Phacoemulsification with gonioscopy-assisted transluminal trabeculotomy versus phacoemulsification alone in primary angle closure glaucoma: A randomized controlled study

PURPOSE

To assess the safety and efficacy of combining phacoemulsification with gonioscopy-assisted transluminal trabeculotomy (GATT) compared to phacoemulsification alone in the management of primary angle closure glaucoma (PACG).

METHODS

Prospective, institutional study in which eyes requiring surgery for PACG were randomized to undergo phacoemulsification followed by GATT (phaco-GATT group) or phacoemulsification alone. Success was defined as having a final IOP of 6-20 mmHg with no subsequent glaucoma surgery or vision-threatening complications.

RESULTS

Thirty-six eyes underwent phaco-GATT with 360° angle incision and 38 eyes underwent phacoemulsification alone. IOP and glaucoma medications were significantly lower in the phaco-GATT group at 1, 3, 6, 9 and 12 months. The success rate in the phaco-GATT group was 94.4% after 12.16 ± 2.03 months, with 75% of eyes being off medications compared to 86.8% after 12.47 ± 4.27 months in the phaco group, with 42.1% off medications. (p = 0.008). Hyphema and fibrinous anterior chamber reaction were the most common complications in the phaco-GATT group and resolved with conservative treatment or required YAG capsulotomy. Although this delayed visual rehabilitation in the phaco-GATT group, it did not affect the final visual outcome with no significant difference in the final best-corrected visual acuity between both groups (p = 0.25).

CONCLUSION

Combining phacoemulsification with GATT in PACG yielded more favourable outcomes in terms of IOP, glaucoma medications and surgical success. Although the postoperative hyphema and fibrinous reaction may delay visual rehabilitation, GATT further lowers the IOP by breaking residual peripheral anterior synechiae and removing the dysfunctional trabeculum circumferentially, while avoiding the risks inherent in more invasive filtering procedures.

Atypical presentation of bilateral iridoschisis with abnormal visibility of iris vessels: Role of anterior segment optical coherence tomography

PURPOSE

To describe clinical and anterior segment optical coherence tomography (AS-OCT) findings in a patient with bilateral iridoschisis and unilateral angle closure glaucoma (ACG) associated with abnormal visibility of iris vessels.

CASE PRESENTATION

A 67-year-old male patient with a history of red and painful left eye (LE) one year earlier, presented to our ophthalmology department for a routine examination.Ophthalmic examination of the right eye revealed narrow anterior chamber with sectorial iris atrophy associated to abnormal visibility of an iris vessel. Intraocular pressure (IOP) was 12 mmHg with normal optic disc appearance. LE anterior chamber was narrow with diffuse iris atrophy and abnormal vessels visibility. IOP was 28 mmHg with an important optic disc excavation. On gonioscopy, angle was narrow without neovessels nor synechiae. AS-OCT of both eyes revealed shallow angles, iris splitting with material release in the anterior chamber, while pigmented epithelium was preservedAnti-glaucoma eye drops were prescribed and peripheral laser iridotomy was performed in both eyes with decreased IOP at 14 mmHg in the LE.

CONCLUSION

Iridoschisis is a rare ocular condition characterized by a separation between the anterior and posterior layers of iris stroma with several clinical presentations, and may be associated with abnormal visibility of iris vessels in some cases. The diagnosis of iridoschisis may be challenging and AS-OCT can be a very useful tool to confirm the diagnosis in atypical presentations and to detect associated angle closure.

Does Cataract Extraction Significantly Affect Intraocular Pressure of Glaucomatous/Hypertensive Eyes? Meta-Analysis of Literature

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the effect of cataract extraction on intraocular pressure at 6, 12, and 24 months and their difference compared to the baseline in diverse glaucoma subtypes.

MATERIALS AND METHODS

We carried out research in the MEDLINE, Cochrane Library and EMBASE databases, as of April 2022 for relevant papers, filtered according to established inclusion and exclusion criteria. The meta-analysis evaluated the Mean Reduction and relative Standard Error in these subpopulations at predetermined times. A total of 41 groups (2302 eyes) were included in the systematic review. Due to the significant heterogeneity, they were analysed through a Random Effects Model.

RESULTS

We obtained these differences from baseline: (1) Open Angle Glaucoma at 6, 12 and 24 months, respectively: -2.44 mmHg, -2.71 mmHg and -3.13 mmHg; (2) Angle Closure Glaucoma at 6, 12 and 24 months, respectively: -6.81 mmHg, -7.03 mmHg and -6.52 mmHg; (3) Pseudoexfoliation Glaucoma at 12 months: -5.30 mmHg; (4) Ocular Hypertension at 24 months: -2.27 mmHg.

