Comparative of OCT and OCTA parameters in patients with early chronic angle-closure glaucoma and early pituitary adenoma.

Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) have the potential application in evaluating pathological structural change of the optic nerve. We aimed to evaluate the value of the OCT and OCTA parameters of the optic disk and macular in differentiating early chronic primary angle-closure glaucoma (CPACG) and early pituitary adenoma (PA) in case of mild visual field defects (the mean defect (MD) > 6 dB). The results showed that regarding OCTA parameters, CPACG patients had lower retinal blood flow density of most layers of the optic disk and macular than PA patients. Regarding OCT parameters, CPACG patients had thinner circumpapillary retinal nerve fiber layer (CP-RNFL) in all quadrants and average CP-RNFL, ganglion cell layer (GCL) and macular ganglion cell complex (GCC) in each quadrant of macular inner and outer rings, and inner plexus layer (IPL) of macular inner ring, superior-outer ring and temporal-outer ring than PA patients. The Z test indicated that OCTA parameters and OCT parameters had similar value in the diagnosis of disease. In conclusion, in the case of similar visual field damage, early CPACG patients have smaller blood flow density and thinner optic disk and macular than early PA. OCTA has similar performance to OCT in diagnosing CPACG and PA.

Bilateral neovascular glaucoma associated with Radium-223 infusions for prostate cancer.

Purpose: To report two cases of neovascular glaucoma associated with Radium-223 infusion. Observations: Presented are two patients with metastatic prostate cancer who developed uncontrolled intraocular pressure secondary to neovascular glaucoma requiring surgical intervention. Both patients had received six cycles of Radium-223, a calcium mimetic that causes DNA double strand breaks and tumor cell death in bony metastases as part of their treatment regimen for metastatic prostate cancer. One patient had been a prior glaucoma suspect while the other had no significant ocular history. Conclusions and importance: Radium-223 may increase vascular permeability contributing to uveitis and promote angiostimulatory growth factors that can lead to neovascularization. We postulate this is through possible disruption in VEGF signaling pathways as well as Ra-223's calcium mimetic properties that could affect the trabecular meshwork. Neovascular glaucoma is uncommonly reported with Ra-223. There is one other case report that experienced uveitis and hyphema within weeks of the Ra-223 infusion. This case report has a similar proposed biologic mechanism. A literature review using the key words "radium-223, neovascularization, secondary angle closure glaucoma, neovascular glaucoma" did not yield any prior reports of neovascular glaucoma associated with Ra-223. The goal of this case series is to argue there is biological plausibility and to contribute to current literature of possible ocular complications of Ra-223 infusion.

The Mirror Theory: Parallels between Open Angle and Angle Closure Glaucoma.

Glaucoma is a widespread ophthalmological disease, with a high impact and frequent visual morbidity. While the physiopathology of the two types of primary glaucoma (open angle and angle closure) has been studied, there seems to be little relationship between the two. In this study, we gather clinical and preclinical data to support the idea that the two primary glaucomas are "mirrored" in terms of morphological parameters and disease physiopathology. In short, primary angle closure glaucoma (PACG) is associated with hyperopia and low axial length, and primary open angle glaucoma (POAG) is associated with myopia and high axial length. Moreover, in PACG and in primary angle closure or primary angle closure suspect cases, while there is extensive iridotrabecular contact, the intraocular pressure (IOP) is still maintained in the lower half of the normal range throughout the evolution of the disease, which suggests a baseline trabecular hyperfiltration in PACG. In the opposite case, myopic eyes with open angles and a higher risk of developing POAG often have a baseline IOP in the upper half of the normal range, suggesting a baseline trabecular hypofiltration. As we explore clinical, genetic and animal model data regarding these opposing aspects, we hypothesize the existence of a mirroring relationship between PACG and POAG. Defining the relationship between the two potentially blinding diseases, with a high prevalence worldwide, may aid in understanding the mechanisms better and refining diagnosis and treatment. Thus, our theory has been named the Mirror Theory of Primary Glaucomas.

Ophthalmological examination and imaging features that better predict risk of Angle Closure in siblings.

