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Romano V, Passaro ML, Airaldi M, Ancona C, Pagano L, Semeraro F, Pineda R. Double trouble in DMEK surgery: Learning experience and review of the literature. Eur J Ophthalmol 2024; 34:NP22-NP28. [PMID: 38387873 DOI: 10.1177/11206721241228346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE To report a challenging Descemet Membrane Endothelial Keratoplasty (DMEK) case, complicated by intraoperative aqueous misdirection and spontaneous anterior chamber fibrin reaction. METHODS A 70-year-old female affected by corneal edema due to Fuchs endothelial dystrophy underwent a triple procedure (cataract extraction - IOL implantation - DMEK surgery) in her left eye. This report illustrates the management of the intraoperative complications of aqueous misdirection syndrome and anterior chamber fibrin reaction. RESULTS Despite the optimal management of the posterior pressure and the thorough removal of the fibrinous reaction during the case, the DMEK graft was not completely unfolded and centred at the end of the surgical procedure. Nonetheless, the patient showed good long-term anatomical and functional recovery: at the last follow-up (2 years after surgery), central corneal thickness was 526 µm with a best corrected visual acuity of 20/25 and an endothelial cell density of 1112 cell/mm2. CONCLUSION Early recognition and prompt management of intraoperative aqueous misdirection syndrome and anterior chamber fibrin reaction during DMEK surgery is essential to ensure good functional and anatomical outcomes.
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Affiliation(s)
- Vito Romano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Ophthalmic Unit, ASST Spedali Civili di Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italia
| | - Maria Laura Passaro
- Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Matteo Airaldi
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Chiara Ancona
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luca Pagano
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Francesco Semeraro
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Ophthalmic Unit, ASST Spedali Civili di Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italia
| | - Roberto Pineda
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
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2
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AlQahtani RD, Al Owaifeer AM, AlShahwan S, AlZaben K, AlMansour R. Outcomes of Medical and Surgical Management in Aqueous Misdirection Syndrome. Clin Ophthalmol 2023; 17:797-806. [PMID: 36926527 PMCID: PMC10010933 DOI: 10.2147/opth.s385864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023] Open
Abstract
Purpose To report the outcomes of medical and surgical management in patients diagnosed with aqueous misdirection syndrome (AMS). Patients and Methods A retrospective chart review of all cases diagnosed with AMS at a single tertiary care eye center during the period from 2014 to 2021. Outcome measures were anatomical success (deepening of the anterior chamber (AC)), functional success (improvement in visual acuity), and treatment success (control of intraocular pressure (IOP)). Results A total of 26 eyes with AMS from 24 patients were included. The patients were followed for a mean duration of 24 ± 18 months. Although some patients initially responded to medical and laser therapy, all but one (3.8%) eventually required surgery during the first 3 months after presentation. The mean duration from presentation until surgery was 45.9 ± 45.8 days (range: 2-119 days). The majority of cases (69.2%) were managed by pars plana vitrectomy. At the last follow-up visit, anatomical success was achieved in 20 (76%) eyes, 15 (57%) eyes had a final visual acuity that was either similar to or better than baseline, and successful control of IOP was achieved in 17 (65%) eyes. Univariate analysis revealed that a history of trabeculectomy as a cause of AMS was a risk factor for treatment failure (OR, 7.8; 95% CI, 1.16-52.35; P, 0.02). Conclusion Our findings indicate that medical and laser management of AMS provide temporary control, and almost all patients eventually require surgery within the first 3 months. A history of trabeculectomy was found to be a risk factor for treatment failure.
