Pars plana vitrectomy combined with hyaloido-zonula-iridectomy in treatment of patients with chronic aqueous misdirection: A systematic literature review and case series.

PURPOSE: To evaluate the efficacy of vitrectomy combined with hyaloido-zonula-iridectomy from an anterior or a posterior approach in patients with treatment-resistant aqueous misdirection (chronic aqueous misdirection) by systematically reviewing existing literature in combination with presentation of a case series. METHODS: A systematic literature review was performed in PubMed, EMBASE and Cochrane Library databases using search terms: malignant glaucoma, ciliary block, ciliolenticular block and aqueous misdirection. A consecutive series of three pseudophakic patients (5 eyes) diagnosed with chronic aqueous misdirection after cataract surgery is presented. RESULTS: A literature search identified 31 articles describing treatment of chronic aqueous misdirection with vitrectomy and a hyaloido-zonula-iridectomy. Studies, where patients were treated with a complete vitrectomy from pars plana in combination with a hyaloido-zonula-iridectomy, reported low relapse rates. Studies describing a surgical approach with vitrectomy performed from the anterior chamber, followed by a hyaloido-zonula-iridectomy, also reported low relapse rates except for one reporting relapse in nearly half of the patients. In our case series, a complete vitrectomy combined with a hyaloido-zonula-iridectomy resolved the chronic aqueous misdirection in all five eyes after one procedure except one eye where the hyaloido-zonula-iridectomy was repeated due to an insufficient opening. Some of the eyes still needed antiglaucomatous treatment due to chronic angle closure. CONCLUSION: In treatment-resistant malignant glaucoma, vitrectomy combined with a hyaloido-zonula-iridectomy should be considered performed to ensure communication between the anterior chamber and the vitreous cavity. If the condition has been unresolved for a long time, extensive synechiae of the angle may decrease the success rate due to chronic angle closure.

Spontaneous Resolution of a Rapidly Formed Dense Cataract Following Nd: YAG Laser Peripheral Iridotomy in a Case of Pigmentary Glaucoma.

A 54-year-old man was referred for a senior opinion. His vision had acutely dropped in his right eye from 6/6 to hand movements following Nd:YAG laser peripheral iridotomy for treatment of pigmentary glaucoma. A dense rosette posterior subcapsular cataract had formed in his right eye rapidly after surgery. Within 4 weeks the cataract resolved spontaneously and his vision returned to 6/6. It is hypothesized that a dual mechanism caused the rapidly formed cataract. Shockwaves stemming from Nd:YAG laser resulted in a reversible misalignment of the lenticular fibers, and localized direct damage to capsule caused osmotic imbalance and fluid collection between lamellae. Restoration of the osmotic balance, repair, and formation of lens fibers and clearing of vacuoles led to the resolution of the cataract. The proximity of the concave iris to the lens equator in pigmentary glaucoma was a predisposing factor. This highlights the importance of exercising great caution in using laser peripheral iridotomy in cases of pigmentary glaucoma, particularly if a higher laser power is used and considering initial conservative management of this complication.

Massive Hyphaema Following Laser Iridotomy in a Patient on Dual Antiplatelet Therapy (Aspirin plus Ticagrelor): Case report and literature review.

Massive hyphaema presentation after a laser iridotomy is very rare. We report a 63-year-old man with ischaemic heart disease on dual antiplatelet therapy (aspirin plus ticagrelor) who was diagnosed as a primary angle-closure suspect and was to undergo a neodymium-doped yttrium aluminium garnet laser iridotomy at Centro Oftalmológico Virgilio Galvis, Floridablanca, Colombia in 2016. While performing the iridotomy in the left eye, active bleeding occurred that finally filled approximately 75% of the anterior chamber. Intraocular pressure (IOP) increased to 62 mmHg. Mannitol and a topical dorzolamide/timolol were used to control the increase in IOP. The hyphaema slowly resolved over the following week without sequelae. This case revealed that massive hyphaema can complicate laser iridotomy in patients on dual antiplatelet therapy, although this is rare. Therefore, if patients are taking aspirin and ticagrelor, it would be advisable to stop the second medication if possible. In addition, sequential application of photocoagulation and photodisruption lasers might diminish the risk of significant bleeding.

Malignant Glaucoma After Laser Peripheral Iridotomy.

