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.

Factors associated with blindness three months following treatment for acute primary angle glaucoma.

AIMS: To study the risk factors associated with blindness after treatment of acute primary angle closure (APAC), and to identify the critical time window to decrease rate of blindness. METHODS: In this multicentre retrospective case series, 1030 consecutive subjects (1164 eyes) with APAC in China were recruited. The rates of blindness were analysed up to 3 months after treatment of APAC. A logistic regression was used to identify the risk factors associated with blindness, including age, gender, distance to hospital, rural or urban settings, treatment method, education level, time from symptom to treatment (TST, hours) and presenting intraocular pressure (IOP). The critical time window associated with a blindness rate of ≤1% was calculated based on a cubic function by fitting TST to the rate of blindness at each time point. RESULTS: The rate of blindness after APAC was 12.54% after treatment. In multivariate regression, education level, TST and presenting IOP were risk factors for blindness (p=0.022, 0.004 and 0.001, respectively). The critical time window associated with a blindness rate of ≤1% was 4.6 hours. CONCLUSIONS AND RELEVANCE: Education level, TST and presenting IOP were risk factors for blindness after APAC. Timely medical treatment is key in reducing blindness after APAC.

Newly Onset Optic Disc Pit Maculopathy (ODP-M) in a Patient With Primary Angle-closure Glaucoma (PACG) After Surgical Iridectomy: A Case Report.

Optic disc pit maculopathy (ODP-M) is a subtype of ODP, characterized by a serous retinal detachment and/or macular retinoschisis. Currently, ODP and ODP-M pathogenesis remain unknown although many hypotheses exist about their clinical features. In this study, we report a case of new ODP-M detected after surgical iridectomy in a patient with primary angle-closure glaucoma (PACG) with a preoperative normal retina and optic nerve. Fine optic disc and the macular area structures were investigated using several imaging techniques. Findings revealed that the course of ODP and ODP-M provide us with some insights and understanding of their underlying pathogenesis.

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.

Aqueous humour flow in the posterior chamber of the eye and its modifications due to pupillary block and iridotomy.

The anterior chamber (AC) and posterior chamber (PC) of the eye are connected through the pupil and are filled with aqueous humour. The aqueous flows from the posterior to the AC at an approximately constant rate, and the intraocular pressure is governed by this rate and the resistance to aqueous outflow. In some patients the iris and lens come into contact, leading to pressure build-up in the PC, peripheral axial shallowing of the AC and, possibly, to angle-closure glaucoma. This can lead to blindness, which may be prevented by surgically creating an iridotomy, that is a hole through the iris to facilitate the flow from the posterior to the AC. The problem of optimal size and location of an iridotomy is still poorly understood. In this article, we study aqueous flow in the PC and investigate how it is modified in the presence of an iridotomy. Our approach is based on the lubrication theory, which allows us to solve the problem semi-analytically. We treat the iridotomy as a point sink and assume that the flux through it is proportional to the pressure. We find that the ideal size and location of an iridotomy are influenced by various geometrical and fluid mechanical factors, the most relevant of which are the size of the hole and the length and height of the iris-lens channel. For certain iridotomy diameters, we find that the jet velocity through the iridotomy might be large enough to cause possible corneal damage.

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.

Changes in ocular biometry and anterior chamber parameters after pharmacologic mydriasis and peripheral iridotomy in primary angle closure suspects.

PURPOSE: The aim of this study was to evaluate the effects of pharmacologic mydriasis and Peripheral Iridotomy (PI) on ocular biometry and anterior chamber parameters in primary angle closure suspects. METHODS: In this prospective interventional case series, 21 primary angle closure suspects were enrolled. Intraocular pressure, refraction, ocular biometry (Lenstar, LS900), and anterior chamber parameters (Pentacam HR) were measured at four occasions: before PI (before and after mydriasis with phenylephrine) and two weeks after PI (before and after mydriasis). The study was conducted on both eyes and only one eye per patient, in random, was included in the analysis. RESULTS: The mean age of the participants was 60±7 years and 17 (81%) were female. There were no significant differences in intraocular pressure, refraction, keratometry, biometric and anterior chamber parameters between groups, except for anterior chamber volume, which showed increments with PI and mydriasis. The corresponding values for anterior chamber volume were as follows: 88.2±13.7mm(3) before PI, undilated; 106.3±18.8 before PI, dilated; 99.0±14.6 after PI, undilated, and 107.4±16.5 after PI, dilated (P<0.001). CONCLUSIONS: This study showed no change in the ocular biometric and anterior chamber parameters including iridocorneal angle after PI and/or pharmacologic mydriasis except for increments in anterior chamber volume. This factor has the potential to be used as a numerical proxy for iris position in evaluating and monitoring patients with primary angle closure suspects after PI.

Opciones quirúrgicas en el cierre angular primario por iris en meseta / Surgical options for the primary angle closure in a plateau iris case

Se describen dos casos clínicos (hermanos), con el objetivo de mostrar diferentes opciones terapéuticas en el glaucoma por cierre angular primario por iris en meseta. El primer caso representa una paciente femenina con antecedentes de iris en meseta e iridectomía periférica quirúrgica, quien presentaba cifras de tensión intraocular elevadas y progresión del daño glaucomatoso, por lo que se decidió realizar trabeculectomía en ambos ojos, con evolución satisfactoria. El segundo caso se trata de un paciente masculino, con antecedentes de salud, quien acudió por molestias oculares. Tras examen físico oftalmológico se constató glaucoma por cierre angular por iris en meseta, con presión intraocular elevada y opacidad del cristalino asociada, por lo que se realizó trabeculectomía en ojo derecho más extracción del cristalino en ambos ojos. Como complicaciones posoperatorias presentó desprendimiento coroideo y edema macular, resueltos con tratamiento mÚdico. La trabeculectomía luego de la extracción del cristalino en ojo derecho falló, por lo que actualmente se encuentra compensado con tratamiento médico. La elección de la terapéutica adecuada debe tener en cuenta los factores fisiopatológicos involucrados y la forma de presentaciónAU)

Different therapeutic options for the primary angle closure glaucoma by plateau iris were described in two clinical cases. The first one was a female patient with a a history of plateau iris and peripheral iridectomy. Elevation of intraocular pressure and progression to glaucoma was confirmed, so it was decided to perform trabeculectomy in both eyes and the result was satisfactory. The second case was a male patient with history of health problems, who suffered with eye disturbances. After ophthalmological exam, a primary angle closure glaucoma caused by plateau iris was confirmed with marked eye hypertension and associated crystalline lens opacity. Trabeculectomy of right eye and lens extraction in both eyes was applied. Choroidal detachment and macular edema were the postoperative complications, but the medical treatment managed to solve this situation. After the lens extraction, trabeculectomy in the right eye failed and today it is compensated with medical treatment. The right therapeutic choice should take into consideration the physiopathologic factors and the form of presentation(AU)

The best of the best: a review of select glaucoma case reports published in 2015.

This review article summarizes four key case reports published in the field of glaucoma in the year 2015. The first article describes a novel technique for draining choroidal fluid in patients with uveal effusion syndrome. The second article describes 2 cases of recurrent vitreous block despite adequate surgical intervention. The third article describes 2 cases of endogenous steroid response glaucoma. The last article describes the treatment of visual phenomena following iridectomy using femtosecond laser assisted keratopigmentation.

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.