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Affiliation(s)
| | - Adi Mohammed Al Owaifeer
- King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.,Ophthalmology Unit, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Sami AlShahwan
- King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | | | - Raghad AlMansour
- College of Medicine, Imam Mohammed bin Saud University, Riyadh, Saudi Arabia
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Ghadamzadeh M, Karimi F, Ghasemi Moghaddam S, Daneshvar R. Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial. J Glaucoma 2022; 31:147-155. [PMID: 35210384 DOI: 10.1097/ijg.0000000000001977] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
PRCIS We used anterior segment optical coherence tomography to investigate anterior chamber angle in primary angle-closure glaucoma (PACG) eyes following phacoemulsification and phacotrabeculectomy. Angle widening was significantly greater after phacoemulsification up to 6 months after the surgery. PURPOSE To compare anterior chamber angle following 2 common surgeries for PACG. METHODS One hundred ten glaucoma patients were evaluated in this single center, prospective, randomized clinical trial. Those with concomitant PACG and senile cataract and without a history of ocular surgery, trauma, or chronic miotic use were recruited. Monocular patients were also excluded. Finally, 52 eligible subjects were randomly assigned to phacoemulsification ("Phaco" group, 25 eyes) or phacotrabeculectomy ("Combined" group, 27 eyes) surgeries. A swept-source, anterior segment optical coherence tomography device (CASIA SS-1000 OCT) was used to image the anterior segment. Mask graders used the images to measure the following parameters before and 1 week, 1 month, and 6 months after surgery: angle opening distance at 500 µm, trabecular iris surface area at 500 µm, and trabecular iris angle at 500 µm. RESULTS There was no significant difference between study groups regarding best-corrected visual acuity, intraocular pressure (IOP), and the number of glaucoma medications in preoperative or postoperative visits (P>0.076). Also, the measured angle parameters were not statistically significantly different between the 2 groups before surgery (P>0.123). After surgery, all measured parameters were significantly increased in both groups (P<0.0001). At the 6-month follow-up, nasal angle opening distance at 500 µm was 0.383±0.027 vs. 0.349±0.017, trabecular iris surface area at 500 µm was 0.141±0.007 vs. 0.125±0.005, and trabecular iris angle at 500 µm was 40.1±12.9 vs. 34.6±3.1 in Phaco and Combined groups, respectively (P<0.0001 for all). CONCLUSIONS Anterior chamber angle widening by anterior segment optical coherence tomography was observed in PACG patients following surgery and was significantly greater after phacoemulsification compared with combined phacotrabeculectomy at all time points. Similar IOP and medication burden were noted for up to 6 months as secondary outcomes. The contribution of angle changes to the IOP-lowering effect of phacoemulsification in PACG eyes needs further study.
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Affiliation(s)
| | - Farshid Karimi
- Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ramin Daneshvar
- Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Ophthalmology, University of Florida, Gainesville, FL
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4
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Zuo C, Wang D, Guo X, Xiao H, Zheng S, Lin M, Fang L, Liu X. Associations Between the Choroidal Vascularity Index and Malignant Glaucoma After Trabeculectomy for Primary Angle Closure Glaucoma. Front Med (Lausanne) 2021; 8:747720. [PMID: 34957140 PMCID: PMC8692757 DOI: 10.3389/fmed.2021.747720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To compare the choroidal vasculature characteristics by using the choroidal vascularity index (CVI) in eyes with malignant glaucoma (MG), fellow eyes with non-MG, and eyes with uncomplicated primary angle-closure glaucoma (PACG) after trabeculectomy by spectral-domain optical coherence tomography (SD-OCT). Methods: This case-control study included 53 patients diagnosed with MG after trabeculectomy. Eyes with MG (n = 53) and the fellow eyes with non-MG (n = 50) were included. Eyes with PACG without MG after trabeculectomy (n = 60) were also enrolled as controls. The choroidal parameters, including CVI and the subfoveal choroidal thickness (SFCT), were measured by using SD-OCT images. Results: Eyes with MG and the fellow eyes showed a significantly lower CVI than eyes with PACG controls (p < 0.001). After adjusting for age, sex, axial length (AL), and intraocular pressure (IOP), eyes with the greater CVI [odds ratio (OR), 0.44] were significantly related to MG. The area under the receiver operating characteristic curve of the CVI was greater than that of the SFCT in the diagnosis of MG (0.911 vs. 0.840, p = 0.034). Conclusion: Eyes with MG showed a significantly lower macular CVI than eyes with PACG controls. A higher macular CVI was an associated factor of eyes with MG. The CVI serves as a more stable and sensitive indicator for MG than the SFCT in this group of patients with PACG.
