Primary angle-closure glaucoma with goniodysgenesis in a Beagle dog.

BACKGROUND: Open angle glaucoma is the only type of primary glaucoma reported in Beagles. This case report describes a primary angle-closure glaucoma in a Beagle and its diagnostic and prognostic relevance. CASE PRESENTATION: A 12-year-old, neutered male Beagle presented to the Michigan State University (MSU) Comparative Ophthalmology Service for evaluation of suspected visual impairment. Complete ophthalmic examination of the left eye (OS) revealed: blepharospasm, absent menace response, moderate episcleral congestion, mild diffuse corneal edema, mydriasis, asteroid hyalosis, decreased myelination and cupping of the optic nerve head, and mild retinal vascular attenuation. Examinations of the right eye (OD) were within normal limits. Intraocular Pressure (IOP) were 24 mmHg OD and 49 mmHg OS. Gonioscopy OD revealed a narrow iridocorneal angle with moderate pectinate ligament dysplasia characterized by broad-based pectinate ligament strands (fibrae latae) and solid sheets (laminae) throughout all 4 quadrants. DNA testing revealed that the dog did not carry the Gly661Arg ADAMTS10 mutation responsible for primary open angle glaucoma (POAG) in Beagles. The OS was medically managed with latanoprost 0.005% and dorzolamide HCl 2% /timolol malate 0.5% ophthalmic solutions for 7 months and then enucleated due to uncontrolled IOP. Histopathologic evaluation was consistent with goniodysgenesis with a broad, non-perforate, sheet-like band of uveal stroma bridging from the base of the iris to the terminal arborization of Descemet's membrane. Approximately 14 months from the initial diagnosis of glaucoma OS, OD also developed glaucoma and was enucleated. Histopathologic findings were consistent with goniodysgenesis OD. CONCLUSIONS: To our knowledge, this is the first reported case of PACG with goniodysgenesis in a Beagle supported by clinical, genetic, and histopathologic data. It highlights the importance of gonioscopy in Beagles with glaucoma. Further studies with a larger number of dogs are warranted to characterize clinical manifestations and inheritance of PACG in this breed.

Patterns of care for glaucoma patients in Korea from 2002 to 2013 using the national health insurance service claims data.

Due to the rapidly increasing life-expectancy, the prevalence of glaucoma has increased steadily in recent years. We aimed to evaluate the patterns of care and primary treatment strategy patterns in Korea according to glaucoma subtypes to assess the quality of care for glaucoma patients.In this serial cross-sectional survey, the claims data from the Korean National Health Insurance Service was used to identify and group glaucoma patients into primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG), other types of glaucoma, and ocular hypertension from 2002 to 2013. Records for outpatient visits, hospitalizations, drug prescriptions, admissions, and surgical interventions were used to determine the patterns of care and identify primary treatment strategies.Both the prevalence (0.11% in 2002 to 0.43% in 2013) and incidence rates (0.06% in 2003 to 0.11% in 2013) for glaucoma increased over time. The mean number of outpatient visits increased (4.9-6.0 visits per year), while the proportion of hospitalized patients (2.3-1.0% of patients) and duration of hospital stay (4.5-3.4 days among hospitalized patients) decreased between 2002 and 2013 for patients with POAG. The proportion of patients not being managed by medication or surgery decreased, with POAG and PACG patients receiving medications increasing from 70.9% and 59.2% in 2002 to 88.4% and 63.3% in 2013, respectively. Finally, while the proportion of trabeculectomy decreased (22.2% to 10.0% of surgical procedures in 2002 and 2013, respectively), more patients with PACG have received iridectomy (59.3% to 86.0% of surgical procedures in 2002 and 2013, respectively).Between 2002 and 2013, the pattern of care for both patients with POAG and PACG has shifted toward management by outpatient visits and intervention with anti-glaucoma medications in Korea.

Management of Primary Angle-Closure Glaucoma.

Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension caused by closure of the drainage angle. Angle closure is caused by appositional approximation or adhesion between the iris and the trabecular meshwork. The main treatment strategy for PACG lies in the reduction of intraocular pressure, reopening of the closed angle, and possible prevention of further angle closure. There is no universally agreed best surgical treatment for PACG. Trabeculectomy, goniosynechialysis (GSL), glaucoma implant, and cyclodestructive procedures are effective surgical options. Each of them plays an important role in the management of PACG with its own pros and cons. Accumulating evidence is available to show the effectiveness of visually significant and visually nonsignificant cataract extraction in the treatment of PACG. Trabeculectomy and GSL are often combined with cataract extraction, which may offer additional pressure control benefits to patients with PACG. This review article will discuss laser peripheral iridotomy, argon laser peripheral iridoplasty, and surgeries such as GSL, phacoemulsification, and phaco plus glaucoma surgeries that lower intraocular pressure and also alter the anterior segment and/or drainage angle anatomy. Currently, glaucoma implants and cyclodestruction are mainly reserved for PACG patients who have failed previous filtering operations. Their role as initial surgical treatment for PACG will not be discussed.

