**3. The main results of our clinical research**

The main results of our clinical research included 4 fields as following: the clinical character‐ istics of PSS; the glaucomatous optic nerve damage in PSS patients; the clinical approach of optic nerve damage in PSS patients; other diseases concomitant with PSS.

#### **3.1. Study on the clinical characteristics of the PSS**

The research about clinical characteristics of the PSS included four aspects: clinical observation and analyzation of monocular primary open-angle glaucoma(POAG) and binocular PSS; clinical features of elderly PSS patients; characteristics and clinical value of the intraocular pressure and the C- value in PSS patients ; the characteristic of postural intraocular pressure change in PSS patients.

#### *3.1.1. Clinical observation and analyzation of monocular primary open-angle glaucoma and binocular PSS*

**Background:** As we knew, most of POAG patients are binocularly involved, while monocular attack is one of typical features of PSS. However, clinically suspected monocular POAG patient is not rare and binocular PSS cases are often reported. So following questions should be put forward based on the facts as follows [3, 11, 14]: Does monocular POAG really exist? What are the differences between monocular and binocularly involved PSS cases? Is there any relation‐ ship between the monocular POAG and binocular PSS?

15 of 17 binocular PSS cases were confirmed with glaucomatous visual field damage, that was much more serious than in monocular cases; however, no remarkable difference was found

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The result suggests that the course of disease cannot explain the severity of visual field damage in binocular PSS. We speculate that binocular PSS may be more relevant to POAG essentially through the following two ways.First, the insufficiency in adjusting IOP result in combination with POAG in some cases; secondly, the weak resistance of optic nerve to high IOP make it ease for a cumulative effect of high intraocular pressure during attacks of pure PSS to bring

The results of clinical follow-up observation on the 22 cases with clinically suspected monoc‐ ular POAG is as follows: 15 of the 22 cases were confirmed not to be POAG, 9 of them had been proved to be PSS. Although no definite diagnoses was made in the other 7 cases,but clinical manifestations contradictory with POAG were found in most cases, 3 of them were

between the course of disease in monocular and binocular cases. (See Figure3)

**Figure 3.** Results of visual field examination and defect in binocular PSS.

**3.** Results of clinical follow-up to monocular POAG

**Figure 4.** Results of clinical follow-up to monocular POAG.

about visual field damage.

suspected of PSS.(See Figure4)

#### **Objects and methods**

A long-term, systematic clinical observation and analysis were completed on 121 cases with tentative diagnosis of POAG (22 cases of monocular) and 126 cases of PSS (17 cases of which was binocular). (See figure2)

**Figure 2.** Distribution of monocular and binocular cases in PSS and POAG

#### **Results**

**1.** Glaucomatous visual field damage of monocular/ binocular PSS and binocular POAG

Analyzation of the clinical data of patients without doubt with the chi-square test showed: 1) The incidence of glaucomatous visual field damage in binocular PSS (15/16) was much higher than that in monocular cases(30/85), (X2 =27.43, P<0.01). 2) The damage in 26 of 30 monocular cases were in early stage, while that in 9 of 15 binocular cases were in middle/ last stage, the difference was significant(X2 =3.53, P<0.01).3) There is no significant difference in incidence and degree of glaucomatous visual field damage between binocular PSS and binocular POAG. (See Table 2)


**Table 2.** Visual field defect of monocular/ binocular PSS and binocular POAG

#### **2.** Visual field damage in binocular PSS

15 of 17 binocular PSS cases were confirmed with glaucomatous visual field damage, that was much more serious than in monocular cases; however, no remarkable difference was found between the course of disease in monocular and binocular cases. (See Figure3)

**Figure 3.** Results of visual field examination and defect in binocular PSS.

is not rare and binocular PSS cases are often reported. So following questions should be put forward based on the facts as follows [3, 11, 14]: Does monocular POAG really exist? What are the differences between monocular and binocularly involved PSS cases? Is there any relation‐

A long-term, systematic clinical observation and analysis were completed on 121 cases with tentative diagnosis of POAG (22 cases of monocular) and 126 cases of PSS (17 cases of which

**1.** Glaucomatous visual field damage of monocular/ binocular PSS and binocular POAG

Analyzation of the clinical data of patients without doubt with the chi-square test showed: 1) The incidence of glaucomatous visual field damage in binocular PSS (15/16) was much higher

cases were in early stage, while that in 9 of 15 binocular cases were in middle/ last stage, the

and degree of glaucomatous visual field damage between binocular PSS and binocular POAG.

**Moderate stage**

Monocur PSS **55 7 26 1 2 1 17 109** Binoculus PSS **1 1 6 5 4 0 0 17** Binoculus POAG **4 7 22 8 39 7 12 99**

=27.43, P<0.01). 2) The damage in 26 of 30 monocular

**Absolute stage**

**Unknown Total**

=3.53, P<0.01).3) There is no significant difference in incidence

**Advanced stage**

ship between the monocular POAG and binocular PSS?

**Figure 2.** Distribution of monocular and binocular cases in PSS and POAG

**Normal Suspicious Early**

**Table 2.** Visual field defect of monocular/ binocular PSS and binocular POAG

**stage**

than that in monocular cases(30/85), (X2

**2.** Visual field damage in binocular PSS

difference was significant(X2

**Objects and methods**

384 Glaucoma - Basic and Clinical Aspects

**Results**

(See Table 2)

**Disease/ Visual field defect**

was binocular). (See figure2)

The result suggests that the course of disease cannot explain the severity of visual field damage in binocular PSS. We speculate that binocular PSS may be more relevant to POAG essentially through the following two ways.First, the insufficiency in adjusting IOP result in combination with POAG in some cases; secondly, the weak resistance of optic nerve to high IOP make it ease for a cumulative effect of high intraocular pressure during attacks of pure PSS to bring about visual field damage.

**3.** Results of clinical follow-up to monocular POAG

The results of clinical follow-up observation on the 22 cases with clinically suspected monoc‐ ular POAG is as follows: 15 of the 22 cases were confirmed not to be POAG, 9 of them had been proved to be PSS. Although no definite diagnoses was made in the other 7 cases,but clinical manifestations contradictory with POAG were found in most cases, 3 of them were suspected of PSS.(See Figure4)

**Figure 4.** Results of clinical follow-up to monocular POAG.

The result suggests that the diagnosis of monocular POAG should be very careful, in addition to angle closure glaucoma and other secondary glaucoma, PSS which appears late or last transitorily should not be ignored. Close attention to slit lamp examination for KP and its relationship with IOP should be paid for such cases.

of the fellow one, and its C- value was higher. It means that binocular IOP and C- value in

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Crossed-over phenomenon of binocular IOP and C- value had not appeared in the control group (primary glaucoma) as well as Group C (PSS combined with POAG). **Conclusion:** Such an inference could be deduced based on our results that Crossed-over phenomenon of IOP and C- value was one characteristic for pure PSS cases, it is conducive to distinguish pure PSS from primary glaucoma and PSS combined with POAG to observe this phenomenon. (See Figure5,6)

**Figure 5.** the difference of IOP and its dynamic changes between 3 PSS groups (A, B, C) and primary glaucoma.

**Figure 6.** the difference of C- value and its dynamic changes between 3 PSS groups (A, B, C) and primary glaucoma.

episodes and intermission were crossed-over.

All in all, it cannot be stated too strongly: we should be very deliberative when making a diagnose of monocular POAG or binocular PSS, as half part of suspicious monocular POAG cases were confirmed with PSS after clinical follow-up, and there was a closer connection between binocular PSS and POAG. [15]

#### *3.1.2. Clinical observation of aged PSS cases*

**Background:** Among the cases of PSS, the 50s are rare; the 60s are seldom. What is the feature of the aged PSS cases?

**Objects and methods:** The clinical data of 14 cases aged above 50 with a definite diagnosis of PSS collected in the past 4 years were summarized and analyzed. Clinical data met all the re‐ quirements were obtained in 11cases. The cases aged from 50 to 73 years old, with an average of 61.4. 1 case had a course of the disease beyond 30 years, 4 beyond 10 years and 6 beyond 5 years.

**Results:** Visual acuity of more than half of the cases was inferior to 0.5, 9 of 11 cases had visual field damage that was of moderate or advanced stage in most cases.

**Conclusion:** The aged PSS cases had a longer course of the disease and much more frequent and serious visual function damage. [16, 17, 18]

#### *3.1.3. The characteristics and clinical value of the intraocular pressure and the C- value in PSS cases*

**Background:** It is generally acknowledged that IOP of the attacked eye increased and C- value of attack eye decreased in episodes, and both were normal in intermission. Individual author reported that the IOP of the affected eye was lower than that of the fellow one in part of cases, and C- value was higher. It was not confirmed that this phenomenon could be considered as the unique characteristic of PSS; and what clinical significance should it mean. [3, 19, 20]

**Objective and methods:** Binocular IOP measurement and tonography were done in 90 cases of PSS; According to the symptom, sign and results of examination for IOP, fundus, visual field, our cases were divided into 3 groups. Group A (typical type): with a normal optic disc, visual field and the diagnostic tests for glaucoma in intermission. Group B (development type): with a damaged optic disc and visual field; except for high intraocular pressure in episodes, binocular IOP and C values were normal. Group C (mixed type): with a damaged optic disc, visual field and abnormal results of binocular IOP, IOP diurnal variation and C value in both episodes and intermission. Another group case of primary glaucoma with a great fluctuation and difference in IOP level between his or her right and left eye was taken as the control group.

**Results:** IOP of PSS cases in group A and B increased in episodes, and were obviously higher than that of the fellow eye; C- value of them decreased and was lower. In intermission, binocular IOP and C- value turned normal, moreover, IOP of attacked eye was lower than that of the fellow one, and its C- value was higher. It means that binocular IOP and C- value in episodes and intermission were crossed-over.