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Affiliation(s)
- Chengguo Zuo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Dingqiao Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xinxing Guo
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, United States
| | - Hui Xiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Shaoyang Zheng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Mingkai Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lei Fang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xing Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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5
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Jamjoom H, Osman M, Osman EA. Overfiltering Bleb en Route to Annular Ciliochoroidal Effusion. Middle East Afr J Ophthalmol 2021; 27:241-243. [PMID: 33814824 PMCID: PMC7993050 DOI: 10.4103/meajo.meajo_340_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/24/2022] Open
Abstract
Annular ciliochoroidal effusion is a rare condition that can complicate trabeculectomy. We report a case of ciliochoroidal effusion mimicking aqueous misdirection after combined glaucoma and cataract surgery. A 75-year-old male with pseudoexfoliation, chronic angle-closure glaucoma, and advanced optic disc damage developed ciliochoroidal effusion after a combined trabeculectomy and phacoemulsification with intraocular lens implantation. The patient presented with overfiltering bleb, hypotony, and a uniformly shallow anterior chamber that mimicked aqueous misdirection in the clinical picture. Reformation of anterior chamber followed by revision of the bleb was performed. Ultrasound biomicroscopy confirmed the diagnosis. Atropine and steroid eye drops improved the condition. Ciliochoroidal effusion should be ruled out in hypotony with shallow anterior chamber post glaucoma surgery.
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Affiliation(s)
- Hanan Jamjoom
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed Osman
- Department of Urgent and Emergency Care Centre, Rotherham General Hospital, Rotherham, UK
| | - Essam A Osman
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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6
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Chira-Adisai T, Mori K, Ueno M, Sotozono C, Kinoshita S. Choroidal detachment-induced secondary angle-closure after trabeculectomy in patient with ocular venous congestion: A case report. Am J Ophthalmol Case Rep 2020; 19:100782. [PMID: 32596553 PMCID: PMC7306613 DOI: 10.1016/j.ajoc.2020.100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 10/26/2022] Open
Abstract
Purpose To report a particular circumstance that led to the abnormal complication of choroidal detachment (CD)-induced secondary angle-closure after trabeculectomy with mitomycin C (MMC). Observations An 82-year-old Japanese male patient with underlying chronic obstructive pulmonary disease and suspicion of ocular venous congestion in both eyes whom diagnosed as primary open-angle glaucoma with uncontrolled intraocular pressure (IOP) of his left eye then underwent an uneventful trabeculectomy with MMC. After the surgery, his left eye had high IOP with a shallow anterior chamber (A/C) but the bleb was hyperfiltration. The high CD was found by B-scan ultrasonography behind the iris and after conservative treatment, the CD was improved, A/C was deepened, and IOP was lower to 16 mmHg. Conclusion and Importance CD-induced secondary angle-closure after trabeculectomy with MMC is a complication to be considered in patients with shallow A/C and high IOP. Fundus examination should be done to rule out this condition before any aggressive treatment as CD can resolve spontaneously with time. Clinicians should be aware of this condition especially in patients with any signs of ocular venous congestion as there have been few reports mentioned about the complication in the patients.
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Affiliation(s)
- Tanate Chira-Adisai
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Ophthalmology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Kazuhiko Mori
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Morio Ueno
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of
Medicine, Kyoto, Japan
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7
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Shute TS, Varma DK, Tam D, Klein T, Moinul P, Ahmed IIK, Sheybani A. Seasonal Variation in the Incidence of Malignant Glaucoma after Cataract Surgery. J Ophthalmic Vis Res 2019; 14:32-37. [PMID: 30820284 PMCID: PMC6388520 DOI: 10.4103/jovr.jovr_41_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose: To investigate a potential link between the incidence of malignant glaucoma after cataract surgery and seasonal variations in daylight. Methods: In total, 18,374 uncomplicated cataract surgeries were performed between June 2008 and June 2013 at an ambulatory surgery center in Toronto. Toronto's average monthly daylight over that time period—in hours per day for each month—was determined. The number of malignant glaucoma cases that developed after cataract surgery performed in months with above average daylight was compared to the number of cases that developed after cataract surgery performed in months with below average daylight. Fisher's exact test was used to analyze the relationship between the development of malignant glaucoma and variation in daylight during the month of cataract surgery. Results: Malignant glaucoma developed in 16 eyes. Thirteen cases of malignant glaucoma developed in months with above average daylight and three cases developed in months with below average daylight (P = 0.01). Eyes that developed malignant glaucoma in months with more daylight were slightly longer (21.95 ± 1.23 mm) than those that developed malignant glaucoma in months with less daylight (21.55 ± 0.88 mm). Conclusion: Light-induced choroidal expansion may play a major role in the development of malignant glaucoma following cataract surgery.
