A unique case of bilateral nanophthalmos and pigmentary retinal abnormality with unilateral angle closure glaucoma and optic disc pit.

BACKGROUND: Microophthalmos or 'dwarf eye' is characterized by an axial length 2 standard deviation less than age-matched controls. It is classified into nanophthalmos, relative anterior microphthalmos, and posterior microphthalmos based on the anterior segment: posterior segment ratio. Nanophthalmos can occur in association with optic disc drusen, foveoschisis, and retinitis pigmentosa, as an autosomal recessive syndrome linked to mutations in the MFRP gene. We report a case of bilateral nanophthalmos and pigmentary retinopathy with angle closure glaucoma and optic disc pit in one eye. We believe this to be the first case presenting with optic disc pit in association with nanophthalmos. CASE PRESENTATION: A 56-year-old female presented with bilateral small eyes, high hypermetropia, shallow anterior chamber depth, increased lens thickness, mid-peripheral retinal flecks, and macular edema. She also had high intraocular pressure in the right eye, with a disc cupping of 0.9 with an Optic disc pit. The macular edema in the right eye was found to occur in association with the Optic disc pit, whereas, in the left eye, it was associated with intra-retinal hemorrhages and diagnosed as macular branch retinal vein occlusion secondary to hypertension. She was started on anti-glaucoma medications in both eyes and planned for Anti-VEGF injection in the left eye. CONCLUSION: This case report is unique as it reports an association of Nanophthalmos with Optic Disc pit, with an associated angle closure glaucoma in the same eye, an association which has never been previously reported in the literature.

Bilateral Multiple Ciliary Body Cysts with Angle-Closure Glaucoma in an 18-Year-Old Patient.

We present the rare case of an 18-year-old medically free male who had a history of decrease in vision in the left eye (LE) in the last 4 years. On examination, best-corrected visual acuity was 20/20 in the right eye (RE) and counting fingers 3 feet in the LE. Intraocular pressure was 34 and 40 mmHg in RE and LE, respectively. Fundus examination showed cupping of 0.7 on the RE and 0.9 on the LE. Gonioscopy revealed bilateral angle closure with a double-hump sign. Ultrasound biomicroscopy showed multiple ciliary body cysts replacing ciliary body sulcus space bilaterally.

Lens subluxation after use of a percussion massage gun: A case report.

RATIONALE: To report the first case of lens dislocation and secondary acute angle-closure glaucoma (AACG) following use of a percussion massage gun (PMG) around the eye. PATIENT CONCERNS: A 69-year-old Chinese man had been using a PMG around his right eye for 2 months in order to relieve headache. After eye pain and blurred vision for 5 days, he went to the ophthalmological emergency department. His best-corrected visual acuity at distance was counting fingers. DIAGNOSIS: The patient was diagnosed with lens subluxation, secondary AACG and pterygium in the right eye. Cataracts were diagnosed in both eyes. INTERVENTIONS: The patient underwent phacoemulsification and anterior vitrectomy. After surgery, the patient was given eye drops containing tobramycin, dexamethasone, 0.1% bromfenac sodium hydrate ophthalmic solution and Mydrin-P for 1 month. OUTCOMES: At 3-month follow-up, uncorrected visual acuity in the right eye was counting fingers. The outcome of optometry in the right eye was +11.50 DS/-0.50 DC * 110°, with corrected-distance visual acuity of 4/20. IOP was 20.7 mm Hg in the right eye and 15.7 mm Hg in the left. Endothelium in the right cornea showed endothelial damage. Nevertheless, the patient reported no right eye pain anymore, and he indicated that he was satisfied with his situation. LESSONS: Caregivers, sports professionals and the general public should be aware of the dangers of PMGs and the need to use them appropriately and safely, for example during self-massage and rehabilitation therapy. In particular, we recommend not using PMGs above the neck, which should be clearly indicated in instruction manuals.

Serous detachment of the macula associated with advanced glaucomatous cupping.

Enhanced depth imaging of the optic nerve of a patient with a serous detachment and profound cupping of the optic nerve secondary to angle-closure glaucoma revealed a large dehiscence of the lamina cribrosa. Adjacent to the defect in the lamina were cystoid spaces within the nerve appearing to contain fluid. The most temporal of these could be seen to extend through the optic nerve and up into the macula. This visualized pathway suggests that mechanical dehiscence of the lamina may allow fluid, possibly derived from cerebrospinal fluid, to track up into the macula.

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.

[Chronic angle-closure glaucoma in a pseudophakic eye with Soemmering's ring and plateau iris: case report]. / Glaucome chronique par fermeture de l'angle chez le pseudophake avec anneau de Soemmering et antéroposition du corps ciliaire : à propos d'un cas.

