Case 1 – 2023

Learning Objectives:

Recognise the presenting symptoms and clinical signs of Posner Schlossman Syndrome (PSS)
Formulate a list of differential diagnoses with reasons for exclusion
Become familiar with the aetiology and epidemiology of PSS
Describe the management strategies for patients with PSS
Explain the long-term prognosis for patients with PSS

Case Presentation:

A 42 year-old male presents acutely to your practice with a sore right eye (described as a mild ache). He has noted that over the past day or so the vision in the right eye is more blurred than normal, but he is still able to perform his day-to-day activities. His partner has pointed out that his right eye has looked a bit red and suggested he goes to see his optometrist.

His previous ocular history includes a couple of similar episodes in the past (unsure of timepoints), but he did not see anyone for an assessment at these times because the pain stopped and his vision went back to normal after a few days to a week. He is not sure but thinks that both previous episodes may have also affected his right eye. He has no history of ocular injury or surgery, and has never been prescribed eye drops. He has glasses he wears as needed for distance and near (prescribed overseas) but has not seen an optometrist in over five years.

He reports good general health, and his only current medication is escitalopram for anxiety. He has a family history of wet age-related macular degeneration (mother) but no known history of glaucoma or other eye disease.

Initial examination findings are below:

	Right Eye	Left Eye
Aided distance vision	6/7.5-2	6/4.8
Pinhole visual acuity	No improvement	N/A
Refraction	+1.00/-2.00 x 091	+0.75/-1.25 x 083
Colour Vision (Ishihara Plates)	14/14	14/14
Pupils	No RAPD. RE sluggish response.
IOP (Goldmann at 10:45 am)	49 mmHg	16 mmHg
Slit-lamp examination	Grade 1 diffuse conjunctival injection. Mild corneal stromal haze, with trace inferior faint white keratic precipitates on corneal endothelium. Van Herick 1.0. Grade 1+ cells in anterior chamber. Vitreous quiet.	Ocular media clear, anterior chamber deep and quiet
Corneal Pachymetry	602 µm	573 µm
Gonioscopy	Open angles (Schafer grade 4 all quadrants), with moderately pigmented trabecular meshwork. No peripheral anterior synechiae.	Open angles (Schafer grade 4 all quadrants), with moderately pigmented trabecular meshwork.
Fundus examination	See optic nerve photo (Figure 1a). Macula clear. Peripheral retina clear and flat	See optic nerve photo (Figure 1b). Macula clear. Peripheral retina clear and flat
Visual Fields	See visual fields (Figures 2a and 2b)
OCT	See RNFL analysis (Figure 3) and GCC scan (Figure 4)

Figure 1 a – R ONH 2015

Figure 1 b – L ONH 2015

Figure 2 a – R VF 2015

Figure 2 b – L VF 2015

Figure 3 – RNFL OU 2015

Figure 4 – GCC OU 2015

The patient moves overseas and is lost to follow-up. When he returns to New Zealand three years later, he comes back to see you for another assessment. When asked, he mentions that his adherence to his eye drop routine has been poor and there have been long periods of time that he did not take his ocular medication. He thinks he has had two to three more episodes of PSS during this time, all affecting the right eye. At the time of his visit he is not on any medication, but his eyes feel comfortable and his vision is 6/4.8 in each eye with glasses. His IOP is 21 mmHg in the RE and 14 mmHg in the left.

Please review his optic disc photos (Figures 5a and 5b), visual fields (Figures 6a and 6b), RNFL OCT (Figure 7) and GCC OCT (Figure 8).