Diagnosis and Management of Iridocorneal Endothelial Syndrome

Outcomes of Trabeculectomy and Ahmed Glaucoma Valve Implantation in Patients With Iridocorneal Endothelial Syndrome

PRCIS

Our study highlights the long-term success of trabeculectomy or Ahmed glaucoma valve (AGV) surgery in patients with glaucoma secondary to iridocorneal endothelial (ICE) syndrome. However, many ICE syndrome cases may need multiple glaucoma surgeries to achieve controlled intraocular pressure (IOP), with/without concomitant corneal graft surgery.

OBJECTIVE

To evaluate the long-term outcome of trabeculectomy and AGV implantation in ICE syndrome.

METHODS

Patients with glaucoma secondary to ICE syndrome who underwent either trabeculectomy or AGV surgery with intraoperative adjunctive mitomycin-C from 2009 to 2020 were included in this study. All patients were followed for at least 6 months after initial surgery. The main outcome measures were IOP, number of IOP-lowering medications, and surgical success. Surgical success was defined as complete according to the levels of IOP ( < 18) and at least 20% reduction from preoperative IOP without medications and qualified as a complete success but with medications, where the number of medications was less than preoperative numbers. Cumulative success was the sum of the qualified and complete success.

RESULTS

Twenty-nine eyes of 29 patients were included. Trabeculectomy was done in 13 patients (group A, 44.8%) and 16 patients underwent AGV surgery (group B, 55.2%). The median age was 50 (42-56.50) and 47 (36.75-52.75) years in groups A and B, respectively ( P = 0.10). All patients completed at least 2 years of follow-up. Mean IOP was not significantly different between groups preoperatively ( P = 0.70) and the effect of the type of surgery on IOP was not statistically significant at multiple follow-up time points (repeated measures analysis of variance, P = 0.44). The mean IOP decreased from 35.76 ± 6.36 mm Hg preoperatively to 16.00 ± 3.10 in group A and from 36.12 ± 8.11 mm Hg to 17.00 ± 3.75 in group B ( P = 0.449) at year 2 of follow-up. The effect of the type of surgery was not significant on the total number of IOP-lowering medications used throughout the study (repeated measures analysis of variance, P = 0.81). Kaplan-Meier analysis shows complete success in 14 patients (48.3%), 11 patients (37.9%), and 7 patients (24.1%) at 6-month, 1-year, and 2-year follow-up, respectively. The cumulative success rate was 95% at 2 years follow-up for all patients.

CONCLUSIONS

In 2-year follow-up, trabeculectomy or AGV significantly reduced the IOP in glaucoma patients secondary to ICE syndrome.

Posterior corneoscleral limbus: Architecture, stem cells, and clinical implications

The limbus is a transition from the cornea to conjunctiva and sclera. In human eyes, this thin strip has a rich variation of tissue structures and composition, typifying a change from scleral irregularity and opacity to corneal regularity and transparency; a variation from richly vascularized conjunctiva and sclera to avascular cornea; the neural passage and drainage of aqueous humor. The limbal stroma is enriched with circular fibres running parallel to the corneal circumference, giving its unique role in absorbing small pressure changes to maintain corneal curvature and refractivity. It contains specific niches housing different types of stem cells for the corneal epithelium, stromal keratocytes, corneal endothelium, and trabecular meshwork. This truly reflects the important roles of the limbus in ocular physiology, and the limbal functionality is crucial for corneal health and the entire visual system. Since the anterior limbus containing epithelial structures and limbal epithelial stem cells has been extensively reviewed, this article is focused on the posterior limbus. We have discussed the structural organization and cellular components of the region beneath the limbal epithelium, the characteristics of stem cell types: namely corneal stromal stem cells, endothelial progenitors and trabecular meshwork stem cells, and recent advances leading to the emergence of potential cell therapy options to replenish their respective mature cell types and to correct defects causing corneal abnormalities. We have reviewed different clinical disorders associated with defects of the posterior limbus and summarized the available preclinical and clinical evidence about the developing topic of cell-based therapy for corneal disorders.