OBJECTIVE: Characteristics of individuals with angle closure may be useful in targeted screening of family members. Here, we assess if findings gathered during examination and imaging of patients with a known angle closure diagnosis (probands) could better determine the risk of angle closure in the patients' siblings. DESIGN: Cross-sectional study of patients with known angle closure and their siblings. SUBJECTS: Participants, and Controls: South Indian patients (probands) 30 years and older with open angles, suspect primary angle closure (PACS), or primary angle closure/primary angle closure glaucoma (PAC/PACG), and a biological sibling age 30 years or older (n=292 proband/sibling pairs). METHODS: Demographic data, relevant ocular history, and a comprehensive ophthalmic examination with Anterior Segment Optical Coherence Tomography (ASOCT) were obtained. Three clinically relevant models were created to analyze the contribution of specific proband factors in predicting sibling angle closure diagnosis, using demographic (age, gender), ocular exam (gonioscopy, optic nerve exam, visual acuity, intraocular pressure [IOP]), and ASOCT features to improve prediction beyond proband diagnosis alone evaluated by log likelihood ratio testing and statistical comparison of receiver operating characteristics (ROC). MAIN OUTCOME MEASURES: Sibling angle closure diagnostic accuracy. RESULTS: Demographic and ocular exam metrics did not improve the prediction of sibling angle closure for all three outcomes (sibling diagnosis: (1) PACS/PAC/PACG vs OA, (2) PAC/PACG vs PACS/OA, and (3) PAC/PACG vs PACS), adding no model improvement when compared to diagnosis alone. Models adding ASOCT metrics to the prior model including proband diagnosis, demographics and ocular exam measures led to significantly improved prediction of 2 of the 3 angle closure outcomes. Specifically, improvement was noted via likelihood ratio testing for prediction of PAC/PACG vs PACS/OA (p=0.01), or PAC/PACG vs PACS (p=0.001). For all 3 angle closure outcomes, ROC comparisons demonstrated significant improvement in AUC between the three models predicting sibling outcomes, demonstrating an increase in AUC with each successive nested model across all 3 sibling angle closure outcomes. CONCLUSIONS: Structural features of eyes with angle closure may assist in stratifying the risk of angle closure in patients' siblings. Further studies should consider evaluating this approach to achieve more targeted screenings.

Primary Angle Closure Observed During a House Visit: A Case Treated With Laser Iridotomy.

Laser iridotomy (LI) is an effective treatment for patients with pupillary block mechanisms. Here, we report a case of LI performed on a patient with primary angle closure (PAC) and elevated intraocular pressure (IOP), who was unsuitable for other treatments due to specific social circumstances. The patient, a 97-year-old female residing in a private nursing home, had a medical history notable only for mild dementia and was wheelchair-bound. She had not undergone ophthalmologic evaluation for over 50 years. The patient presented with intermittent tenderness and redness in the left eye. Therefore, an ophthalmologist visited the nursing home. Examination revealed visual acuity of 20/200 in the right eye and 20/100 in the left eye, IOP of 24 mmHg in the right eye and 26 mmHg in the left eye, no conjunctival hyperemia, shallow anterior chambers, and nuclear sclerosis grade 4 cataracts in both eyes. Fundus examination was challenging due to lens opacity, and both optic nerve papillae appeared pale. Given her history of episodic eye pain and hyperemia, PAC was diagnosed. Treatment options, including eye drops and cataract surgery, were discussed. However, the patient opted for LI due to her advanced age and inability to attend frequent follow-up visits. LI was successfully performed on both eyes during her visit to the clinic. One week post-procedure, IOP decreased to 12 mmHg bilaterally, with no complications. This case demonstrates that LI can be a viable option for managing PAC and high IOP in patients who are not candidates for surgery or eye drops due to social constraints.

Relationship between anterior segment biometry and primary angle-closure glaucoma in Hubei region: a retrospective case-control study.