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Affiliation(s)
- Thomas S Shute
- Department of Ophthalmology and Visual Sciences, Washington University, St Louis, MO, USA
| | - Devesh K Varma
- Prism Eye Institute, Department of Ophthalmology and Vision Sciences, University of Toronto, Mississauga, Ontario, Canada
| | - Diamond Tam
- Prism Eye Institute, Department of Ophthalmology and Vision Sciences, University of Toronto, Mississauga, Ontario, Canada
| | - Thomas Klein
- Prism Eye Institute, Department of Ophthalmology and Vision Sciences, University of Toronto, Mississauga, Ontario, Canada
| | - Prima Moinul
- Department of Ophthalmology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Iqbal Ike K Ahmed
- Prism Eye Institute, Department of Ophthalmology and Vision Sciences, University of Toronto, Mississauga, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Trillium Health Partners, Mississauga, Ontario, Canada
| | - Arsham Sheybani
- Department of Ophthalmology and Visual Sciences, Washington University, St Louis, MO, USA
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8
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Hu PH, Gao GP, Yu Y, Pei CG, Zhou Q, Huang X, Zhang Y, Shao Y. Analysis of corneal topography in patients with pure microphthalmia in Eastern China. J Int Med Res 2015; 43:834-40. [PMID: 26378068 DOI: 10.1177/0300060515594195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/10/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine the typical corneal changes in pure microphthalmia using a corneal topography system and identify characteristics that may assist in early diagnosis. METHODS Patients with pure microphthalmia and healthy control subjects underwent corneal topography analysis (Orbscan IIZ® Corneal Topography System; Bausch and Lomb, Bridgewater, NJ, USA) to determine degree of corneal astigmatism (mean A), simulation of corneal astigmatism (sim A), mean keratometry (mean K), simulated keratometry (sim K), irregularities in the 3 - and 5-mm zone, and mean thickness of nine distinct corneal regions. RESULTS Patients with pure microphthalmia (n = 12) had significantly higher mean K, sim K, mean A, sim A, 3.0 mm irregularity and 5.0 mm irregularity, and exhibited significantly more false keratoconus than controls (n = 12). There was a significant between-group difference in the morphology of the anterior corneal surface and the central curvature of the cornea. CONCLUSIONS Changes in corneal morphology observed in this study could be useful in borderline situations to confirm the diagnosis of pure microphthalmia.
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Affiliation(s)
- Pei-Hong Hu
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Gui-Ping Gao
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yao Yu
- Department of Endocrinology and Metabolism, Third Hospital of Nanchang City, Nanchang, Jiangxi Province, China
| | - Chong-Gang Pei
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qiong Zhou
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xin Huang
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Ying Zhang
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yi Shao
- Department of Ophthalmology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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9
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Malignant glaucoma-like syndrome after EX-PRESS filtration surgery. Eur J Ophthalmol 2015; 25:e42-5. [PMID: 25720839 DOI: 10.5301/ejo.5000588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To report a case of postsurgical shallow anterior chamber and elevated intraocular pressure (IOP) simulating malignant glaucoma. METHODS A 20-year-old woman underwent EX-PRESS® device implant for treatment of primary open-angle glaucoma. RESULTS Postoperative examination showed a shallow anterior chamber, the EX-PRESS® device embedded in the iris, an IOP of 28 mm Hg, and an annular detachment of the choroid ciliary body, suggesting hyperfiltration followed by EX-PRESS® blockage. The anterior chamber was restored using an ophthalmic viscoelastic and an additional suture was applied ensuring the scleral flap. The IOP progressively decreased in the following days and the anterior chamber remained deep and stable. New ocular ultrasonography showed complete resolution of the ciliary body detachment 15 days after surgery. CONCLUSIONS After glaucoma surgery, not every patient with shallow anterior chamber and normal or high IOP necessarily has a ciliary block glaucoma. In our case, hyperfiltration led to choroidal expansion, shallow anterior chamber, obstruction of the EX-PRESS®, and secondary blockage of outflow. The differential diagnosis is important in order to avoid further invasive procedures (i.e., lensectomy or vitrectomy).
