Ultrasound biomicroscopy of Chinese eyes with iridocorneal endothelial syndrome

Comparison of penetrating and endothelial keratoplasty in patients with iridocorneal endothelial syndrome: A registry study

BACKGROUND

To compare graft survival of endothelial keratoplasty (EK) versus penetrating keratoplasty (PK) in patients with iridocorneal endothelial (ICE) syndrome and identify ocular features associated with graft survival.

METHODS

Observational, prospective, cohort study. A total of 30 806 first grafts performed between 1985 and 2020 were identified through the Australian Corneal Graft Registry and included in this observational, prospective cohort study. A total of 196 eyes underwent a primary corneal graft for ICE syndrome. Kaplan-Meier graft survival plots and Chi-squared tests were performed to identify graft survival rates for EK and PK. A history of raised intraocular pressure (IOP) was also recorded and analysed. Graft survival of eyes with ICE syndrome were compared to that of other indications.

RESULTS

Grafts performed for ICE syndrome increased to 0.8% of all cases during the 2005 to 2020 period compared with 0.5% between 1985 to 2004 (χ2 =9.35, p = 0.002). From 2010, EK surpassed PK as the preferred graft type. Survival of primary grafts in eyes with ICE syndrome was lower than for other indications (log-rank = 56.62, p < 0.001). Graft survival was higher following PK than Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) (log-rank = 10.56, p = 0.001). Graft survival was higher in eyes without a history of raised IOP compared to those with a reported history of raised IOP (log-rank = 13.06, p < 0.001).

CONCLUSIONS

ICE syndrome carries a poor prognosis for graft survival. DS(A)EK had a poorer prognosis than PK. A history of raised IOP is associated with higher risk of graft failure.

Bilateral laser peripheral iridotomy in a co-occurrence of unilateral iridocorneal endothelial syndrome and chronic angle closure glaucoma

PURPOSE

To report a case of unilateral Iridocorneal endothelial (ICE) syndrome- Progressive iris atrophy (PIA) with an overlapping chronic angle closure glaucoma (CACG) and to highlight the effect of bilateral Laser peripheral iridotomy (LPI) in such a co-occurrence.

CASE DESCRIPTION

A patient presented to us with bilateral gradual painless progressive diminution of vision. Both eyes (BE) had a clear cornea, shallow peripheral anterior chamber depth, grade 2 nuclear sclerosis, raised intraocular pressure and glaucomatous optic neuropathy. In addition, the Left eye (LE) had an irregular anterior chamber, peripheral anterior synechiae (PAS) extending to cornea, patchy iris atrophy, subtle corectopia and a low endothelial cell count on specular microscopy. Indentation gonioscopy led to the diagnoses of CACG BE with ICE syndrome- PIA LE. LPI was performed bilaterally. On Anterior Segment Optical Coherence Tomography (ASOCT), there was evident widening of the angle away from PAS in the Right eye as well as in the LE with PIA post LPI.

CONCLUSION

This is a unique case of unilateral PIA with an associated CACG in BE. It is the first case demonstrating the effect of bilateral LPI in such a case scenario. Though not indicated in ICE syndrome, LPI did show short term evidence of significant widening of the angle away from areas of PAS even in the eye with PIA having a limited high PAS and a concurrent primary (chronic) angle closure disease.

Bilateral Chandler's syndrome: Uncommon entity diagnosed by ultrasound biomicroscopy and confocal microscopy

A 22‑year‑old female presented with bilateral, progressive diminution of vision. Slit‑lamp examination revealed bilateral sectoral corneal edema. Gonioscopy showed broad‑based peripheral anterior synechiae and a membrane obscuring angle structure in both the eyes. On ultrasound biomicroscopy (UBM), a membrane extending from corneal endothelium to anterior iris surface causing traction was seen. Confocal microscopy showed an "epithelium‑like" transformation of the corneal endothelium. This case demonstrates a bilateral Chandler variant of the iridocorneal endothelial (ICE) syndrome where the diagnosis of Chandler's disease was confirmed by confocal microscopy, after the mechanism of secondary angle closure was demonstrated by the UBM.

