Sir,

Case

Sexual arousal has been reported to lead to angle-closure glaucoma1 and to blurred vision in women with narrow angles.2 We treated a 34-year-old Caucasian woman with uniocular pain, blurred vision, and haloes since 2 days. She had a past history of recurrent episodes occurring immediately after orgasm, resolving spontaneously and that occurred only when she was having sex in the dark while in the top position, with her upper torso prone. Her mother and maternal grandmother had had angle-closure.

On examination, best-corrected acuity was 20/25 OU with +5.00 sph +1.00 cyl × 90 OD and +5.25 sph +1.75 cyl × 85 OS. Intraocular pressure was 12 mm Hg OD and 17 mm Hg OS. Gonioscopy revealed plateau iris configuration OU and appositional angle-closure OD with scattered peripheral anterior synechiae and a slit angle OS. Axial lengths were 20.72 mm OD and 20.38 mm OS. Anterior chamber depths were 3.06 mm OD and 3.01 mm OS. Lens thicknesses were 4.31 mm OD and 4.35 mm OS. Symptoms responded to laser iridotomy and peripheral iridoplasty OU with widening of the angles.

Comment

Provocative testing for angle-closure includes dark room, prone, and mydriatic tests. The prone test causes anterior displacement of the lens and pupillary block. On prone position UBM (Figures 1 and 2), eyes exhibit shortening and an increase in iris thickness associated with greater anterior convexity.3

Figure 1
figure 1

UBM image of superior angle in supine posture during dark condition from a normal subject. Arrow indicates scleral spur.

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Figure 2
figure 2

UBM image of superior angle in prone posture during dark condition from a normal subject. Note the apposition of peripheral iris to cornea with thickening of the peripheral iris. Arrow indicates scleral spur.

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Activation of the sympathetic and parasympathetic nervous systems can affect mydriasis.4 Sphincter muscle stimulation and pupillary dilation in the dark cause centripetal and posterior forces, respectively, increasing iridolenticular apposition.5 Parasympathetic-induced ciliary contraction causes zonular relaxation, anterior lens movement, increased lens thickness and curvature, and pupillary block. Increased iris thickness, owing to sympathetic stimulation of the iris dilator muscle and its resulting circumferential folding, may prompt angle-closure if a narrow angle is present.

Our patient was a hyperope with short globe and normal anterior chamber depth and lens thickness. Both the dark room and orgasm caused pupillary dilation, with angle crowding and iridotrabecular apposition, while the prone position presumably led to anterior lens movement. The combination of these three factors triggered angle-closure.