Posner Schlossman’s Syndrome (PSS): A Case Refractory to Medical Treatment with Glaucoma Progression

Introduction: A case of unattended Posner Schlossman’s syndrome (PSS) and its conversion to glaucoma is reviewed. It illustrates the risk of progression and becoming refractory to prevailing medical treatment. It debates whether initial surgical intervention should be considered due to minor symptoms during recurrences and poor patient compliance.

Case Presentation: A 52-year-old male presents with blurry vision and minor headache discomfort. Records from the last eye exam 6 years prior indicated a diagnosis of ocular hypertension OD. No symptoms other than blurry vision were reported. Intra-ocular pressures (IOP) were 32 OD, 20 OS mm Hg, with cup disc (C/D) ratios of 0.35 with healthy rim tissue. No presence of anterior chamber cells, nor a relative afferent pupillary defect (RAPD) was documented. He was scheduled for a glaucoma workup but did not return for follow-up. He returned 6 years later. Corrected visual acuities were 20/20 OD, OS. A RAPD OD, IOP of 35 OD and 17 OS mm Hg, C/D ratios of 0.8 glaucomatous cupping OD, 0.45 with healthy rim tissue OS and less than grade 1 anterior chamber cells (AC) were noted. Gonioscopy revealed open angles to the ciliary body OU. Optical coherence tomography and Visual field revealed glaucomatous damage OD. A diagnosis of PSS-related glaucoma OD was specified, and prednisolone acetate 1% qid OD was prescribed. Subsequently, dorzolamide and timolol bid OD were added. The elevated IOP did not respond to treatment. He was referred for surgery as PSS was considered refractory.

Conclusion: PSS may be challenging to diagnose and manage since AC cells may be difficult to detect, and patients may have minimal symptoms during recurrences. With poor compliance, it may become refractory and progress to glaucoma. Patient education and the importance of strict compliance should be stressed. Primary surgical intervention should be considered in cases of regular recurrences and poor compliance.