Unilateral keratoconus associated with iridocorneal endothelial syndrome: Case report

We report a rare association of unilateral keratoconus (KC) and iridocorneal endothelial syndrome in a 34-year-old female. Slit-lamp examination showed advanced KC with faint apical scarring in her right eye. The pupil was superiorly displaced with superior peripheral anterior synechia. Specular microscopy showed abnormal endothelium with low endothelial cell count in the right eye. Corneal topography confirmed the unilateral KC diagnosis. As the patient did not tolerate hard contact lens, penetrating keratoplasty with pupilloplasty was performed with excellent outcome.

Clinical Outcomes of the Intraocular Lens Injector and Busin Glide for Descemet Stripping Automated Endothelial Keratoplasty in Patients with Iridocorneal Endothelial Syndrome

Purpose: To report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed in iridocorneal endothelial (ICE) syndrome patients using the intraocular lens injector (injector), in comparison with those using the Busin glide. Methods: In this retrospective, interventional comparative study, we evaluated the outcomes of DSAEK performed using the injector (n = 12) or the Busin glide (n = 12) for patients with ICE syndrome. Their graft position and postoperative complications were recorded. Their best-corrected visual acuity (BCVA) and endothelial cell loss (ECL) were monitored over a 12-month follow-up period. Results: DSAEK was conducted successfully in the 24 cases. The BCVA improved from the preoperative 0.99 ± 0.61 to 0.36 ± 0.35 at 12 months after operation (p < 0.001), with no significant difference between the two groups (the injector group and the Busin group) (p = 0.933). ECL at 1 month after DSAEK was 21.80 ± 15.01% in the injector group, which was significantly lower than 33.69 ± 9.75% of the Busin group (p = 0.031). No surgery-related complications were observed in the 24 cases intraoperatively or postoperatively except that one case suffered from postoperative graft dislocation, without statistical difference between the two groups. Conclusions: At 1 month after surgery, the use of graft injector for delivering DSAEK-based endothelial graft may cause significantly less endothelial cell damage than the pull-through technique used in the application of Busin glide. The injector allows safe endothelial graft delivery without the need of anterior chamber irrigation, which increases the ratio of successful graft attachment.

Outcomes of the Aurolab aqueous drainage implant and trabeculectomy with mitomycin C in iridocorneal endothelial syndrome

PURPOSE

To compare the surgical outcomes of the Aurolab aqueous drainage implant (AADI) and trabeculectomy with mitomycin C (MMC) in patients with glaucoma secondary to iridocorneal endothelial (ICE) syndrome.

MATERIALS AND METHODS

This retrospective comparative case series included 41 eyes of 41 patients with ICE syndrome and glaucoma who underwent either a trabeculectomy with MMC (n = 20) or AADI surgery (n = 21) with a minimum of 2 years follow-up. Outcome measures included intraocular pressure (IOP), the use of glaucoma medications, visual acuity, additional surgical interventions, and surgical complications. Surgical failure was defined as IOP > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg, reoperation for glaucoma or a complication, or loss of light perception vision.

RESULTS

The cumulative probability of failure at 2 years was 50% in the trabeculectomy group (95%CI = 31-83%) and 24% in the AADI group (95%CI = 11-48%) (p = 0.09). The IOP was consistently lower in the AADI group compared with the trabeculectomy group at 6 months and thereafter. Surgical complications occurred in 13 eyes (65%) in the trabeculectomy group and 12 eyes (57%) in the AADI group (p = 0.71). Reoperations for glaucoma or complications were performed in 12 eyes (60%) in the trabeculectomy group and 5 patients (24%) in the tube group (p = 0.06). Cox proportional hazards showed that AADI had a 53% lower risk of failure at 2 years (p = 0.18; HR = 0.47; 95%CI = 0.16-1.40).

CONCLUSION

AADI surgery achieved lower mean IOPs than trabeculectomy with MMC in managing glaucoma secondary to ICE syndrome. A trend toward lower rates of surgical failure and reoperations for glaucoma and complications was observed following AADI placement compared with trabeculectomy with MMC in eyes with ICE syndrome.