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10
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Kaplowitz K, Yung E, Flynn R, Tsai JC. Current concepts in the treatment of vitreous block, also known as aqueous misdirection. Surv Ophthalmol 2014; 60:229-41. [PMID: 25639795 DOI: 10.1016/j.survophthal.2014.12.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 12/10/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
Vitreous block (VB), a rare secondary angle-closure caused by anterior rotation of the ciliary body, occurs in a variety of settings, but most frequently after glaucoma filtering surgery. The etiology remains unclear, but choroidal expansion and anterior vitreous abnormalities have been proposed. In the past, treatment of VB has yielded high rates of failure and recurrence. Advancements in surgical techniques, however, have led to improved visual outcomes. We review the history of this condition and present a stepwise approach to its diagnosis and treatment using modern imaging modalities and surgical techniques.
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Affiliation(s)
- Kevin Kaplowitz
- Stony Brook University School of Medicine, East Setauket, NY, USA.
| | - Edward Yung
- Stony Brook University School of Medicine, East Setauket, NY, USA
| | - Rachel Flynn
- Stony Brook University School of Medicine, East Setauket, NY, USA
| | - James C Tsai
- New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Shallow Anterior Chamber After Trabeculectomy: Risk Reduction by Use of Removable Compression Sutures. J Glaucoma 2014; 25:223-7. [PMID: 25264999 DOI: 10.1097/ijg.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the risk of shallow anterior chamber after trabeculectomy with removable compression sutures. METHODS A total of 263 eyes affected by primary open-angle glaucoma that was unresponsive to medical treatments were divided into 2 groups: 126 eyes were treated with conventional trabeculectomy (group A) and 137 with a modified surgery technique using 3 removable compression 10-0 nylon sutures (group B). All the participants received intraoperative antimetabolites (mitomycin 0.04%). Increased intraocular pressure (IOP) of >14 mm Hg in the eyes of group B patients was followed by removal of compression sutures. Best corrected visual acuity, slit lamp examination, IOP, and anterior chamber depth were evaluated 1, 7, 30, 60, 90, and 180 days after surgery. RESULTS On the first postoperative day, 12 eyes from group A (9.5%) exhibited a shallow anterior chamber with marked hypotony and no eyes in group B showed flat anterior chamber at any control evaluation (P<0.001). The day after surgery, group A showed a mean IOP of 5.3 mm Hg (± 2.02), whereas group B had a mean of 7.4 mm Hg (± 2.10). At 7 days postoperation, the values for IOP were 10.95 (± 1.55) and 11.7 mm Hg (± 1.66) in groups A and B, respectively. One month later, mean IOP was 11.05 mm Hg (± 1.08) for group A and 13.9 mm Hg (± 3.26) for group B. The surgeon removed the compression sutures from all eyes with IOP>14 mm Hg (90%). The day after suture removal, mean IOP decreased to 10.45 mm Hg (± 1.37). There was no significant statistical difference in visual acuity between the 2 groups at any point during follow-up (P>0.001). At 180 postoperative days the difference in mean IOP between the 2 groups was statistically significant (P<0.001). CONCLUSIONS The application of removable corneoscleral compression sutures during trabeculectomy reduced the risk of postoperative shallow anterior chamber and allowed for safe IOP control after the procedure giving further postoperative chance to reduce the intraocular pressure.
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12
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13
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Liu S, Sun LL, Kavanaugh AS, Langford MP, Liang C. Recurrent annular peripheral choroidal detachment after trabeculectomy. Case Rep Ophthalmol 2013; 4:192-8. [PMID: 24348402 PMCID: PMC3843902 DOI: 10.1159/000356166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We report a challenging case of recurrent flat anterior chamber without hypotony after trabeculectomy in a 54-year-old Black male with a remote history of steroid-treated polymyositis, cataract surgery, and uncontrolled open angle glaucoma. The patient presented with a flat chamber on postoperative day 11, but had a normal fundus exam and intraocular pressure (IOP). Flat chamber persisted despite treatment with cycloplegics, steroids, and a Healon injection into the anterior chamber. A transverse B-scan of the peripheral fundus revealed a shallow annular peripheral choroidal detachment. The suprachoroidal fluid was drained. The patient presented 3 days later with a recurrent flat chamber and an annular peripheral choroidal effusion. The fluid was removed and reinforcement of the scleral flap was performed with the resolution of the flat anterior chamber. A large corneal epithelial defect developed after the second drainage. The oral prednisone was tapered quickly and the topical steroid was decreased. One week later, his vision decreased to count fingers with severe corneal stromal edema and Descemet's membrane folds that improved to 20/50 within 24 h of resumption of the oral steroid and frequent topical steroid. The patient's visual acuity improved to 20/20 following a slow withdrawal of the oral and topical steroid. Eight months after surgery, the IOP was 15 mm Hg without glaucoma medication. The detection of a shallow anterior choroidal detachment by transverse B-scan is critical to making the correct diagnosis. Severe cornea edema can occur if the steroid is withdrawn too quickly. Thus, steroids should be tapered cautiously in steroid-dependent patients.