CONCLUSIONS

Despite a certain variability, the reduction in ocular pressure was statistically significant at 6, 12 and 24 months in both Open Angle Glaucoma and Angle Closure Glaucoma, the latter being superior. Data for Pseudoexfoliation Glaucoma and for Ocular Hypertension are available, respectively, only at 12 months and at 24 months, both being significant.

Cytomegalovirus-Induced Hypertensive Anterior Uveitis: Diagnostic Challenge in an Immunocompetent Patient

Hypertensive anterior uveitis poses diagnostic challenges owing to its multiple potential etiologies. Cytomegalovirus (CMV) infection is an under-recognized cause that exhibits diverse clinical presentations. This case report focuses on the intricate diagnostic challenge encountered in a 66-year-old immunocompetent patient with CMV-induced hypertensive anterior uveitis. The patient's history, encompassing angle closure glaucoma and topiramate use, contributed to the hypertensive crisis. Initial management included intraocular pressure (IOP)-lowering medication, topiramate discontinuation, and bilateral phacoemulsification, successfully normalizing IOP. However, a subsequent recurrence prompted a detailed investigation. The identification of keratic precipitates and a synechial closed angle led to aqueous humor sampling and polymerase chain reaction (PCR) testing, unveiling the presence of CMV-DNA. Treatment led to a favorable response, resolving ocular inflammation and effectively controlling IOP. This case underscores the complexity of diagnosing and managing CMV-induced hypertensive anterior uveitis, emphasizing the critical role of a comprehensive approach in achieving successful outcomes.

A paradigm shift in the treatment of refractory angle closure glaucoma in a patient with X-linked juvenile retinoschisis

BACKGROUND

X-linked retinoschisis (XLRS) is a rare inherited bilateral retinal degeneration caused by mutations in RS1 gene, occurring exclusively in men. Various ocular complications associated with XLRS are reported, and angle closure glaucoma in these eyes is one such complication that is refractory and needs surgery for intraocular pressure control. Glaucoma surgery in these eyes often results in refractory malignant glaucoma with its serious sequelae. Several surgical modifications to prevent this complication have been tried with no or limited success.

METHODOLOGY

In this report, we present a case of XLRS in a young male with a 22-year follow-up. We have described the natural history and progression of retinal disease and glaucoma.

RESULTS

Refractory angle closure glaucoma in our patient was treated with core vitrectomy, phacoemulsification with intraocular lens implantation, and irido-zonulo-hyaloido-vitrectomy. This helped in successful deepening of anterior chamber, good IOP control, and preventing malignant glaucoma.

CONCLUSION

Our case highlights the role of vitrectomy in managing the secondary angle closure glaucoma in eyes with X-LRS.

Microspherophakic Angle Closure Glaucoma in a Patient with Coffin-Siris Syndrome: Case Report

Background

Bilateral secondary angle closure glaucoma is a presenting symptom of microspherophakia and ectopia lentis. Characterizing the associated syndrome and confirmation by genetic testing can identify associated systemic abnormalities and provide appropriate genetic counseling.

Case Presentation

A 42-year-old woman with severe intellectual disability presented with light perception visual acuity and glaucoma, with intraocular pressure (IOP) in her right and left eyes of 69 and 70 mmHg, respectively. She underwent two sessions of 270-degree laser diode transscleral cytophotocoagulation treatment at a 6-month interval and was prescribed topical anti-glaucoma medication. Her family noticed a progressive decrease in her vision while on treatment for 2 years. She was diagnosed with apparent Weill-Marchesani syndrome, accompanied by angle closure glaucoma and microspherophakia. Cataract surgery and intraocular lens implantation were successful in both eyes and post-operative IOP was controlled with anti-glaucoma medication but her vision did not improve from severe glaucomatous optic neuropathy. Her underlying syndrome was investigated genetically by whole exome sequencing.

Results

Sequencing showed a pathogenic variant in ARID1B, c.3955dupC (p.Gln1319Profs*14), diagnostic of Coffin-Siris syndrome. This is the first report of Coffin-Siris syndrome associated with microspherophakia and angle closure glaucoma.