Descemet Membrane Endothelial Keratoplasty and Goniosynechialysis in Iridocorneal Endothelial Syndrome: Surgical Perspective and Long-Term Outcomes

PURPOSE

The purpose of this study was to report the long-term outcomes of Descemet membrane endothelial keratoplasty (DMEK) with goniosynechialysis in eyes with iridocorneal endothelial syndrome with an emphasis on the surgical technique.

METHODS

This was a retrospective series of 5 eyes of 5 patients undergoing a DMEK procedure at a tertiary eye care institute by a single surgeon. Modifications in the standard surgical technique, including the release of peripheral anterior synechiae, peripheral descemetorhexis, the release of adherent membranes, maneuvers in the anterior chamber with or without cataract extraction were logged. Long-term outcomes of the surgery in these patients are reported.

RESULTS

Five DMEK procedures were performed in 5 eyes of 5 patients. The average age of the patients was 48.2 ± 10.8 years, and the donor was 55.2 ± 3.2 years with a mean endothelial cell density (ECD) of 2784.6 ± 231 cells/mm 2 . After a mean follow-up period of 29.6 months (24-41 mo), all the 5 grafts remained clear; the mean BCVA at the last follow-up was 0.18 ± 0.17 logarithm of the minimum angle of resolution with a mean ECD of 1086.2 ± 338 cells/mm 2 with a 61.1% reduction in ECD. intra ocular pressure was normal in all the cases. None of the patients had graft detachments that required rebubbling, and all eyes had a clear graft at the last follow-up.

CONCLUSIONS

DMEK can be performed successfully in a case with iridocorneal endothelial syndrome with good visual outcomes with modifications to the surgical technique, including peripheral anterior synechiae release and minimizing surgical manipulation.

Achieving inner aqueous drain in glaucoma secondary to iridocorneal endothelial syndrome: One year results of penetrating canaloplasty

PURPOSES

To report the efficacy of a bleb-independent penetrating canaloplasty in the management of glaucoma secondary to iridocorneal endothelial syndrome (GS-ICE).

DESIGN

Prospective, non-comparative clinical study.

METHODS

Penetrating canaloplasty was performed on 35 eyes from 35 patients with GS-ICE and medically uncontrolled IOP between January 2018 and April 2020. Patients were followed up at one week, month 1, 3, 6, 12 postoperatively, and semi-annually thereafter. Intraocular pressure (IOP), number of anti-glaucoma medication and surgery-related complications were recorded. Surgical success was defined as IOP ≥5 and ≤21mmHg without (complete success) or with/without (qualified success) IOP-lowering medications.

RESULTS

A total of 29 eyes (82.9%) had 360° catheterization and successfully received penetrating canaloplasty. Of these eyes, 24 (82.8%) achieved qualified success and 22 (75.9%) achieved qualified success at 12 months after surgery. The mean IOP decreased from 39.5±11.8 mmHg on 2.9±1.0 medications before surgery to 16.6±5.3 mmHg (P<0.001) on 0.2±0.6 medications (P<0.001) at 12 months post-operation, respectively. Hyphema (37.9%), transient hypotony (34.5%) and transient post-operative IOP elevation (≥30mmHg, 17.9%) were the most commonly observed early complications at the one week and one month visits. From one month and beyond, all treated eyes showed no obvious bleb at the operation quadrant.

CONCLUSIONS

Penetrating canaloplasty rescued the inner aqueous outflow in ICE eyes and demonstrated quite acceptable success in IOP control with few complications, providing a new option for the management of GS-ICE.

Macular edema in Cogan-Reese syndrome

PURPOSE

Iridocorneo-endothelial (ICE) syndrome is known as a rare spectrum causing glaucoma, corneal and iris damages. Retinal complications are uncommon.

OBSERVATIONS

We report the case of a middle-aged woman suffering from a Cogan-Reese Syndrome (CRS) with refractory ocular hypertension (OHT) who presented a cystoid macular edema (CME) during follow up.

CONCLUSIONS AND IMPORTANCE

We suspect the CME to be inflammatory linked to the pathophysiological hypotheses of the CRS. The CME was successfully treated with topical nonsteroidal anti-inflammatory drugs (NSAID). No consensus is available on its duration. A recurrence happened when treatment was stopped, its reintroduction was successful.

