Factors Associated With Zonular Instability During Cataract Surgery in Eyes With Acute Angle Closure Attack

To investigate differences between preoperative target refraction and postoperative spherical equivalent refraction in eyes with the first attack of acute angle closure glaucoma before and after surgery. We retrospectively examined eyes of 36 patients who suffered the first attack of acute primary angle closure after undergoing cataract extraction and intraocular lens implant. We measured keratometric values (K1, K2) due to medical therapy for high ocular tension and the mean time interval until surgery. We compared the axial length, expected diopter, logMAR visual acuity, K1, K2, refractive spherical equivalent, and intraocular pressure (IOP) before and 6 months after surgery. The average preoperative IOP was 51.3 ± 9.0 mmHg, but it decreased to 14.8 ± 3.6 mmHg after surgery. No corneal edema was observed after surgery. The average axial length was 22.12 ± 1.03 mm and there was no significant change in keratometric values, which were 7.72 ± 0.33 mm (K1) and 7.51 ± 0.31 mm (K2) before surgery and 7.67 ± 0.33 mm (K1) and 7.49 ± 0.29 mm (K2) after surgery. Similarly, no significant difference was observed in average preoperative target refractive error (-0.57 ± 0.53 D) and average postoperative refractive spherical equivalent (-0.67 ± 0.97 D). The inability to accurately determine preoperative refractive error due to corneal edema or other complications is a concern during the first attack of acute angle closure glaucoma. However, our results indicate that no differences should be expected between preoperative refractive error and postoperative refractive spherical equivalent.

Aim: To evaluate the biometric difference between eyes with acute angle-closure (AAC) attack, their uninvolved fellow eyes and eyes with chronic angle-closure glaucoma (CACG). Methods: Patients with prior laser iridotomy on both eyes for unilateral AAC attack or CACG were recruited. We compared ocular biometric parameters by A-scan ultrasonography of the acutely affected eyes with those of the uninvolved fellow eyes and with eyes affected by CACG. Results: Thirty-three patients with unilateral AAC attack and 41 patients with CACG were included. The eyes with AAC attack had a significantly shallower anterior chamber depth (ACD), thicker lens, shorter axial length, higher lens/axial length factor and more anteriorly positioned lens than the eyes with CACG. The uninvolved fellow eyes had a significantly shallower ACD, shorter axial length and higher lens/axial length factor compared with the eyes with CACG. Acutely affected eyes had a shallower ACD and more anteriorly positioned lens than did the uninvolved fellow eyes. Conclusion: Eyes with AAC attack had a more crowded anterior segment compared with uninvolved fellow eyes and those affected by CACG. In addition to ACD, relative lens size, represented by the lens/axial length factor, and relative lens position appear to play important roles in the development of AAC attack.

To compare ocular biometry of the contralateral eyes of individuals seen with acute angle closure (AAC) with eyes of population-based control subjects, and to assess novel provocative tests to study the mechanism of AAC. Prospective case-control study. Chinese persons seen as incident cases of AAC and Chinese population-based controls. Slitlamp assessment, ultrasonographic biomicroscopy, Scheimpflug photography, and provocative testing were performed. Ocular biometric parameters including anterior chamber depth, limbal anterior chamber depth, axial length, lens thickness, and radius of corneal curvature were obtained. Ultrasonographic biomicroscopy parameters that include the angle-opening distance at 500 micro m and the angle-recess area were noted. Scheimpflug photography produced a single measure of angle width. Contralateral eyes of cases of AAC had shorter axial lengths, shallower anterior chamber depths, thicker lenses, and steeper radii of corneal curvature (P<.01). After adjusting for age and sex, cases had a mean adjusted axial length that was 1.2 mm shorter, an optical anterior chamber depth that was 0.63 mm shallower (24% shallower than controls), and lenses that were, on average, 0.35 mm thicker (P<.01). Furthermore, using multiple logistic regression to adjust for age and sex, patients with primary angle-closure glaucoma were 19 times as likely to have a shallower limbal anterior chamber depth (25%; 95% confidence interval, 8.3-45.2). Adjusting for age and sex, the mean angle-opening distance at 500 microm was 0.14 U less for cases, with a mean of 0.26 U in controls, making the angle-opening distance at 500 microm, on average, 54% less among cases. Scheimpflug photographs revealed an adjusted angle width of 21.6 degrees for controls and 15.1 degrees for cases (P<.05). Dynamic testing showed that the angle of control eyes tended to shallow less when going from light to dark and tended to open more when given 1 drop of pilocarpine hydrochloride. Contralateral eyes of individuals having an AAC attack tend to be shorter and have more crowded anterior segments than those of healthy controls. These static measures of ocular biometry indicate why some individuals are predisposed to AAC. Dynamic measures of the response to luminance changes and pilocarpine therapy indicate that differential reactions to these stimuli are also associated with an AAC attack.