Conclusion

Bilateral angle closure glaucoma from ectopia lentis in patients with genetic syndromes could be an indicator of microspherophakia in adulthood. Ophthalmological surveillance is important in patients with Coffin-Siris syndrome.

Hidden Kiss: A Rare Case of Spontaneous Suprachoroidal Hemorrhage Masquerading as Vitreous Hemorrhage Causing Secondary Angle-Closure Glaucoma

Suprachoroidal hemorrhage (SCH) is an uncommon sight-threatening pathology, most often encountered intraoperatively. However, spontaneous presentation of SCH is even rarer. We report the case of a 69-year-old diabetic patient with spontaneous SCH (SSCH) in her left eye masquerading as a vitreous hemorrhage. She developed treatment-resistant secondary angle-closure glaucoma. She was referred to the vitreoretinal team for intraocular exploration to identify the source of the hemorrhage. Pars plana vitrectomy identified extensive SCH intraoperatively. As far as the authors are aware, this is the first case in which the patient had such severe SSCH that the characteristic kissing choroidal sign was not visualized on repeated examinations and multimodal imaging. All initial evidence pointed towards a diagnosis of vitreous hemorrhage. This case demonstrates that if a patient has angle-closure glaucoma and persistently raised intra-ocular pressure that is treatment-resistant, then SCH is an important differential diagnosis to consider. Clinicians need to be aware of the risk factors of SCH, and early recognition with a timely intervention of SCH is important to optimize visual outcomes.

Prevalence of Risk Factors Among Patients With Glaucoma in Jeddah, Saudi Arabia

Objective The objective of this study is to estimate the prevalence of risk factors among patients with glaucoma in Jeddah, Saudi Arabia. Methods  This cross-sectional study was conducted on 215 patients diagnosed with glaucoma in the period between March 2022 and August 2022 at King Abdulaziz University Hospital, in Jeddah, Saudi Arabia. We used the participants' medical records and contacted the patients to collect information on sociodemographic characteristics and known risk factors of glaucoma. Results Among the 215 patients with glaucoma, 142 (66.0%) patients had open-angle glaucoma, 15 (7.0%) patients had closed-angle glaucoma, and 58 (27.0%) patients had congenital glaucoma. Among the patients with open-angle glaucoma, 122 (85.9%) patients were aged > 40 years, and 99 (69.7%) patients had myopia. Among the patients with closed-angle glaucoma, 13 (86.7%) patients had hyperopia and 10 (66.7%) patients were aged > 60 years. Among the patients with congenital glaucoma, 21 (36.2%) patients had a family history of congenital glaucoma and 28 (48.3%) patients had consanguine parents.  Conclusion The prevalence of advanced age, hyperopia, and consanguine parents was the highest among patients with open-angle glaucoma, closed-angle glaucoma, and congenital glaucoma, respectively. These findings could inform public health policies among practitioners involved in ophthalmological care.

Confounder for Optic Disc Evaluation in Glaucoma

Congenital disc anomalies like optic disc coloboma or optic disc pit are rare occurrences. Coloboma involving disc or optic disc coloboma occurs due to defective closure of choroidal fissure, which can be unilateral or bilateral. These anomalies are discovered on routine examination or referred to as an open-angle glaucoma suspect. These anomalies can be asymptomatic or may present with visual field defects. Here we report a case of both eyes angle closure glaucoma with incidental finding of unilateral coloboma involving disc in the left eye. Optical coherence tomography of the optic nerve head showed peripapillary nerve fiber loss. Thus assessing such patients for diagnosis and the progression of visual field defects in managing glaucoma is quite challenging.

Role of pilocarpine use following laser peripheral iridotomy in eyes with refractory acute angle closure glaucoma: A case report and literature review

RATIONALE

Angle closure glaucoma (ACG) is one of the most emergent types of glaucoma in clinical practice. Laser peripheral iridotomy (LPI) could minimize pupillary block and prevent ACG from an acute attack. However, recurrent increase in intraocular pressure (IOP) may still occur despite successful LPI. The aim of this study is to highlight the importance of postLPI pilocarpine use and larger LPI size as well as to share some experiences of cataract surgery in patients with ACG.

PATIENT CONCERNS

A 63-year-old female was referred to our hospital for headache, and poor control of IOP in the right eye for 3 hours.

DIAGNOSES

The patient was diagnosed ACG in the right eye. Recurrence of ACG in the right eye and new-onset and recurrent ACG in the left eye were noted during follow-up, despite successful LPI. The diagnosis was confirmed through slit lamp and gonioscope examination.