Cogan-Reese syndrome: image analysis with specular microscopy, optical coherence tomography, and ultrasound biomicroscopy

Iridocorneal endothelial (ICE) syndrome is a progressive clinical spectrum of corneal endothelial abnormalities affecting the cornea, iris, and iridocorneal angle. Three clinical variations are recognized: essential (progressive) iris atrophy, Chandler syndrome, and Cogan-Reese syndrome. Direct slit-lamp visualization of the cornea and anterior segment in cases of ICE syndrome is inadequate for precise and objective assessment of the affected structures. We describe the evolution of corneal and anterior segment structural changes in a woman with Cogan-Reese syndrome using three different methods of image analysis: specular microscopy, anterior segment optical coherence tomography, and ultrasound biomicroscopy.

Iridocorneal endothelial syndrome: clinical perspectives

This article aims to review the clinical management strategies available for the rare iridocorneal endothelial syndrome. The different clinical variations as well as the imaging techniques available to aid diagnosis are discussed. We then present the evidence available to help the reader to understand how the condition can be managed medically and also the important surgical aspects of treatment. This involves raised intraocular pressure management in addition to the visual management options of partial or full thickness keratoplasty. We hope that this review provides an exhaustive but also succinct review of the literature available on what is a rare and difficult condition to treat.

Unique variations and characteristics of iridocorneal endothelial syndrome in China: a case series of 58 patients

PURPOSE

Iridocorneal endothelial (ICE) syndrome is a rare condition, and unique characteristics in Chinese patients can make diagnosis difficult. Our purpose was to describe the clinical characteristics and variations of ICE syndrome in 58 consecutive Chinese patients.

METHODS

The clinical data of consecutive patients with ICE syndrome who were seen between 2008 and 2011 at the glaucoma clinic of our ophthalmology department were retrospectively reviewed. The diagnostic criteria for ICE syndrome were a "hammered-silver" appearance of the corneal endothelium and specular microscopy showing ICE cells characterized by the absence of a hexagonal appearance, dark areas within the cells, and a light-dark reversal pattern. The general characteristics of the cornea, iris, pupil, and anterior chamber angles were compiled and examined.

RESULTS

Fifty-eight patients with ICE syndrome were identified: 26 had Chandler's syndrome (CS), 23 Cogan-Reese syndrome, and nine progressive iris atrophy (PIA). The incidence of glaucoma was 98%. Twenty-three (39.7%) patients had atypical ICE syndrome. Intraocular pressure was relatively high in 13 patients with slightly damaged irises, while the corneal endothelium remained relatively intact. Slit lamp examination showed an intact iris in ten patients (17.2%), with massive deposition of black pigment in the anterior chamber angle. In the 25 patients in whom the anterior chamber angle was only partially closed, 80% of the anterior chamber angles were hyperpigmented.

CONCLUSIONS

CS is the most common variation of ICE syndrome in Chinese patients, and PIA is the least common. A slight change or an intact iris under slit lamp examination is a characteristic of ICE syndrome.

A review of the role of ultrasound biomicroscopy in glaucoma associated with rare diseases of the anterior segment

Ultrasound biomicroscopy is a non-invasive imaging technique, which allows high-resolution evaluation of the anatomical features of the anterior segment of the eye regardless of optical media transparency. This technique provides diagnostically significant information in vivo for the cornea, anterior chamber, chamber angle, iris, posterior chamber, zonules, ciliary body, and lens, and is of great value in assessment of the mechanisms of glaucoma onset. The purpose of this paper is to review the use of ultrasound biomicroscopy in the diagnosis and management of rare diseases of the anterior segment such as mesodermal dysgenesis of the neural crest, iridocorneal endothelial syndrome, phakomatoses, and metabolic disorders.

Diagnosis and Management of Iridocorneal Endothelial Syndrome

The iridocorneal endothelial (ICE) syndrome is a rare ocular disorder that includes a group of conditions characterized by structural and proliferative abnormalities of the corneal endothelium, the anterior chamber angle, and the iris. Common clinical features include corneal edema, secondary glaucoma, iris atrophy, and pupillary anomalies, ranging from distortion to polycoria. The main subtypes of this syndrome are the progressive iris atrophy, the Cogan-Reese syndrome, and the Chandler syndrome. ICE syndrome is usually diagnosed in women in the adult age. Clinical history and complete eye examination including tonometry and gonioscopy are necessary to reach a diagnosis. Imaging techniques, such as in vivo confocal microscopy and ultrasound biomicroscopy, are used to confirm the diagnosis by revealing the presence of “ICE-cells” on the corneal endothelium and the structural changes of the anterior chamber angle. An early diagnosis is helpful to better manage the most challenging complications such as secondary glaucoma and corneal edema. Treatment of ICE-related glaucoma often requires glaucoma filtering surgery with antifibrotic agents and the use of glaucoma drainage implants should be considered early in the management of these patients. Visual impairment and pain associated with corneal edema can be successfully managed with endothelial keratoplasty.