The result suggests that the diagnosis of monocular POAG should be very careful, in addition to angle closure glaucoma and other secondary glaucoma, PSS which appears late or last transitorily should not be ignored. Close attention to slit lamp examination for KP and its

All in all, it cannot be stated too strongly: we should be very deliberative when making a diagnose of monocular POAG or binocular PSS, as half part of suspicious monocular POAG cases were confirmed with PSS after clinical follow-up, and there was a closer connection

**Background:** Among the cases of PSS, the 50s are rare; the 60s are seldom. What is the feature

**Objects and methods:** The clinical data of 14 cases aged above 50 with a definite diagnosis of PSS collected in the past 4 years were summarized and analyzed. Clinical data met all the re‐ quirements were obtained in 11cases. The cases aged from 50 to 73 years old, with an average of 61.4. 1 case had a course of the disease beyond 30 years, 4 beyond 10 years and 6 beyond 5 years.

**Results:** Visual acuity of more than half of the cases was inferior to 0.5, 9 of 11 cases had visual

**Conclusion:** The aged PSS cases had a longer course of the disease and much more frequent

*3.1.3. The characteristics and clinical value of the intraocular pressure and the C- value in PSS cases*

**Background:** It is generally acknowledged that IOP of the attacked eye increased and C- value of attack eye decreased in episodes, and both were normal in intermission. Individual author reported that the IOP of the affected eye was lower than that of the fellow one in part of cases, and C- value was higher. It was not confirmed that this phenomenon could be considered as the unique characteristic of PSS; and what clinical significance should it mean. [3, 19, 20]

**Objective and methods:** Binocular IOP measurement and tonography were done in 90 cases of PSS; According to the symptom, sign and results of examination for IOP, fundus, visual field, our cases were divided into 3 groups. Group A (typical type): with a normal optic disc, visual field and the diagnostic tests for glaucoma in intermission. Group B (development type): with a damaged optic disc and visual field; except for high intraocular pressure in episodes, binocular IOP and C values were normal. Group C (mixed type): with a damaged optic disc, visual field and abnormal results of binocular IOP, IOP diurnal variation and C value in both episodes and intermission. Another group case of primary glaucoma with a great fluctuation and difference in IOP level between his or her right and left eye was taken as the control group.

**Results:** IOP of PSS cases in group A and B increased in episodes, and were obviously higher than that of the fellow eye; C- value of them decreased and was lower. In intermission, binocular IOP and C- value turned normal, moreover, IOP of attacked eye was lower than that

field damage that was of moderate or advanced stage in most cases.

relationship with IOP should be paid for such cases.

between binocular PSS and POAG. [15]

*3.1.2. Clinical observation of aged PSS cases*

and serious visual function damage. [16, 17, 18]

of the aged PSS cases?

386 Glaucoma - Basic and Clinical Aspects

Crossed-over phenomenon of binocular IOP and C- value had not appeared in the control group (primary glaucoma) as well as Group C (PSS combined with POAG). **Conclusion:** Such an inference could be deduced based on our results that Crossed-over phenomenon of IOP and C- value was one characteristic for pure PSS cases, it is conducive to distinguish pure PSS from primary glaucoma and PSS combined with POAG to observe this phenomenon. (See Figure5,6)

**Figure 5.** the difference of IOP and its dynamic changes between 3 PSS groups (A, B, C) and primary glaucoma.

**Figure 6.** the difference of C- value and its dynamic changes between 3 PSS groups (A, B, C) and primary glaucoma.

#### *3.1.4. The characteristics of postural IOP change in PSS cases*

**Background:** It is well known that the recumbent IOP is higher than sedentary one in most of people; however, such an IOP change in PSS cases was not reported so far.

of trabecular meshwork which result in more and more futile eduction function of aqueous humour was the primary mechanism for the increased IOP in POAG, so the IOP increment in POAG cases is related to C value significantly whenever the IOP is high or low as the adjust ability for IOP had been declining eventually. PSS is a secondary glaucoma for which the intermittent increased release of PGs maybe the primary mechanism. Increases PGs may expand the blood vessels and recedes eduction function of trabecular meshwork. On the contrary, the diluent PGs in remission promotes eduction function of aqueous humourm and turn IOP and C value to normal or even better. Therefore, there is no significant correlation between the IOP increment and C value no matter IOP was high or normal. [20, 22, 23]

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Although reports about that glaucomatous optical neural damage occurred in some cases of PSS were constantly released for past twenty years, we saw little of the systematic research

aimed at the incidence, severity and probable relating facts of the damage. [3, 9]

**Objective:** To study the incidence and severity of the Visual field damage in PSS cases.

**Methods:** Visual field examinations at regular intervals with perimeter of Goldmann or Humphrey 750 type were completed in 145 cases of PSS followed up for 5 to 15 years and 166

**Results:** The prevalence of visual field damage in PSS and POAG was 35.43% and 93.42% (P<0.001), 72.11% of the field damage in PSS cases was of early or suspected stage, 78.92% of that in POAG cases was of middle or late stage(P<0.001), 10% of PSS cases suffered a field damage of middle or late stage, 2 became absolute blind and one case had developed into

**Conclusions:** Even the visual field damage in cases of PSS was less and slighter than that in cases of POAG, It is necessary to treat PSS efficiently and timely, as recurrent attacks of PSS

**3.2. The visual field damage in PSS cases**

*3.2.1. Incidence and severity of the damage*

bullous keratitis at last.(See Figure8)

cases of POAG observed meanwhile (as the control). [17]

**Figure 8.** the stage distribution of visual field damage in PSS and POAG.

for long period would result in a sad outcome like POAG.

**Objective:** 83 cases of PSS with regular IOP change, 42 cases of POAG and 61 cases of PACG with a great wave in IOP level. [21]

**Methods:** IOP measurement was performed with a handheld applanation tonometer before and after laying for five and thirty minutes, and a tonography was finished 1~3 days before or after postural IOP measurement. (See Figure7)

**Figure 7.** handheld applanation tonometer.

**Results:** 1) Recumbent IOP is much higher than sedentary one in cases of all groups, however, their rising degrees after laying were different.2) There was no significant difference of rising degrees after laying in three kinds of glaucoma when IOP was high; when the IOP turned normal, however, the rising degrees in POAG, PACG were much higher than in PSS. 3) When the sedentary IOP is higher than 24mmHg, the number of cases with recumbent IOP elevated more than 5mmHg in three kinds glaucoma wasn't different statistically; When the sedentary IOP is lower than 24mmHg, cases with recumbent IOP elevated more than 5mmHg were rare in PSS group, much less than that in the other two groups. 4) The IOP increment after laying in the attacked eye of PSS cases in episodes was much higher than that of the fellow eye and the both eye in intermission. 5) The IOP increment was related to C value significantly for POAG when IOP was high and normal, for PACG when IOP was normal only; But wasn't related for PSS no matter IOP was high or normal.

**Conclusion:** Measurement of postural IOP change is beneficial to diagnose suspicious glaucoma cases with a normal or slightly elevated IOP ,it maybe as valuable as tonography clinically but more convenient, comfort and safer than tonography, Complications such as corneal scratches were rarely seen in the measurement of postural IOP change

**Discussion:** Different pathogenesis of the three kinds of glaucoma accounts for the correlation between the IOP increment and C value in different conditions. PACG is caused by the closed anterior chamber angle, when the IOP is high, the increased IOP is related to C value signifi‐ cantly as the closed anterior chamber angle loses the ability to reduce IOP, however, the adjust ability recoverys as the anterior chamber angle open partly when the IOP is low. Degeneration of trabecular meshwork which result in more and more futile eduction function of aqueous humour was the primary mechanism for the increased IOP in POAG, so the IOP increment in POAG cases is related to C value significantly whenever the IOP is high or low as the adjust ability for IOP had been declining eventually. PSS is a secondary glaucoma for which the intermittent increased release of PGs maybe the primary mechanism. Increases PGs may expand the blood vessels and recedes eduction function of trabecular meshwork. On the contrary, the diluent PGs in remission promotes eduction function of aqueous humourm and turn IOP and C value to normal or even better. Therefore, there is no significant correlation between the IOP increment and C value no matter IOP was high or normal. [20, 22, 23]

#### **3.2. The visual field damage in PSS cases**

*3.1.4. The characteristics of postural IOP change in PSS cases*

with a great wave in IOP level. [21]

388 Glaucoma - Basic and Clinical Aspects

**Figure 7.** handheld applanation tonometer.

related for PSS no matter IOP was high or normal.

after postural IOP measurement. (See Figure7)

**Background:** It is well known that the recumbent IOP is higher than sedentary one in most of

**Objective:** 83 cases of PSS with regular IOP change, 42 cases of POAG and 61 cases of PACG

**Methods:** IOP measurement was performed with a handheld applanation tonometer before and after laying for five and thirty minutes, and a tonography was finished 1~3 days before or

**Results:** 1) Recumbent IOP is much higher than sedentary one in cases of all groups, however, their rising degrees after laying were different.2) There was no significant difference of rising degrees after laying in three kinds of glaucoma when IOP was high; when the IOP turned normal, however, the rising degrees in POAG, PACG were much higher than in PSS. 3) When the sedentary IOP is higher than 24mmHg, the number of cases with recumbent IOP elevated more than 5mmHg in three kinds glaucoma wasn't different statistically; When the sedentary IOP is lower than 24mmHg, cases with recumbent IOP elevated more than 5mmHg were rare in PSS group, much less than that in the other two groups. 4) The IOP increment after laying in the attacked eye of PSS cases in episodes was much higher than that of the fellow eye and the both eye in intermission. 5) The IOP increment was related to C value significantly for POAG when IOP was high and normal, for PACG when IOP was normal only; But wasn't

**Conclusion:** Measurement of postural IOP change is beneficial to diagnose suspicious glaucoma cases with a normal or slightly elevated IOP ,it maybe as valuable as tonography clinically but more convenient, comfort and safer than tonography, Complications such as

**Discussion:** Different pathogenesis of the three kinds of glaucoma accounts for the correlation between the IOP increment and C value in different conditions. PACG is caused by the closed anterior chamber angle, when the IOP is high, the increased IOP is related to C value signifi‐ cantly as the closed anterior chamber angle loses the ability to reduce IOP, however, the adjust ability recoverys as the anterior chamber angle open partly when the IOP is low. Degeneration

corneal scratches were rarely seen in the measurement of postural IOP change

people; however, such an IOP change in PSS cases was not reported so far.