INTERVENTIONS

The LPI size was enlarged and pilocarpine use was maintained at 2% (1 drop 4 times a day) in both the eyes. Finally, cataract surgery was performed in both the eyes.

OUTCOMES

No recurrence of ACG was noted during postLPI pilocarpine use in both the eyes. The postoperative IOP was stable for >6 months after cataract surgery without any surgical intervention or antiglaucoma medication use. No discomfort or major complication was observed.

CONCLUSION

This report highlights the importance of postLPI pilocarpine use and larger LPI size in patients with refractory ACG.

Outcomes of Small Size Ahmed Glaucoma Valve Implantation in Asian Chronic Angle-Closure Glaucoma

For chronic angle-closure glaucoma (ACG), Ahmed glaucoma valve (AGV) is a useful drainage device for intraocular pressure (IOP) control but there are few reports discussing the outcomes of small size AGV in adult patients. This retrospective study involved 43 Asian adult patients (43 eyes) with chronic ACG. All patients had undergone small size AGV insertion and were divided into anterior chamber (AC) group and posterior chamber (PC) group. In the AC group, tube was inserted through sclerectomy gap into the anterior chamber. In the PC group, tube was inserted into posterior chamber through a needling tract. Outcome measures were intraocular pressure (IOP), visual acuity, number of antiglaucoma medications, survival curve and incidence of complications. In total, 43 eyes of 43 patients, 24 in the AC group and 19 in the PC group, were reviewed. The mean follow-up period was 28.5 months (95% confidence interval: 25.5-31.4). Mean IOP had significantly decreased following AGV insertion. The Kaplan-Meier survival analysis demonstrated a probability of success at 24 months of 67.4% for qualified success and 39.5% for complete success. There were no significant differences between the AC and PC groups in terms of the mean IOP, cumulative probability of success, visual acuity change or antiglaucoma medication change, except IOP at 1-day and 1-month mean IOP. The most common complications noted was hyphema in the PC group. For adult chronic ACG patients, small size AGV insertion could be effective at lowering IOP. Besides, tube insertion into AC with sclerectomy may prevent the hypertensive phase in the early postoperative period.

Evaluation of anterior chamber angle by van Herick grading and ultrasound biomicroscopy in light and dark conditions for finding appositional angle closure and plateau iris configuration

PURPOSE

To evaluate association of the van Herick (VH) grades with the ultrasound biomicroscopic (UBM) parameters, appositional irido-trabecular contact (A-ITC) and plateau iris (PI) in a randomly sampled population.

METHODS

A 10% random sample of all residents aged 40 or older of the Kumejima study underwent UBM under dark and light conditions in the four quadrants of right eyes.

RESULTS

Of 301 right eyes with eligible UBM images, 101 (33.6%) and 200 (66.4%) were classified as VH ≤ 2 and VH ≥ 3, respectively. The UBM parameters on angle width and ciliary body configuration were significantly different between VH ≤ 2 and VH ≥ 3 eyes (p < 0.001). A-ITC was found in at least one quadrant in 54.5% and 75.2% of VH ≤ 2 eyes under light and dark conditions, respectively; and 20.5% and 45.5% of VH ≥ 3 eyes. When 'VH ≤ 2' was used to screen eyes with A-ITC in three or more quadrants, the sensitivity and specificity were 74.1% and 75.3%, respectively. A-ITC was significantly associated with shallower anterior chamber (p = 0.018) and higher intraocular pressure (p = 0.044) in VH ≥ 3 eyes. Plateau iris (PI) was found in 15.8% and 6.0% of VH ≤ 2 and VH ≥ 3 eyes, respectively. Plateau iris (PI) was significantly associated with the UBM parameters on angle width and ciliary body configuration. When 'VH ≤ 2' was used to screen eyes with PI, the sensitivity and specificity were 57.1% and 68.9%, respectively.

CONCLUSIONS

The VH grade of ≤2 and ≥3 showed significant association with UBM angle width and ciliary body configuration parameters. The VH ≤ 2 criterion should be useful for screening of A-ITC and PI.