Comparison of Descemet Membrane Endothelial Keratoplasty for Iridocorneal Endothelial Syndrome and Fuchs Endothelial Dystrophy

PURPOSE

To evaluate the clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) for treating eyes with iridocorneal endothelial (ICE) syndrome and comparing the outcomes with those achieved after treating Fuchs endothelial dystrophy (FED).

DESIGN

Prospective interventional comparative case series.

METHODS

Sixty-three patients (68 eyes) with ICE syndrome or FED were enrolled at the Zhongshan Ophthalmic Center between March 10, 2014 and May 11, 2018. Eligible patients were divided into 2 groups: ICE group (eyes, 24; patients, 24) and FED group (eyes, 44; patients, 39). DMEK was performed in all cases. Corrected distance visual acuity (CDVA), endothelial cell loss (ECL), intraocular pressure (IOP), graft survival, and surgical complications were documented.

RESULTS

In the ICE and FED groups, the mean follow-up duration was 24.9 ± 5 months and 25.2 ± 7.7 months, respectively. At 1 year postoperatively, Kaplan-Meier survival analysis demonstrated 85.7% and 100% cumulative graft success rates (P = .017) in patients with ICE and FED, respectively. Postoperative CDVA level was comparable between the 2 groups through 12-month follow-up; thereafter CDVA was better in the FED group than in the ICE group (P < .001). Moreover, postoperative ECL was significantly higher in the ICE group than in the FED group throughout the follow-up period (P < .001). A discernable increase in structural abnormalities of the anterior chamber angle was observed in 2 eyes (8.3%) in the ICE group; however, no significant differences were observed in the incidence of principal complications between the 2 groups.

CONCLUSIONS

DMEK provides comparable short-term visual outcomes in the treatment of ICE to those observed in the treatment of FED, with higher postoperative ECL over FED.

Ultrasound biomicroscopy in glaucoma assessment

Ultrasound biomicroscopy (UBM) is an important tool in the diagnosis, evaluation and follow up of glaucoma patients. Even if we are dealing with a primary angle closure glaucoma (PACG) or a primary open angle glaucoma (POAG) patient, the mechanism of angle closure can be revealed by performing an UBM. The device can help differentiate between the two types of glaucoma even in patients with opaque corneas when gonioscopy cannot be performed. Knowing the type of glaucoma is vital, especially regarding an individualized treatment, since each patient is unique and needs to be treated accordingly, in order to prevent glaucomatous optic neuropathy and visual field loss. Abbreviations: AC = anterior chamber, ICE = iridocorneal endothelial syndrome, IOP = intraocular pressure, NTG = normal tension glaucoma, PACG = primary angle closure glaucoma, PC = posterior chamber, PEX = pseudoexfoliation syndrome, POAG = primary open angle glaucoma, UBM = ultrasound biomicroscopy.

Iridoschisis-A Systematic Review

Iridoschisis is a rare condition defined as a separation of the anterior iris stroma from the posterior stroma and muscle layers. In this paper, we review current data about the epidemiology, pathophysiology, clinical characteristics and differential diagnoses of this condition and discuss the specificity of surgical treatment of concomitant ocular diseases in iridoschisis patients. Iridoschisis may pose a challenge for both an ophthalmologist in an outpatient setting and an ophthalmic surgeon. Glaucoma, primarily angle-closure glaucoma, is the most often described condition concomitant to iridoschisis. Other ocular abnormalities found relatively often in iridoschisis patients include cataract, lens subluxation and corneal abnormalities. Special attention has been paid to potential complications of cataract surgery and prevention thereof. Beside addressing the practical aspects, we point to discrepancies and suggest topics for further investigation.