Objective: To investigate the pathogenesis of Primary Angle-Closure Glaucoma (PACG) and its relationship with the anatomical structure of the anterior segment by obtaining biometric parameters using the IOL-Master 700. Methods: A retrospective case-control study was conducted. Clinical data from 39 PACG patients and 40 normal controls treated at the Aier Eye Hospital affiliated with Wuhan University from January to December 2022 were collected. Anterior chamber depth (AC), white-to-white (WTW), lens thickness (LT), central corneal thickness (CCT), axial length (AL), corneal curvature (K1), corneal curvature (K2), and lens position (LP) were measured using the IOL-Master 700 to analyze the characteristics and differences in the anterior segment structure of both groups. Statistical methods included independent sample t-tests and logistic regression analysis. Results: Significant differences were found in the anterior segment biometric parameters between PACG patients and normal controls (p < 0.05). Anterior chamber depth, white-to-white, lens thickness, central corneal thickness, axial length, and K2 were all related to the occurrence of PACG (p < 0.05). The occurrence of PACG was negatively correlated with ACD, CCT, and AL (OR = 0.12-0.64, p < 0.05), and positively correlated with LT. Conclusion: Compared to the normal control group, PACG patients in the Hubei region have a smaller anterior segment space, narrower angles, thicker lens, thinner cornea, shorter axial length, flatter cornea, and more anteriorly positioned lens.

BEST1 associated bestrophinopathies with angle closure and post-surgical malignant glaucoma.

INTRODUCTION: Mutations in BEST1 gene have been linked to the development of refractory angle closure glaucoma (ACG). This study aims to delineate the clinical characteristics, genetic mutations, and disease progression in patients with autosomal recessive bestrophinopathy (ARB) and autosomal dominant Best vitelliform macular dystrophy (BVMD) who are presented with treatment-resistant ACG. METHODS: This retrospective analysis encompasses a comprehensive ophthalmic assessment, retinal imaging, and mutational profiling of six patients diagnosed with bestrophinopathy and concurrent ACG, with a particular emphasis on the risk of post-glaucoma filtration surgery malignant glaucoma (MG). Exome sequencing was conducted utilizing a next-generation sequencing (NGS) based gene panel. RESULTS: The cohort included five patients with ARB and one with BVMD, with a mean (±SD) age at ACG diagnosis of 35.1 ± 6.9 years. NGS analysis revealed homozygous BEST1 variants in four patients (ARB; cases 1-4) and a heterozygous BEST1 variant in one patient (BVMD; case 5). One patient (ARB; case 6), despite a recessive pedigree, showed a single heterozygous variant, suggesting the presence of an undetected heterozygous variant indicative of compound heterozygous autosomal recessive inheritance. A novel non-frameshift deletion (c.841_843delTTC; p.Phe281del) was identified in case 2. Surgical intervention was required due to uncontrolled glaucoma in all cases except case 4. All five cases that underwent glaucoma filtration surgery developed MG, which was effectively managed with combined iridozonulo-hyaloido-vitrectomy (IZHV) and pars plana vitrectomy (PPV). Cases 5 and 6, harboring a heterozygous pathogenic variant (c.241 G>A; p.Val81Met), experienced refractory MG and corneal decompensation necessitating multiple interventions. CONCLUSION: Genomic analysis plays a pivotal role in the management of bestrophinopathies with ACG. Characterization of mutational types facilitates prognostication and enables timely interventions. IZHV with PPV emerges as a promising standalone or adjunctive procedure for the management of glaucoma among patients with BEST1 mutations and ACG.

Analysis of anterior segment in primary angle closure suspect with deep learning models.

OBJECTIVE: To analyze primary angle closure suspect (PACS) patients' anatomical characteristics of anterior chamber configuration, and to establish artificial intelligence (AI)-aided diagnostic system for PACS screening. METHODS: A total of 1668 scans of 839 patients were included in this cross-sectional study. The subjects were divided into two groups: PACS group and normal group. With anterior segment optical coherence tomography scans, the anatomical diversity between two groups was compared, and anterior segment structure features of PACS were extracted. Then, AI-aided diagnostic system was constructed, which based different algorithms such as classification and regression tree (CART), random forest (RF), logistic regression (LR), VGG-16 and Alexnet. Then the diagnostic efficiencies of different algorithms were evaluated, and compared with junior physicians and experienced ophthalmologists. RESULTS: RF [sensitivity (Se) = 0.84; specificity (Sp) = 0.92; positive predict value (PPV) = 0.82; negative predict value (NPV) = 0.95; area under the curve (AUC) = 0.90] and CART (Se = 0.76, Sp = 0.93, PPV = 0.85, NPV = 0.92, AUC = 0.90) showed better performance than LR (Se = 0.68, Sp = 0.91, PPV = 0.79, NPV = 0.90, AUC = 0.86). In convolutional neural networks (CNN), Alexnet (Se = 0.83, Sp = 0.95, PPV = 0.92, NPV = 0.87, AUC = 0.85) was better than VGG-16 (Se = 0.84, Sp = 0.90, PPV = 0.85, NPV = 0.90, AUC = 0.79). The performance of 2 CNN algorithms was better than 5 junior physicians, and the mean value of diagnostic indicators of 2 CNN algorithm was similar to experienced ophthalmologists. CONCLUSION: PACS patients have distinct anatomical characteristics compared with health controls. AI models for PACS screening are reliable and powerful, equivalent to experienced ophthalmologists.

