Acute angle closure glaucoma following ileostomy surgery Glaucoma

Angle-closure glaucoma can be induced by drugs that may cause pupillary dilatation. We report a case of a patient that developed bilateral angle closure glaucoma after an ileostomy surgery because of systemic atropine injection. This case report highlights the importance of a fast ophthalmologic evaluation in diseases with ocular involvement in order to make accurate diagnoses and appropriate treatments.


A
cute angle-closure glaucoma can be induced by drugs that cause pupillary dilation, among other causes.Individuals with narrow angles, undiagnosed primary angle-closure glaucoma, shorter axial length, hyperopia, increased ratio of lens thickness to axial length and patients with shallow anterior chambers are more prone to develop angle closure (1) .
This paper reports a case of angle-closure glaucoma following ileostomy surgery (1) .

Case report
A 55 year-old white female patient was admitted to the surgery clinic to perform an ileostomy.On the fourth day after surgery, the patient developed pulsatile hemicranial headache, especially in the left temporal area, associated with ipsilateral sudden vision loss, eye pain, tearing and redness.The neurology clinic started the patient on oral steroids and indometacin as a treatment for temporal arteritis.On the sixth day after surgery, the patient remained with the same complaints and then was referred for ophthalmology evaluation.
Past medical history revealed familial poliposis, which lead the patient to surgery.Past ocular history was unremarkable.Ophthalmologic examination showed best corrected visual acuity of 20/20 in both eyes (OU).Refraction was +1.75/ -0.5 x150 on the right eye (OD) and +0.25/-1.0x20on the left eye (OS).Moderate conjunctival congestion was seen on OS.Biomicroscopy revealed a normal reactive pupil on OD and a mid-dilated pupil with sluggish reaction on OS.Corneas were transparent and shallow anterior chambers were evident (figure 1) on OU.Gonioscopy revealed a narrow angle, visible until the Schwalbe's line (Shaffer 1) on OD and a 360 angle-closure on OS (Schaffer 0).Intra-ocular pressure (IOP) was 15mmHg OD and 40mmHg OS, measured with a Goldman applanation tonometry at 12:15pm.Fundus examination disclosed cup-to-disc ratios of 0.2x0.2OD and 0.4x0.4OS.
The patient chart review revealed the use of several systemic drugs such as ranitidine, intravenous atropine, midazolam, fentanyl citrate and propofol.
Based on the clinical history and physical examination, we diagnosed the patient as having an angle-closure glaucoma induced by systemic medication.The previous treatment with oral steroids was interrupted and appropriate treatment was initiated with pilocarpine 2% (1 drop every 30 minutes), brinzolamide (1 drop OS) and timolol maleate 0,5% (1 drop OS).Ninety minutes later, intra-ocular pressure had dropped to 8mmHg on the left eye, breaking the acute crisis.An ndYAG-laser (Laserex LQP 3106, Ellex Medical PTY.LTD) iridotomy was performed on OS on the same day disclosing a wider anterior chamber right after the procedure (Figure 2) and gonioscopy revealed an open angle (Schaffer 3).Intraocular pressure was then controlled without hypotensive medication and a prophylactic laser iridotomy was performed on OD.Visual acuity remained 20/20 OU.
We reported a case of angle-closure glaucoma following intestinal surgery in a 55 year-old patient with familiar polyposis.
Systemic drugs, beyond other factors inherent to the surgical procedure itself, may change the IOP and precipitate an acute angle-closure crisis or aggravate previous angle-closure glaucoma in predisposed individuals.
Several drugs can trigger this clinical picture by different mechanisms such as narrowing of the anterior chamber by pupillary dilation and/or forward movement of the iris/lens diaphragm or swelling of the ciliary body epithelium, lens or vitreous body (2) .
Next, we discuss the drugs used by the patient and their possible effects on the IOP augmentation or induction of the acute attack.
Atropine is often used to treat bradycardia related to general anesthesia.It is a parasympatholytic drug that acts by blocking the muscarinic acetylcholine receptor (7) .This effect in the eye may cause paralysis of the ciliary muscle and iris sphincter leading to mydriasis and cycloplegia, which may cause an angleclosure attack in susceptible individuals (8)(9)(10) .
Ranitidine is a histamine H2 receptor antagonist, used to Lopes MM, Tavares ACF, Almeida CBM, Porraccio T, Meirelles SHS inhibit gastric secretion.It has a weak anticholinergic effect, which can also induce pupillary dilation and acute angle closure glaucoma (2,8,(11)(12)(13) .However, so far there is no sufficient evidence that this class of drug would increase IOP (14) .Midazolam is a benzodiazepine drug used as tranquilizer in the anesthetic induction.Some authors contraindicate the use of this drug, because of its possible anticholinergic effects (1) .A case of angle-closure glaucoma has been reported in a patient taking diazepam (15) .Betinjane et al. did not observe IOP augmentation with this medication in both normal subjects and glaucoma patients (16) .
Sedatives including propofol and fentanyl may induce pupillary dilation in toxic doses (8) .
Piridostigmina is an anticholinesterase drug used to reverse the neuromuscular blockage.Its possible ocular side effects include marked miosis, conjunctival congestion, ciliary spasm and hypertension followed by ocular hypotension (1,8) .
Angle-closure glaucoma has been previously reported in patients undergoing general anesthesia for non-ophthalmologic surgery (8,12,(17)(18)(19) .Many factors may contribute to the onset of an acute angle closure attack during anesthesia in predisposed individuals: CO 2 retention (20,21) ; endotracheal intubation associated with laryngospasm and cough leading to IOP augmentation, and the use of anticholinergic and adrenergic drugs.Moreover, the preoperative period carries the risk of psychological stress and darkness-induced mydriasis that may increase the risk of glaucoma attacks (17) .
This case report highlights the importance of a fast ophthalmologic evaluation in diseases with ocular involvement in order to make accurate diagnoses and appropriate treatments.In this particular case, if the patient had not been correctly treated she would have ended up blind.However, in other cases a delay in treatment would cause irreversible and serious consequences.Ophthalmologist and non-ophthalmologist doctors should be aware of potential ocular side effects of systemic drugs.
Ophthalmologists should be able to identify the patients that are at risk of developing an angle crisis in order to prevent undesirable outcomes.Gonioscopy should be performed in all patients that present with shallow anterior chambers and patients with narrow angles should be aware of the side effects of certain drugs.One should always be aware of other medications used by their patients and not only care about topical drugs used in the eye.In some situations, the combination of ocular findings and the necessity of using systemic therapy is an indication for prophylactic iridotomy.