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A tooth for an eye: dental procedures in unrecognized glaucoma

A woman aged 57 consulted her dentist because of intermittent pain in her right upper jaw associated with blurring of vision in her right eye. Both symptoms occurred towards evening and were relieved by sleep. There was no history of haloes, ocular pain or redness of the eye. The pain was unrelated to chewing. The dentist extracted two teeth first an impacted right upper third molar (wisdom tooth); then, when the pain persisted, the right upper second molar, which had previously been treated for caries. A sharp bony spicule on the right maxillary alveolus was later detected and filed under local anaesthesia. Her symptoms continued and, ten weeks later, the right eye became red and painful with drastically reduced vision. The pain in the right upper jaw was worse. In the eye casualty department visual acuities were counting fingers in the right and 6/9 in the left eye. Intraocular pressure was 62 mm Hg in the right eye and 20 mm Hg in the left. The affected eye was inflamed and examination revealed corneal epithelial oedema, a shallow anterior chamber and a vertically oval fixed pupil. The left eye had a shallow anterior chamber and narrow angle. Acute angle closure glaucoma was diagnosed and she was treated with intravenous acetazolamide, intensive topical 4% pilocarpine to the right eye and ultimately intravenous mannitol. Bilateral NdYAG laser iridotomies were performed to prevent further attacks. Three months later she was completely free of symptoms with visual acuities of 6/6 and 6/9 in the right and left eyes, respectively. COMMENT