Zonular ligament abnormalities intermingled in acute primary angle closure: A diagnostic and therapeutic challenge.

Purpose: This study aims to investigate patient characteristics with lens zonular ligament abnormalities in Acute Primary Angle Closure (APAC), identifying related risk factors, and evaluating the efficacy of Pilocarpine, a miotic agent. Design: Retrospective case-control study. Methods: Conducted as a retrospective case-control study at Hebei Provincial Eye Hospital from January 1, 2019, to December 31, 2021, the study included APAC cases undergoing ultrasound phacoemulsification with or without glaucoma surgery. Zonular ligament status was determined by intraoperative indicators such as lens equator visibility post-mydriasis and anterior capsule wrinkling during capsulorhexis. Patients were categorized into APAC and APAC with Lens Subluxation (APACLS) groups. Demographic details, Central Anterior Chamber Depth (ACD), Axial Length (AL), ACD difference between eyes (ACDD), Lens Thickness (LT), Lens Position (LP), and Relative Lens Position (RLP) were recorded and compared. Pilocarpine's impact on intraocular pressure reduction was assessed. Statistical analysis involved bilateral t-tests (for normally distributed data comparing both eyes in each group), non-parametric tests (for comparing two groups with non-normally distributed data), binary logistic regression, and Receiver Operating Characteristic (ROC) curve analysis for cutoff value determination related to zonular abnormalities. Results: The APAC and APACLS groups showed no significant difference in age of onset (70.11 ± 8.67 years vs. 70.11 ± 8.67 years, P = 0.159) or axial length of the eye (22.35 ± 0.64 mm vs. 22.36 ± 0.78 mm, P = 0.929). In the APACLS group, LT was greater (5.24 ± 0.37 mm vs. 5.01 ± 0.36 mm, P = 0.011), ACD was shallower (1.42 ± 0.24 mm vs. 1.69 ± 0.24 mm, P = 0.000), and ACDD was larger (0.38 ± 0.22 mm vs. 0.18 ± 0.18 mm, P = 0.000). The LP was lower (4.04 ± 0.32 vs. 4.20 ± 0.22, P = 0.013), and RLP was also lower (0.18 ± 0.02 vs. 0.19 ± 0.01, P = 0.015) in the APACLS group. A shallow ACD and a large ACDD were identified as risk factors associated with lens zonular abnormalities in the affected eyes (ACD OR value 63.97, P = 0.027; ACDD OR value 0.029, P = 0.027). Using ROC curve analysis, the cutoff value for ACDD was determined to be 0.375 mm, and for ACD, it was 1.6 mm. After pupil constriction with Pilocarpine eye drops, the proportion of patients whose intraocular pressure normalized was 75.36 % (52/69) in the APAC group and 71.43 % (25/35) in the APACLS group. Conclusion: ACD and ACDD in the affected eye are indicative of increased risk for APACLS. An ACD <1.6 mm and ACDD >0.375 mm should prompt consideration of zonular ligament abnormalities. Pilocarpine as a miotic treatment is safe and effective for such patients.

Automated classification of angle-closure mechanisms based on anterior segment optical coherence tomography images via deep learning.