Although reports about that glaucomatous optical neural damage occurred in some cases of PSS were constantly released for past twenty years, we saw little of the systematic research aimed at the incidence, severity and probable relating facts of the damage. [3, 9]

#### *3.2.1. Incidence and severity of the damage*

**Objective:** To study the incidence and severity of the Visual field damage in PSS cases.

**Methods:** Visual field examinations at regular intervals with perimeter of Goldmann or Humphrey 750 type were completed in 145 cases of PSS followed up for 5 to 15 years and 166 cases of POAG observed meanwhile (as the control). [17]

**Results:** The prevalence of visual field damage in PSS and POAG was 35.43% and 93.42% (P<0.001), 72.11% of the field damage in PSS cases was of early or suspected stage, 78.92% of that in POAG cases was of middle or late stage(P<0.001), 10% of PSS cases suffered a field damage of middle or late stage, 2 became absolute blind and one case had developed into bullous keratitis at last.(See Figure8)

**Figure 8.** the stage distribution of visual field damage in PSS and POAG.

**Conclusions:** Even the visual field damage in cases of PSS was less and slighter than that in cases of POAG, It is necessary to treat PSS efficiently and timely, as recurrent attacks of PSS for long period would result in a sad outcome like POAG.

#### *3.2.2. The characteristic of the visual field damage in PSS*

**Objective:** To study the characteristic of the visual field damage in PSS.

**Methods:** Compare the visual field damage in glaucoma cases with higher and lower IOP (PSS belongs to that with higher IOP). [24]

**Conclusions:** There are difference visual field defects between higher IOP patients and lower

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Methods: Analysis the clinical data of 145 PSS cases and 166 POAG cases for recent 15 years. Results about the incidence and severity of visual field damage in the two kinds of glaucoma

**Results:** 1) Compared with the undamaged group of PSS, the damaged cases were older and with longer course of the disease while there was no remarkable difference in the averaged IOP value during crisis. 2) There was a much higher risk for the visual field damage in binocular cases of PSS. Most of the cases of PSS reported were monocular affected, but later, there were reports about some binocularly affected cases. In our study, 15 of the 35 cases with definite damage were binocularly affected while only one of the 82 cases without damage was affected binocularly. It needs further study to determine whether there is different pathological mechanism for the monocular and binocularly involved cases of PSS. 3) IOP manifestation: although no great difference in the average IOP value during crisis was found between the two groups of PSS, the damage group showed a higher average IOP between crises and included much more cases with an abnormal diurnal and nocturnal variance of IOP or without the IOP crossed-over phenomenon than the undamaged group. These data indicated that the adjustment of IOP between crises was insufficient in those PSS patients with visual field damage. Loss of IOP crossed-over phenomenon meant that other than PSS there were some

**Conclusions:** These data indicated that the harmful effect of the raised IOP during crises of

In recent years a number of authors have confirmed that glaucomatous optic nerve damage similar to that in primary glaucoma cases occurred in part of the PSS cases, but the clinical approach of the occurrence was not reported. Clinical data of cases with PSS during a period of 25 years in our hospital was collected and analyzed, and four clinical approaches via which

208 cases with PSS during the recent 25 years collected in our hospital(male 124 cases, female 84 cases), from 9 to 71 years old, with an average of 39.56±12.80. Diagnosis standard for PSS

**3.3. The clinical approach of optic nerve damage in Posner Schlossman syndrome**

IOP patients.

had been showed above.

factors affecting the IOP. [25]

*3.3.1. Propose*

*3.3.2. Methods*

PSS on the optic disc could be accumulated.

the damage occurred in PSS cases were deduced.

To investigate the clinical approach of optic nerve damage in PSS.

*3.2.3. Relating factors of the visual field damage in PSS*

**Objective:** To study the relating factors of the visual field damage in PSS.

**Results:** 1) The visual field damage in cases with lower IOP is less and slighter than that in cases with higher IOP. 2) Paracentral, arcuate and ring scotoma was more seen in cases with normal IOP, while constriction of visual field and nasal field were more common in cases with higher IOP. 3) Most of the visual field damages in cases with higher IOP comes from the periphery. (See Figure9)

**Figure 9.** Visual field of a PSS case and a LTG case. The visual field damages in PSS case exist in the periphery area (A), on the contrary, those in glaucoma case with normal IOP exist in the centre area (B).

**Conclusions:** There are difference visual field defects between higher IOP patients and lower IOP patients.

#### *3.2.3. Relating factors of the visual field damage in PSS*

*3.2.2. The characteristic of the visual field damage in PSS*

belongs to that with higher IOP). [24]

periphery. (See Figure9)

390 Glaucoma - Basic and Clinical Aspects

**Objective:** To study the characteristic of the visual field damage in PSS.

**Methods:** Compare the visual field damage in glaucoma cases with higher and lower IOP (PSS

**Results:** 1) The visual field damage in cases with lower IOP is less and slighter than that in cases with higher IOP. 2) Paracentral, arcuate and ring scotoma was more seen in cases with normal IOP, while constriction of visual field and nasal field were more common in cases with higher IOP. 3) Most of the visual field damages in cases with higher IOP comes from the

**Figure 9.** Visual field of a PSS case and a LTG case. The visual field damages in PSS case exist in the periphery area (A),

on the contrary, those in glaucoma case with normal IOP exist in the centre area (B).

**Objective:** To study the relating factors of the visual field damage in PSS.

Methods: Analysis the clinical data of 145 PSS cases and 166 POAG cases for recent 15 years. Results about the incidence and severity of visual field damage in the two kinds of glaucoma had been showed above.

**Results:** 1) Compared with the undamaged group of PSS, the damaged cases were older and with longer course of the disease while there was no remarkable difference in the averaged IOP value during crisis. 2) There was a much higher risk for the visual field damage in binocular cases of PSS. Most of the cases of PSS reported were monocular affected, but later, there were reports about some binocularly affected cases. In our study, 15 of the 35 cases with definite damage were binocularly affected while only one of the 82 cases without damage was affected binocularly. It needs further study to determine whether there is different pathological mechanism for the monocular and binocularly involved cases of PSS. 3) IOP manifestation: although no great difference in the average IOP value during crisis was found between the two groups of PSS, the damage group showed a higher average IOP between crises and included much more cases with an abnormal diurnal and nocturnal variance of IOP or without the IOP crossed-over phenomenon than the undamaged group. These data indicated that the adjustment of IOP between crises was insufficient in those PSS patients with visual field damage. Loss of IOP crossed-over phenomenon meant that other than PSS there were some factors affecting the IOP. [25]

**Conclusions:** These data indicated that the harmful effect of the raised IOP during crises of PSS on the optic disc could be accumulated.

#### **3.3. The clinical approach of optic nerve damage in Posner Schlossman syndrome**

In recent years a number of authors have confirmed that glaucomatous optic nerve damage similar to that in primary glaucoma cases occurred in part of the PSS cases, but the clinical approach of the occurrence was not reported. Clinical data of cases with PSS during a period of 25 years in our hospital was collected and analyzed, and four clinical approaches via which the damage occurred in PSS cases were deduced.

#### *3.3.1. Propose*

To investigate the clinical approach of optic nerve damage in PSS.

#### *3.3.2. Methods*

208 cases with PSS during the recent 25 years collected in our hospital(male 124 cases, female 84 cases), from 9 to 71 years old, with an average of 39.56±12.80. Diagnosis standard for PSS was basically accorded to clinical features described by Posner and Schlossman, except for the cases who suffered binocularly or had damage were contained in. [23, 26]

**A B C D**

**Early stage**

monocular

with KP

**Later stage**

similar to POAG middle-aged and aged people

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monocular KP, binocular high IOP

normal

normal

normal

negative

normal

shallow

positive negative

high\*/normal

high\*/normal

high\*/normal

positive \*/ negative

abnormal \*/ normal

Very shallow

Narrow II-III Narrow III-IV

**Early stage Later stage**

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**Later stage**

normal normal normal normal high high high\*/

normal normal normal normal high high high\*/

positive positive negative negative negative positive \*/

normal normal normal abnormal abnormal abnormal abnormal \*/

medium width

medium width

medium width

**Early stage**

aged people

Monocular/ monocular monocular binocular or

Typical PSS course positive positive positive negative Intermittent attack

Age of onset middle-aged and

another eye

another eye

Cross phenomenon of intraocular pressure

Intraocular pressure of 24 hours in period of intermittent

Anterior chamber angle medium

(83.1%) regarded as definite damage.

*3.3.3. Results*

width

**Later stage**

**Early stage**

Family history of glaucoma usually not usually not sometimes have most have

IOP Episodes Sick eye rise rise rise rise higher higher rise rise

Intermission Sick eye normal normal normal rise high high high\*/

Anterior chamber depth normal normal normal normal normal normal A little

medium width

190 cases of 208 patients with PSS had a set of complete material. There were 71 cases (34.1%) with optic nerve damage, in which 12 cases (16.9%) regarded as suspicious damage, 59 cases

medium width

\*When adhesive closure of the angle or damage of trabecular meshwork occurred.

**Table 4.** Classification method of the clinical approach for optic nerve damage in PSS

**1.** Incidence and stage distribution of glaucomatous optic nerve damage

Stage distribution of glaucomatous optic nerve damage was shown in Table 5:

**Early stage Moderate stage Advanced stage Absolute stage Total** 35 11 11 2 59 59.32% 18.64% 18.64% 3.39% 100%

**Table 5.** Stage distribution of glaucomatous optic nerve damage in 59 cases regarded as clear damage

middle-aged and aged people

#### **Research project of first diagnosis at the first attendance in our hospital**

History, eyesight, intraocular pressure of episode and intermission, depth of anterior chamber, gonioscope or UBM, intraocular pressure during 24 hours in intermission without eyedrops more than five days, panretinalscope or OCT, FFA in episode of part cases, and so on.

#### **Analytical methods**

**1.** Analysis for damage

Standard: repeatable glaucomatous visual field damage and corresponding fundus perform‐ ance

**2.** Stage division standard of glaucomatous visual field damage(see Table3)


**Table 3.** Stage division standard of glaucomatous visual field defect

#### **3.** Classification method

According to the results of comprehensive and dynamical analyzation to the clinical data of each cases and classification method shows as table 4, each case was discriminated for the clinical approach of optic nerve damage. [20,21,22,24,27,28]


\*When adhesive closure of the angle or damage of trabecular meshwork occurred.

