CASE REPORTS: Ultrasound biomicroscopy demonstrating pupillary block in near-total hyphema: a case report and implications for surgical planning

Introduction: Pupillary block, a concerning complication of cataract surgery, is heightened when a single-piece acrylic (SPA) intraocular lens (IOL) is implanted in the ciliary sulcus. We report an unusual occurrence of relative pupillary block and chronic angle-closure glaucoma (ACG) identified in the late postoperative period due to unintentional SPA IOL implantation in the sulcus. Case Presentation: An 82-year-old woman presented with a history of chronic ACG 5 years after bilateral cataract extraction. Postoperatively, she experienced anterior chamber shallowing, elevated intraocular pressure (IOP), and two acute angle-closure attacks in the left eye, successfully managed with laser peripheral iridotomies (LPIs). Despite neodymium:YAG capsulotomy, elevated IOP persisted. Maximal medical therapy effectively controlled IOP; however, a shallow anterior chamber remained, prompting referral to our glaucoma service. Slit-lamp examination revealed a shallow peripheral anterior chamber, patent LPIs, and an Alcon SA60WF SPA IOL situated posteriorly with the optic against the pupil margin OS. Gonioscopy indicated a closed angle with peripheral anterior synechiae (PAS). Ultrasound biomicroscopy (UBM) confirmed haptics in the sulcus, with the lens optic and haptics anterior to the bag. These findings suggest relative pupillary block as the cause of her chronic ACG. The SPA IOL’s bulky haptics in the sulcus likely induced iris bowing, leading to prolonged appositional angle-closure and chronic PAS formation. Conclusion: IOLs designed for the capsular bag should not be placed in the sulcus. Therefore, IOLs of varying dimensions should be taken to the operating room in the event of complicated cataract extraction. Finally, UBM proves valuable in identifying causes of pupillary block.

Angle-Closure

Possible case of capsular block syndrome

Clinical relevance Angle closure glaucoma is one of the most common blinding diseases encountered mainly in older age groups, although it may also occur at a younger age. Identifying the underlying cause of angle closure helps in designing specific treatment strategies essential for effective disease management. Background Primary angle closure disease, caused due to pupillary block (PB) and plateau iris configuration (PIC), necessitates different management strategies. This study assessed the potential utility of anterior segment optical coherence tomography (ASOCT) and optical biometry in distinguishing PIC from PB in primary angle closure disease of the young (PACDy). Methods Patients aged 20–40 years with PACDy and age-matched healthy controls were recruited. Ophthalmic examinations included gonioscopy, ultrasound biomicroscopy, ASOCT, and biometry. Anterior chamber depth, lens thickness, axial length, central corneal thickness, lens position, relative lens position, vitreous cavity length, lens vault, relative lens vault and angle opening distance, trabecular iris space area, and trabecular iris angle were measured. Receiver operating characteristics curve analysis evaluated the discriminative ability of these parameters. Results Of the 280 eyes, 128 were normal and 152 had PACDy. Of 128 PACDy, 88 had PIC, and 64 had PB. Both PIC and PB had significantly smaller ASOCT and biometric parameters than normal eyes. However, PIC had intermediate biometric values that fell between normal eyes and PB. All the aforementioned parameters, except central corneal thickness, showed excellent discriminating ability of PIC and PB from normal eyes; however, no single parameter can strongly differentiate PB from PIC. Axial length and relative lens vault had the highest, although weak, power for discriminating PB from PIC. Conclusion ASOCT and biometry effectively distinguish PIC and PB from normal eyes, but no single parameter reliably differentiates PIC from PB. Comprehensive gonioscopy and ultrasound biomicroscopy may be necessary for accurate diagnosis in PACDy.

Anterior chamber depth in plateau iris syndrome and pupillary block as measured by ultrasound biomicroscopy

Anterior chamber depth in plateau iris syndrome and pupillary block as measured by ultrasound biomicroscopy

Angle Widening and Alteration of Ciliary Process Configuration after Cataract Surgery for Primary Angle Closure

Spherophakia is an uncommon diagnosis. This is the first case report of spherophakia evaluated by ultrasound biomicroscopy. Ultrasound biomicroscopy is a new diagnostic technique developed by one of the authors and provides images with microscopic resolution of the anterior segment. A patient with spherophakia was evaluated by ultrasound biomicroscopy (Zeiss-Humphrey, 50MHz) before and after YAG laser iridotomy. Ultrasound biomicroscopic assessment revealed a shallow anterior chamber, a very steep anterior lens curvature, iridolenticular contact, elongated zonules, and an increased distance between the lens equator and the ciliary processes. Angle closure glaucoma was due to a pupil block mechanism. The pupil block was relieved by YAG laser iridotomy. Ultrasound biomicroscopy is a useful technique to confirm the diagnosis of spherophakia. The pupil block in spherophakia is relieved by YAG laser iridotomy.