Purpose: To develop and validate deep learning algorithms that can identify and classify angle-closure (AC) mechanisms using anterior segment optical coherence tomography (AS-OCT) images. Methods: This cross-sectional study included participants of the Handan Eye Study aged ≥35 years with AC detected via gonioscopy or on the AS-OCT images. These images were classified by human experts into the following to indicate the predominant AC mechanism (ground truth): pupillary block, plateau iris configuration, or thick peripheral iris roll. A deep learning architecture, known as comprehensive mechanism decision net (CMD-Net), was developed to simulate the identification of image-level AC mechanisms by human experts. Cross-validation was performed to optimize and evaluate the model. Human-machine comparisons were conducted using a held-out and separate test sets to establish generalizability. Results: In total, 11,035 AS-OCT images of 1455 participants (2833 eyes) were included. Among these, 8828 and 2.207 images were included in the cross-validation and held-out test sets, respectively. A separate test was formed comprising 228 images of 35 consecutive patients with AC detected via gonioscopy at our eye center. In the classification of AC mechanisms, CMD-Net achieved a mean area under the receiver operating characteristic curve (AUC) of 0.980, 0.977, and 0.988 in the cross-validation, held-out, and separate test sets, respectively. The best-performing ophthalmologist achieved an AUC of 0.903 and 0.891 in the held-out and separate test sets, respectively. And CMD-Net outperformed glaucoma specialists, achieving an accuracy of 89.9 % and 93.0 % compared to 87.0 % and 86.8 % for the best-performing ophthalmologist in the held-out and separate test sets, respectively. Conclusions: Our study suggests that CMD-Net has the potential to classify AC mechanisms using AS-OCT images, though further validation is needed.

Altered dynamic large-scale brain networks and combined machine learning in primary angle-closure glaucoma.

Primary angle-closure glaucoma (PACG) is a severe and irreversible blinding eye disease characterized by progressive retinal ganglion cell death. However, prior research has predominantly focused on static brain activity changes, neglecting the exploration of how PACG impacts the dynamic characteristics of functional brain networks. This study enrolled forty-four patients diagnosed with PACG and forty-four age, gender, and education level-matched healthy controls (HCs). The study employed Independent Component Analysis (ICA) techniques to extract resting-state networks (RSNs) from resting-state functional magnetic resonance imaging (rs-fMRI) data. Subsequently, the RSNs was utilized as the basis for examining and comparing the functional connectivity variations within and between the two groups of resting-state networks. To further explore, a combination of sliding time window and k-means cluster analyses identified seven stable and repetitive dynamic functional network connectivity (dFNC) states. This approach facilitated the comparison of dynamic functional network connectivity and temporal metrics between PACG patients and HCs for each state. Subsequently, a support vector machine (SVM) model leveraging functional connectivity (FC) and FNC was applied to differentiate PACG patients from HCs. Our study underscores the presence of modified functional connectivity within large-scale brain networks and abnormalities in dynamic temporal metrics among PACG patients. By elucidating the impact of changes in large-scale brain networks on disease evolution, researchers may enhance the development of targeted therapies and interventions to preserve vision and cognitive function in PACG.

Bilateral angle-closure attack in a COVID-19-positive patient.

Ophthalmic examination of a patient with active COVID-19 infection can be challenging. We describe a woman with active COVID-19 infection who was misdiagnosed initially as having conjunctivitis and later presented with acute angle-closure attack in both eyes. Intraocular pressure (IOP) on presentation was about 40 mmHg in both eyes. She was on multiple medications for her COVID-19 infection. A nonpupillary block mechanism of secondary angle closure was suspected and laser iridotomy was avoided. Her IOP was well controlled with medications. Due to significant cataract, phacoemulsification with IOL was performed using femto-assisted rhexis in lieu of the postdilatation IOP spike. There was good IOP control and 6/6 vision postoperatively. Bilateral angle closure of probable multifactorial cause can occur in COVID-19-positive patients.

Intraocular pressure and gonioscopic findings in primary angle-closure disease in India-a big data study.

AIM: To describe the gonioscopic profile and intraocular pressure (IOP) in primary angle-closure (PAC) disease in patients presenting to a tertiary eye care network in India. METHODS: A cross-sectional hospital-based study that included 31 484 new patients presenting between 2011 and 2021. Patients with a clinical diagnosis of PAC/suspect/glaucoma were included. The data was collected from an electronic medical record system. RESULTS: PAC glaucoma (PACG) (47.55%) was the most common diagnosis followed by PAC (39.49%) and PAC suspect (PACS; 12.96%). Female preponderance (54.6%) was noted with higher mean age at presentation among males (P<0.0001). PACS and PAC showed the highest prevalence in 6th decade but PACG was higher at 7th decade. The probability of angle opening was 95.93%, 90.32% and 63.36% in PACS, PAC and PACG eyes respectively post peripheral iridotomy (PI). Plateau iris syndrome (PIS) was noted in 252 eyes and all showed post dilated rise of IOP. A post dilated IOP rise was also noted with 8.86%, 33.95% and 57.19% eyes with PACS, PAC and PACG respectively with IOP rise between 6-8 mm Hg across the disease spectrum. CONCLUSION: The superior quadrant is the narrowest angle and difficult to open with indentation and post PI. The probability of angle opening is less in PIS especially the complete variety along with post dilated IOP rise. The post dilated IOP rise in angle closure eyes warrants a careful dilatation, especially with PIS.