Anterior Chamber Angle Assessment Techniques: A Review

Assessment of the anterior chamber angle (ACA) is an essential part of the ophthalmological examination. It is intrinsically related to the diagnosis and treatment of glaucoma and has a role in its prevention. Although slit-lamp gonioscopy is considered the gold-standard technique for ACA evaluation, its poor reproducibility and the long learning curve are well-known shortcomings. Several new imaging techniques for angle evaluation have been developed in the recent years. However, whether these instruments may replace or not gonioscopy in everyday clinical practice remains unclear. This review summarizes the last findings in ACA evaluation, focusing on new instruments and their application to the clinical practice. Special attention will be given to the comparison between these new techniques and traditional slit-lamp gonioscopy. Whereas ultrasound biomicroscopy and anterior segment optical coherence tomography provide quantitative measurements of the anterior segment’s structures, new gonio-photographic systems allow for a qualitative assessment of angle findings, similarly to gonioscopy. Recently developed deep learning algorithms provide an automated classification of angle images, aiding physicians in taking faster and more efficient decisions. Despite new imaging techniques made analysis of the ACA more objective and practical, the ideal method for ACA evaluation has still to be determined.

Iridoschisis: visual outcome in treated versus untreated eye

A 67-year-old man was referred for iris color change. He was noted to have narrow angles with atrophic iris appearance and visually significant cataracts. The iris findings were consistent with iridoschisis. The patient was recommended to have cataract surgery. Unfortunately, he was lost to follow-up. One year later, he presented with chronic angle closure glaucoma on the right eye with very high pressure and very poor remaining vision. Left-eye vision was also compromised with cataract. Despite the presence of small pupil, abnormal iris stroma, and dense cataract, the patient underwent successful cataract surgery and achieved 20/20 vision post-operatively. Iridoschisis can cause substantial ocular morbidity if not treated timely.

Acute angle closure glaucoma from spontaneous massive subretinal hemorrhage

Purpose: To report a case of acute angle closure glaucoma from spontaneous massive hemorrhagic retinal detachment from hypertension and diabetes mellitus.

Methods: A 52-year-old woman with controlled systemic hypertension and newly diagnosed diabetes mellitus presented with sudden onset painful loss of vision of the right eye. Examination of the right eye showed no light perception, an intraocular pressure of 60 with shallow anterior chamber, microystic corneal edema, closed angles on gonioscopy, and massive subretinal hemorrhage on indirect ophthalmoscopy. The left eye was essentially normal except for arterio-venous crossing changes. Ocular ultrasound revealed massive subretinal hemorrhage with possible intraocular mass. Enucleation of the painful blind eye was done for histologic diagnosis.

Results: The ocular pathology revealed complete angle closure with total retinal detachment from massive subretinal hemorrhage with no mass or tumor seen. Metastatic work-up included liver enzymes, mammography, transvaginal ultrasound, chest radiography, and cranial and abdominal computerized tomography which were all normal.

Conclusion: Hypertension and diabetes mellitus may cause spontaneous massive subretinal hemorrhagic retinal detachment resulting in secondary angle closure glaucoma. Enucleation is a therapeutic option if a suspicion of an intraocular tumor is present.

Anterior Segment Parameters of Filipino-Americans Compared to Chinese-Americans and Caucasian Americans Using Anterior Segment Optical Coherence Tomography

Purpose

We compare anterior segment characteristics of Filipino- versus Chinese- and Caucasian-Americans to describe the differences in risk factors among each ethnic group.

Methods

A cross-sectional study was conducted among Filipino, Chinese, and Caucasian subjects without glaucoma who underwent a standardized set of ocular examinations and anterior segment optical coherence tomography (Visante ASOCT) imaging. Zhongshan Angle Assessment Program (ZAAP) 4 was used for ASOCT image analysis. The following quantitative parameters wereobtained from ZAAP: (1) angle opening distance (AOD500, AOD750), angle recess area at 750 μm (ARA), and trabecular-iris space area at 500 and 750 μm (TISA500, TISA750); (2) iris parameters, including iris thickness at 750 μm from the scleral spur (IT750), iris area (IArea), iris curvature or convexity (ICurv), and pupil diameter; 3) anterior chamber parameters; and (4) lens vault.

Results

The Filipino (122 eyes), Chinese (121 eyes), and Caucasian (111 eyes) subject groups were similar in terms of demographic and clinical characteristics. We reported pairwise comparisons of Filipino parameter values to Chinese or Caucasian values, represented as B-coefficients and P values. In multivariate analysis, Filipinos had narrower angles than Caucasians (AOD750, TISA 500, TISA 750, ARA, P < 0.001). Filipinos had thicker and more convex irises than Caucasians (IT750, IT 2000, ICurv P < 0.003). Angle and iris parameters were similar overall for Filipino and Chinese.