PURPOSE: We describe a patient with primary angle-closure glaucoma who developed malignant glaucoma following laser peripheral iridotomy. METHODS: A 58-year-old male presented with peripheral and central anterior chamber shallowing following an uncomplicated Nd: YAG laser peripheral iridotomy. Intraocular pressure (IOP) and B-scan echography were normal, and there was -1.5 Ddiopter asymmetric myopia. Despite treatment with aqueous suppression and cycloplegia for 7 months, the patient developed progressive myopic shift and anterior chamber shallowing. RESULTS: The patient underwent 23-G pars plana vitrectomy and lensectomy using a standard 3-port technique, and sulcus posterior chamber intraocular lens implantation in the left eye. Twelve months postoperatively, the anterior chamber has remained deep, best-corrected visual acuity is 20/15, and the IOP is 11 mm Hg. CONCLUSIONS: Malignant glaucoma is a rare complication of laser iridotomy and should be considered in eyes with progressive anterior chamber shallowing and myopia despite normal IOP.

Pattern Scanning Laser (PASCAL) for Peripheral Iridoplasty in Eyes With Plateau Iris Syndrome: A Novel Application.

PURPOSE: The purpose of this study was to evaluate safety and efficacy of pattern scanning laser (PASCAL) for peripheral iridoplasty in eyes with plateau iris syndrome. MATERIALS AND METHODS: This study was a retrospective review of cases that underwent PASCAL laser peripheral iridoplasty. Eyes with plateau iris syndrome confirmed on gonioscopy and ultrasound biomicroscopy were included in the study. Primary and secondary outcome measures were angle widening on gonioscopy and magnitude of intraocular pressure (IOP) reduction, respectively. RESULTS: Twelve eyes of 8 patients that completed 1-year follow-up were analyzed. Angle widening was noted in 46% of treated quadrants by at least 1 grade (Shaffer classification) at 1-month follow-up. A statistically significant IOP reduction was noted at 1 year from 20.6±4.8 to 17.8±3.8 mm Hg (P=0.01). At 1 month, 8 of 12 eyes (66.6%) achieved gonioscopic success (widening of the angle by at least 1 grade in 2 of 4 quadrants). At 1 year, 6 of 12 eyes (50%) achieved tonometric success (20% reduction or 3 mm Hg IOP reduction from the baseline without addition of new antiglaucoma medications). No adverse effects associated with PASCAL laser peripheral iridoplasty were observed. CONCLUSIONS: PASCAL laser iridoplasty can be a safe and effective alternative to argon laser peripheral iridoplasty in the management of eyes with plateau iris syndrome. Our findings need to be further validated on larger sample size and in different ethnicities.

Slit-lamp Needling of the Anterior Capsule for Aqueous Misdirection After Hyaloido-zonulectomy and Iridectomy.

INTRODUCTION: We present a case of persistent aqueous misdirection, after Ahmed glaucoma valve surgery, despite undergoing an anterior vitrectomy with hyaloido-zonulectomy and iridectomy. CASE REPORT: A 73-year-old female patient, 4 months after phacotrabeculectomy, was referred with persistent high intraocular pressure (IOP). Postoperatively, she developed aqueous misdirection with a flat anterior chamber (AC) but with an IOP of 15 mm Hg. On presentation, her AC was shallow with peripheral iris-cornea touch, and her IOP was 39 mm Hg. Posterior Nd:Yag capsulotomy with disruption of anterior hyaloid face partially deepened the AC. With failure of the trabeculectomy and high IOP, an Ahmed valve was placed. On the first operative day the AC was deep with an IOP of 10 mm Hg. On day 6 the patient presented with pain, flat AC, and an IOP of 10 mm Hg. Fundus examination revealed no choroidal effusion. Despite repeated reformation with viscoelastic, the AC failed to deepen. An anterior vitrectomy with hyaloido-zonulectomy was performed. Initially, the AC was deep, but, a few days later, it was flat. Multiple reformations and vitreous tap failed to keep the AC deep. A 30-G needle was passed at the slit lamp across the temporal cornea, iris, and anterior capsule into the anterior vitreous cavity. The needle was then partially withdrawn and used to create a space between the intraocular lens and anterior capsule. This immediately deepened the AC and remained so for the duration of follow-up (4 mo). CONCLUSION: Slit-lamp needling of the anterior lens capsule can be successfully performed to help resolve a persistent case of aqueous misdirection after anterior vitrectomy.