We present a case of a pseudophakic woman with chronic angle-closure glaucoma. She had undergone uncomplicated bilateral phacoemulsification in 1994 with 21-diopter implants in the capsular bag. Fourteen years later, the right eye developed progressive angle closure with ocular hypertension, disc cupping and visual field defect. We observed a shallow anterior chamber, myopic shift, and closed angle, not openable on indentation gonioscopy. UBM revealed anteroposition of the ciliary body and a Soemmering's ring, with both appearing to contribute to the angle closure. After two incomplete iridotomies and one complete but blocked by the Soemmering's ring, a final UBM-guided iridotomy afforded a partial reopening of the angle, and satisfactory IOP control. The appearance and development of a Soemmering's ring after phacoemulsification are not always appreciated. It is common but usually asymptomatic. However, in some cases, when it is thick and/or located anteriorly, in the case of an anteroposition of the ciliary body (as in our case), it seems to cause direct pressure on the iris and pupillary block. Angle-closure glaucoma in pseudophakic eyes remains uncommon, the use of UBM is recommended, the role of a Soemmering's ring should be investigated, iridotomies must often be repeated, and long-term monitoring of pseudophakic patients remains necessary.

Characteristics of optic disc changes in Taiwanese patients with primary angle-closure glaucoma.

BACKGROUND AND PURPOSE: Primary angle-closure glaucoma (PACG) is the predominant form of glaucoma among Asians. Although numerous studies have been done to describe the characteristic optic disc changes in patients with primary open angle glaucoma (POAG) which is the predominant form of glaucoma among Western populations, few studies have evaluated the optic disc changes in patients with PACG. The aim of this study was to elucidate the characteristic intrapapillary and parapapillary disc changes in PACG in a cross-sectional study and to develop a practical approach to the detection of glaucomatous optic disc changes in PACG by ophthalmoscopic examination. METHODS: A total of 103 eyes in 103 PACG patients were studied. Forty one eyes of 41 age- and sex-matched healthy subjects served as controls. Three glaucoma-trained subspecialists examined stereophotographs of optic discs to evaluate the intrapapillary and parapapillary changes. The differences in PACG and control group eyes were compared. RESULTS: Concentric steep enlargement of the optic disc was found in 99 PACG eyes (96%). Local notching was noted in only 3 eyes, and vertically oval-shaped cupping of the optic disc in only 1 eye. Disc hemorrhage was not detected in any eye. Parapapillary atrophy of the alpha zone involving both temporal and nasal side of the optic disc and parapapillary atrophy of beta zone were significantly more frequent in the PACG group. The presence of an alpha zone or a beta zone simultaneously involving both the temporal and nasal side of the optic disc was associated with more severe optic nerve head damage. CONCLUSIONS: The intrapapillary change in the PACG group eyes reflected the development of cupping in PACG patients with small and compact optic discs. The parapapillary atrophy paralleled the intrapapillary optic disc cupping in eyes of the PACG group.

Cataract surgery under topical anesthesia in patients with coexisting glaucoma.

PURPOSE: To evaluate and compare levels of patient discomfort and complications during phacoemulsification with implantation of a foldable intraocular lens (IOL) under topical lidocaine hydrochloride in patients with and without various forms of chronic open-angle and chronic angle-closure glaucoma. SETTING: Two university eye centers in Germany. METHODS: This prospective nonrandomized comparative study comprised 176 eyes of 176 patients with various forms of chronic open-angle glaucoma and chronic angle-closure glaucoma. Eyes with cataract and without a glaucoma diagnosis or history of intraocular surgery served as a control group (n = 212). All patients received a minimum of 5 doses (2 drops per dose) of topical lidocaine hydrochloride 2% before standard temporal clear corneal phacoemulsification and foldable IOL implantation. No intracameral anesthetic injection was given, and no systemic sedatives were used. The main outcome measures were the number of complications and adverse events. RESULTS: The intraoperative complication rate in all patients (n = 388) was capsule tear, 1.3%; zonule tear, 1.8%; vitreous loss, 1.0%; iris prolapse, 0.8%. No statistically significant differences in intraoperative or early postoperative complications were found between the glaucoma and control groups. The mean pain scores of patients were 0.38 +/- 1.1 (SD) in the glaucoma group and 0.36 +/- 0.8 in the control group (P =.21) Patient preference for cataract surgery under topical anesthesia was similar in both groups. CONCLUSIONS: Surgery-related complications and patient discomfort were similar in patients with and without glaucoma who had phacoemulsification and IOL implantation under topical anesthesia. These results indicate that topical anesthesia is safe for routine phacoemulsification with foldable IOL implantation in patients with glaucoma and does not compromise patient comfort.

Topical plus intracameral lidocaine versus retrobulbar anesthesia in phacotrabeculectomy: prospective randomized study.

