during acute episodes (3). Additionally, topical and/or systemic antiglaucoma medications, such as topical beta-blockers or carbonic anhydrase inhibitors, are employed to lower IOP (4). Cycloplegic agents like atropine may be used to alleviate symptoms and reduce ciliary body inflammation (5).

Prognosis and complications

The prognosis for Posner-Schlossman syndrome is largely favourable, with most individuals experiencing spontaneous resolution of acute episodes (1,2). However, persistent episodes may lead to cumulative trabecular meshwork damage, subsequently resulting in persistent elevation of IOP and glaucomatous optic neuropathy (1,2). Regular monitoring and long-term follow-up are imperative to identify and manage complications promptly (4,5).

References

1. POSNER A, SCHLOSSMAN A. Syndrome of unilateral recurrent attacks of glaucoma with cyclitic symptoms. Arch Ophthal. 1948 Apr;39(4):517-35. doi: 10.1001/archopht.1948.00900020525007. PMID: 18123283.
2. Ritch R, Schlötzer-Schrehardt U, Konstas AG. Why is glaucoma associated with exfoliation syndrome? Prog Retin Eye Res. 2003 May;22(3):253-75. doi: 10.1016/s1350-9462(02)00014-9. PMID: 12852486.
3. Tugal-Tutkun I, Araz B, Taskapili M, Akova YA, Yalniz-Akkaya Z, Berker N, Emre S, Gezer A. Bilateral acute depigmentation of the iris: report of 26 new cases and four-year follow-up of two patients. Ophthalmology. 2009 Aug;116(8):1552-7, 1557.e1. doi: 10.1016/j.ophtha.2009.02.019. Epub 2009 Jul 9. PMID: 19545903.
4. Okonkwo ON, Tripathy K. Posner-Schlossman Syndrome. [Updated 2023 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK576412/
5. Teixeira SH, Abegão Pinto L. Posner-Schlossman Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.