Objective To discover primary angle closure (PAC) in eyes of anatomic narrow angle (ANA),evaluate quantify changes of the PAC in anterior segment morphology after laser iridotomy using ultrasound biomicroscopy (UBM) and explore the therapy of primary angle closure.Methods Prospective interventive observational case series.Twenty-eight eyes of patients presented PAC in the Department of Ophthalmology at Zunyi Medical College Hospital.PAC was presented on iris contacting with trabecular meshwork temporally in one UBM image.The PAC eyes were examined again by UBM in the both same light conditions and items at two weeks after laser peripheral iridotomy (LPI).Results The rate of PAC was significantly decreased after LPI in the same condition,the rate of PAC was 96.43％ before LPI in dark condition,and it was significantly dropped down to 32.14％ after LPI (x2 =14.45,P ＜0.05).In light condition,it was cut down from 67.86％ to 7.14％ after LPI (x2 =15.06,P ＜0.05).The AOD500 and TIA were increased after LPI (P ＜0.001),it indicated that the angle of PAC was widened after LPI.The ILCD of PAC was also added after LPI,but the ILA was decreased after LPI (P ＜0.001).This phenomenon suggested that the pupillary block was relieved after care of LPI.The IT1 was thinner in laser site quadrant in dark condition after LPI which combined Nd-YAG and green laser (P ＜0.05).There were no significant changes of the ACD (P ＞0.05).The ICPD was reduced in dark after LPI (t =2.519,P =0.012).The pupillary block was relieved; it leaded to iris caving backward.But the TCPD was added in light after LPI (t =-2.967,P =0.003).It suggested that the ciliary body removed towards the back after LPI.Conclusions LPI produces a significant widening of the peripheral anterior chamber angle and reducing the power of pupillary block for major PAC eyes,which have not peripheral anterior synechia,but not deeping the central anterior chamber distance.LPI can prevent most PAC from developing to PACG.LPI is an efficient method for PAC in a short time. Key words: Primary angle closure; Laser peripheral iridotomy; Ultrasound biomicroscopy

To correlate UBM and clinical findings in patients with closed globe injury. Prospective observational study of 75 patients, ≥ 12 years of age presenting to ophthalmic outpatient department within one week of sustaining closed globe injury. Patients with seriously ill polytrauma and open globe injuries were excluded from the study. Comprehensive ophthalmic examination including Visual acuity assessment, slit lamp examination, fundus examination and IOP measurement. Gonioscopy and UBM examination was done in all patients on presentation except for patients with hyphema (UBM and gonioscopy done at 4 weeks to prevent rebleed).Mean age of the patients was 31.4 ±8 years, most common external findings included lid ecchymosis (47%), subconjunctival hemorrhage (93%). The common anterior segment finding included traumatic iritis (87%), traumatic hyphema (61%) and traumatic cataract in 27% of patients. Clinical evidence of zonular dialysis was seen in 13% of patients. UBM was able to detect zonular defects in 62% patients (P=0.008). Most of the patients (57%) had zonular dialysis less than 3 clock hours on UBM examination. UBM confirmed the presence of other clinical findings like iridodialysis, cyclodialysis. UBM is a safe and effective adjunctive tool for clinical assessment and management of ocular trauma. It can diagnose subtle zonular dialysis and other anterior segment changes following blunt trauma. UBM should be an integral part of ophthalmic examination especially in patients requiring surgical intervention after closed globe injury.

Purpose: We report the successful surgical treatment of a case of spontaneous complete anterior crystalline lens luxation in a patient affected by retinitis pigmentosa (RP), associated with elevated intraocular pressure and pupillary block. Additionally, we review the current literature regarding the association between ectopia lentis and RP. Case description: A 44-year-old female RP patient presented to our emergency department reporting severe ocular pain in her left eye (LE) and sickness. She had no history of ocular trauma and did not report systemic disorders. The best corrected visual acuity at presentation was 1/20 in her LE, the intraocular pressure was 60 mmHg, and slit lamp examination showed in her LE a complete dislocation of the lens in the anterior chamber, with mydriasis, atalamia, and a pupillary block. The patient had been administered intravenous mannitol 18% solution and dorzolamide-timolol eye drops and was hospitalized for urgent lens extraction. Anterior segment optical coherence tomography and ultrasound biomicroscopy were performed before surgery. Decompressive 23-gauge pars plana vitrectomy and phacoemulsification were performed, and the capsular bag was removed due to marked zonular weakness, with deferred intraocular lens implant. Conclusions: Acute angle closure glaucoma in patients with RP may be rarely caused by spontaneous anterior lens dislocation. To our knowledge, this is the first report of spontaneous anterior lens dislocation in an RP patient, documented through photographs, anterior segment optical coherence tomography, and ultrasound biomicroscopy.

*Vietnam National Institute of Ophthalmology, Vietnam †Singapore Eye Research Institute (SERI) ‡Singapore National Eye Center (SNEC) Singapore Disclosure: The authors declare no conflict of interest.