Conclusions

Filipinos appear to have more convex and thicker irises, smaller lens vault and narrower angles compared to Caucasians. Filipino eyes closely resembled Chinese eyes with similar iris and angle parameters.

Translational Relevance

The anatomic angle parameters of Filipinos may contribute to angle closure risk among this population, thus ASOCT and thorough angle analysis is recommended in this population.

The role of clear lens extraction in angle closure glaucoma

Clear lens extraction can be considered a therapeutic option in angle closure glaucoma (ACG). Even if it does not represent the first choice of treatment, it can be taken into consideration when the topical treatment does not control the intraocular pressure (IOP) and iridotomy does not have a positive effect on the angle closure, especially in appositional angle closure when biometry or ultrabiomicroscopy (UBM) show lens involvement. In angle closure glaucoma, clear lens extraction represents an etiological treatment that takes into account the role of the lens in the pathogenesis of the disease. If we ignore it and we choose a filtrating surgery as therapeutic option we can end up with complications such as prolonged athalamia, corneal damage and lens opacification that will eventually require cataract surgery, but performed late and with higher risks. Before performing a filtrating surgery in ACG, we should take an UBM. We also need to choose the best moment to perform surgery, after topical treatment and iridotomy have been tested, but before trabecular damage appears.

A Novel Method of Quantitative Anterior Chamber Depth Estimation Using Temporal Perpendicular Digital Photography

Purpose

We hypothesize that: (1) Anterior chamber depth (ACD) is correlated with the relative anteroposterior position of the pupillary image, as viewed from the temporal side. (2) Such a correlation may be used as a simple quantitative tool for estimation of ACD.

Methods

Two hundred sixty-six phakic eyes had lateral digital photographs taken from the temporal side, perpendicular to the visual axis, and underwent optical biometry (Nidek AL scanner). The relative anteroposterior position of the pupillary image was expressed using the ratio between: (1) lateral photographic temporal limbus to pupil distance (“E”) and (2) lateral photographic temporal limbus to cornea distance (“Z”). In the first chronological half of patients (Correlation Series), E:Z ratio (EZR) was correlated with optical biometric ACD. The correlation equation was then used to predict ACD in the second half of patients (Prediction Series) and compared to their biometric ACD for agreement analysis.

Results

A strong linear correlation was found between EZR and ACD, R = −0.91, R² = 0.81. Bland-Altman analysis showed good agreement between predicted ACD using this method and the optical biometric ACD. The mean error was −0.013 mm (range −0.377 to 0.336 mm), standard deviation 0.166 mm. The 95% limits of agreement were ±0.33 mm.

Conclusions

Lateral digital photography and EZR calculation is a novel method to quantitatively estimate ACD, requiring minimal equipment and training.

Translational Relevance

EZ ratio may be employed in screening for angle closure glaucoma. It may also be helpful in outpatient medical clinic settings, where doctors need to judge the safety of topical or systemic pupil-dilating medications versus their risk of triggering acute angle closure glaucoma. Similarly, non ophthalmologists may use it to estimate the likelihood of acute angle closure glaucoma in emergency presentations.

IMPORTANCE OF DEMOGRAPHIC RISK FACTORS FOR PRIMARY ANGLE CLOSURE

According to the Guidelines of the European Glaucoma Society (fourth edition), the family history in the closing angle is an important factor that makes the family screening vital in these families. It is present in the clinical case in which two twin patients in different circumstances show the same symptoms of angle closure.

Appositional angle closure in Chinese with primary angle closure and primary angle closure glaucoma after laser peripheral iridotomy

PURPOSE

To determine the prevalence of appositional angle closure (AAC) after laser peripheral iridotomy (LPI) in the eyes of Chinese patients with primary angle closure (PAC) and primary angle closure glaucoma (PACG) and to evaluate its pathogenesis by investigating anatomic characteristics.

METHODS

This was a cross-sectional observational study. PAC and PACG subjects were consecutively enrolled after LPI. Ultrasound biomicroscopy (UBM) images, obtained in darkness, of each quadrant without peripheral anterior synechia (PAS) under gonioscopy were qualitatively assessed. Darkroom provocative test (DRPT) was also performed.