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Affiliation(s)
- Shaohui Liu
- Department of Ophthalmology, Louisiana State University Health Science Center-Shreveport, Shreveport, La., USA
| | - Lisa L Sun
- Department of Ophthalmology, Louisiana State University Health Science Center-Shreveport, Shreveport, La., USA
| | - A Scott Kavanaugh
- Department of Ophthalmology, Louisiana State University Health Science Center-Shreveport, Shreveport, La., USA
| | - Marlyn P Langford
- Department of Ophthalmology, Louisiana State University Health Science Center-Shreveport, Shreveport, La., USA
| | - Chanping Liang
- Department of Ophthalmology, Louisiana State University Health Science Center-Shreveport, Shreveport, La., USA
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14
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Altan C, Ozturker C, Bayraktar S, Eren H, Ozturker ZK, Yilmaz OF. Post-trabeculectomy choroidal detachment: not an adverse prognostic sign for either visual acuity or surgical success. Eur J Ophthalmol 2008; 18:771-7. [PMID: 18850557 DOI: 10.1177/112067210801800518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report the incidence of choroidal detachment (CD) following trabeculectomy and to evaluate its effect on long-term surgical success and best-corrected visual acuity (BCVA). METHODS A total of 253 eyes of 198 subjects who underwent trabeculectomy between 1993 and 2003 with at least 1 year follow-up were reviewed retrospectively. Twenty-eight eyes of 28 subjects which developed CD postoperatively were classified as Group 1 and the remaining 225 eyes of 170 subjects as Group 2. The risk factors for the development of CD and the influence of CD on BCVA and on the success of trabeculectomy were analyzed and compared between the two groups. RESULTS In Group 1, preoperative BCVA was significantly lower and cup to disc ratio and the frequency of pseudoexfoliative glaucoma were higher with respect to the control group (p=0.009, p=0.01, p=0.02). The correlations between the development of CD and postoperative findings such as shallowing of the anterior chamber, hypotony, hypotonic maculopathy, hyphema, and fibrin reaction in the anterior chamber were statistically significant.CD was not associated with a significant reduction of BCVA. Intraocular pressures at postoperative first day, sixth month, and first year were lower in Group 1. The success of trabeculectomy and the average number of medications used were not significantly different between the two groups. CONCLUSIONS CD following trabeculectomy occurred in 11% of our patients. CD was not associated with either a significant drop in BCVA or an adverse influence on long-term IOP control.
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Affiliation(s)
- C Altan
- Beyoglu Eye Training and Research Hospital, Istanbul - Turkey.
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15
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Abstract
PURPOSE OF REVIEW Primary angle closure typically causes acute intraocular pressure rise in the phakic elderly. Alternative diagnoses, however, for which iridotomy is usually ineffective, occur commonly in younger, nonhyperopic, and pseudophakic patients. RECENT FINDINGS High-resolution ultrasonography has advanced our understanding of these entities. Management of platueau iris, present in over half of angle closures with patent iridotomy, may depend on disease stage. Early postoperative pseudophakic patients with myopic shift and narrow angle should be treated with laser capsulotomy for capsular block. Bilateral angle closure is usually due to an offending systemic pharmacologic agent, which must be stopped to resolve the closure. Ciliary body swelling often produces angle closure by blocking the access of aqueous to the anterior chamber, sometimes paradoxically after hypotony. Annular choroidal effusions, difficult to detect without ultrasound, may mimic angle closure. Although cycloplegic and corticosteroid therapy may resolve some entities, pars plana vitrectomy and lensectomy may be necessary to resolve severe ciliary block. We also discuss unique variants of angle closure in patients with retinal disease. SUMMARY Atypical angle closures should always be considered. Careful examination techniques and new technology can detect the mechanisms involved and direct treatment.