Cornea thinning in two cases of ICE syndrome

We present two patients with a new finding of symmetrical corneal thinning early in the clinical course of iridocorneal endothelial syndrome. Patient 1 was evaluated for uncontrolled angle closure glaucoma of the left eye (OS) status post laser peripheral iridotomy (LPI). After placement of an Ahmed glaucomatous valve and trabeculectomy with mitomycin C were performed, the patient was diagnosed with Chandler syndrome. The patient's pachymetry at the time of diagnosis revealed stable central corneal thickness (CCT) of 481 µm of the right eye (OD) (baseline 494 µm) and central cornea thinning with CCT of 407 µm OS (baseline 486 µm). Patient 2 was evaluated for ocular hypertension and Chandler syndrome OS was diagnosed. The patient had a good short-term response to LPI and ocular hypotensive medications. This patient was also found to have thinning of his affected cornea with CCT 523 µm OD and 476 µm OS.

Iridocorneal endothelial syndrome in a patient with keratoconus - a case report

Background

To describe a case of a rare association of bilateral keratoconus and unilateral essential iris atrophy and to conduct a literature review of the current strategies of treatment of the corneal disease and glaucoma in patients with Iridocorneal Endothelial Syndrome (ICE).

Case presentation

We report a rare association of bilateral keratoconus and unilateral essential iris atrophy in a 38-year-old man. Diagnosis of bilateral keratoconus was confirmed by corneal topography. Slit-lamp examination showed extensive iris atrophy with corectopia and policoria in one eye. Corneal specular microscopy revealed an abnormal endothelium morphology in the same eye with extensive peripheral anterior synechiae and closure of the drainage angle at gonioscopy. Intraocular pressure was 26 mmHg, despite maximal topical therapy. Optic disc examination showed severe glaucomatous cupping. Surgery by glaucoma drainage device implantation was performed.

Conclusion

Essential iris atrophy is a rare clinical variant of ICE syndrome characterized by profound anatomical alterations of the anterior segment associated with corneal edema and secondary glaucoma. In these patients, selective keratoplasties have replaced penetrating keratoplasty to treat corneal decompensation and glaucoma drainage devices are preferred to conventional trabeculectomy for the treatment of secondary glaucoma.

Fuchs endothelial corneal dystrophy and corneal endothelial diseases: East meets West

Fuchs endothelial corneal dystrophy (FECD) is amongst one of the most common indications for endothelial keratoplasty worldwide. Despite being originally described among Caucasians, it is now known to be prevalent among a large number of populations, including Asians. While the FECD phenotype is classically described as that of central guttate and pigment deposits associated with corneal endothelial dysfunction, there are subtle yet important differences in how FECD and its phenocopies may present in Caucasians vs Asians. Such differences are paralled by genotypic variations and disease management preferences which appear to be geographically and ethnically delineated. This article provides a succinct review of such differences, with a focus on diagnostic and management issues which may be encountered by ophthalmologists practicing in the different geographic regions, when evaluating a patient with FECD.

CUGC for posterior polymorphous corneal dystrophy (PPCD)

Name of the disease (synonyms) CUGC for posterior polymorphous corneal dystrophy (PPCD).OMIM# of the disease 122000; 609141; 618031.Name of the analysed genes or DNA/chromosome segments OVOL2 (PPCD1); ZEB1 (PPCD3); GRHL2 (PPCD4).OMIM# of the gene(s) 616441; 189909; 608576. Review of the analytical and clinical validity as well as of the clinical utility of DNA-based testing for variants in theOVOL2, ZEB1andGRHL2gene(s) in a diagnostic setting, predictive and parental settings and for risk assesment in relatives.

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.

Ex-PRESS mini-shunt implanted in a pregnant patient with iridocorneal endothelial syndrome

Introduction:

The failure rate of both filtration surgery and of aqueous shunt implantation is higher for iridocorneal endothelial syndrome than in other scenarios, due to the continuous proliferation of abnormal endothelial cells over the trabecular meshwork and the filtration area and also due to the more pronounced cicatrizing response shown by these young patients. We present the first case ever described in the literature of a pregnant patient with iridocorneal endothelial syndrome and uncontrolled ocular hypertension who was implanted an Ex-PRESS mini-shunt.

