Prospective study on retinal nerve fibre layer changes after an acute episode of phacomorphic angle closure

Efficacy and safety of primary customized phacoemulsification combined with goniosynechialysis for refractory acute primary angle closure

PURPOSE

To assess the safety, efficacy, and long-term clinical outcomes of primary customized phacoemulsification (phaco) combined with goniosynechialysis (GSL; phaco-GSL) in refractory acute primary angle closure (APAC) eyes with uncontrolled high intraocular pressure (IOP).

METHODS

This retrospective case series comprised 51 eyes of 42 consecutive patients with refractory APAC and high IOP who were treated using primary customized phaco-GSL at 3 hospitals in China, from 2014 to 2021. Preoperative and postoperative IOP, corrected distant visual acuity (CDVA), corneal endothelial cell density (CECD), intraoperative and postoperative complications were recorded. The safety, efficacy and subsequent long-term clinical outcomes were analyzed.

RESULTS

The mean CDVA (LogMAR) was improved from 1.67 ± 0.94 preoperatively to 0.23 ± 0.26 postoperatively (P < 0.001). Preoperative CECD was 2309.39 ± 541.03 cells/mm2 in 33 eyes and inaccessible in 18 eyes due to severe corneal edema; at the final follow-up, the mean CECD of all patients was 1823.50 ± 533.40 cells/mm2 (P < 0.001). The mean IOP decreased from 48.51 ± 6.25 mmHg preoperatively to 15.66 ± 2.27 mmHg at the final follow-up (P < 0.001). Among 51 eyes, additional customized procedures performed were corneal indentation in 42 eyes, epithelial debridement in 9 eyes, giant epithelial bullae view in 4 eyes, pars-plana fluid aspiration in 3 eyes, and secondary intraocular lens implantation in 7 eyes. The IOP of all eyes was well controlled eventually and 47 eyes (92.16%) were successfully treated by phaco-GSL alone. No significant intraoperative or postoperative complications were observed.

CONCLUSIONS

Primary customized phaco-GSL is a safe and effective surgical management strategy for patients with refractory APAC and high IOP.

Predictors of long-term visual field outcome after an episode of acute primary angle closure

BACKGROUND

To investigate the long-term visual field (VF) outcome and baseline factors associated with functional sequelae in patients who experienced an episode of acute primary angle closure (APAC) and underwent subsequent lens extraction.

METHODS

Fifty patients (50 eyes) who experienced an APAC episode and underwent subsequent lens extraction at Chonnam National University Hospital were enrolled in this retrospective study. Patients underwent VF examinations after 1 year of an acute episode. They were classified into two groups based on whether they had significant VF defects or not. Demographic data were recorded, and baseline anterior-segment OCT (AS-OCT) images were analysed. Multivariate logistic regression analysis was performed to assess baseline risk factors for presence of VF defects.

RESULTS

Twenty-five (50%) eyes were found to have varied degree of VF defects after 1 year of an acute episode. Longer duration between the symptom onset and IOP lowering (p = 0.005), a higher presenting IOP (p = 0.014), and flat iris curvature (p = 0.037) at baseline AS-OCT measurement were significant predictors of VF loss. The area under the receiver operating characteristic curve (AUC) revealed that combination of these three potential baseline factors could predict the long-term VF outcome (AUC = 0.921).

CONCLUSIONS

Patients exhibiting a long duration between symptom onset and IOP lowering, a high presenting IOP, and flat iris curvature were at a higher risk of visual impairment after an episode of APAC. The eyes with such features may require more careful follow-up after an episode of APAC.

Peripapillary Perfused Capillary Density in Acute Angle-Closure Glaucoma: An Optical Coherence Tomography Angiography Study

PURPOSE

To compare peripapillary perfused capillary density (PCD) on optical coherence tomography angiography among resolved acute angle-closure (AAC), primary open-angle glaucoma (POAG), and control eyes.

DESIGN

Prospective, cross-sectional, observational study.

METHODS

All patients with resolved AAC or POAG of varying severity and controls were enrolled. We obtained 4.5 × 4.5 mm2 optical coherence tomography angiography images of the optic nerve head. PCD was analyzed using customized software with major vessel removal. Continuous variables were assessed using the analysis of variance and Bonferroni correction test. A marginal model of generalized estimating equations was used to adjust for confounding factors and interocular correlation.

RESULTS

The study included 44 eyes with resolved AAC (mean duration of elevated intraocular pressure, 8.1 ± 10.9 days), 69 eyes with POAG, and 49 control eyes. PCD showed a similar decrease between AAC and POAG eyes (P > 0.99). After adjusting for age and sex, the mean difference in global PCD between each of the POAG stage groups and the AAC group was the highest in the severe POAG group (-3.43; 95% confidence interval [CI], -11.38 to 2.52; P = 0.211), followed by the mild POAG (0.68; 95% CI, -3.26 to 4.62; P = 0.735) and moderate POAG (0.20; 95% CI, -5.21 to 5.61; P = 0.942) groups. The duration of increased intraocular pressure did not affect PCD (P = 0.258 and 0.168 for global and annular PCDs, respectively).

CONCLUSIONS

The degree of microvascular attenuation in AAC eyes was not different from that in POAG eyes.

Measurement of Retinal Changes in Primary Acute Angle Closure Glaucoma under Different Durations of Symptoms

Purpose

To investigate the changes of retinal nerve fiber layer (RNFL) in patients after an attack of primary acute angle closure glaucoma (PAACG) and to assess the impact of attack time on prognosis of retinal changes.

Design

cross-sectional study.

