In a young patient with narrow angles, consider the possibility of plateau iris. Perform indentation gonioscopy and ultrasound biomicroscopy to confirm the diagnosis.

Plateau iris syndrome is a condition where the iris inserts anteriorly into the ciliary body which in turn pushes the peripheral iris forward. Despite a patent iridotomy it can lead to angle-closure glaucoma. It usually occurs in younger patients with narrow angles who are typically less hyperopic than patients with angle closure glaucoma. Patients can even be myopic. Key diagnostic tools include indentation gonioscopy, revealing a “double-hump sign”, and ultrasound biomicroscopy (UBM), which confirms anteriorly positioned ciliary processes [1]. The condition may mimic primary angle-closure glaucoma, so careful evaluation is essential. Treatment may include the use of miotic agents and laser peripheral iridoplasty to flatten the iris profile and prevent angle closure [2]. In cases where a pupillary block component is present, a peripheral iridotomy, cataract surgery, or lensectomy may become necessary. Goniosynechiolysis can additionally be performed if synechiae are present. If these measures still do not lead to adequate IOP control, then filtering surgical procedures should be considered [3]. Early detection and proper management are crucial to avoid progressive vision loss associated with this condition.

References

1. Ritch, R. and S. Dorairaj, Plateau iris syndrome in younger patients. Clin Exp Ophthalmol, 2007. 35(5): p. 399-400.
2. Ritch, R., C.C. Tham, and D.S. Lam, Long-term success of argon laser peripheral iridoplasty in the management of plateau iris syndrome. Ophthalmology, 2004. 111(1): p. 104-8.
3. Ng, W.T. and W. Morgan, Mechanisms and treatment of primary angle closure: a review. Clin Exp Ophthalmol, 2012. 40(4): p. e218-28.

Contributor: Constance Liegl, MD, Bonn, Germany

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