**Table 4.** Classification method of the clinical approach for optic nerve damage in PSS

#### *3.3.3. Results*

was basically accorded to clinical features described by Posner and Schlossman, except for the

History, eyesight, intraocular pressure of episode and intermission, depth of anterior chamber, gonioscope or UBM, intraocular pressure during 24 hours in intermission without eyedrops more than five days, panretinalscope or OCT, FFA in episode of part cases, and so on.

Standard: repeatable glaucomatous visual field damage and corresponding fundus perform‐

Without defect static visual field: no more than 2 spots with sensitivity reduces more than 5dB , no spot with

Early stage paracentral scotoma, nasal step, , arcuate scotoma not linked with physiological blind spot

According to the results of comprehensive and dynamical analyzation to the clinical data of each cases and classification method shows as table 4, each case was discriminated for the

Moderate stage arcuate scotoma linked with physiological blind spot, nasal hemianopsia,ring scotoma,

constriction of visual field more than 30 degrees,

sensitivity reduces more thandB; dynamic visual field: no nasal step and temporal more than 10 degrees, no significantly constriction of visual field (except for refractive interstitial lesions

cases who suffered binocularly or had damage were contained in. [23, 26]

**Research project of first diagnosis at the first attendance in our hospital**

**2.** Stage division standard of glaucomatous visual field damage(see Table3)

**Analytical methods**

ance

**1.** Analysis for damage

392 Glaucoma - Basic and Clinical Aspects

Advanced stage tubular

**3.** Classification method

Absolute stage no light perception

and retinopathy)

**Table 3.** Stage division standard of glaucomatous visual field defect

clinical approach of optic nerve damage. [20,21,22,24,27,28]

**1.** Incidence and stage distribution of glaucomatous optic nerve damage

190 cases of 208 patients with PSS had a set of complete material. There were 71 cases (34.1%) with optic nerve damage, in which 12 cases (16.9%) regarded as suspicious damage, 59 cases (83.1%) regarded as definite damage.

Stage distribution of glaucomatous optic nerve damage was shown in Table 5:


**Table 5.** Stage distribution of glaucomatous optic nerve damage in 59 cases regarded as clear damage

**2.** The clinical approach of optic nerve damage

Four clinical approaches via which the damage occurred in PSS were deduced, they were represented as Type A, B, C and D.

There is not significant difference in the stage distribution of visual field damage in different type of PSS patients. ( X2 =6.904, P>0.05).Make the early and moderate stage as one group, advanced and absolute stage as anothe group, Statistical result shows that there is significant difference in the stage distribution of visual field damage in different type of PSS patients.The incidence of early stage of glaucomatous visual field damage in Type A (63%) was higher.While

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**Conclusion:** Most cases in type A suffered a early stage damage, and most in other types suffered a moderate or advanced stage damage, but there were 2 cases in type A who had gone

In the past PSS was considered to be a self-limited disease and has a favorable prognosis,how‐ ever, in recent years a number of authors have confirmed that part of the PSS cases suffered glaucomatous optic nerve damage similar to those in primary glaucoma cases, but the incidence, degree, related factors and clinical approach of the occurrence is unknown. This part focused on the clinical approach of optic nerve damage in Posner-Schlossman syndrome after aforementioned researches. Report about optic nerve damage caused by PSS combined with primary open-angle glaucoma is common; the other types were seldomly reported.Sys‐ tematic research aimed at this question has never been seen so far at home and abroad. We determined the damage approach by analyzing each patient's clinical data dynamically and comprehensively according to the discrimination method established on the basis of relating literatures and the results of our long-term systematic study, and got the conclusion that there were four clinical approaches via which the damage occurred. Beyond all question, further researches, supplement and correct is necessary in this field, but the method and result of our

**2.** Clinical features and treatment principle for cases with damage from different clinical

*3.3.4.1. Type A Cumulative effect of repeated episodes of high intraocular pressure of pure PSS leads to*

Except for visual field damage, type A cases complied with the basic characteristics of typical PSS: monocular attacked; intermittently onset of high intraocular pressure with hoar and suetshaped KP ;normal intraocular pressure(including 24 hours intraocular pressure )of the fellow eye in episode and the both eyes in intermission ; Crossed-over phenomenon and postures change of IOP; Normal anterior chamber depth; wide anterior chamber angle; Visual field change of vascular shadow usually appears in episode and recover in intermission at the initial in most cases, and true visual field damage is of mild and early stage usually , but loss of light perception can be seen in a few cases; the attack lasts a long time frequently in middle-aged

**1.** The clinical approach of optic nerve damage in Posner-Schlossman syndrome.

7 of 19 Type C cases were in advanced stage.

study maybe a wind vane for the further researches.

to absolute stage.

*3.3.4. Discussion*

approach

**Clinical features**

*damage*

Type A Cumulative effect of repeated episode of high intraocular pressure of pure PSS leads to visual field damage: 27 cases

Type B Recurrent attacks of PSS which results in secondary trabecular meshwork damage causes secondary open-angle glaucoma: 6 cases

Type C PSS combined with primary open-angle glaucoma: 19 cases

Type D PSS combined with primary closed-angle glaucoma: 7 cases

Composition of the clinical approach in 59 cases regarded as definite glaucomatous optic nerve damage was showed in Figure10.

**3.** Distribution of stage of visual field damage in different optic nerve damage approaches was showed in Table 6

**Figure 10.** The distribution of clinical approach of optic nerve damage in PSS.


**Table 6.** Stage distribution of Visual field damage in different type of PSS patients

There is not significant difference in the stage distribution of visual field damage in different type of PSS patients. ( X2 =6.904, P>0.05).Make the early and moderate stage as one group, advanced and absolute stage as anothe group, Statistical result shows that there is significant difference in the stage distribution of visual field damage in different type of PSS patients.The incidence of early stage of glaucomatous visual field damage in Type A (63%) was higher.While 7 of 19 Type C cases were in advanced stage.

**Conclusion:** Most cases in type A suffered a early stage damage, and most in other types suffered a moderate or advanced stage damage, but there were 2 cases in type A who had gone to absolute stage.

#### *3.3.4. Discussion*

**2.** The clinical approach of optic nerve damage

causes secondary open-angle glaucoma: 6 cases

Type C PSS combined with primary open-angle glaucoma: 19 cases

Type D PSS combined with primary closed-angle glaucoma: 7 cases

**Figure 10.** The distribution of clinical approach of optic nerve damage in PSS.

**Table 6.** Stage distribution of Visual field damage in different type of PSS patients

**Early stage Moderate stage Advanced**

Type A 17 7 1 2 27 Type B 2 2 2 0 6 Type C 5 7 7 0 19 Type D 2 3 2 0 7

**stage**

**Absolute stage Total**

represented as Type A, B, C and D.

to visual field damage: 27 cases

394 Glaucoma - Basic and Clinical Aspects

damage was showed in Figure10.

was showed in Table 6

Four clinical approaches via which the damage occurred in PSS were deduced, they were

Type A Cumulative effect of repeated episode of high intraocular pressure of pure PSS leads

Type B Recurrent attacks of PSS which results in secondary trabecular meshwork damage

Composition of the clinical approach in 59 cases regarded as definite glaucomatous optic nerve

**3.** Distribution of stage of visual field damage in different optic nerve damage approaches

**1.** The clinical approach of optic nerve damage in Posner-Schlossman syndrome.

In the past PSS was considered to be a self-limited disease and has a favorable prognosis,how‐ ever, in recent years a number of authors have confirmed that part of the PSS cases suffered glaucomatous optic nerve damage similar to those in primary glaucoma cases, but the incidence, degree, related factors and clinical approach of the occurrence is unknown. This part focused on the clinical approach of optic nerve damage in Posner-Schlossman syndrome after aforementioned researches. Report about optic nerve damage caused by PSS combined with primary open-angle glaucoma is common; the other types were seldomly reported.Sys‐ tematic research aimed at this question has never been seen so far at home and abroad. We determined the damage approach by analyzing each patient's clinical data dynamically and comprehensively according to the discrimination method established on the basis of relating literatures and the results of our long-term systematic study, and got the conclusion that there were four clinical approaches via which the damage occurred. Beyond all question, further researches, supplement and correct is necessary in this field, but the method and result of our study maybe a wind vane for the further researches.

**2.** Clinical features and treatment principle for cases with damage from different clinical approach

*3.3.4.1. Type A Cumulative effect of repeated episodes of high intraocular pressure of pure PSS leads to damage*

#### **Clinical features**

Except for visual field damage, type A cases complied with the basic characteristics of typical PSS: monocular attacked; intermittently onset of high intraocular pressure with hoar and suetshaped KP ;normal intraocular pressure(including 24 hours intraocular pressure )of the fellow eye in episode and the both eyes in intermission ; Crossed-over phenomenon and postures change of IOP; Normal anterior chamber depth; wide anterior chamber angle; Visual field change of vascular shadow usually appears in episode and recover in intermission at the initial in most cases, and true visual field damage is of mild and early stage usually , but loss of light perception can be seen in a few cases; the attack lasts a long time frequently in middle-aged and aged people for long course, also with higher IOP; heterochromia iridis occurred in later stage in some cases. (See Figure11) [20, 22, 29]

and the duration extended. This attack happened one month before this visits to our hospi‐

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Examination at first visit: Vision 1.0(OU), IOP19.7mmHg(R), 12mmHg (L), anterior cham‐

Fundus examination: C/D0.3(R) 0.6(L), there wasn't other abnormalities. She was diagnosed as secondary glaucoma of left eye. On September 13 (10 days after withdrawal), the 24 hours IOP of both eyes were measured: right eye: 14-18mmHg, left eye 12-14mmHg, Corneal thickness: right eye: 584µm, left eye: 575µm. She was diagnosed as "glaucomatocyclitis crisis

Another onset lasted for more than 10 days, IOP of the left eye was 43mmHg, there was 2 hoar and suet--like KP and faded iris pigment in left eye. There were total seven attacks in oneyear, with the duration from 1 week to 20 days, during one of which the KP appeared 9 day after the occurrence. 24 hours IOP during this episode: right Eye: 14-19mmHg, left Eye: 23-29mmHg; iris depigmentation of her left eye exacerbated, no abnormal was found with fundus angiography. The recent onset occurred in September this year, the medication of hormone and pranopulin continued for 3 months, with another minor attack during that

She made another visit to our hospital one year later. It was found that the iris of her left eye appeared a typical "rain dozen sand samples", meanwhile, there were two off-white round medium-sized lipid-like KP.and she was diagnosed as "left eye glaucomatocyclitic crisis with heterochromatic iris." Since then, the attack occurred more frequently, with frequency of 1 to 2 times per month, the visual field damage exacerbated. She was hospitalized in our department, and the surgery of glaucoma valve implantation was performed. Postoperative intraocular pressure: 19mmHg for her right eye and 6mmHg for her left eye:, visual acuity:: 1.0 left eye (with pink hole) for her both eye, and the syndrome did not attack postoperation.