[The irido-corneo-endothelial syndrome. The loss of the control of corneal endothelial cell cycle. A review]

The three major symptoms of the irido-corneo-endothelial syndrome are the alterations of the corneal endothelium and of the iris with a loss of the regulation of the cell cycle, and the progressive obstruction of the irido-corneal angle. This rare pathology attacks mainly young adult women. Most of the symptoms and complications originate from the excessive proliferation of the corneal endothelial cells accompanied by the evolution of their phenotype towards that of the epithelial cells. In normal conditions the corneal endothelial cells do not divide, they are blocked in the G1 stage of the cell cycle, mainly because of the action of the inhibitors of cyclin-dependent kinases. Still these cells retain a good capacity for proliferation, which can be induced by the down-regulation of the expression of the inhibitors of the cyclin-dependent kinases. This proliferative capacity declines with age and is also different according to the localization of the cells: it is more intense with those originating from the central area then in those from the peripheral area of the cornea. The age-related decline of the proliferative capacity is not due to the shortening of the telomers, but to the stress-induced accelerated senescence of the cells.

Distinctive findings in a patient with Axenfeld-Rieger syndrome using high-resolution AS-OCT

Some distinct findings of a patient with Axenfeld-Rieger syndrome from the anterior chamber angle images by high-resolution anterior segment optical coherence tomography (AS-OCT) are described. The typical anterior segment anomalies of Axenfeld-Rieger syndrome, including iris atrophy, posterior embryotoxon, peripheral bridging tissue bands, trabecular meshwork elongation, and high insertion of the iris root into the posterior trabecular meshwork, can be visualized clearly on AS-OCT images. Specifically, the high-resolution mode of the AS-OCT program had improved performance in outlining finer structures such as the distinctive endothelial membrane covering the iris in Axenfeld-Rieger syndrome, which enabled better understanding of the pathophysiology in the patient. The high-resolution imaging and non-contact method of AS-OCT make it an effective and feasible option in the diagnosis and evaluation of Axenfeld-Rieger syndrome.

Progression of essential iris atrophy studied with confocal microscopy and ultrasound biomicroscopy: a 5-year case report

PURPOSE

The purpose of this study was to report the progression of the iridocorneal endothelial syndrome during a 5-year period in a patient with the essential iris atrophy variant using confocal microscopy and ultrabiomicroscopy (UBM).

METHODS

A 47-year-old woman was referred to us in January 2002 with suspected iridocorneal endothelial syndrome. Examination of both eyes included visual acuity, biomicroscopy, intraocular pressure measurement, gonioscopy, visual field test, and UBM. Afterward, she was examined yearly and confocal microscopy performed.

RESULTS

Visual acuity was 20/20 in both eyes. Examination of the right eye revealed endothelial degeneration, peripheral anterior synechiae, and iris atrophy around the pupil that appeared displaced to the temporal side. Biomicroscopy of the left eye was unremarkable. Posterior segment was normal in both eyes. UBM of the right eye showed thickening of the iris adherent to the corneal endothelium. Diagnosis of essential iris atrophy was confirmed. One year later, the right eye showed increasing iridoendothelial adherences confirmed by UBM. Confocal microscopy revealed endothelial cell abnormalities and groups of endothelial "epithelium-like" cells with hyperreflective nuclei. In April 2007, the pupil appeared more temporally dislocated. UBM showed more extended synechiae. Confocal microscopy displayed hyporeflective opacities in the endothelial layer and many grouped keratocytic clusters in the posterior stroma. No alteration of the intraocular pressure and visual field was found during the follow-up.

CONCLUSIONS

UBM and confocal microscopy permit observation of any corneal and iridocorneal angle changes and evaluation of essential iris atrophy progression.