Simple Preoperative Ink Test as a Novel Adjunct to Intrastromal Keratopigmentation for Post-laser Peripheral Iridotomy Dysphotopsias.

PURPOSE: To describe a simple preoperative ink test as a novel adjunct to intrastromal keratopigmentation for post-laser peripheral iridotomy (LPI) dysphotopsias. METHODS: A surgical marking pen is applied to the area over a peripheral iridotomy before intrastromal keratopigmentation. The patient can then assess whether there is any improvement in their symptoms of dysphotopsias. Manual intrastromal keratopigmentation can then be performed using a crescent blade into the clear cornea at 50% depth and tunneled centrally to create a pocket ensuring that the peripheral iridotomy is fully occluded. The crescent blade is coated with an alcohol-based commercially available black tattoo pigment, and the pocket is filled. RESULTS: We have used the preoperative ink marker test on 5 eyes in patients with post-LPI (4 temporal and 1 superior) dysphotopsias before performing intrastromal keratopigmentation, with good patient satisfaction. Patients report immediate symptomatic relief after the procedure. This ink marking technique can also be extended to help identify which iris defect is symptomatic in patients with multiple iris defects. CONCLUSIONS: The preoperative ink test before intrastromal keratopigmentation is a novel adjunct to the treatment of post-LPI dysphotopsias.

Laser peripheral iridotomy versus laser peripheral iridotomy plus laser peripheral iridoplasty in the treatment of multi-mechanism angle closure: study protocol for a randomized controlled trial.

BACKGROUND: China has the largest burden of primary angle-closure glaucoma (PACG) worldwide. The mechanism of the angle closure is complex and includes pupillary block and non-pupillary block. Currently, opinion is that laser peripheral iridotomy (LPI) alone is not sufficient to prevent disease progression. Laser peripheral iridoplasty (LPIP) is an alternative and effective way of widening the angle recess in eyes that are affected by primary angle closure (PAC). However, it is not known if greater benefit would be achieved using LPI plus LPIP for PAC with multiple mechanisms (MAC). Thus, the aim of this study is to demonstrate if LPI plus LPIP would be more effective than single LPI in controlling the progression of PAC with multiple mechanisms, based on ultrasound biomicroscopy (UBM) classification. A secondary aim is to determine whether or not this would result in the use of less medication and/or prolong the time to antiglaucoma surgery. METHODS: This multiple-mechanism angle-closure study will comprise a 3-year, multicenter, randomized, parallel-group, open-label, superiority trial, the aim of which will be to evaluate the safety and efficacy of LPI plus LPIP versus LPI for PAC. It is anticipated that 240 adults, diagnosed with PAC (the mechanism of angle closure will be assessed by UBM and it will be determined whether or not it involves multiple mechanisms) will be recruited from ten ophthalmic centers in China. Participants will be randomly allocated to receive either single LPI or LPI plus LPIP. Participant assessment will be designed to test the rate of disease progression and who will be followed up for 3 years. The primary outcome will be the disease progression rate and a comparison will be made between the LPI and LPI plus LPIP groups using Pearson's χ2 test. Logistic regression analysis will be performed to account for the central effect. DISCUSSION: If the LPI plus LPIP is found to significantly decrease the rate of PAC progression, this intervention could potentially be a standard therapy to be used to treat PAC when multiple mechanisms are involved in angle closure. Subsequently, this would have the potential to delay the rate of PAC progression to PACG and delay the time to the administration of antiglaucoma medication or trabeculectomy surgery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02613013 . Registered on 24 November 2015. In fact, the study was due to start in late October 2015, however, there were no patients recruited in October, and when we registered at ClinicalTrials.gov on 5 November 2015, we received suggestions on the English translation of our protocol from the PRS Team at Clinicaltrial.gov, so the final successful registration date was on 24 November 2015.

Is prophylactic laser peripheral iridotomy for primary angle closure suspects a risk factor for cataract progression? The Chennai Eye Disease Incidence Study.