Episodic Angle Closure after Visian™ Implantable Collamer Lens Implantation in a Patient Using Adderall®.

Introduction: Amphetamine-based medications such as Adderall®, used for the treatment of attention deficit-hyperactivity disorder (ADHD), may theoretically elicit angle closure through their adrenergic mechanisms. The relationship between the use of implantable collamer lenses (ICLs) and angle closure has been extensively investigated based on appropriate vault and lens sizing and postoperative changes in the anterior chamber angle (ACA) and corneal morphology. This case reflects a synergistic impact from both Adderall® use and ICL implantation for the proposed mechanism of angle closure. Case Presentation: A 36-year-old myopic female with ADHD controlled with Adderall® underwent toric ICL implantation in the right eye after undergoing preoperative laser peripheral iridotomy. Shortly after, the patient developed episodic angle closure in the right eye, with episodes mainly occurring after taking an additional dose of Adderall® in a dimly lit environment. The patient later had an ICL exchange with a smaller sized EVO+ toric ICL in the right eye and remained asymptomatic after. Conclusion: Additive mechanisms from both the ICL and Adderall® were present in our patient. The ICL caused crowding of the ACA through a pseudophacomorphic mechanism, and the Adderall® caused increased iridotrabecular contact secondary to pharmacologic mydriasis. This resulted in episodic angle closure with subsequent spikes in the intraocular pressure. There are no current reports or studies in the current literature describing the combined mechanisms of ICL implantation and Adderall® use in the potential development of angle closure. Further studies may be done to assess interactions of such medications in patients after ICL implantation.

Bilateral Chandler Syndrome, Nanophthalmos, and Angle Closure Glaucoma: A Complex Presentation, Challenging Diagnosis, and Pathological Insight-A Case Report.

Aim and background: Chandler syndrome (CS) is one of the iridocorneal endothelial syndromes (ICEs) with proliferation of abnormal corneal endothelial cells over the anterior chamber (AC) angle and iris, resulting in complications, for example, secondary angle closure glaucoma (SACG). We report an association between CS and nanophthalmos, highlighting diagnostic and therapeutic challenges and pathological insights. Case description: A 46-year-old female patient presented with bilateral progressive blurring of vision. Examination revealed bilateral (OU) small corneal diameter, shallow AC, closed AC angle, beaten-bronze appearance of corneal endothelium, and mild iris atrophy in the right eye (OD). Intraocular pressure was 48 mm Hg and 22 mm Hg in the OD and left eye (OS), respectively. Fundus examination revealed optic nerve head cupping. Biometry showed short axial length and microcornea OU, that is, nanophthalmos. Optical coherence tomography and visual field revealed structural and functional evidence of glaucomatous optic neuropathy. Specular microscopy demonstrated reduction of corneal endothelial cell density and the light-dark reversal characteristic of ICE. Therefore, a diagnosis of CS with SACG and nanophthalmos was made. The patient was referred to a specialized glaucoma center with recommendation of clear lens extraction and a glaucoma drainage device with retropupillary tube placement. Conclusion: This is the first report of an association between CS and nanophthalmos. It highlights the possibility of SACG despite evident risk factors for primary angle closure glaucoma (PACG). Furthermore, it provides a hypothesis about the etiology of ICE. The concurrence of CS and nanophthalmos suggests that a common developmental mechanism could be implicated since periocular mesenchyme, the embryological precursor of corneal endothelium, plays a role in the development of optic cup and stalk. Clinical significance: SACG should be considered even in the presence of evident risk factors for PACG, such as nanophthalmos. Additionally, the association of nanophthalmos and CS warrants revisiting the yet inconclusive etiology of CS, where a developmental mechanism could be considered. How to cite this article: Ameen Ismail A, El-Ruby SA. Bilateral Chandler Syndrome, Nanophthalmos, and Angle Closure Glaucoma: A Complex Presentation, Challenging Diagnosis, and Pathological Insight-A Case Report. J Curr Glaucoma Pract 2024;18(2):68-73.

