The most appropriate approach out of the options provided would be to refer for selective laser trabeculoplasty (SLT). Commencing eye drops, e.g. latanoprost, is also a reasonable option.

This is a case of pigment dispersion syndrome (PDS) with secondary ocular hypertension. At this point, there is no glaucoma present. The case is typical for PDS – most often affecting young or middle aged male myopes. A family history of glaucoma is often present.

On examination, pigment can be detected on the corneal endothelium (Figure 1), and this sign is called a Krukenberg spindle[1]. Transillumination defects in the iris can be detected by shining the slit lamp light through the pupil with a bright 1x1mm beam (Figure 2).

The LiGHT Trial[2] included patients with pigment dispersion syndrome and overall, the SLT treatment arm showed superiority to eye drops, with no sight threatening complications from SLT. Patients receiving SLT demonstrated less progression of visual field loss and reduced need for glaucoma surgery, compared to patients who received eye drops.

Eye drops are also a viable treatment option. They particularly suit more risk averse patients who are not keen on laser intervention. The first line treatment for most patients will be a prostaglandin analogue.

YAG peripheral iridotomy (PI) has been suggested as a potential treatment option for patients in whom PDS is present, but without elevated IOP. It would not be an appropriate treatment in this case where the IOP is already elevated. There is conflicting evidence on the efficacy of PI for PDS and resulting conflicting opinions on its benefits. Some clinicians advocate for its use on patients less than 45 years old, without elevated IOP. Other clinicians don’t consider PI useful at any stage of the disease process.

Monitoring this patient would not be appropriate given the elevated IOP. He would be at significant risk of developing glaucoma without IOP lowering treatment. It is also likely that the IOP is elevating high than recorded at this visit, as the patient described blurred vision following exercise.