2) He was hospitalized in our hospital for the reason of "intermittent pain of left eye for 25

Since 25 years ago, the patient got intermittent episodes of pain and blurred vision with his left eye, which occurred 1 to 2 times per month with the duration of 3to 5 days, and can be selfcured. In many hospitals he was diagnosed as "glaucomatocyclitic crisis" and treated with irregular medication. The occurrence becomes more frequently in the recent 10 years, and the

In the intermittent period, he was hospitalized for systematic examination. Visual acuity was 1.0 for his right eye and no light perception for his left eye. All the results of IOP, tonography, 24 hours IOP measurement and other tests during the intermittent period were normal for his

The result of the medical examination at this hospitalization showed as fellowing: his right eye had a corrected visual acuity of 1.0, IOP 14mmHg, C/D 0.4, wide anterior chamber angle; his

tal and stop one week ago without use of any drug.

in left eye."

this period.

both eyes.

(Clinical data please see Figure 12)

years, decrease of vision for 20 years, blind for 1 year".

duration longer, and the vision recessions gradually.

bers of both eyes were not shallow, iris color was symmetrical, KP (-).

#### **Treatment principle**

Pay enough attention to treatment for each attack, in which the most important is control‐ ling intraocular pressure timely and effectively. Surgery is necessary for the cases with ex‐ cessive frequent attacks, heavy damage or obvious progress of his damage.

The surgery method and the time: glaucoma valve or EX-press glaucoma filtration device implantation maybe suit for cases with excessive frequent attack, high IOP but light inflam‐ mation (intermission or episodes); trabeculectomy could be selected for cases with low at‐ tack frequency, high IOP as well as severe inflammation (intermission only).

#### **Typical cases**

1) She visited our hospital and was diagnosed as glaucomatocyclitis crisis of left eye in other hospital six years ago. In the initial stage, she attacked once or twice per year with duration of 3~7 days for each attack and ceased spontaneously, then the frequency of attack increased and the duration extended. This attack happened one month before this visits to our hospi‐ tal and stop one week ago without use of any drug.

and aged people for long course, also with higher IOP; heterochromia iridis occurred in later

**Figure 11.** The iridis of a PSS patient. (A) is that of the normal eye (B) is that of the affected eye.

cessive frequent attacks, heavy damage or obvious progress of his damage.

tack frequency, high IOP as well as severe inflammation (intermission only).

Pay enough attention to treatment for each attack, in which the most important is control‐ ling intraocular pressure timely and effectively. Surgery is necessary for the cases with ex‐

The surgery method and the time: glaucoma valve or EX-press glaucoma filtration device implantation maybe suit for cases with excessive frequent attack, high IOP but light inflam‐ mation (intermission or episodes); trabeculectomy could be selected for cases with low at‐

1) She visited our hospital and was diagnosed as glaucomatocyclitis crisis of left eye in other hospital six years ago. In the initial stage, she attacked once or twice per year with duration of 3~7 days for each attack and ceased spontaneously, then the frequency of attack increased

**Treatment principle**

**Typical cases**

stage in some cases. (See Figure11) [20, 22, 29]

396 Glaucoma - Basic and Clinical Aspects

Examination at first visit: Vision 1.0(OU), IOP19.7mmHg(R), 12mmHg (L), anterior cham‐ bers of both eyes were not shallow, iris color was symmetrical, KP (-).

Fundus examination: C/D0.3(R) 0.6(L), there wasn't other abnormalities. She was diagnosed as secondary glaucoma of left eye. On September 13 (10 days after withdrawal), the 24 hours IOP of both eyes were measured: right eye: 14-18mmHg, left eye 12-14mmHg, Corneal thickness: right eye: 584µm, left eye: 575µm. She was diagnosed as "glaucomatocyclitis crisis in left eye."

Another onset lasted for more than 10 days, IOP of the left eye was 43mmHg, there was 2 hoar and suet--like KP and faded iris pigment in left eye. There were total seven attacks in oneyear, with the duration from 1 week to 20 days, during one of which the KP appeared 9 day after the occurrence. 24 hours IOP during this episode: right Eye: 14-19mmHg, left Eye: 23-29mmHg; iris depigmentation of her left eye exacerbated, no abnormal was found with fundus angiography. The recent onset occurred in September this year, the medication of hormone and pranopulin continued for 3 months, with another minor attack during that this period.

She made another visit to our hospital one year later. It was found that the iris of her left eye appeared a typical "rain dozen sand samples", meanwhile, there were two off-white round medium-sized lipid-like KP.and she was diagnosed as "left eye glaucomatocyclitic crisis with heterochromatic iris." Since then, the attack occurred more frequently, with frequency of 1 to 2 times per month, the visual field damage exacerbated. She was hospitalized in our department, and the surgery of glaucoma valve implantation was performed. Postoperative intraocular pressure: 19mmHg for her right eye and 6mmHg for her left eye:, visual acuity:: 1.0 left eye (with pink hole) for her both eye, and the syndrome did not attack postoperation. (Clinical data please see Figure 12)

2) He was hospitalized in our hospital for the reason of "intermittent pain of left eye for 25 years, decrease of vision for 20 years, blind for 1 year".

Since 25 years ago, the patient got intermittent episodes of pain and blurred vision with his left eye, which occurred 1 to 2 times per month with the duration of 3to 5 days, and can be selfcured. In many hospitals he was diagnosed as "glaucomatocyclitic crisis" and treated with irregular medication. The occurrence becomes more frequently in the recent 10 years, and the duration longer, and the vision recessions gradually.

In the intermittent period, he was hospitalized for systematic examination. Visual acuity was 1.0 for his right eye and no light perception for his left eye. All the results of IOP, tonography, 24 hours IOP measurement and other tests during the intermittent period were normal for his both eyes.

The result of the medical examination at this hospitalization showed as fellowing: his right eye had a corrected visual acuity of 1.0, IOP 14mmHg, C/D 0.4, wide anterior chamber angle; his

His left eye still had attacks of PSS after he left hospital and each attack could be self-cured. IOP and 24-hour IOP during the intermittent period were measured to be normal, and his left eye had an IOP lower than that of his right eye, a typical IOP cross phenomenon appeared every time. Three years later, the fundus and visual field of his right eye kept normal. (Clinical

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**Figure 13.** Visual field of the right eye of patient (Clinical number 241163). PSS results in blind of his left eye, but the

*3.3.4.2. Type B secondary open-angle glaucoma from secondary damage to trabecular meshwork by*

Type B cases complied with the basic characteristics (above mentioned) of typical PSS in early stage. These characteristics lost eventually as the damage to trabecular meshwork gradually accelerated, the attack takes place more frequently and lasts a longer and longer time with a higher and higher IOP, and serious visual field damage developed at last. [30, 31] However, the fundus, visual field, IOP in intermittent and episode of the fellow eye maintained normal.

It is necessary to reduce IOP with drugs according to extent and characteristics of elevated IOP and diminish inflammation with hormone of weak effect on elevating IOP for short time, for

Patients of this type usually had a long course of the disease with an order age.

data see Figure 13)

visual field of his right eye without PSS is normal.

*recurrent attacks of PSS*

**Clinical features**

**Treatment principle**

**Figure 12.** Clinical data of a cases suffered from PSS with glaucomatous optic nerve damage combined with heterochro‐ mia iris (Clinical number 488368). Visual field (A) and Optical Coherence Tomography (B) indicate glaucoma damages; An‐ terio segment of normal right eye (C) and left eye (D), arrow shows heterochromia iris and KP in the attacked eye (E).

left eye had no photoreception, intraocular pressure 56mmHg, C / D1.0, width of N1 ~ N3 for the anterior chamber angle with some small limited adhesions; corneal edema, a dozen of round lipid-like KP.

Without any treatment, the IOP of his fell to 14mmHg within one week. All results of exami‐ nations including 24 hours IOP measurement, drinking water experiment, darkroom prone test for his right eye were normal. Laboratory results of systemic body check were normal.

His left eye still had attacks of PSS after he left hospital and each attack could be self-cured. IOP and 24-hour IOP during the intermittent period were measured to be normal, and his left eye had an IOP lower than that of his right eye, a typical IOP cross phenomenon appeared every time. Three years later, the fundus and visual field of his right eye kept normal. (Clinical data see Figure 13)

**Figure 13.** Visual field of the right eye of patient (Clinical number 241163). PSS results in blind of his left eye, but the visual field of his right eye without PSS is normal.

#### *3.3.4.2. Type B secondary open-angle glaucoma from secondary damage to trabecular meshwork by recurrent attacks of PSS*

#### **Clinical features**

left eye had no photoreception, intraocular pressure 56mmHg, C / D1.0, width of N1 ~ N3 for the anterior chamber angle with some small limited adhesions; corneal edema, a dozen of

**Figure 12.** Clinical data of a cases suffered from PSS with glaucomatous optic nerve damage combined with heterochro‐ mia iris (Clinical number 488368). Visual field (A) and Optical Coherence Tomography (B) indicate glaucoma damages; An‐ terio segment of normal right eye (C) and left eye (D), arrow shows heterochromia iris and KP in the attacked eye (E).

Without any treatment, the IOP of his fell to 14mmHg within one week. All results of exami‐ nations including 24 hours IOP measurement, drinking water experiment, darkroom prone test for his right eye were normal. Laboratory results of systemic body check were normal.

round lipid-like KP.

