A C T A O P H T H A L M O L O G I C A VOL. 5 4 1976
From the Department of Ophthalmology (Head: Ul{ Halldkn), University of Unied, Sweden
TRANSIENT GLAUCOMA
AS A MANIFESTATION OF MUMPS A Case Report BY
WERNER POLLAND and WILLIAM THORBURN
A case report of a 43-year-old man who during convalescence after mumps (parotitis epidemica) developed bilateral glaucoma associated with redness of his eyes hut no other ocular manifestations. The chamber angles were open. No signs of scleritis or iritis were present. The best treatment was found to he prednisolone topically and acetaxolamide orally. After ten days the intraocular pressure was normalized and after a fortnight all treatment could be discontinued. K e y words: mumps - epidemic parotitis - glaucoma, transient.
Case Report
A 43-year-old m a n with a family history of glaucoma was seen at the Umei University Eye Clinic complaining of slight pain and redness of the eyes of two to three days duration. Increasingly hazy vision had been noted the last day. T h e r e was no history of a n y previous eye disease. Four weeks prior to admission he had been exposed to mumps, and was given mumps hyperimmune globulin two days after exposure. A serological test at the same time showed n o immunity against mumps. Seventeen days later h e showed typical symptoms of mumps with swelling a n d tenderness of the parotid a n d submaxillary glands Received August 25, 1976.
779
Werner Polland and W i l l i a m Thorbzirn
and fever. One week after the onset of his illness the fever and swelling of the glands subsided and he began to notice his eye symptoms. There were no symptoms of orchitis. Mumps serology during convalescence showed a significant rise in antibody titre. The physical findings were identical in both eyes. Uncorrected distant vision was 20120 each eye. A t first sight the bulbar conjunctiva showed a uniform, increased redness. There was no discharge or local tenderness. The pupils were slightly wider than normal, but reacted briskly. The appearance was similar to that of viral conjunctivitis. Slitlamp examination showed that the redness was due to an increased vasodilatation of the superficial vessels with no episcleral component. The corneae were slightly steamy without signs of keratitis. There were no cells or flare in the anterior chambers. No corneal precipitates or anterior lens surface exfoliations were seen. Gonioscopical examination showed wide open chamber angles with no pigment increase or anterior synechiaes. The optic discs had physiological cups. There were no signs of papilloedema or papillitis. Tension measured with applanation tonometer was 40 mmHg in the right eye and 39 mmHg in the left eye. Initially, the patient was given 500 mg acetazolamide orally and pilocarpine 4 o/o eye drops. Next morning the intraocular pressure was reduced in both eyes, but in spite of continued 4 O/o pilocarpine topically three times a day in
50 40
L mI
J1
,
Prednlsolon o d Pilocarpme 2% o s
Prednrsolon o a
*
I
P
20 30!
- ugh1 eye
10-
-_.. lefl
0
1
2
3
eye
5
1
6
7
8
>
9 D a y s
Fig. 1. The course of the intraocular pressure (ordinate) from the day of admission (abscissa) during different treatments. 0. d. = right eye. 0. s. = left eye. 0. a. = both eyes. P. 0. a. = Pilocarpine, 4 Oio, instilled in both eyes, C. 0.a. = Carbachole, 3 "/o, instilled in both eyes, Az = acetazolamide orally, Ph. = 10 "/a phenylephrine in the right eye. Further comments in the text.
780
Trcmsient Glaucoma as a Manifestation of Mumps
both eyes the pressure rose again to about 50 mmHg (Fig. 1). A change of miotics to 3 "/o carbachole had no obvious effect. Acetazolamide 0.25 g x 3 added from the second day again reduced the tension. This therapy was discontinued after one day. Instillation of 10 o/o phenylephrine in the right eye three times with five min intervals resulted in a transitory normalizing of the tension. The therapy was then changed to 0.5 O/O prednisolone topically five times a day in the right eye and no treatment in the left eye. The next day the tension in the right eye was 10 mmHg lower while the tension in the left eye was unchanged. During the following two days 20/0 pilocarpine three times a day was administered in the left eye with little effect as shown in Fig. 1. H e was then given prednisolone 0.5 o / o topically three times a day in both eyes. On the ninth day the IOP was normalized in both eyes and soon afterwards all therapy was discontinued. Further follow-up during the course of one year showed normal tension and no further need for therapy. T h e optic discs and the visual fields remained quite normal.