RESULTS

A total of 134 eyes of 134 patients were enrolled. AAC was observed in ≥ 1 quadrant of UBM image in 85 subjects (63.4%). There were 116 randomly selected quadrants without PAS for 134 patients (86.6%). AAC existed in 38 quadrants (32.8%). Among these, plateau iris accounted for 44.7%, anteriorly inserted iris for 13.2%, thick iris for 13.2%, and anteriorly inserted iris combined with thick iris for 18.4% of the total. One hundred fifteen patients underwent DRPT and its positive rate of eyes with AAC ≥ 2 quadrants (37.5% [12 of 32 patients]) was significantly higher than those ≤ 1 quadrant (16.9% [14 of 83 patients]; P = 0.018). However, no significant differences were found between eyes with nonsynechia plateau iris ≥ 2 quadrants (36.4% [4 of 11 patients]) and those ≤ 1 quadrant (21.2% [22 of 104 patients]; P = 0.266).

CONCLUSIONS

Approximately two-thirds of PAC and PACG eyes of Chinese patients after LPI had AAC. Plateau iris accounted for less than 50% of AAC. Other factors such as a thick peripheral iris and an anteriorly inserted iris also contributed to AAC. DRPT results suggested AAC might have more functional meaning than plateau iris.

Intermittent acute angle closure glaucoma and chronic angle closure following topiramate use with plateau iris configuration

This is a case report describing recurrent intermittent acute angle closure episodes in the setting of topiramate use in a female suffering from migraines. Despite laser peripheral iridotomy placement for the pupillary block component, and the discontinuation of topiramate, the acute angle closure did not resolve in the left eye with chronic angle closure and the patient required urgent trabeculectomy. The right eye responded to laser peripheral iridotomy immediately and further improved after the cessation of topiramate. While secondary angle closure glaucoma due to topiramate use has been widely reported, its effects in patients with underlying primary angle closure glaucoma have not been discussed. Our report highlights the importance of recognizing the often multifactorial etiology of angle closure glaucoma to help guide clinical management.

Spontaneous dislocation of a crystalline lens to the anterior chamber with pupillary block glaucoma in Noonan Syndrome: a case report

We report a 13-year-old child with Noonan Syndrome who developed spontaneous dislocation of the crystalline lens in anterior chamber leading to pupillary block glaucoma in the left eye and subluxation of lens in right eye. Intracapsular extraction of the dislocated lens was done in the left eye. Prompt diagnosis and management is needed in such cases to avoid glaucoma and corneal endothelial cell damage. We could not find any such case after thorough Medline search.

Genotype-phenotype correlation analysis for three primary angle closure glaucoma-associated genetic polymorphisms

PURPOSE

Recently, three genetic susceptibility loci for primary angle closure glaucoma (PACG) were identified: COL11A1 rs3753841, PCMTD1-ST18 rs1015213, and PLEKHA7 rs11024102. The purpose of this study was to investigate whether these single nucleotide polymorphisms (SNPs) affect the phenotype of PACG patients.

METHODS

A retrospective analysis was performed for 700 Singaporean Chinese PACG patients who had been genotyped. The associations between the three SNPs and clinical features related to severity of glaucoma were studied. For a subgroup of patients who had ≥ 5 years of follow-up and ≥ 5 reliable visual field (VF) tests, differences in glaucoma progression, as measured by the proportion of VF progression and blindness, were compared among groups with different genotypes.

RESULTS

The minor allele frequencies at COL11A1 rs3753841, PCMTD1-ST18 rs1015213, and PLEKHA7 rs11024102 were 36%, 2.1%, and 41.5%, respectively. There were no significant differences in sex, diagnosis (acute primary angle closure [APAC] versus non-APAC), age at diagnosis, laterality of glaucoma, or need for filtration surgery among patients with different genotypes (all P > 0.05). We also found no significant difference between genotypes and the IOP at presentation, and other clinical characteristics at DNA collection (vertical cup-to-disc ratio, best corrected visual acuity, baseline VF mean deviation, or pattern standard deviation). For the subgroup analysis, we did not observe significant associations between VF progression and the proportion of blindness with any of the PACG susceptibility loci.

CONCLUSIONS

The three genetic susceptibility loci for PACG did not underlie any major phenotypic diversity in terms of disease severity or progression.

Comparison of factors associated with occludable angle between american Caucasians and ethnic Chinese

PURPOSE

To determine if factors associated with gonioscopy-determined occludable angle among American Caucasians are similar to those found in ethnic Chinese.