398 Glaucoma - Basic and Clinical Aspects

Type B cases complied with the basic characteristics (above mentioned) of typical PSS in early stage. These characteristics lost eventually as the damage to trabecular meshwork gradually accelerated, the attack takes place more frequently and lasts a longer and longer time with a higher and higher IOP, and serious visual field damage developed at last. [30, 31] However, the fundus, visual field, IOP in intermittent and episode of the fellow eye maintained normal. Patients of this type usually had a long course of the disease with an order age.

#### **Treatment principle**

It is necessary to reduce IOP with drugs according to extent and characteristics of elevated IOP and diminish inflammation with hormone of weak effect on elevating IOP for short time, for example, lotemax. PGA is useful and myotic is prohibitive. Surgery or other treatment (SLT, trabeculectom, glaucoma valve or EX-press implantation) should be taken into account according to the IOP level controlled by drugs in intermittent and the situation of visual field damage.

### **Typical case**

He was diagnosed as "left eye PSS" with the complain of vision decline associated with distending pain of his left eye in other hospitals five years ago.

The medical records of other hospitals showed: IOP and other relating examinationgs of his right eye in episode and these in intermittent period of his both eyes was normal at the initial stage. The visual acuity decreased gradually, IOP fluctuated from 32 to 48 mmHg in recent years. He was hospitalized in our hospital three times, the results of clinical observation showed: IOP including 24 hours IOP in intermittent period, the fundus and visual field of his right eye appeared normal; while IOP of his left eye was high frequently and higher when PSS attacked, 24 hours IOP in intermittent period appeared abnormal including the highest IOP and IOP variation. The left eye was diagnosed as secondary open-angle glaucoma from secondary damage to trabecular meshwork by recurrent attacks of PSS, and then a trabecu‐ lectomy was performed on his left eye. Postoperative IOP of his left eye was from 12 to 10 mmHg in intermittent period, 20 to 31 mmHg in episodes, while his right eye kept normal in all ways. (Clinical data see Figure 14)

*3.3.4.3. Type C PSS combined with primary open-angle glaucoma*

### **Clinical features**

Monocular/ binocular paroxysmal increased IOP with mild cyclitis; wide anterior chamber angle; binocular abnormal IOP and visual field damage; high average IOP; grate fluctuation of IOP level; absence of IOP cross phenomenon; PSS attacks at the same eye in most cases; at the two eyes alternately or at the same time in a few cases; visual field damage was serious, and more serious in the eye often attacked by PSS. [27, 32]

#### **Treatment principle**

Enough attention should be given to the treatment for cases of this type, whose incidence reached up to 31% as reported.

Drug treatment is similar to that of POAG, but in episode of PSS, corticosteroid is useful transitorily, while PGA and myotic is prohibitive. Indication of surgery is similar to that of POAG, but classical trabeculectomy should be performed in intermission, and the effect and safety of nonpenetrating trabeculectomy, implantation of Ahmed glaucoma valve or EX-PRESS Glaucoma Filtration Device has not been confirmed. Laser trabeculoplasty( ALT), Se‐ lective laser trabeculoplasty (SLT) or Pneumatic trabeculoplasty (PNT) should be adopted in intermission, however, there has not related report. [11, 33, 34, 35]

showed: KP (-), IOP16.3/42.7(R/L), and she was treated with Travoprost Eye Drops to her left eye and brimonidine and brinzolamide to the both eye. 1 week after treatment, her IOP turned to 36/17(R/L), the treatment had been changed to travoprost, brimonidine and brin‐

**Figure 14.** Clinical data of a patient suffered from PSS with glaucomatous optic nerve damage due to secondary open angle glaucoma (Clinical number 81304). Normal visual field in right eye (A) and advanced visual field defect in left

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eye (B); UBM shows the normal right eye and the affected left eye post-operation (C).

zolamide for the both eye.

### **Typical cases**

1) With complaints of discomfort and blurred vision of her left eye for more than 1 year, the patient was diagnosed as POAG in other hospital 10 days ago. Clinical date of that time

example, lotemax. PGA is useful and myotic is prohibitive. Surgery or other treatment (SLT, trabeculectom, glaucoma valve or EX-press implantation) should be taken into account according to the IOP level controlled by drugs in intermittent and the situation of visual field

He was diagnosed as "left eye PSS" with the complain of vision decline associated with

The medical records of other hospitals showed: IOP and other relating examinationgs of his right eye in episode and these in intermittent period of his both eyes was normal at the initial stage. The visual acuity decreased gradually, IOP fluctuated from 32 to 48 mmHg in recent years. He was hospitalized in our hospital three times, the results of clinical observation showed: IOP including 24 hours IOP in intermittent period, the fundus and visual field of his right eye appeared normal; while IOP of his left eye was high frequently and higher when PSS attacked, 24 hours IOP in intermittent period appeared abnormal including the highest IOP and IOP variation. The left eye was diagnosed as secondary open-angle glaucoma from secondary damage to trabecular meshwork by recurrent attacks of PSS, and then a trabecu‐ lectomy was performed on his left eye. Postoperative IOP of his left eye was from 12 to 10 mmHg in intermittent period, 20 to 31 mmHg in episodes, while his right eye kept normal in

Monocular/ binocular paroxysmal increased IOP with mild cyclitis; wide anterior chamber angle; binocular abnormal IOP and visual field damage; high average IOP; grate fluctuation of IOP level; absence of IOP cross phenomenon; PSS attacks at the same eye in most cases; at the two eyes alternately or at the same time in a few cases; visual field damage was serious,

Enough attention should be given to the treatment for cases of this type, whose incidence

Drug treatment is similar to that of POAG, but in episode of PSS, corticosteroid is useful transitorily, while PGA and myotic is prohibitive. Indication of surgery is similar to that of POAG, but classical trabeculectomy should be performed in intermission, and the effect and safety of nonpenetrating trabeculectomy, implantation of Ahmed glaucoma valve or EX-PRESS Glaucoma Filtration Device has not been confirmed. Laser trabeculoplasty( ALT), Se‐ lective laser trabeculoplasty (SLT) or Pneumatic trabeculoplasty (PNT) should be adopted in

1) With complaints of discomfort and blurred vision of her left eye for more than 1 year, the patient was diagnosed as POAG in other hospital 10 days ago. Clinical date of that time

distending pain of his left eye in other hospitals five years ago.

*3.3.4.3. Type C PSS combined with primary open-angle glaucoma*

and more serious in the eye often attacked by PSS. [27, 32]

intermission, however, there has not related report. [11, 33, 34, 35]

all ways. (Clinical data see Figure 14)

**Clinical features**

**Treatment principle**

**Typical cases**

reached up to 31% as reported.

damage.

**Typical case**

400 Glaucoma - Basic and Clinical Aspects

**Figure 14.** Clinical data of a patient suffered from PSS with glaucomatous optic nerve damage due to secondary open angle glaucoma (Clinical number 81304). Normal visual field in right eye (A) and advanced visual field defect in left eye (B); UBM shows the normal right eye and the affected left eye post-operation (C).

showed: KP (-), IOP16.3/42.7(R/L), and she was treated with Travoprost Eye Drops to her left eye and brimonidine and brinzolamide to the both eye. 1 week after treatment, her IOP turned to 36/17(R/L), the treatment had been changed to travoprost, brimonidine and brin‐ zolamide for the both eye.

The results of examination in our hospital showed as follows: visual acuity R1.0 (-1.25DS), L0.05(-3.75DS), IOP17(OU); absence of conjunctiva hyperemia; cup/disc ratios 0.8 OD and0.9 OS,and inferior RNFLD(by OCT:) in the both eye; severe glaucomatous visual field damage in both eye.;extended latent time and descended amplitude on VEP; CCT:540/520 (R/L),corneal endothelium cells 1730/2747(R/L); center anterior chamber depth ≥3.0mm and open anterior chamber angle in every direction for the both eye by UBM. She was diagnosed as binocular POAG,and treated successively with travatan, alphagan and brinzolamide to binoculus, but her IOP was not controlled well. Thus, a trabeculectomy was performed the left eye.Two weeks after the operation, the filtration bubble turned fibrosis,and IOP increased. By 3 times of pindelamination with 5- fluorouracil and eyeball massage, IOP was controlled on 12 to 14 mmHg. Her right eye was treated with travatan, carteolol hydrochloride and brimonidine, IOP was controlled from 12 to 14 mmHg.She was discharged from hospital.

Four months later, the right eye appeared 5 small rounds and mutton-fat like KP, IOP in‐ creased to 19mmHg. A week late, KP played down, IOP descended to 12 mmHg. A month later; KP appeared again, IOP increased to 37, after treatment in hospital for a week, the IOP decreased to 12 mmHg. She was diagnosed as POAG combined with PSS. Two months later PSS of her right attacked again, IOP increased to 44 mmHg; visual field damage has pro‐ gressed remarkably. FFA showed optic atrophy without any other abnormal. She was hospi‐ talized again,and a implantation of Ahmed valve to her right eye was done on the next day. During the operation, the valve appeard out of control; we dealt it well with removable re‐ straint line processing; the IOP and anterior chamber stability was controlled. 2 month after the operation, the IOP increased to 22 mmHg because of the draining disc was packaged. By pin-delamination and eyeball massage, IOP was controlled near to 20mmHg. Carteolol hy‐ drochloride was added and the IOP was controlled well in intermittent, but PSS attacked frequently and the IOP was out of control during episode. she was hospitalized once more and the right eye was treated with no-penetrating glaucoma surgery. 1 month after opera‐ tion, the IOP was controlled well, binocular IOP was 10mmHg. 2 month after operation, PSS attacked her right eye again, IOP increased to 20 mmHg. This attack faded a week late and IOP of her both maintained 14mmHg below until now. (Clinical data please see Figure 15)

2) She was diagnosed as POAG in other hospitals because of intermittent attacks of distending pain and gradually aggravated blurred vision to her right eye for six years. The left eye has the same symptoms slighter than that of her right eye.

When she was examined in our hospital the results showed as follow: visual acuity: R 0.4, L 0.2; IOP: R 50mmHg and L 17mmHg; anterior chamber angle NI~NII in every direction; The optic cup depressed and enlarged. Argon laser trabeculoplasty was carried out after the diagnosis of POAG. But after that, the right eye relapsed frequently. One year later, the right eye relapsed again. There were three KP which were gray-white, round, and like mutton-fat in the right eye and a wreck of the keratic precipitate in the left eye. After a series of relating examinations such as visual activity, IOP, fundus, visual field, gonioscopy, she was diagnosed as PSS.

