Glaucoma TodayThree Weeks of the Wrong Diagnosis—and a Minimally Invasive Path Forward

🧩 Diagnostic Reasoning Exercise / Teaching Case

A 34-year-old hyperopic man was referred after 3 weeks of misdiagnosed acute angle-closure glaucoma in the left eye. Initial examination revealed IOP of 48 mm Hg, severe corneal edema, markedly shallow anterior chambers, and anatomic features consistent with a crowded, short eye. Despite laser peripheral iridotomy, pressure remained difficult to control, prompting consideration of a minimally invasive anatomy-based surgical strategy rather than traditional filtration surgery.

Diagnostic Considerations

• Persistent angle closure despite patent LPI suggested that pupillary block was not the sole mechanism driving elevated IOP.
• Biometry demonstrated a short axial length and relatively thick crystalline lens, supporting a phacomorphic component.
• Rising IOP after acetazolamide discontinuation indicated inadequate long-term control with medical therapy and iridotomy alone.
• Anterior segment OCT, gonioscopy, and biometry helped identify anatomic crowding as the dominant disease driver and guided surgical planning.

Practice Pearls

• Check IOP and anterior chamber depth in patients presenting with painful vision loss and corneal edema.
• Recognize that LPI may not fully address lens-driven angle closure in phacomorphic anatomy.
• Consider anatomy-directed interventions when structural crowding remains the primary mechanism.
• Preserve future surgical options when feasible, particularly in younger patients.