Discussion Several ocular manifestations of mumps are known, dacryoadenitis, optic neuritis, keratitis, conjunctivitis, scleritis and iritis (Riffenburgh 1961). The occurrence of elevated intraocular pressure without signs of iritis has not been described previously. In fact, to the best of our knowledge, there are only two cases of secondary glaucoma reported (Riffenburgh 1954; Roussel 1946). These were in conjunction with iritis and affected mainly one eye. The occurrence of glaucoma without signs of flare, cells or precipitates has not been described earlier. It is known that in scleritis a secondary rise of tension is a frequent complication. Several cases of scleritis following mumps are described (Berg 1927; North 1953; Swan et al. 1962) but no rise in tension was noted in these cases. In the present case no sign of scleritis was observed. A transient rise in the intraocular pressure during convalescence after mumps might easily be overlooked. As a rule, when a young person is affected, a slightly red eye and some pain might be misinterpreted as a conjunctivitis. Therefore it is possible that this complication is sometimes overlooked. T h e different treatments of the elevated intraocular pressure showed that miotics alone did not reduce the pressure. A good response was obtained with acetazolamide, as well as transitorily by the frequent instillation of 10 O / o phenylephrine (Fig. 1). Prednisolone topically promptly reduced the tension. 781
Werner Polland and William Thorburn
The conclusion drawn is that the treatment of choice is acetazolamide orally combined with prednisolone topically. Probably glaucoma of this kind will revert spontaneously. We think the use of topical steroids reduces the duration of the increased intraocular tension. It is interesting to speculate on the pathogenesis of the increased tension in this case. A reasonable explanation is a reduced outflow of aqueous humour due to an increase in resistance in the structures of the chamber angle. This idea is supported by the prompt reduction of the pressure by steroids. Prednisolone might reduce oedema of the trabecular meshwork, resulting in an increase in the facility of outflow of the aqueous humour.
References Berg F. (1927) Scleritis pericornealis nach Parotitis epidemica. Deutsche Ophth. Gesellsch. 46, 368-372. North D. P. (1953) Ocular complications of mumps. Brit. /. Ophthal. 37, 99-101. Riffenburgh R. S. (1954) Iritis and glaucoma associated with mumps. Arch. Ophthal. (Chicago) 51, i02. Riffenburgh R. S. (1961) Ocular manifestations of mumps. Arch. Ophthal. (Chicago) 66, 739-743. Roussel F. (1946) Une complication rare des oreillons (Uveite). Rev. Mkd. Lidge I , 305. Swan J. W . & Penn R. F. (1962) Scleritis following mumps. Amer. /. Ophthal. 53, 366-368.
Author’s arlcliess: Dr. Werner Polland, Department of Ophthalmology, University of UmeB, S-901 85 Umei, Sweden.
782
From the Department of Ophthalmology (Head: Ul{ Halldkn), University of Unied, Sweden
TRANSIENT GLAUCOMA
AS A MANIFESTATION OF MUMPS A Case Report BY
WERNER POLLAND and WILLIAM THORBURN
A case report of a 43-year-old man who during convalescence after mumps (parotitis epidemica) developed bilateral glaucoma associated with redness of his eyes hut no other ocular manifestations. The chamber angles were open. No signs of scleritis or iritis were present. The best treatment was found to he prednisolone topically and acetaxolamide orally. After ten days the intraocular pressure was normalized and after a fortnight all treatment could be discontinued. K e y words: mumps - epidemic parotitis - glaucoma, transient.
Case Report
A 43-year-old m a n with a family history of glaucoma was seen at the Umei University Eye Clinic complaining of slight pain and redness of the eyes of two to three days duration. Increasingly hazy vision had been noted the last day. T h e r e was no history of a n y previous eye disease. Four weeks prior to admission he had been exposed to mumps, and was given mumps hyperimmune globulin two days after exposure. A serological test at the same time showed n o immunity against mumps. Seventeen days later h e showed typical symptoms of mumps with swelling a n d tenderness of the parotid a n d submaxillary glands Received August 25, 1976.
779
Werner Polland and W i l l i a m Thorbzirn
and fever. One week after the onset of his illness the fever and swelling of the glands subsided and he began to notice his eye symptoms. There were no symptoms of orchitis. Mumps serology during convalescence showed a significant rise in antibody titre. The physical findings were identical in both eyes. Uncorrected distant vision was 20120 each eye. A t first sight the bulbar conjunctiva showed a uniform, increased redness. There was no discharge or local tenderness. The pupils were slightly wider than normal, but reacted briskly. The appearance was similar to that of viral conjunctivitis. Slitlamp examination showed that the redness was due to an increased vasodilatation of the superficial vessels with no episcleral component. The corneae were slightly steamy without signs of keratitis. There were no cells or flare in the anterior chambers. No corneal precipitates or anterior lens surface exfoliations were seen. Gonioscopical examination showed wide open chamber angles with no pigment increase or anterior synechiaes. The optic discs had physiological cups. There were no signs of papilloedema or papillitis. Tension measured with applanation tonometer was 40 mmHg in the right eye and 39 mmHg in the left eye. Initially, the patient was given 500 mg acetazolamide orally and pilocarpine 4 o/o eye drops. Next morning the intraocular pressure was reduced in both eyes, but in spite of continued 4 O/o pilocarpine topically three times a day in
50 40
L mI
J1
,
Prednlsolon o d Pilocarpme 2% o s
Prednrsolon o a
*
I
P
20 30!