BACKGROUND: To report the risk of cataract progression among primary angle closure suspects (PACS) 6 years after they underwent laser peripheral iridotomy (LPI). METHODS: In the Chennai Eye Disease Incidence Study, 6 years after their baseline evaluation, 4421 subjects were examined again. As part of a detailed evaluation cataract was graded using the Lens Opacities Classification System II; progression was defined as change of cataract by two or more grades or history of cataract surgery in the 6-year period. Only bilaterally phakic subjects with less than N2 or C2 or P2 cataract at baseline with no history of any form of glaucoma, primary angle closure and pseudoexfoliation were included. RESULTS: There were 3205 eligible subjects. Of these, 190 had undergone LPI for PACS. In comparison to the study population, they were significantly older (p<0.001), female (p=0.008), urban residents (p=0.001) and patients with hypertension (p<0.001). During the intervening period, 53 subjects had undergone cataract surgery. The cataract progression rate was significantly greater (OR 1.7, 95% CI 1.3 to 2.4, p<0.001) in those who had undergone LPI. For the study population the baseline risk factors for progression of cataract were age (p<0.001), female gender (p=0.01), diabetes (p<0.001) and LPI (p<0.001). Diabetes and female gender were significant risk factors for nuclear and cortical cataract progression; LPI was a risk factor only for cortical cataract (OR 1.6, 95% CI 1.1 to 2.3, p=0.007). CONCLUSIONS: There was significant cataract progression in 6 years following LPI for PACS.

Optic Disc Swelling After Intraocular Pressure Lowering Treatment in Acute Primary Angle Closure.

PURPOSE OF THE STUDY: The purpose of the study was to report cases with acute primary angle closure where optic disc swelling was documented after intraocular pressure (IOP) lowering by laser iridotomy. PATIENTS AND METHODS: Two patients with acute primary angle closure underwent funduscopic examination of the optic disc and spectral-domain optical coherence tomography circumpapillary scanning at the time of acute primary angle closure attack before laser iridotomy, and after the laser iridotomy treatment. RESULTS: Optic disc swelling was developed in both patients following IOP lowering by laser iridotomy, which was documented by spectral-domain optical coherence tomography imaging as a diffuse thickening of the circumpapillary retinal nerve fiber layer. CONCLUSIONS: This is the first report demonstrating a temporal relationship between IOP lowering and optic disc swelling in patients with acute primary angle closure. Optic disc swelling documented after acute episode of acute primary angle closure may suggest choroidal effusion or axoplasmic overflow associated with sudden IOP lowering, rather than coexistence of other optic neuropathy.

Inadvertent cyclodialysis cleft and annular ciliochoroidal detachment after hyperopic phakic intraocular lens implantation and prophylactic surgical iridectomy.

UNLABELLED: We present the case of a 26-year-old man with severe early hypotony after implantation of the Implantable Collamer Lens phakic intraocular lens (pIOL) in the left eye for hyperopia. To our knowledge, this is the first documented case of cyclodialysis cleft and secondary annular ciliochoroidal detachment after implantation of a pIOL, presumably provoked by a straightforward prophylactic surgical iridectomy. The initial diagnosis was determined using swept-source Fourier-domain anterior segment optical coherence tomography as gonioscopy and ultrasound biomicroscopy did not reveal the cleft. Conservative treatment was not effective. Argon laser photocoagulation resolved the problem. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Femtosecond laser-assisted keratopigmentation for the management of visual disabilities due to peripheral iridectomies.

PURPOSE: To report the technique and result of keratopigmentation using a femtosecond laser for the treatment of functional visual disabilities caused by peripheral iridectomies. DESIGN: Case report. METHODS: Two eyes of 2 patients underwent femtosecond laser-assisted keratopigmentation (FLAK) for moderate to severe visual dysfunction secondary to peripheral iridectomies. The main outcomes measures of the study were changes in visual-related symptoms, cosmesis, and intraoperative surgical complications. RESULTS: Following FLAK, the visual-related symptoms (ghosting, glare, and monocular diplopia) improved in both cases with significant improvement to total elimination of symptoms. No patient lost any lines of visual acuity, and no significant complications were observed during the follow-up period. The cosmetic appearance was reported as very good. CONCLUSIONS: FLAK is minimally invasive and results in a significant decrease in the subjective glare and photophobia and even in resolution of monocular diplopia. The cosmetic outcome was also favorable. This technique allows surgeons to correct visual disabilities associated with iris defects with a high success rate while avoiding more aggressive intraocular surgery.

[Laser iridectomy and anatomical and functional parameters in primary angle-closure glaucoma].

