A previously fit and well 55-year-old man on no medication presented to Eye Casualty with a 2-day history of bilateral blurred vision and unsteadiness. His best-corrected visual acuities (BCVA) were hand movements and 6/18 in the right and left eyes, respectively. Examination revealed bilateral limitation of extraocular movements in all gaze positions, sluggish pupillary responses, bilateral corneal oedema, shallow anterior chambers and IOPs of 56 and 48 mm Hg (normal range 10–21 mm Hg). (). Gonioscopic assessment of the iridocorneal angle was precluded by corneal oedema. There was no proptosis, ptosis or periorbital swelling.
(A) Right eye at presentation showing corneal oedema and a mid dilated pupil. (B) Right eye after treatment, note that the pupil is persistently enlarged.
The raised IOP was immediately treated with intravenous acetazolamide 500 mg, and topical pilocarpine 2%, timolol 0.25%, iopidine 1% and prednisolone 0.5% bilaterally. A neurological examination revealed normal tone and power in all limbs with no truncal ataxia. Supinator, biceps and triceps reflexes were absent, and ankle and knee jerk reflexes were grossly reduced. He also had a broad-based gait with inability to tandem walk. He was systemically well otherwise with normal vital observations.