Sir,

Muralidhar and associates’ 18-patient case series on glaucoma in spherophakia is a welcome contribution to the literature on an uncommon type of glaucoma.1 We would like to query with the authors their thoughts and experience on the role of cycloplegia in the medical management of this condition. This type of glaucoma is technically a ‘posterior pushing force’ type of glaucoma (as per Ritch classification2). This type is subdivided into being of ciliary body, zonule–lens diaphragm or vitreous in origin. As such, it is not ‘pupil block’ with the role of peripheral iridotomies (PIs) in its management limited to eliminating pupil block, assuming appositional closure on gonioscopy in the diagnostic work up.3 Miotic agents can induce angle closure as they promote forward movement of the lens–iris diaphragm.3 In an acute setting, if spherophakia is suspected based on a manifestly myopic eye, combined with a shallow anterior chamber in the setting of elevated intraocular pressure, then, concurrent to the use of pressure lowering agents, the medical management after a PI would include cycloplegia in order to attempt to posteriorly displace the lens–iris diaphragm in the first instance.4, 5 We note the authors point regarding zonular laxity preventing this option being effective, but this can only be confirmed in retrospect. No reference is made to the role of miotics or cycloplegics in the medical management of these patients and further comment would be of educational value.