PurposeTo identify the preoperative biometric factors, including subfoveal choroidal thickness (CT), associated with refractive outcome after cataract surgery in eyes with primary angle closure (PAC).MethodsThis study included 50 eyes of 50 PAC patients who underwent uneventful cataract surgery. Preoperatively, anterior segment parameters including anterior chamber depth (ACD) and lens vault were determined by anterior segment optical coherence tomography. Subfoveal CT was measured by spectral domain optical coherence tomography enhanced depth imaging before and at one month after surgery. Mean refractive error (MRE) was calculated as the difference in spherical equivalent between actual postoperative refraction determined one month postoperatively and that predicted using each of three IOL calculation formulas (SRK/II, SRK/T, and Haigis). Regression analyses were performed to investigate potential associations between MRE and putative factors.ResultsMean ACD was 1.9 ± 0.4 mm, and preoperative subfoveal CT was 250.8 ± 56.9 µm. The SRK/T (MRE, 0.199 ± 0.567 diopters [D]) and Haigis (MRE, 0.190 ± 0.727 D) formulas showed slight hyperopic shift, while the SRK/II formula demonstrated a myopic shift (MRE, −0.077 ± 0.623 D) compared with that expected after cataract surgery. Mean absolute refractive error was not significantly different between formulas. Higher preoperative lens vault and shallower ACD were associated with a hyperopic shift in all formulas, but not in a statistically significant manner. Thicker preoperative subfoveal choroid was associated with a myopic shift after cataract surgery in all formulas (SRK/II: β = −0.511, p < 0.001; SRK/T: β = −0.652, p < 0.001; Haigis: β = −0.671, p < 0.001). Greater postoperative reduction of subfoveal CT was associated with a myopic shift after cataract surgery in all formulas (SRK/II: β = −0.511, p < 0.001; SRK/T: β = −0.652, p < 0.001; Haigis: β = −0.671, p < 0.001).ConclusionsOur results indicate that preoperative subfoveal CT and the difference between pre- and postoperative subfoveal CT are significant factors for predicting refractive error after cataract surgery in PAC patients. These findings should be considered when performing cataract surgery to optimize visual outcomes.

Ocular Biometry in the Subtypes of Angle Closure: An Anterior Segment Optical Coherence Tomography Study

Background: Glaucoma is the second leading cause of blindness worldwide, with a particularly high prevalence of primary angle-closure glaucoma (PACG) in Asia. Anatomical factors such as shallow anterior chamber depth (ACD) and increased lens vault (LV) are key mechanisms contributing to angle closure. However, specific biometric data in the Indonesian population remain limited. Objective: This study aimed to describe the demographic and clinical characteristics of glaucoma patients at the Outpatient Ophthalmology Clinic of Dr. Soetomo General Hospital, Surabaya, in 2024 and to analyze the relationship between ACD and LV as risk factors for glaucoma. Methods: A cross-sectional analytic observational design was employed using medical records of glaucoma patients. A total of 49 subjects (69 eyes) meeting inclusion criteria were included. Measurements of ACD and LV were obtained using Anterior Segment Optical Coherence Tomography (AS-OCT). Results: The majority of patients were female (71.4%), with the largest age group being 51–60 years. PACG was the most common diagnosis (53.6%), followed by PAC (34.8%). The mean ACD was 1.99 mm, with shallower values in females compared to males. The mean LV was 962.7 µm, higher in females and increasing with age. Statistical analysis revealed a strong and significant negative correlation between ACD and LV, indicating that higher LV is associated with shallower ACD. Conclusion: This study demonstrates an inverse relationship between lens vault (LV) and anterior chamber depth (ACD), with higher LV associated with shallower ACD.. Females showed higher LV and shallower ACD, reflecting greater anatomical susceptibility. Overall, increased LV combined with reduced ACD represents a key anatomical risk factor for angle-closure glaucoma, supporting the need for early biometric screening in high-risk groups.