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Sakai H, Morine-Shinjyo S, Shinzato M, Nakamura Y, Sakai M, Sawaguchi S. Uveal effusion in primary angle-closure glaucoma. Ophthalmology 2005; 112:413-9. [PMID: 15745767 DOI: 10.1016/j.ophtha.2004.08.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2003] [Accepted: 08/31/2004] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To determine the prevalence of uveal effusion in acute and chronic primary angle-closure glaucoma (PACG) or primary angle closure (PAC) and to compare it with the prevalence in eyes with open-angle glaucoma (OAG) or ocular hypertension. DESIGN Prospective consecutive case series. PARTICIPANTS Five hundred one eyes of 351 consecutive patients with PAC and 156 eyes of 116 randomly selected primary OAG or ocular hypertension patients. The PAC group included 40 eyes of 35 patients with acute PACG and 30 unaffected fellow eyes, 39 eyes and 35 fellow eyes with a history of acute PACG, and 357 eyes with chronic PAC. METHODS Ultrasound biomicroscopic examination was performed to diagnose uveal effusion and to measure anterior chamber depth (ACD). MAIN OUTCOME MEASURES Presence of uveal effusion and ACD. RESULTS Uveal effusion was demonstrated in 23 eyes (58%) with acute PACG and 7 fellow eys (23%) (chi2 = 8.17, P = 0.0043). Among eyes with chronic PAC, uveal effusion was present in 69 [corrected](14%[corrected]), a higher prevalence than was found in open-angle patients (2 eyes [1.3%]) (chi2 = 19.3, P<0.001). In the chronic PAC group, the ACD of phakic eyes with uveal effusion (1.92+/-0.42 mm) was significantly shallower than that of phakic eyes without effusion (2.06+/-0.32 mm) (P = 0.019). CONCLUSIONS Uveal effusion diagnosed by ultrasound biomicroscopy is a special feature in PAC, and is prevalent in acute PACG. Uveal effusion in phakic eyes with PAC is associated with shallowing of ACD.
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Affiliation(s)
- Hiroshi Sakai
- Ophthalmology, University of the Ryukyus Hospital, Okinawa, Japan
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Tumuluri K, Woo T, Crowston J, Healey PR, Gottlieb D, Maloof AJ. Bilateral Leukemic Orbital Infiltration Presenting as Proptosis and Narrow-Angle Glaucoma. Ophthalmic Plast Reconstr Surg 2004; 20:248-50. [PMID: 15167739 DOI: 10.1097/01.iop.0000129018.17256.38] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 71-year-old man with acute myeloid leukemia presented with bilateral uveal and orbital leukemic infiltration presenting as tense bilateral proptosis, orbital inflammation, and acute-angle closure glaucoma. B-scan ultrasonography revealed uveoscleral thickening and anterior rotation of the ciliary body. Orbital CT and MRI showed bilateral proptosis with streaking of intraconal fat. Temporary pressure lowering occurred after lateral canthotomy and inferior cantholysis. Definitive treatment included systemic chemotherapy and steroids. Over a 2-week period, vision improved and proptosis resolved, and the intraocular pressure returned to normal. The patient died of cerebral complications of his illness after 6 weeks. This is the first reported case of orbital and ocular leukemic infiltration presenting simultaneously as tense proptosis and narrow-angle glaucoma.
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Affiliation(s)
- Krishna Tumuluri
- Cornea and EyePlastic Surgery Unit, Department of Ophthalmology, Western Sydney Eye Hospital, Westmead Hospital Westmead, Australia
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Sabti K, Lindley SK, Mansour M, Discepola M. Uveal effusion after cataract surgery: an echographic study. Ophthalmology 2001; 108:100-3. [PMID: 11150272 DOI: 10.1016/s0161-6420(00)00414-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To determine the incidence of uveal effusion after cataract surgery and to relate its presence to selected preoperative, intraoperative, and postoperative variables. DESIGN Prospective consecutive observational case series. PARTICIPANTS Two hundred seven eyes of 205 subjects undergoing cataract surgery. METHODS Several preoperative, intraoperative, and postoperative variables of potential significance in uveal effusion after cataract surgery were studied. On the first postoperative day and within 2 weeks after the surgery, subjects were examined clinically and echographically with B-scan for evidence of suprachoroidal (uveal) effusion. When effusion was present, follow-up examinations were performed until complete resolution was documented. MAIN OUTCOME MEASURES Echographic presence of uveal effusion in the postoperative period. RESULTS Uveal effusion was documented echographically in 12 patients (5.8%). Only one of these cases was clinically evident. All effusions were small and resolved with no intervention. The presence of postoperative hypotony related to wound leak (intraocular pressure <10 mmHg) was significantly correlated with uveal effusion after cataract surgery (P<0.0001). The combination of oral acetazolamide and topical pilocarpine gel given after the surgery also correlated with effusion (P<0.02). Intraoperative complications and prolonged phacoemulsification time were not shown to be risk factors for effusion. CONCLUSIONS Uveal effusion is rarely seen after modern, small-incision, closed-system cataract surgery. It is correlated with postoperative hypotony related to wound leak and with the administration of both oral acetazolamide and topical pilocarpine after surgery.