The paper discusses literature data on the effectiveness of laser iridectomy in patients with primary angle-closure glaucoma. The main methods of anatomical and functional assessment and changes evaluation are reviewed.

Three-year outcome of Descemet stripping automated endothelial keratoplasty for bullous keratopathy after argon laser iridotomy.

PURPOSE: The aim of this study was to evaluate the 3-year outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) for the treatment of bullous keratopathy secondary to argon laser iridotomy (ALI). METHODS: A total of 22 consecutive patients (22 eyes) with ALI who underwent DSAEK were retrospectively analyzed. Best spectacle-corrected visual acuity (BSCVA), endothelial cell density, and complications were investigated over 3 years postoperatively. The outcome of DSAEK was also compared between the ALI group and 21 other patients with Fuchs endothelial dystrophy (FED) or pseudophakic bullous keratopathy (PBK) (FED/PBK group). RESULTS: The median BSCVA improved from logarithm of the minimum angle of resolution 1.40 before DSAEK to 0.30 at 6 months, 0.30 at 12 months, 0.22 at 24 months, and 0.15 at 36 months after surgery. The median endothelial cell loss was 20.3% at 6 months, 18.4% at 12 months, 32.5% at 24 months, and 46.5% at 36 months. Comparison of the ALI group with the FED/PBK group showed no significant difference in the BSCVA or endothelial cell density. Rejection affected 9.1% of the ALI group versus 0% of the FED/PBK group (P = 0.49), the graft dislocation rate was 0% versus 9.5% (P = 0.23), and posterior synechiae were found in 31.8% versus 4.8% (P = 0.046). CONCLUSIONS: The 3-year outcome of DSAEK for bullous keratopathy after ALI was excellent. However, caution should be exercised in patients with a history of ALI to avoid posterior synechiae after DSAEK.

Abnormal binocular vision: monocular diplopia of physical origin: two case reports. Its relationship to the physiology and arrangement of the visual directions of the retinal areas; binocular triplopia.

BACKGROUND AND PURPOSE: Monocular diplopia is an infrequent but disabling complication following laser peripheral iridotomy, or following cataract surgery. Our purpose is to clarify the intraocular mechanism of monocular diplopia (and binocular triplopia) of physical origin and its relation to the physiology and arrangement of the visual directions of the retinal areas in each eye. CASE REPORTS: This is a report of one patient who developed monocular diplopia following an "exposed" laser peripheral iridotomy, and of a second patient who developed monocular diplopia due to a swollen opacified central posterior capsule following cataract surgery. CONCLUSION: Monocular diplopia of physical origin results from stimulation, by an object of regard, of two separate retinal areas that have two different visual directions due to optical ocular pathology.

Prophylactic laser peripheral iridotomy and cataract progression.

PURPOSE: To determine whether prophylactic laser peripheral iridotomy (LPI) for primary angle closure (PAC) is associated with cataract progression. METHODS: In 1999, Mongolian volunteers aged>or=50 years were invited to participate in a longitudinal study. Glaucoma was excluded in all participants and 712 of them were selected to undergo a full ophthalmic examination as part of the study protocol. Lenses were graded and PAC diagnosed using international classification systems. In 2005, all traced participants underwent a similar dilated examination. Diagnosis of cataract progression was based on the inter-observer variation +2 standard deviations. The association between LPI at baseline and cataract progression was assessed using chi2-test and logistic regression. RESULTS: Of 712 participants, 158 were diagnosed with occludable angles and treated with LPI. In 2005, 137 participants (19.2%) had died, 315 (315/575=54.8%) were traced, and dilated examination was performed on 276 (48%) of them. Progression of nuclear opacity (NO), cortical, and posterior subcapsular (PSC) opacities were evident in 40 (14.5%, 95% confidence interval (CI)=10.6-19.2%), 89 (32.2%, 95% CI=26.8-38.1%), and 11 participants (4.0%, 95% CI=2.0-7.0%), respectively. Although NO was more likely to progress in those with LPI in a crude analysis (odds ratio (OR)=2.02, 95% CI=1.00-4.11, P=0.05), no evidence of an independent association was detected in multivariate analysis adjusting for age, sex, and baseline Schaffer grading (adjusted OR=1.24, 0.41-3.75, P=0.7). There was no evidence of an association between LPI and progression of PSC or cortical opacities. CONCLUSIONS: There is no evidence that prophylactic LPI is independently associated with cataract progression in this study.