Bilateral acute primary angle closure attack, though possible, is a rare condition. Secondary causes such as psychotropic drugs (topiramate), snake bite, and general anesthesia have been implicated in various case reports. We hereby describe a rare case of bilateral simultaneous acute angle closure attack secondary to microspherophakia and lens subluxation in a young lady with Weill–Marchesani syndrome, which was initially misdiagnosed as acute primary angle closure glaucoma. This case highlights the importance of eliciting proper history and paying attention to general examination findings to rule out secondary causes in a young patient with bilateral acute angle closure glaucoma.

Purpose To analyze anatomical factors contributing to angle closure based on anterior segment optical coherence tomography (AS-OCT) imaging. Methods A total of 238 patients with angle closure and 1122 normal controls were consecutively recruited for this study. Participants’ eyes were imaged using AS-OCT under the same darkened ambient light conditions. The following parameters were analyzed: central anterior chamber depth (ACD); anterior chamber area (ACA); anterior chamber volume (ACV), anterior chamber width (ACW); corneal diameter (CD); posterior cornea curvature (PCC); anterior cornea curvature (ACC); maximum iris thickness (ITM); iris thickness at 750 um (IT750) and 2000 um (IT2000) from the scleral spur; iris curvature (IC); iris area (IA); lens vault (LV); angle opening distance (AOD); trabecular iris space area at 500 um (TISA500) and 750 um (TISA750) from the scleral spur; angle recess area (ARA). Lasso regression models were used to detect the collinearity of parameters. The multivariable logistic regression was performed to determine the independent association between angle closure and those parameters included in Lasso regression model. Also Factor analysis was performed to extract a few underlying factors (components) from these parameters. Results Lasso regression showed that ACD, ACV, PCC, IT750, IT2000 and LV were screened in the model. The multivariable logistic regression indicated that ACV, PCC, IT750 and LV were significantly associated with angle closure. Factor analyses revealed that 4 factors, each with its closely associated clusters of variables, produced the best results: ACA, ACV and ACD (Factor 1); LV, tIC and nIC, (Factor 2); ACW, CD and PCC (Factor 3); and tITM, tIT2000, tIT750, nIT2000 and nIT750 (Factor 4). Conclusions Four separate mechanisms were showed to be involved in the pathogenesis of angle closure, from anterior chamber dimensions, lens, iris and cornea respectively. The parameters ACV, PCC, IT750, and LV are more predominant in determining angle closure.

Évolution démographique de la crise aiguë par fermeture de l’angle entre 2001–2003 et 2008–2010 : impact de la chirurgie moderne de la cataracte

The purpose of this study is to compare anterior segment-optical coherence tomography (AS-OCT) parameters in phacomorphic angle closure and acute primary angle closure (APAC) eyes. In this cross-sectional case series, a total of 134 patients with phacomorphic angle closure (28 eyes) or APAC (54 eyes), as well as normal control subjects (52 eyes), were enrolled. Patients underwent AS-OCT imaging and A-scan biometry of both eyes. Anterior chamber depth (ACD), anterior chamber area (ACA), iris thickness (IT), iris curvature, lens vault (LV), anterior vault (AV), and angle parameters including angle opening distance (AOD 500 and AOD750) and trabecular iris space area (TISA500 and TISA750) were measured in qualified images using the Zhongshan Angle Assessment Program and compared among eyes with phacomorphic angle closure, APAC, and normal control subjects. Phacomorphic angle closure and APAC eyes had smaller AOD, ACD, ACA, ACW, AV, and posterior corneal arc length and greater LV than normal controls (P < 0.001 for all comparisons). After adjustment for age, sex, and pupil diameter, phacomorphic angle closure had greater AOD500 (P = 0.02), TISA500 (P = 0.003), TISA750 (P = 0.05), axial length (P = 0.03), and LV (P = 0.001) and less ACD (P = 0.001), ACA (P = 0.003), IT750 (P = 0.01), and IT2000 (P = 0.04) than APAC eyes: ACD < 1.59 mm (odds ratio [OR], 29.57; P < 0.01) and LV > 1042 μm (OR,12.12; P < 0.01) were the two biometric parameters that could highly discriminate phacomorphic angle closure from the APAC eyes. In multivariate analysis, ACD, LV, AOD500, and axial length could significantly distinguish the two entities. Ocular biometric parameters can differentiate phacomorphic angle closure from APAC eyes. Shallower ACD and greater LV, axial length, and ACA are the main parameters that distinguish phacomorphic angle closure from APAC.