Change in Iridotrabecular Contact and Intraocular Pressure after Phacoemulsification in Primary Angle Closure Disease Spectrum.

Purpose: To compare changes in the swept-source anterior segment optical coherence tomography (SS AS-OCT) parameters and intraocular pressure (IOP) control after lens extraction in various spectra of primary angle closure disease (PACD). Methods: A total 92 eyes from 92 patients with PACD who underwent lens extraction were included in the study. All patients underwent IOP measurement preoperatively and postoperatively at 1 day, 1 week, 1 month, 3 months, and 6 months. SS AS-OCT was performed in all subjects preoperatively and 1 month postoperatively. All participants were divided into two groups depending on the presence of glaucomatous optic disc or visual field damage (group A: primary angle closure suspect or primary angle closure; group B: primary angle closure glaucoma). The changes in IOP and anterior chamber angle (ACA) parameters of SS AS-OCT of each group were compared. Regression analysis was performed to find factors associated with the degree of IOP reduction after lens extraction. Results: Preoperatively, there was no significant difference in IOP (16.3 ± 2.5 vs 16.9 ± 3.2 mmHg, P=0.297) between the two groups, but the number of glaucoma medications used (0.6 ± 1.0 vs 2.0 ± 0.9, P<0.001) was greater in group B. Postoperatively, IOP was not significantly different, but the number of medications used was greater in group B (0.2 ± 0.7, 0.9 ± 0.8, P<0.001). ACA parameters including angle opening distance and trabecular-iris angle had a greater increase in group B after lens extraction. However, the residual iridotrabecular contact (ITC) index (5.6 ± 7.0 vs 10.7 ± 12.1, P=0.014) was significantly greater in group B. A greater change in the ITC index was related to a greater degree of IOP reduction (beta coefficient = 0.429, P<0.001). Conclusions: Eyes with PACG had a greater residual ITC index after lens extraction compared with eyes of other PACD spectrum, and required a greater number of glaucoma medications to maintain a similar level of IOP.

The Beijing angle closure progression study: design and methodology.

Purpose: The purpose of this study is to summarize the design and methodology of a large-scale trial in northern China, the Beijing Angle Closure Progression Study (BAPS). This trial is designed to explore the 5-year incidence of primary angle-closure suspect (PACS) progressing to primary angle-closure (PAC) or primary angle-closure glaucoma (PACG) and to determine the possible risk factors of disease progression. Methods/design: The BAPS is a clinic-based, multicenter, noninterventional trial conducted on a sample of urban Chinese adults. Consecutive eligible patients who meet PACS diagnostic criteria will be recruited from eight participating centers, with the trial commencing on August 4, 2022. The target sample size is set at 825 subjects, with follow up planned for a minimum period of 5 years. Baseline examination will include presenting visual acuity, best corrected visual acuity, intraocular pressure (IOP), undilated slit-lamp biomicroscopy, stereoscopic evaluation of the optic disc, visual field test, optical coherence tomography evaluation of retinal nerve fiber layer, ultrasound biomicroscopy and IOLMaster. Questionnaires will also be used to collect detailed personal history. Patients are scheduled to visit the glaucoma clinic every 12 months and may visit the emergency room in case of acute attack of angle closure. Study endpoints include acute PAC episodes, elevated IOP, peripheral anterior synechiae, glaucomatous visual field defect, or glaucomatous abnormality of optic nerve. Discussion: The BAPS will provide data on the 5-year incidence of PACS progressing to PAC or PACG and determine the risk factors for disease progression. This study will also help redefine high-risk patients with PACS.

The Macular Pigment Optical Density (MPOD) Decrease in Chinese Primary Angle Closure Glaucoma Using the One-Wavelength Reflectometry Method.