- ugh1 eye
10-
-_.. lefl
0
1
2
3
eye
5
1
6
7
8
>
9 D a y s
Fig. 1. The course of the intraocular pressure (ordinate) from the day of admission (abscissa) during different treatments. 0. d. = right eye. 0. s. = left eye. 0. a. = both eyes. P. 0. a. = Pilocarpine, 4 Oio, instilled in both eyes, C. 0.a. = Carbachole, 3 "/o, instilled in both eyes, Az = acetazolamide orally, Ph. = 10 "/a phenylephrine in the right eye. Further comments in the text.
780
Trcmsient Glaucoma as a Manifestation of Mumps
both eyes the pressure rose again to about 50 mmHg (Fig. 1). A change of miotics to 3 "/o carbachole had no obvious effect. Acetazolamide 0.25 g x 3 added from the second day again reduced the tension. This therapy was discontinued after one day. Instillation of 10 o/o phenylephrine in the right eye three times with five min intervals resulted in a transitory normalizing of the tension. The therapy was then changed to 0.5 O/O prednisolone topically five times a day in the right eye and no treatment in the left eye. The next day the tension in the right eye was 10 mmHg lower while the tension in the left eye was unchanged. During the following two days 20/0 pilocarpine three times a day was administered in the left eye with little effect as shown in Fig. 1. H e was then given prednisolone 0.5 o / o topically three times a day in both eyes. On the ninth day the IOP was normalized in both eyes and soon afterwards all therapy was discontinued. Further follow-up during the course of one year showed normal tension and no further need for therapy. T h e optic discs and the visual fields remained quite normal.
Discussion Several ocular manifestations of mumps are known, dacryoadenitis, optic neuritis, keratitis, conjunctivitis, scleritis and iritis (Riffenburgh 1961). The occurrence of elevated intraocular pressure without signs of iritis has not been described previously. In fact, to the best of our knowledge, there are only two cases of secondary glaucoma reported (Riffenburgh 1954; Roussel 1946). These were in conjunction with iritis and affected mainly one eye. The occurrence of glaucoma without signs of flare, cells or precipitates has not been described earlier. It is known that in scleritis a secondary rise of tension is a frequent complication. Several cases of scleritis following mumps are described (Berg 1927; North 1953; Swan et al. 1962) but no rise in tension was noted in these cases. In the present case no sign of scleritis was observed. A transient rise in the intraocular pressure during convalescence after mumps might easily be overlooked. As a rule, when a young person is affected, a slightly red eye and some pain might be misinterpreted as a conjunctivitis. Therefore it is possible that this complication is sometimes overlooked. T h e different treatments of the elevated intraocular pressure showed that miotics alone did not reduce the pressure. A good response was obtained with acetazolamide, as well as transitorily by the frequent instillation of 10 O / o phenylephrine (Fig. 1). Prednisolone topically promptly reduced the tension. 781
Werner Polland and William Thorburn
The conclusion drawn is that the treatment of choice is acetazolamide orally combined with prednisolone topically. Probably glaucoma of this kind will revert spontaneously. We think the use of topical steroids reduces the duration of the increased intraocular tension. It is interesting to speculate on the pathogenesis of the increased tension in this case. A reasonable explanation is a reduced outflow of aqueous humour due to an increase in resistance in the structures of the chamber angle. This idea is supported by the prompt reduction of the pressure by steroids. Prednisolone might reduce oedema of the trabecular meshwork, resulting in an increase in the facility of outflow of the aqueous humour.
References Berg F. (1927) Scleritis pericornealis nach Parotitis epidemica. Deutsche Ophth. Gesellsch. 46, 368-372. North D. P. (1953) Ocular complications of mumps. Brit. /. Ophthal. 37, 99-101. Riffenburgh R. S. (1954) Iritis and glaucoma associated with mumps. Arch. Ophthal. (Chicago) 51, i02. Riffenburgh R. S. (1961) Ocular manifestations of mumps. Arch. Ophthal. (Chicago) 66, 739-743. Roussel F. (1946) Une complication rare des oreillons (Uveite). Rev. Mkd. Lidge I , 305. Swan J. W . & Penn R. F. (1962) Scleritis following mumps. Amer. /. Ophthal. 53, 366-368.
Author’s arlcliess: Dr. Werner Polland, Department of Ophthalmology, University of UmeB, S-901 85 Umei, Sweden.
782