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Affiliation(s)
- K Sabti
- Department of Ophthalmology, McGill University, Montreal, Canada
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Abstract
OBJECTIVE To report two cases of a malignant glaucoma-like syndrome following pars plana vitrectomy. DESIGN Two interventional case reports. INTERVENTION The first patient was treated with a neodymium:YAG laser peripheral iridectomy with hyaloidectomy and with intracameral tissue plasminogen activator. The second patient was treated with a posterior approach iridectomy through residual hyaloid, zonules, and iris. MAIN OUTCOME MEASURES Axial anterior chamber depth and intraocular pressure (IOP). RESULTS The interventions resulted in deepening of the anterior chambers and normalization of IOPs. CONCLUSION A pseudomalignant glaucoma syndrome may be related to obstruction of aqueous flow, either by residual anterior hyaloid or by fibrin and other inflammatory debris at the level of the ciliary body-zonular apparatus. Treatment of this syndrome involves restoring aqueous flow to the anterior chamber by disrupting the residual anterior hyaloid or clearing fibrin or inflammatory debris. The clinician should not disregard the possibility of a pseudomalignant glaucoma syndrome following vitrectomy despite the fact that vitrectomy has traditionally been considered a curative treatment for malignant glaucoma.
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Affiliation(s)
- E C Massicotte
- New England Eye Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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Greenfield DS, Tello C, Budenz DL, Liebmann JM, Ritch R. Aqueous misdirection after glaucoma drainage device implantation. Ophthalmology 1999; 106:1035-40. [PMID: 10328410 DOI: 10.1016/s0161-6420(99)00530-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the clinical presentation, outcome, and possible underlying mechanism of aqueous misdirection after glaucoma drainage device implantation. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Ten eyes (five primary open-angle glaucoma, four chronic angle-closure glaucoma, one nanophthalmos) of nine patients with a mean age of 68.5+/-12.0 years (range, 43-83 years). INTERVENTION The authors reviewed the medical records of all patients with a clinical diagnosis of aqueous misdirection after Baerveldt glaucoma drainage device implantation at two tertiary care referral centers from October 1992 to October 1997. Surgery was performed in a standardized fashion; all drainage tubes were inserted in the anterior chamber and occluded with an external 7-0 polyglactin ligature. All eyes were treated with topical corticosteroids, cycloplegia, and aqueous suppressants. Eyes with persistent aqueous misdirection received neodymium:YAG (Nd:YAG) hyaloidotomy or pars plana vitrectomy. MAIN OUTCOME MEASURES Visual acuity, intraocular pressure, biomicroscopic anterior chamber depth, and antiglaucomatous medication. RESULTS All eyes had axial shallowing of the anterior chamber, one or more patent iridotomies, and no ophthalmoscopic or B-scan ultrasonographic evidence of serous or hemorrhagic ciliochoroidal detachment. Median time to the development of angle-closure glaucoma was 33.5 days (range, 1-343 days) and mean intraocular pressure at diagnosis was 27.7+/-18.7 mm Hg (range, 10-62 mm Hg). Normalization of anterior segment anatomy was achieved with aqueous suppression and cycloplegia (one eye); Nd:YAG capsulotomy (four eyes); pars plana vitrectomy alone (two eyes) or with lensectomy (one eye), and pars plana vitrectomy with intraocular lens explanation (two eyes). Mean final intraocular pressure was 14.1+/-6.0 mmHg at a mean follow-up of 9.1+/-7.8 months after the development of aqueous misdirection (range, 1-23 months). CONCLUSIONS Aqueous misdirection may develop days to months after glaucoma drainage device implantation. In this series, there was a poor response to medical therapy, and normalization in anterior chamber depth required aggressive laser and surgical therapy.
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Affiliation(s)
- D S Greenfield
- Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, USA
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