PURPOSE: The objective of this study was to observe the macular pigment optical density (MPOD) and the relationship between MPOD and retinal thickness in Chinese primary angle-closure glaucoma (PACG) patients by the one-wavelength reflectometry method. METHODS: This study was a prospective comparative observational study, including 39 eyes from 39 PACG patients (15 men and 24 women, mean age 61.89 ± 12.30) and 41 eyes from 41 controls (20 men and 21 women, mean age 63.24 ± 14.02). We measured the MPOD 7-degree area by the one-wavelength reflectometry method and analyzed both the max and mean optical density (OD). The central retinal thickness (CRT) and the total thickness of the macular ganglion cell layer (GCL), and inner plexiform layer (IPL)were measured by spectral-domain-optical coherence tomography (SD-OCT). Statistical methods such as Shapiro-Wilk test, Fisher's exact test, chi-square test, two independent samples test and Spearman's correlation coefficient were used to observe the differences in the MPOD between normal subjects and PACG patients and the correlation between the MPOD and retinal thickness. RESULTS: The max optical density (Max OD) (PACG group: 0.302 ± 0.067d.u, control group: 0.372 ± 0.059d.u., p < .001) and mean optical density (Mean OD) (PACG group: 0.124 ± 0.035d.u., control group: 0.141 ± 0.028d.u., p < 0.05) were significantly reduced in PACG patients compared with control subjects. Significant decreases in GCL + IPL thickness (PACG group: 74.71 ± 39.56 µm, control group:113.61 ± 8.14 µm, p < 0.001) and CRT (PACG group: 254.49 ± 41.47 µm, control group:329.10 ± 18.57 µm, p < 0.001) were also observed in PACG eyes. There was no statistically significant correlation between the MPOD and GCL + IPL thickness (p = .639, p = .828). CONCLUSIONS: MPOD was significantly lower in Chinese PACG patients than in the control group, potentially due to thinning of the GCL + IPL thickness. This study provides insights for the pathophysiology, assessment of PACG and potential guidance for lifestyle modifications.

In this study, we measured the MPOD values of Chinese PACG patients for the first time using the one-wavelength reflectance method and clarified that the MPOD of PACG patients was significantly lower than that of the normal group. This study provides insights for the pathophysiology, assessment of PACG and potential guidance for lifestyle modifications.

Diagnosis of Marfan Syndrome Following Progressive Myopia and Secondary Lens-Induced Angle Closure Crisis.

Marfan syndrome (MFS) is a well-described genetic connective tissue disease that heightens the risk of cardiovascular, ocular, pulmonary, and other emergencies in affected individuals. The wide range of phenotypic presentations, spanning from mild, chronic, and asymptomatic to acute and life-threatening, can pose challenges in diagnosing MFS when disease manifestations are subtle. We report a pathogenetic variant of MFS characterized by subtle systemic findings that was identified only after the patient presented with visual changes and pain associated with angle closure, despite a medical history indicating other pathologies linked to this condition. This case underscores the importance of recognizing the varied and sometimes subtle clinical features of MFS. Vigilance in identifying the constellation of findings associated with MFS can enhance its diagnosis and treatment outcomes by enabling appropriate and timely referrals for prophylactic evaluation and care to address potentially life-threatening complications.

Acute primary angle closure during the Omicron outbreak.

AIM: To investigate Omicron's impact on clinical presentation of acute primary angle closure (APAC) in China. METHODS: A consecutive case series with historical controls was conducted at Shenzhen Eye Hospital, the largest specialized hospital in Shenzhen, China. Medical records from a two-month period during the Omicron pandemic (December 1, 2022, to January 31, 2023) were compared with records from two control groups (12/2018-1/2019 and 12/2021-1/2022) before pandemic. Patients with APAC were included, and the prevalence of APAC and demographic characteristics in Omicron-infected and non-infected patients were compared. RESULTS: Seventy-one (23.43%) out of 303 patients were diagnosed with APAC in the pandemic cohort, which was 2.98 and 2.61 times higher than that in control cohorts (7.87% in 2019, 8.96% in 2022, P<0.001). The pandemic cohort has significantly higher Omicron-infected rate (78.87% vs 0 vs 0; P<0.001), lower proportion of glaucoma history (16.90% vs 42.86% vs 41.67%, P=0.005), higher surgical rate (95.77% vs 83.33% vs 78.57%, P=0.024), higher total medical costs and larger pupil diameter (5.63±0.15 vs 4.68±0.15 vs 4.69±0.22 mm, P<0.01). In 83% Omicron-infected patients, ocular symptoms appeared within 3d after systemic symptoms onset. In multivariate analysis, Omicron infection (P<0.001) was the only independent predictor of pupil diameter. CONCLUSION: In the Omicron epidemic in China, there is an increase of prevalence and severity of APAC, particularly focusing on the first 3d following infection.