Methods

Twenty-six patients with unilateral PAACG attack and cataracts from 2017 to 2019 were enrolled. Eyes with PAACG attack time less than 1 day constituted the group A (n = 13), while eyes with PAACG attack time more than 1 day constituted the group B (n = 13). All patients received phacoemulsification and viscogoniosynechialysis after intraocular pressure (IOP) lowering. All patients underwent ophthalmic examinations including IOP, best-corrected visual acuity (BCVA), and visual field (VF). Optical coherence tomography angiography (OCTA) was used to obtain circumpapillary RNFL vessel density (cpVD). Spectral domain optical coherence tomography (SD-OCT) was used to examine the peripapillary RNFL and macular ganglion cell complex (GCC). All patients accepted 2 assessments before and 1 month after the procedure.

Results

The IOP of all patients recovered to normal (12.77 ± 2.65 mm Hgvs. 12.77 ± 3.85 mmHg, p=0.834) after the procedure. Patients in the group A had better BCVA improvement than those in the group B (1.32 ± 0.84 vs. 0.50 ± 0.21, p=0.004), as well as better mean defect (MD) values from VF (-3.65 ± 2.54 vs -16.05 ± 5.99, p < 0.001). Compared with group B, patients in the group A had thicker macula (Fovea area: 255.00 ± 27.94 μm vs. 203.92 ± 59.73 μm, p=0.010), thicker GCC (82.62 ± 8.76 μm vs. 65.23 ± 18.56 μm, p=0.005), and thicker RNFL (105.08 ± 9.38 μm vs. 77.69 ± 20.23 μm, p < 0.001). Higher blood flow density in all-plexus peripapillary retina was observed in the group A eyes compared with group B (full sector: 0.56 ± 0.02 vs. 0.41 ± 0.07, p < 0.001). In both groups, the association between average RNFL thickness and cpVD as well as MD values and pattern standard deviation (PSD) values from VF was stronger (R ² = 0.58, 0.60, -0.54, respectively, all p < 0.001) than the association between GCC thickness and cpVD, as well as MD values and PSD values (R ² = 0.37, p=0.001; R ² = 0.37, p=0.001; R ² = -0.27, p=0.007).

Conclusion

Patients with attack time less than 1 day had better retinal thickness and all-plexus peripapillary retina blood flow density. Controlling the attack time could decrease retinal damage by PAACG.

Cross-sectional study of the retinal nerve fiber layer thickness at 7 years after an acute episode of unilateral primary acute angle closure

The purpose of this article is to investigate the long-term retinal nerve fiber layer (RNFL) status and determinants of RNFL thinning after an episode of unilateral primary acute angle closure (AAC). This cross-sectional study analyzed the medical records of consecutive patients with a single episode of unilateral AAC from 1999 to 2009 in Hong Kong. The peripapillary RNFL thickness was correlated with age, gender, presenting intraocular pressure (IOP), time to laser iridotomy, time to cataract extraction, follow-up duration, as well as the last IOP, vertical cup-to-disc ratio (CDR), and vision. The fellow uninvolved eye was used as a proxy comparison of RNFL loss in the attack eye. In 40 eligible patients, the mean age was 68.3 ± 8.7 years with a male-to-female ratio of 1:7. The mean presenting IOP was 49.2 ± 14.0 mm Hg and the time from presentation to laser iridotomy was 6.7 ± 6.9 days. Forty percent of subjects received a cataract extraction at 3.2 ± 2.9 years after the attack. The last IOP, CDR, and LogMAR vision were 16.0 ± 3.8 mm Hg, 0.6 ± 0.2, and 0.6 ± 0.6 LogMAR units, respectively, at 7.9 ± 2.4 years. The RNFL thickness in the attack eye (69.2 ± 19.1 μm) was 25.2 ± 17.9% thinner than the fellow eye (93.0 ± 17.8 μm) at 7.5 ± 2.9 years post-AAC. Using univariate analysis, the last vertical CDR (odds ratio [OR] = 17.2, P = 0.049) and LogMAR visual acuity (VA) (OR = 6.6, P = 0.03) were the only significant predictors for RNFL thinning whereas none of the other covariates showed significant associations (P > 0.1). At 7.5 years following unilateral AAC, the RNFL thickness was 25% thinner than the fellow eye. CDR enlargement and poor VA were the only significant predictors for RNFL loss.

Argon laser peripheral iridoplasty versus systemic intraocular pressure-lowering medications as immediate management for acute phacomorphic angle closure

BACKGROUND

The purpose of this study was to compare the efficacy and safety of argon laser peripheral iridoplasty (ALPI) and systemic intraocular pressure (IOP)-lowering medications in the immediate management of acute phacomorphic angle closure.

METHODS

Consecutive cases of acute phacomorphic angle closure were randomized to receive ALPI and an intravenous or oral carbonic anhydrase inhibitor as initial treatment. Intravenous mannitol was administered for presenting IOP > 60 mmHg or IOP > 40 mmHg 2 hours posttreatment in both arms.

RESULTS

Of 10 consecutive cases, six received medical therapy and four received ALPI. Fifty percent in the medical group and none in the ALPI group required intravenous mannitol. The ALPI group took less time to achieve IOP < 25 mmHg (18.8 ± 7.5 minutes versus 115.0 ± 97.0 minutes, P = 0.001, F test); had a greater IOP reduction within 30 minutes (69.8% ± 7.7% versus 40.9 ± 23.9%, P = 0.03, t-test); and had a consistently smaller post-attack cup to disc ratio (0.50 ± 0.02 versus 0.60 ± 0.20, P = 0.002, F test).

CONCLUSION

ALPI offers greater safety, consistency, and efficacy than systemic IOP-lowering medications as initial treatment for phacomorphic angle closure.