PURPOSE: To compare the efficacy and safety of topical and retrobulbar anesthesia for phacotrabeculectomy. SETTING: Hospital Ramón y Cajal, Madrid, Spain. METHODS: This prospective study comprised 60 patients (60 eyes) having phacotrabeculectomy surgery. Patients were randomly assigned to 1 of 2 groups receiving topical anesthesia plus intracameral lidocaine 1% or retrobulbar anesthesia. Patients were asked to document the discomfort they experienced during the administration of the anesthetic agent, during surgery, and postoperatively using a numeric pain scale. Complications and surgical conditions were also evaluated. RESULTS: The retrobulbar group reported significantly more discomfort during administration of the anesthetic agent than the topical group (P < .001). The topical group reported significantly more discomfort intraoperatively (P < .01). Eyelid squeezing and eyeball movement were more common in the topical group; however, neither was a problem to the surgeon. There was no difference in surgical conditions (P = .38) or the postoperative pain scores between the 2 groups (P = .06). One patient receiving topical anesthesia developed a suprachoroidal hemorrhage intraoperatively. CONCLUSIONS: Topical anesthesia supplemented with intracameral lidocaine was an effective alternative to retrobulbar anesthesia for phacotrabeculectomy. Although the degree of patient discomfort was significantly higher during surgery under topical anesthesia, the method avoids the pain and complications associated with a retrobulbar injection.

Consultation section. Cataract surgical problem.

A 68-year-old diabetic Pakistani presented with a 3 year history of progressive bilateral painless loss of vision. Although he was previously untreated for glaucoma, his examination revealed the following: visual acuity, finger counting in the right eye and 20/60 in the left; intraocular pressure (IOP), 41 and 31 mm Hg, respectively. Physical findings included bilateral shallow anterior chambers, minimal nuclear and cortical cataract formation, and extensive glaucomatous optic nerve cupping and atrophy worse in the right eye than in the left. Gonioscopy revealed angles narrowed to grade 1 for 360 degrees in both eyes. Visual field analysis was commensurate with the marked degree of optic nerve damage and reduced visual acuity. Bilateral laser iridotomies and a combination of topical antiglaucoma agents reduced IOP to the mid-20s in both eyes. Subsequently, the right eye had an uneventful trabeculectomy with application of intraoperative mitomycin. Postoperatively, the patient developed posterior aqueous entrapment and was managed with topical cycloplegics, aqueous suppressants, and corticosteroids. After a few weeks, a shallow anterior chamber was present centrally, a filtration bleb was noted, and IOP was 9 mm Hg. Unexpectedly, the patient returned to his native country, discontinued medications, and was lost to follow-up for 1 year. Upon his return, he presented with these findings: visual acuity, hand motion in the right eye and 20/60 in the left eye; IOP, 10 and 30 mm Hg, respectively. Physical findings in the right eye (Figure 1) included a superiorly oriented, thin-walled filtration bleb, a formed anterior chamber with multiple broad peripheral and midperipheral synechias, and a bound pupil covering a dense nuclear sclerotic cataract. The left eye had progressive glaucomatous optic nerve changes. Given the patient's history, now would you manage the glaucoma in the left eye, and what surgical methods would you plan for the right eye, assuming cataract surgery is indicated?

Red eye unresponsive to treatment.

Red eyes that fail to respond quickly and completely to topical antibiotic treatment require more extensive evaluation to relieve the symptoms and avert possible sight-threatening complications. The initial differential diagnosis of red eye, which includes iritis, acute glaucoma, keratitis and corneal ulcer, and rarer disorders, must be reexamined. A commonly misdiagnosed cause of red eye is the dry eye syndrome. As a primary or secondary problem, the dry eye syndrome must be treated appropriately to avert sight-threatening complications and to alleviate substantial discomfort. The dry eye syndrome may represent the presenting sign of Sjögren's syndrome or it may be due to medication use, with important systemic and ocular implications.

Progressive myopia in early onset chronic angle closure glaucoma.

A 19-year-old girl presented with advanced unilateral chronic angle closure glaucoma and myopia with gross cupping and field loss in a previously hyperopic eye with a marked increase in corneal curvature. This emphasises that a marked myopic shift may be an important sign of glaucoma in a young patient.

Retinitis pigmentosa associated with glaucoma--clinical analysis.

A clinical analysis of Retinitis Pigmentosa (RP) was made in 2,789 eyes of 1,400 patients seen over a 5 year period (1983-1987), 64 eyes of 32 cases (2.3%) of RP associated with glaucoma were investigated. Of these 32 cases, the angle closure glaucoma was much more than the open angle glaucoma (30/2). More than half of the 32 cases were without cupping of disk, 5 cases did not have the glaucomatous damage to disk in spite of persistent elevated intraocular pressure for 0.5-5 yrs under the maximum medical therapy. 31 cases (97%) had subnormal blood pressure compared with the normal blood pressure value in different age groups. Histopathologic changes of the trabecular meshwork (TM) of 14 eyes showed a little bit more pigment cells in the TM than normal subjects, no typical features that would obstruct the outflow channels.