Clinical case:

A 35-year-old female presented with diminution of vision in the left eye for 2 months. She was 20 weeks pregnant. Her visual acuity was 20/20 in right eye and 20/25 in left eye, and intraocular pressure was 11 mmHg in right eye and 34 mmHg in left eye. Slit lamp biomicroscopic examination revealed no alterations in right eye, whereas left eye showed corectopia and uveal ectropion, stroma of iris’ sectoral atrophy and moderate corneal epithelial edema. Gonioscopy showed some anterior iris synechiae in left eye. Fundus evaluation was normal. Based on clinical features and examination, the diagnosis of left eye iridocorneal endothelial syndrome with decompensated intraocular pressure was made. She was prescribed topical timolol (0.5%) and dorzolamide. As a result of uncontrolled intraocular pressure and the impossibility to prescribe other hypotensive treatment available due to her being pregnant, it was decided to perform surgery in left eye using an Ex-PRESS mini-shunt and Ologen®; 6 months post surgery, intraocular pressure was 9 mmHg with no need for hypotensive treatment. The cornea was transparent, and the patient maintained her left eye visual acuity.

Conclusions:

Ex-PRESS mini-shunt can be considered a surgical option for iridocorneal endothelial syndrome. Its composition allows the ostium to remain open and the device triggers a milder postoperative inflammatory response. In our particular case, taking into account that the subject was a young, phakic, pregnant woman, whose intraocular pressure had to be closely controlled and we had to ensure that her postoperative care included as few drugs and as few reoperations as possible, we thought that using this device was the most appropriate option.

Melanoma or glaucoma? A case report

CASE REPORT

The case is presented of a patient referred to us with suspicion of a ciliary body melanoma due to a pigmented lesion in iris root of left eye, associated with high intraocular pressure, despite maximal topical and systemic medication. The systematic workup revealed unilateral changes in the corneal endothelium, compatible with an iridocorneal syndrome. An Ahmed^® valve was inserted, achieving sustained control of intraocular pressure and visual field defects.

DISCUSSION

Iridocorneal syndromes are a wide and heterogeneous group of diseases, in which endothelial cells grow over the trabeculum, leading to an increase in intraocular pressure. Due to the nature of the disease, tube shunt surgery may be the best option in its treatment. Systematic workup is crucial, since the differential diagnosis may include potentially blinding and even life threatening conditions.

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.

Clinical outcome of Descemet stripping automated endothelial keratoplasty in 18 cases with iridocorneal endothelial syndrome

PurposeTo evaluate the clinical outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with iridocorneal endothelial (ICE) syndrome.Patients and methodsA retrospective case series study was conducted. Eighteen consecutive Chinese patients with 20 DSAEK grafts were enrolled. Participants were evaluated by anterior segment optical coherence tomography and confocal microscopy. Postoperative complications, graft survival, endothelial cell counts, corneal thickness, and anterior chamber depth were analysed. A Log-rank test in a Kaplan-Meier analysis and a Cox proportional hazard regression were used to analyse potential risk factors of graft failure.ResultsThe mean follow-up duration was 19.0±8.6 months. The donors' endothelial cell density (ECD) (cells/mm²) values at 1, 3, 6, 12, 18, and 24 months were 3342.2±287.0, 1897.6±745.4, 1793.6±755.7, 1618.1±604.3, 1421.9±650.8, 1265.1±844.1, and 1148.2±1217.8, respectively. Eleven of the 20 grafts exhibited secondary graft failure, with a mean estimated graft survival of 23.4 months. Immediate postoperative complications (air bubble ventilation for elevated intraocular pressure or rebubbling for graft detachment) were more common in eyes exhibiting graft failure (P=0.040). Postkeratoplasty glaucoma surgery emerged as a risk factor of graft failure, with a hazard ratio of 5.174. Eyes with a poor prognosis showed statistically greater central corneal thickness at 1 month, greater graft thickness at 3 months, and a shallower anterior chamber at 6 and 12 months.ConclusionsThe long-term outcome of DSAEK in eyes with ICE syndrome is relatively poor. Immediate postoperative complications, postkeratoplasty glaucoma surgery, thicker corneal parameters, and a shallow anterior chamber were all associated with graft failure.

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.

