A 72-year old male was referred to our clinic for cataract surgery. The patient’s medical history revealed bilateral asymmetric visual acuity worsening in the past 2 years with a generalized blur and no other associated symptoms. He had no previous eye surgery or trauma. His medical and family histories were unremarkable. He had no known allergies and took no regular medication. The ophthalmic examination showed visual acuity (VA) of 0.4 and 1.0 (Snellen chart) in his right and left eye respectively. The subjective refraction was − 3.50 - 1.00 × 80 in the right eye and − 2.25 in the left eye. Intraocular pressure measured with a Goldmann applanation tonometer was 48 mmHg in his right eye and 20 mmHg in his left eye. The patient had blue irises. The external examination was normal, but the slit lamp examination revealed dense asymmetric pigmentation of the posterior lens capsule in both eyes, although the examination of the iris was unremarkable. Gonioscopy showed bilateral wide-open angles with a moderate diffuse grade 2+ pigmentation using Scheie’s grading, a pigmented line at Schwalbe’s line similar to Sampaolesi’s line, and a concavity of the peripheral iris. Dilated fundus examination showed a clear vitreous and a shallow extensive optic nerve head excavation in his right eye. He had pavingstone degenerative changes in the periphery; the rest of the fundus examination was unremarkable. The visual fields by standard static perimetry of the right eye showed generalized severe depression. Optical coherence tomography (OCT) (SS-OCT; DRI OCT Triton©Topcon, Japan) of his right eye showed generalized severe retinal nerve fiber layer (RNFL) thinning with a total thickness of 43 μm. The left eye showed mild RNFL thinning with a total thickness of 89 μm. A diagnosis of pigmentary glaucoma of the right eye and pigment dispersion syndrome of the left eye was made. Due to a severely elevated IOP we decided to prescribe the patient with a prostaglandin analogue (latanoprost once daily) for both eyes and a combination of an α2 adrenergic agonist and a β adrenergic antagonist (brimonidine tartrate/timolol maleate twice daily) for his right eye. The patient had a good response to topical medication. At his last follow up examination 6 months after the presentation, his VA was 0.5–0.6 and 1.0 and IOP 9 mmHg and 10 mmHg in his right and left eye respectively. OCT showed no additional RNFL thinning; also the visual fields defects were unchanged.