April 2025 - 1
Author: Dr John Leaney
A 65-year-old male presents to your office with a painless, chronically red left eye. He admits to a pressure type feeling around the eye for the last 4-5 years. He denies any concerns with his vision. He has a past medical history of hypertension and is on Candesartan. There is no history of trauma, autoimmune disease nor thyroid disease.
VA 6/5, 6/6. IOP = 13, 25. No RAPD. Normal eye movements. Gonioscopy is open without new vessels. There is no proptosis on exam, nor any evidence of thyroid eye disease. Chambers are deep and quiet.
Anterior photo above, disc and fields are below.
What is the likely mechanism given the highly vascularised eye?
A - Neovascular glaucoma
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B - Raised episcleral venous pressure
CORRECT!
C - Thyroid eye disease
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D - Uveitic glaucoma
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Answer B
There are features of raised episcleral venous pressure on exam (corkscrew vessels, unilateral red eye). Underwent MRI brain and orbits with angiogram looking for a carotid cavernous fistula, this was normal. Characteristically he had a poor response to all drops and laser as they don’t address the area of resistance, namely the episcleral venous plexus.
He was diagnosed with Radius Maumanee or idiopathic elevated episcleral venous pressure (IEEVP). This is a fairly rare diagnosis but is typical of raised episcleral venous pressure causing glaucoma.
Causes of raised episcleral venous pressure
- Venous obstruction
- Thyroid ophthalmopathy
- Superior vena cava syndrome
- Retrobulbar tumors
- Cavernous sinus thrombosis
- Arteriovenous abnormalities
- Carotid–cavernous sinus fistula – traumatic or spontaneous
- Traumatic – high flow, ICA to cavernous sinus plexus
- Spontaneous – low flow indirect or dural
- Traumatic – high flow, ICA to cavernous sinus plexus
- Orbital varix
- Sturge-Weber syndrome
- Idiopathic eg Radius Maumenee
Treatment
Generally, drops/laser don’t work as they can’t address the outflow resistance.
Some evidence for PGAs as they can utilise the uveoscleral pathway. Patients tend to need drainage surgery or cyclodestructive procedures, both come with a high risk of complications.