IntroductionPlateau iris is recognised as an important cause of primary angle closure glaucoma. The management of this condition generally comprises laser peripheral iridotomy and iridoplasty, to remove any component of relative pupillary block and to widen the iridotrabecular drainage angle respectively. However, plateau iris may be associated with multiple iris cysts at the iridociliary junction, which then presents diagnostic and management problems.Case presentationWe present a fifty-three year old Caucasian gentleman with plateau iris associated with peripheral iris cysts, in which the iridotrabecular angle did not widen despite having had both laser peripheral iridotomy and iridoplasty. The patient has remained asymptomatic over 12 months, and is under close follow-up to monitor for signs of glaucoma.ConclusionPlateau iris with iridociliary cysts can be difficult to diagnose and manage. Ultrasound biomicroscopy should be performed on patients with appositional iridotrabecular angle closure on gonioscopy, especially if the angle closure is not relieved with either laser peripheral iridotomy or iridoplasty. Question marks can be raised as to the benefit of laser iridotomy when plateau iris without pupillary block has already been conclusively diagnosed on ultrasound biomicroscopy.

Purpose. To investigate the prevalence of pseudoexfoliation syndrome (PES) in primary angle-closure glaucoma (PACG) and the nature of changes in ocular structures in process of PES progression to determine the choice of pathogenically oriented treatment.Material and methods. For this investigation 220 Uzbek patients (358 eyes) with hyperopic type of eyes (axial length was 22.8 mm and less) have been selected. The main group included 176 patients (286 eyes) with PACG and different degrees of lens opacity. The comparative group consisted of 44 patients (72 eyes) without PACG and clinical PES symptoms, and with analogous lens opacity. The average age was not statistically significant in both groups and was 58.6±1.2 and 56.4±1.4 years, respectively.All patients underwent complete ophthalmologic examinations. Ultrasound biomicroscopy (UBM) was the basic method of investigation using the model 840 (Zeiss-Humphrey Instruments). The measurements were performed in the superior, lateral, inferior, and medial segments of iridocilliary zone.Results. The UBM method allowed to detect PES symptoms in 64.5% of PACG cases even in absence of clinical PES symptoms. The presence of flakes of pseudoexfoliative material of different echo-density was found on structures of iridocilliary zone with its insufficiency. The pseudoexfoliative flakes were associated with a ciliary zonule fiber weakness. Difference of cilliary zonule fibers length differed by 0.2-0.7mm in various segments of measurement. In these cases an alteration of space correlation between iridocilliary structures took place. The asymmetry of iridocilliary structure parameters and disturbance of their topographic relationships detected by the UBM in PES cases with zonules damage lead to a combination of intraocular blocks in one eye in PACG cases. In segments of cilliary zonule fibers stretching (0.68±0.02mm) the UBM reflected a pattern of segmental relative pupillary block. In opposite segment a sharp reduction of visualized cilliary zonule fibers (0.27±0.02mm) was revealed. The UBM reflected a pattern of plateau iris syndrome. In other situations there was observed a combination the pupillary block and the block induced by the crystalline lens.Conclusion. The results of investigations using the UBM method in Uzbek patients showed that the PES was accompanied with PACG in the absence of clinical signs of disease. The PES was accompanied by alterations of topographic relationships of iridocilliary zonule structures in PACG eyes and promoted in these situations an appearance of intraocular blocks combination: relative pupillary block, block of plateau iris syndrome and crystalline lens block that requires a differentiated approach to the choice of pathogenetic treatment tactics of PACG.

Investigate anterior segment parameters to distinguish between 2 mechanisms of angle closure, PB and PIC, using swept-source Fourier domain ASOCT. Retrospective ASOCT images from narrow angle eyes were reviewed. PIC was defined either by ultrasound biomicroscopy and/or clinically when an iridoplasty was performed. Images were read by a masked reader using Anterior Chamber Analysis and Interpretation software to identify scleral spur landmarks and calculate anterior chamber, peripheral angle, iris size, iris shape, and lens/pupil size parameters. ASOCT parameters were summarized and compared using the 2-sample t test. Thresholds and area under receiver operating characteristic curve were calculated using logistic regression analysis. One hundred eyes (66 PB and 34 PIC) of 100 participants were reviewed. Of all ASOCT parameters, iris length in each quadrant, pupil arc, lens/pupil parameters (pupil arc, lens vault, and pupil diameter), all pupillary margin-center point-scleral spur landmark (PM-C-SSL) parameters, and all except superior central iris vault parameters were significantly different between PB and PIC. On threshold evaluation, lens/pupil parameters had the greatest area under receiver operating characteristic curve values (0.77 to 0.80), followed by PM-C-SSL angles (0.71 to 0.75). We propose that the pupil size parameters and PM-C-SSL angle are the most reliable novel ASOCT parameters to distinguish between PB and PIC eyes. These parameters do not rely on the visibility of the posterior iris surface, which is difficult to identify with ASOCT, but may be ambient lighting dependent.