METHODS

This is a prospective cross-sectional study with 120 American Caucasian, 116 American Chinese, and 116 mainland Chinese subjects. All three groups were matched for sex and age (40-80 years). Gonioscopy was performed for each subject (occludable angles = posterior trabecular meshwork not visible for ≥2 quadrants). Anterior segment optical coherence tomography and customized software was used to measure anterior segment biometry and iris parameters, including anterior chamber depth/width (ACD, ACW), lens vault (LV), and iris thickness/area/curvature.

RESULTS

In both Chinese and Caucasians, eyes with occludable angles had smaller ACD and ACW, and larger LV and iris curvature than eyes with open angles (all P < 0.005). Chinese eyes had smaller ACD and ACW than Caucasian eyes (both P < 0.01) in the occludable angle cohort. Iris characteristics did not differ significantly between Chinese and Caucasians in the occludable angle cohort. Based on multivariate logistic regression, gonioscopy-determined occludable angle was significantly associated with LV, iris area, and sex (all P < 0.03) in Chinese; and with LV, ACD, iris thickness, age, and sex (all P < 0.04) in Caucasians.

CONCLUSIONS

Several factors associated with occludable angle differed between Caucasians and Chinese, suggesting potentially different mechanisms in occludable angle development in the two racial groups. This is the first study to demonstrate that lens vault is an important anterior segment optical coherence tomography parameter in the screening for angle closure in Caucasians. In addition, iris thickness was a significant predictor for occludable angles in Caucasians but was not in ethnic Chinese.

Longitudinal changes in anterior segment parameters after laser peripheral iridotomy assessed by anterior segment optical coherence tomography

PURPOSE

To quantify long-term changes in anterior segment (AS) parameters after laser peripheral iridotomy (LPI) using AS optical coherence tomography (OCT) in primary angle-closure suspect (PACS).

METHODS

Thirty-two PACS subjects were imaged at pre-LPI and 2 weeks and 18 months post-LPI using AS OCT. Anterior chamber depth (ACD), iris curvature (IC), iris thickness at 750 and 1500 μm from the scleral spur (IT750, 1500), lens vault (LV), anterior chamber area (AA), and iris area (IA) were estimated by ImageJ software (version 1.46). Anterior chamber angle (ACA) parameters (angle opening distance [AOD750], angle recess area [ARA750], and trabecular iris space area [TISA750]) were provided by the manufacturer. Parameters were compared before and after LPI. Uni- and multivariate regression analysis was performed to evaluate factors associated with ACA narrowing.

RESULTS

Mean AA (14.63 vs. 15.87 mm(2)) and three ACA parameters (AOD750 [0.17 vs. 0.28 mm], TISA750 [0.07 vs. 0.11 mm(2)], and ARA750 [0.08 vs. 0.13 mm(2)]) increased at 2 weeks post-LPI (all P < 0.001). The IT750, 1500 and IC also showed change at 2 weeks post-LPI. Eighteen months post-LPI, IC (0.34 vs. 0.16 mm, P < 0.001) and LV (0.88 vs. 1.01 mm, P = 0.001) were significantly different, while three ACA parameters were not different from their pre-LPI status. At post-LPI 18 months, LV was significantly associated with ACA narrowing (P = 0.026).

CONCLUSIONS

The ACA tended to be narrowed at 18 months post-LPI despite resolution of pupillary block, which may be due to LV increment. Our results warrant continuous follow-up of narrow-angle patients after LPI.

Acute bilateral angle closure glaucoma induced by methazolamide

Purpose

To report a case of bilateral acute myopia and angle closure glaucoma after ingestion of methazolamide.

Methods

An interventional case report of a 70-year-old male who developed bilateral, acute myopia and angle closure glaucoma after ingesting methazolamide tablets for the treatment of normal tension glaucoma.

Results

Bilateral anterior chamber shallowing associated with ciliary body edema, supraciliary effusions, and shallow posterior choroidal effusions were documented with slit-lamp photography and high-frequency ultrasonography. Near complete resolution of these signs after discontinuation of methazolamide were also documented.

Conclusion

Methazolamide may be associated with secondary myopia and angle closure glaucoma. Discontinuation of methazolamide leads to resolution of this process, as documented by slit-lamp photography and high-frequency ultrasonography.

Changes in peripheral anterior chamber depth of a case of relapsing polychondritis with recurrent secondary angle closure glaucoma section sign

A case of relapsing polychondritis showed IOP elevations three times during the follow-up due to the angle-closure mechanism. The peripheral anterior chamber depth (ACD) showed a good correlation with IOP elevation, but central ACD did not. The peripheral ACD could be more related to IOP elevation than central ACD.