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Right Cardiac Decompensation Leading to Bilateral Episcleral Glaucoma, Cystoid Macular Edema, Palpebral Edema and Chemosis

1Ruokonen P., 2van Dooren B., 1Tetz M., 1Hartmann C.,
1Humboldt-Universität zu Berlin, Charité Campus Virchow-Klinikum, Augenklinik (Berlin)
2Het Oogziekenhuis, Rotterdam (Rotterdam)

Background: Episcleral glaucoma is uncommonly seen in general ophthalmological practice. Posttrabecular elevated pressure, usually because of increased episcleral venious pressure, is the pathophysiological background.
Patients and methods: A 60-year old woman was referred for treatment of bilateral “primary open angle glaucoma”. With topical therapy of brinzolamid and pilocarpine at admission, IOP values rised up to 40 mm Hg. Her ocular history included recently developed allergy for eye drop preservation substances and a progressive bilateral vision loss since 6 weeks. Her medical history was notable for primary pulmonary hypertension and right ventricular hypertrophy. This condition has been treated with Diltiazem and Phenprocoumone. On admission she showed signs of cyanosis and was short of breath. Visual acuitiy was 0.3 and IOP was 35 mm Hg ODS. Pronounced bilateral palpebral edema and chemosis were observed. Fundus examination showed macular edema with impending macular holes bilaterally. Perimetry showed relative central scotoma ODS.
Results: Cardiologic consultation revealed, after chest X-ray and echocardiography, right cardiac decompensation, caused by primary pulmonary hypertension. Under therapy with Enalapril, Hydrochlorthiazide and Oxygen, palpebral edema, chemosis and cystoid macular edema resolved completely. Episcleral veins remained contorted. IOP had gradually decreased to stable 17-20 mm Hg ODS without antiglaucomatous therapy. Visual acuity rised to 0,7.
Conclusions: An episcleral glaucoma was accompanied by chronic cystoid macular edema, palpebral edema and chemosis because of right-sided cardiac decompensation. This case demonstrates, that ocular hypertension and decrease of visual acuity due to macular edema could be signs of right ventricular decompensation.