**Figure 15.** Clinical data of patient suffered from PSS(right eye) with glaucomatous optic nerve damage combined with POAG(both eye). The right eye is treated with Ahmed valve implantation surgery (A), the left eye is treated with normal trabeculectomy (B), visual fields of right eye (C) and left eye (D) show typical glaucoma damages, the fundus angiography indicates no vascular disorder except of optic atrophy (E) and the optic cups of right eye and left eye are

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non-symmetrical (F).

Seven years later, the patient attended to our clinic because the same symptoms attacked fre‐ quently in recent years and her vision became worse and worse. Attacks appeared as binocular

The results of examination in our hospital showed as follows: visual acuity R1.0 (-1.25DS), L0.05(-3.75DS), IOP17(OU); absence of conjunctiva hyperemia; cup/disc ratios 0.8 OD and0.9 OS,and inferior RNFLD(by OCT:) in the both eye; severe glaucomatous visual field damage in both eye.;extended latent time and descended amplitude on VEP; CCT:540/520 (R/L),corneal endothelium cells 1730/2747(R/L); center anterior chamber depth ≥3.0mm and open anterior chamber angle in every direction for the both eye by UBM. She was diagnosed as binocular POAG,and treated successively with travatan, alphagan and brinzolamide to binoculus, but her IOP was not controlled well. Thus, a trabeculectomy was performed the left eye.Two weeks after the operation, the filtration bubble turned fibrosis,and IOP increased. By 3 times of pindelamination with 5- fluorouracil and eyeball massage, IOP was controlled on 12 to 14 mmHg. Her right eye was treated with travatan, carteolol hydrochloride and brimonidine, IOP was

Four months later, the right eye appeared 5 small rounds and mutton-fat like KP, IOP in‐ creased to 19mmHg. A week late, KP played down, IOP descended to 12 mmHg. A month later; KP appeared again, IOP increased to 37, after treatment in hospital for a week, the IOP decreased to 12 mmHg. She was diagnosed as POAG combined with PSS. Two months later PSS of her right attacked again, IOP increased to 44 mmHg; visual field damage has pro‐ gressed remarkably. FFA showed optic atrophy without any other abnormal. She was hospi‐ talized again,and a implantation of Ahmed valve to her right eye was done on the next day. During the operation, the valve appeard out of control; we dealt it well with removable re‐ straint line processing; the IOP and anterior chamber stability was controlled. 2 month after the operation, the IOP increased to 22 mmHg because of the draining disc was packaged. By pin-delamination and eyeball massage, IOP was controlled near to 20mmHg. Carteolol hy‐ drochloride was added and the IOP was controlled well in intermittent, but PSS attacked frequently and the IOP was out of control during episode. she was hospitalized once more and the right eye was treated with no-penetrating glaucoma surgery. 1 month after opera‐ tion, the IOP was controlled well, binocular IOP was 10mmHg. 2 month after operation, PSS attacked her right eye again, IOP increased to 20 mmHg. This attack faded a week late and IOP of her both maintained 14mmHg below until now. (Clinical data please see Figure 15)

2) She was diagnosed as POAG in other hospitals because of intermittent attacks of distending pain and gradually aggravated blurred vision to her right eye for six years. The left eye has

When she was examined in our hospital the results showed as follow: visual acuity: R 0.4, L 0.2; IOP: R 50mmHg and L 17mmHg; anterior chamber angle NI~NII in every direction; The optic cup depressed and enlarged. Argon laser trabeculoplasty was carried out after the diagnosis of POAG. But after that, the right eye relapsed frequently. One year later, the right eye relapsed again. There were three KP which were gray-white, round, and like mutton-fat in the right eye and a wreck of the keratic precipitate in the left eye. After a series of relating examinations such as visual activity, IOP, fundus, visual field, gonioscopy, she was diagnosed

Seven years later, the patient attended to our clinic because the same symptoms attacked fre‐ quently in recent years and her vision became worse and worse. Attacks appeared as binocular

controlled from 12 to 14 mmHg.She was discharged from hospital.

402 Glaucoma - Basic and Clinical Aspects

the same symptoms slighter than that of her right eye.

as PSS.

**Figure 15.** Clinical data of patient suffered from PSS(right eye) with glaucomatous optic nerve damage combined with POAG(both eye). The right eye is treated with Ahmed valve implantation surgery (A), the left eye is treated with normal trabeculectomy (B), visual fields of right eye (C) and left eye (D) show typical glaucoma damages, the fundus angiography indicates no vascular disorder except of optic atrophy (E) and the optic cups of right eye and left eye are non-symmetrical (F).

high IOP with binocular KP or binocular high IOP with monocular KP in different time. Clini‐ cal data on this visit showed :visual acuity: R 0.2, L 0.15;there has not obvious keratic precipi‐ tates in the right eye, but the left eye has one mutton-fat like keratic precipitate; the ratio of C/D was about 0.9; IOP was R 28 mmHg and L 31 mmHg; the visual field has deteriorated over the last few years; 24-hour IOP measurement during the intermittent period showed that IOP of the right eye was from 21 to35mmHg and 23 to 36mmHg for her left eye.Thus,PSS combined with POAG was proved to be the last diagnosis. Her visual acuity and visual field were in a sta‐ ble condition under regular treatment with carteolol Hydrochloride 2% and brimonidine tar‐ trate as well as anti-inflammatory drug when PSS attacks. (Clinical data see Figure 16)

#### *3.3.4.4. Type D PSS combined with primary closed-angle glaucoma*

#### **Research status**

Except for our data, there had been only two individual reports about PSS combined with PCAG in China and none in abroad. Cases of PSS combined with PCAG at home are much more than those in abroad due to the higher incidence of PCAG as well as PSS at home. In 2004 we reported 6 cases and completed a systematic clinical analysis. It was often reminded by many ophthalmologists that cases of PSS had be mistaken as AACG, but enough attention had not been paid to this type of PSS. [18, 28, 36, 37, 38],

#### **Clinical features**

There is a typical history of PSS attack with binocular shallow anterior chamber and narrow or closed anterior chamber angle. PSS hardly attacked synchronously with PACG, the anterior chamber angle is open in episodes of PSS. Type D cases complied with the basic characteristics of typical PSS in early stage: binocular IOP is normal in intermission; with cross phenomenon of IOP; however, when PACG became more advanced, although the IOP of the PSS attacked eye was much higher than that of the unattacked eye in the episode of PSS, binocular IOP turned higher than normal even in intermittent of PSS without obvious cross phenomenon. Most cases were diagnosed as PACG previously, PSS appeared after the treatment for PACG had been completed and the anterior chamber angle been opened, a few cases were typical PSS with narrow anterior chamber angle when they were young; PACG appeared as anterior chamber angle became narrower and narrower with age. Most of the cases of this type were elder with a longer course of PSS and a more advanced visual field damage.

**Diagnostic gist**

angle,and binocularly attacked.

unnecessary surgery can be avoid.

**Treatment principle**

To find out PACG complicated with PSS as soon as possible, it is necessary to carry out a set of comprehensive and careful examinations relating to PACG in the intermission of PSS for PSS patients with factors as follows: the old-aged ,with a serious visual field damage, longer course of the disease, with a shallow anterior chamber or an narrow anterior chamber

**Figure 16.** Visual field of patient (Clinical number: 232036) with binocular PSS combined binocular POAG. After drug treatment, the damages of binocular visual fields between1991 (A) and 1998 (B) has no significant advance.

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When IOP appeared as repeated, intermittent and sudden elevation in a patient with PACG whose anterior chamber angle had been opened and the IOP been controlled well for a period after treatment by means of laser and/or surgery and/or drugs, it is very important to pay sufficient attention to the depth of the binocular anterior chamber and anterior chamber angle on the time the IOP is higher, and to make clinical follow-up observations for KP and its relationship with IOP, so as to ascertain whether PSS is the cause of elevating IOP, so that

According to condition of PACG, laser and/or surgery and/or drugs may become options.

#### **Diagnosis standard**

The first is that the anterior chamber angle is open when PSS is diagnosed at episode, either in the intermission of PACG or after PACG was treated with Laser/surgery/drug; the second is that the cases complied with the basic characteristics of typical PSS described by Posner-Schlossman. In our study, 2 cases was diagnosed as PSS at a younger age with binocular narrow anterior chamber angle (first was narrow II, narrow III-IV four years later), 5 cases was diagnosed as PSS after treatment of PACG(similar to the two cases reported at home). [28, 39]

**Figure 16.** Visual field of patient (Clinical number: 232036) with binocular PSS combined binocular POAG. After drug treatment, the damages of binocular visual fields between1991 (A) and 1998 (B) has no significant advance.

### **Diagnostic gist**

high IOP with binocular KP or binocular high IOP with monocular KP in different time. Clini‐ cal data on this visit showed :visual acuity: R 0.2, L 0.15;there has not obvious keratic precipi‐ tates in the right eye, but the left eye has one mutton-fat like keratic precipitate; the ratio of C/D was about 0.9; IOP was R 28 mmHg and L 31 mmHg; the visual field has deteriorated over the last few years; 24-hour IOP measurement during the intermittent period showed that IOP of the right eye was from 21 to35mmHg and 23 to 36mmHg for her left eye.Thus,PSS combined with POAG was proved to be the last diagnosis. Her visual acuity and visual field were in a sta‐ ble condition under regular treatment with carteolol Hydrochloride 2% and brimonidine tar‐

trate as well as anti-inflammatory drug when PSS attacks. (Clinical data see Figure 16)

Except for our data, there had been only two individual reports about PSS combined with PCAG in China and none in abroad. Cases of PSS combined with PCAG at home are much more than those in abroad due to the higher incidence of PCAG as well as PSS at home. In 2004 we reported 6 cases and completed a systematic clinical analysis. It was often reminded by many ophthalmologists that cases of PSS had be mistaken as AACG, but enough attention had

There is a typical history of PSS attack with binocular shallow anterior chamber and narrow or closed anterior chamber angle. PSS hardly attacked synchronously with PACG, the anterior chamber angle is open in episodes of PSS. Type D cases complied with the basic characteristics of typical PSS in early stage: binocular IOP is normal in intermission; with cross phenomenon of IOP; however, when PACG became more advanced, although the IOP of the PSS attacked eye was much higher than that of the unattacked eye in the episode of PSS, binocular IOP turned higher than normal even in intermittent of PSS without obvious cross phenomenon. Most cases were diagnosed as PACG previously, PSS appeared after the treatment for PACG had been completed and the anterior chamber angle been opened, a few cases were typical PSS with narrow anterior chamber angle when they were young; PACG appeared as anterior chamber angle became narrower and narrower with age. Most of the cases of this type were elder with a longer course of PSS and a more advanced visual

The first is that the anterior chamber angle is open when PSS is diagnosed at episode, either in the intermission of PACG or after PACG was treated with Laser/surgery/drug; the second is that the cases complied with the basic characteristics of typical PSS described by Posner-Schlossman. In our study, 2 cases was diagnosed as PSS at a younger age with binocular narrow anterior chamber angle (first was narrow II, narrow III-IV four years later), 5 cases was diagnosed as PSS after treatment of PACG(similar to the two cases reported at home).