Goniosynechialysis combined with cataract extraction for iridoschisis: A case report

RATIONALE

Iridoschisis is a rare eye disease. In this case report, we described the examination and diagnosis of a case of iridoschisis accompanied by secondary glaucoma. We also observed the effects of treating the patient with a combination of goniosynechialysis and cataract removal.

PATIENT CONCERN

A 67-year-old female patient presented with decreased vision in both eyes. An eye examination indicated that visual acuities (VAs) were 20/100 and light perception in the right and left eyes, respectively. Both eyes exhibited shallow anterior chambers and narrow angles. The lower portion of the iris was loosened, and cable-like tissue was visible. The intraocular pressures in the right and left eyes were 22 mmHg and 58 mmHg, respectively. At the time of presentation, no medication was being used.

DIAGNOSES

The patient was diagnosed with iridoschisis [oculus sinister (OU), indicates left eye], secondary glaucoma (OU), senile cataract (OU), and pterygium (oculus uterque, indicates both eyes).

INTERVENTION

After relevant examinations were conducted, goniosynechialysis and phacoemulsification with intraocular lens implantation were performed on the right eye under local anesthesia.

OUTCOMES

Two days after surgery, the right eye had VA of 20/40 and a transparent cornea. The anterior chamber was deeper, and intraocular pressure had decreased to 16 mmHg. Three months after surgery, the patient exhibited improved VA in the right eye and a lower IOP of 11 mmHg.

LESSONS

Relative to other approaches, goniosynechialysis combined with cataract removal is a better treatment option for iridoschisis complicated with closed-angle glaucoma triggered by peripheral anterior synechiae.

Iridoschisis: a case report and literature review

Background

Iridoschisis is a rare condition that is characterized by the separation of the iris stroma into layers, with portions of the anterior layer floating freely in the aqueous humour. Here, we report three cases of iridoschisis that were complicated by either a cataract or glaucoma. Based on these cases, we speculate that the scope of iridoschisis has a rare association with intraocular pressure and the loss of corneal endothelial cells after surgery, which is mainly due to the surgery and not iridocorneal mechanical contact.

Case presentation

We report three cases of iridoschisis, two of which were complicated by cataracts and the third by glaucoma. Patient 1 was a 69-year-old man with bilateral iridoschisis complicated by a cataract but not glaucoma, even though the entire anterior layer of the iris stroma in the right eye presented as white atrophic strands. To prevent the detached iris fibrils from invading the phacoemulsification tip and the irrigation/aspiration hand piece port, the separated iris stroma that was floating freely in the aqueous humour was cut with scissors immediately before the cataract extraction. Patient 2 was an 87-year-old woman with iridoschisis complicated by a cataract in the right eye. We successfully performed cataract surgery on the right eye without a pupillary device. Patient 3 was a 66-year-old man who presented with increased intraocular pressure with bilateral iridoschisis. He was discharged and prescribed with a combination of four glaucoma drugs.

Conclusions

Patients with iridoschisis should have continuous follow-up because complications may occur, and extra care from ophthalmologists is required.

Biomechanical relationships between the corneal endothelium and Descemet's membrane

The posterior face of the cornea consists of the corneal endothelium, a monolayer of cuboidal cells that secrete and attach to Descemet's membrane, an exaggerated basement membrane. Dysfunction of the endothelium compromises the barrier and pump functions of this layer that maintain corneal deturgesence. A large number of corneal endothelial dystrophies feature irregularities in Descemet's membrane, suggesting that cells create and respond to the biophysical signals offered by their underlying matrix. This review provides an overview of the bidirectional relationship between Descemet's membrane and the corneal endothelium. Several experimental methods have characterized a richly topographic and compliant biophysical microenvironment presented by the posterior surface of Descemet's membrane, as well as the ultrastructure and composition of the membrane as it builds during a lifetime. We highlight the signaling pathways involved in the mechanotransduction of biophysical cues that influence cell behavior. We present the specific example of Fuchs' corneal endothelial dystrophy as a condition in which a dysregulated Descemet's membrane may influence the progression of disease. Finally, we discuss some disease models and regenerative strategies that may facilitate improved treatments for corneal dystrophies.