Delayed diagnosis of subacute angle closure glaucoma in patients presenting with headaches.

Subacute angle closure glaucoma (SACG) may lead to chronic angle closure glaucoma and irreversible vision loss. Headaches may be the sole presenting symptom. This study characterizes the medical course and symptoms of patients with SACG in whom headache was the major symptom. This retrospective observational study consisted of 30 consecutive patients, suffering from headaches and diagnosed with SACG, collected from the Glaucoma Service at the Ophthalmology Department of Meir Medical Center, Kfar Saba, Israel, a tertiary care referral facility. The primary study outcomes were reasons for referral, number of specialists visited and number of imaging studies performed before diagnosing SACG and headache characteristics. The majority of the patients experienced headaches once or twice a week. Four patients suffered a classic SACG pain involving the eye and frontal or hemicranial area. The mean time from onset of headaches to diagnosis was 2.6 years. The main reason for referral to the glaucoma clinic was consultation (53 %), and SACG was suspected by the referring physicians in two patients. Seventy-three percent of the patients were referred to at least three physicians in various medical specialties prior to referral to the glaucoma clinic. Patients usually do not volunteer history regarding headaches and clinicians often do not associate headaches with SACG in the absence of ocular symptoms. SACG should be included in the differential diagnosis in individuals older than 40 years presenting with late onset of headaches. Such patients should be referred to an ophthalmologist.

National survey of ophthalmologists in Singapore for the assessment and management of asymptomatic angle closure.

PURPOSE: Approximately 10% of Chinese people older than 50 years in Singapore have asymptomatic narrow angles [also termed primary angle closure suspects (PACS)]. The aim of this study was to determine the attitudes and practices of ophthalmologists in Singapore regarding the management of these patients. METHODS: A nation wide questionnaire-based survey was conducted on all registered, practicing ophthalmologists in Singapore by electronic mail and post. An ophthalmologist was defined as a doctor who had completed at least 3 years of specialist training in ophthalmology and had passed the Master's Degree in Ophthalmology or equivalent examinations. The survey asked the ophthalmologists about the methods and criteria used for the diagnosis of angle closure. It also inquired about the management of PACS and opinions on the effectiveness of prophylactic laser peripheral iridotomy (LPI) in preventing both acute and chronic angle closure. RESULTS: A total of 126 out of 158 ophthalmologists responded (79.7% response rate). Of the respondents, 84.9% would advise prophylactic LPI for asymptomatic PACS; 84.9% believed that prophylactic LPI would prevent acute angle closure but only 44% thought that it could prevent the development of glaucomatous optic nerve damage. The preferred method of prophylactic LPI was sequential argon-YAG LPI. In assessing patients for angle closure, 85.4% used gonioscopy, 92.9% assessed anterior chamber depth, and 17.5% performed provocative tests. CONCLUSIONS: Ophthalmologists in Singapore vary in the method of assessment of patients with angle closure. Most believe that prophylactic LPI should be performed for asymptomatic PACS.

What is the direct cost of treatment of acute primary angle closure glaucoma? The Singapore model.

AIM: To estimate the cost of management of acute primary angle closure glaucoma in Singapore. METHODS: In this cost analysis using retrospective data, the authors performed a MEDLINE search of published papers on acute primary angle closure glaucoma (APACG) in Singapore. Using information from published data, clinical management pathways were constructed and clinical outcomes identified. For each management path, costs of medical treatment, hospitalization, clinic charges, investigations, laser treatment and surgery were identified and accounted over a 5-year treatment period, using year 2002 rates. RESULTS: Given that, in Singapore, APACG affects 12.2 per 100,000 per year (95% confidence interval [CI], 10.5-13.9) in those aged 30 and older, each annual cohort would need to pay 261,741.78 US dollars (95%CI: US$225 310.90-298 265.10) or 287,560.26 US dollars (95%CI: 247,274.04-330,624.84 US dollars), if inclusive of cataract surgery, over 5 years after the episode of APACG. In this period, individuals would have to commit between 879.45 US dollars and 2576.39 US dollars, depending on the complexity of disease and accompanying cataract surgery. CONCLUSION: Acute primary angle closure glaucoma produces a substantial financial burden on society as well as on the individuals.