*3.3.4.4. Type D PSS combined with primary closed-angle glaucoma*

not been paid to this type of PSS. [18, 28, 36, 37, 38],

**Research status**

404 Glaucoma - Basic and Clinical Aspects

**Clinical features**

field damage.

[28, 39]

**Diagnosis standard**

To find out PACG complicated with PSS as soon as possible, it is necessary to carry out a set of comprehensive and careful examinations relating to PACG in the intermission of PSS for PSS patients with factors as follows: the old-aged ,with a serious visual field damage, longer course of the disease, with a shallow anterior chamber or an narrow anterior chamber angle,and binocularly attacked.

When IOP appeared as repeated, intermittent and sudden elevation in a patient with PACG whose anterior chamber angle had been opened and the IOP been controlled well for a period after treatment by means of laser and/or surgery and/or drugs, it is very important to pay sufficient attention to the depth of the binocular anterior chamber and anterior chamber angle on the time the IOP is higher, and to make clinical follow-up observations for KP and its relationship with IOP, so as to ascertain whether PSS is the cause of elevating IOP, so that unnecessary surgery can be avoid.

#### **Treatment principle**

According to condition of PACG, laser and/or surgery and/or drugs may become options.

#### **Laser treatment:**


It is necessary to prevent the attack of PACG in either episodes or intermission of PSS for these untreated PACG cases with the appropriate use of miosis drug.

#### **Typical cases**

1) He was diagnosed as "PSS" in our hospital because of pain and discomfort of his right eye,then he was diagnosed as " acute angle-closure glaucoma " in other hospital because of severe sore of his both eyes, and switched to our hospital after remission seven years later.

Examination revealed mutton-fat like KP in the right eye. His right eye was diagnosed as PSS combined with PACG with analysis by synthesis combining history and test results of IOP, fundus, visual field and anterior chamber angle. The right eye was treated with "glaucoma drainage surgery", and the left eye with "YAG laser iridectomy ".

IOP of his both appeared stable for six months after operation, then the right eye was attacked by PSS once again. This attack of PSS appeared as typical KP, open angle and slightly increased IOP. (Clinical data please see Figure 17)

2) The patient came to our clinicbecause of "Repeated intermittent attacks of eye pain and impaired vision for her left eye and right eye as well for more than 14 years". She was treated with YAG laser iridotomy in other hospital for PACG binocularly twice each.,Her left eye had been still attacked intermittently ever since.Clinical date from her medical record showed that KP and IOP rising appeared nearly simultaneously on each episode and the IOP turned persistently higher than normal even if in intermission since 2 years ago, and the drugs could not control the IOP well.

our hospital,and a trabeculectomy was performed on her left eye, and she was discharged 10 days after a IOP of 14mmHg.6 weeks after the operation, an attack of PSS occurred with a IOP of 32mmHg and lasted a week;such attack occurred once or twice a year after that with a maximal IOP of 25mmHg. The IOP in intermission had maintained near 15mmHg during the first 4 years, but the result of 24h IOP measurement showed 13~20mmHg in the right eye and 15~24mmHg in the left eye. Iris heterochromia appeared in the left eye. Such a therapeutic schedule was estab‐ lished and kept 3 years since then: 2% Carteolol Hydrochloride Eye Drops twice a day to the both eye in intermission of PSS; 2% Carteolol twice a day plus brimonidine 3 times a day with shortly use of Lotemax for the left eye during episode of PSS. IOP of the both eye maintained

**Figure 17.** Typical clinical data of patient (Clinical number: 406013) with diagnosis of right PSS combined with binocu‐ lar PACG and treatment with classical trabeculectomy. The visual field show advanced glaucoma damages(A), OCT (C)

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Several attacks of PSS had been recorded with a IOP up to 40mmHg, and her visual field turned worsen, and "rain dozen sand -like" appearance in the iris of her left eye got more pronounced

15mmHg or below, and the visual field maintained stable in the 3 years.

also shows retinal nerve fiber layer defect, UBM indicate binocular closed angle (B).

Examination at this time showed: Vision R 1.0, L 0.4; IOP R 14 mmHg and L 46 mmHg ;2 muttonfat like KP in the left eye ; shallow anterior chamber and angle multiple adhesions in the both eyes; several trace of lasertherapy on iris of her both eye,the only panetrated hole on the right eye be covered with fibrous membrane, and that on the left eye be too small; cup/disc ratios R 0.4 and L 0.8.A diagnosis of "binocular PACG complicated with PSS in left eye" was established.A complementary lasertherapy was given to her right eye just at that moment; after this laserther‐ apy,her right had been kept well until now with only the help of 2% Carteolol Hydrochloride Eye Drops twice a day.3 weeks late, when this attack of PSS fade away, she was hospitalized in

**Laser treatment:**

406 Glaucoma - Basic and Clinical Aspects

**Typical cases**

should be big enough;

**1.** Indications of that for cases of PSS combined with PACG is similar to that PACG patients, except for that examination and treatment should be done in the intermission of PSS;

**3.** The iris surrounding excision mouth by laser must be thoroughly penetrated and the hole

**5.** It is import to pay attention to the treatment for PSS which continue to attack after laser therapy, and to the monitor of IOP and its dynamic change. Additional drug treatment

It is necessary to prevent the attack of PACG in either episodes or intermission of PSS for these

1) He was diagnosed as "PSS" in our hospital because of pain and discomfort of his right eye,then he was diagnosed as " acute angle-closure glaucoma " in other hospital because of severe sore of his both eyes, and switched to our hospital after remission seven years later. Examination revealed mutton-fat like KP in the right eye. His right eye was diagnosed as PSS combined with PACG with analysis by synthesis combining history and test results of IOP, fundus, visual field and anterior chamber angle. The right eye was treated with "glaucoma

IOP of his both appeared stable for six months after operation, then the right eye was attacked by PSS once again. This attack of PSS appeared as typical KP, open angle and slightly increased

2) The patient came to our clinicbecause of "Repeated intermittent attacks of eye pain and impaired vision for her left eye and right eye as well for more than 14 years". She was treated with YAG laser iridotomy in other hospital for PACG binocularly twice each.,Her left eye had been still attacked intermittently ever since.Clinical date from her medical record showed that KP and IOP rising appeared nearly simultaneously on each episode and the IOP turned persistently higher than normal even if in intermission since 2 years ago, and the drugs could

Examination at this time showed: Vision R 1.0, L 0.4; IOP R 14 mmHg and L 46 mmHg ;2 muttonfat like KP in the left eye ; shallow anterior chamber and angle multiple adhesions in the both eyes; several trace of lasertherapy on iris of her both eye,the only panetrated hole on the right eye be covered with fibrous membrane, and that on the left eye be too small; cup/disc ratios R 0.4 and L 0.8.A diagnosis of "binocular PACG complicated with PSS in left eye" was established.A complementary lasertherapy was given to her right eye just at that moment; after this laserther‐ apy,her right had been kept well until now with only the help of 2% Carteolol Hydrochloride Eye Drops twice a day.3 weeks late, when this attack of PSS fade away, she was hospitalized in

**4.** Corticosteroids and drugs for reducing IOP should be sufficient after laser operation;

**2.** Curative effect on cases with typical cross phenomenon of IOP should be better;

even trabeculectomy should be adopted timely when necessary;[27]

untreated PACG cases with the appropriate use of miosis drug.

drainage surgery", and the left eye with "YAG laser iridectomy ".

IOP. (Clinical data please see Figure 17)

not control the IOP well.

**Figure 17.** Typical clinical data of patient (Clinical number: 406013) with diagnosis of right PSS combined with binocu‐ lar PACG and treatment with classical trabeculectomy. The visual field show advanced glaucoma damages(A), OCT (C) also shows retinal nerve fiber layer defect, UBM indicate binocular closed angle (B).

our hospital,and a trabeculectomy was performed on her left eye, and she was discharged 10 days after a IOP of 14mmHg.6 weeks after the operation, an attack of PSS occurred with a IOP of 32mmHg and lasted a week;such attack occurred once or twice a year after that with a maximal IOP of 25mmHg. The IOP in intermission had maintained near 15mmHg during the first 4 years, but the result of 24h IOP measurement showed 13~20mmHg in the right eye and 15~24mmHg in the left eye. Iris heterochromia appeared in the left eye. Such a therapeutic schedule was estab‐ lished and kept 3 years since then: 2% Carteolol Hydrochloride Eye Drops twice a day to the both eye in intermission of PSS; 2% Carteolol twice a day plus brimonidine 3 times a day with shortly use of Lotemax for the left eye during episode of PSS. IOP of the both eye maintained 15mmHg or below, and the visual field maintained stable in the 3 years.

Several attacks of PSS had been recorded with a IOP up to 40mmHg, and her visual field turned worsen, and "rain dozen sand -like" appearance in the iris of her left eye got more pronounced in the last 2 years. She was hospitalized once more, and another trabeculectomy was performed on the left eye near the first one, at the end of which the two filtering blebs(an original and a just manufactured ) were merged into one. She was discharged with an IOP of 12mmHg; the left eye was no longer attacked after this trabeculectomy ,and the IOP kept stable.

(Clinical data see Figure 18)