BackgroundThis study aims to investigate the morphologic features of the crystalline lens in Primary Angle Closure Disease (PACD) patients with zonular instability during cataract surgery using the swept-source CASIA 2 Anterior Segment-Optical Coherence Tomography (AS-OCT) system.MethodsA total of 398 eyes (125 PACD eyes with zonular instability, 133 PACD eyes with zonular stability, and 140 cataract patient controls) of 398 patients who underwent cataract surgery combined or not glaucoma surgery between January 2021 and January 2023 were enrolled. The crystalline lens parameters were measured by CASIA2 AS-OCT. Then, logistic regression was performed to evaluate the risk factors associated with zonular instability.ResultsThe results revealed that PACD eyes had a more anterior lens equator position, a steeper anterior curvature of lens, shorter Axial Length (AL), shallower Anterior Chamber Distance (ACD), higher Lens Vault (LV) and thicker Lens Thickness (LT), when compared to eyes in the cataract control group. Furthermore, PACD eyes in the zonular instability group had steeper front R, front Rs and Front Rf, flatter back Rf, thicker lens anterior part thickness, higher lens anterior-to-posterior part thickness ratios, shallower ACD, and greater LV, when compared to PACD eyes with zonular stability. The logistic regression analysis, which was adjusted for age and gender, revealed that zonular instability was positively correlated with anterior part thickness, lens anterior-to-posterior part thickness ratio, and LV, but was negatively correlated with lens anterior radius and ACD.ConclusionSteeper anterior curvature, increased lens anterior part thickness, higher anterior-to-posterior part thickness ratio, shallower ACD, and greater LV are the anatomic features of PACD eyes associated with zonular instability.

To systematically review the characteristics of patients experiencing acute angle closure (AAC) attacks during the COVID-19 outbreak in Beijing. Patients with AAC attacks during the COVID-19 epidemic and those in the same period the following year were recruited. Demographic characteristics, ocular biometry, ocular signs, sequential relationships, and the prognosis of operative management outcome were recorded and compared between the 2 groups. We included 60 eyes of 55 patients with AAC attacks in the COVID-19 group and 34 eyes of 33 patients in the control group. There was a significantly higher incidence of bilateral attacks during the COVID-19 outbreak compared to the control group (9 vs 1, P = .043). Additionally, a higher proportion of AAC attacks were observed in the COVID-19 group (P = .035). The COVID-19 group had a higher mean peak intraocular pressure (53.42 ± 8.87 mm Hg vs 47.86 ± 11.22 mm Hg; P = .007), larger pupil diameter (5.75 ± 1.04 mm vs 4.86 ± 1.26 mm; P < .001), more pigmented keratic precipitates (39 vs 8, P < .001), and segmental atrophy of the iris (32 vs 10, P = .019). Coronavirus infection was simultaneous with or slightly preceded the appearance of AAC attacks. Most patients had an ideal prognosis after comprehensive management. An increased incidence of AAC attacks, more bilateral cases and severe anterior segment inflammation were observed during the COVID-19 outbreak in Beijing. There may be a correlation between the onset of AAC attacks and coronavirus infection, but further research is needed to explore this link.

Changes in the RNFL

BackgroundWe describe two cases of recurrent acute angle-closure attack in patients with plateau iris syndrome after cataract extraction. Argon laser peripheral iridoplasty and cataract extraction have been used to reduce the occurrence of acute angle-closure attack in plateau iris syndrome although the risk cannot be completely eliminated. There is no consensus on the long term management of plateau iris syndrome. This is, as far as we know, the first case report of recurrent acute angle-closure attack in plateau iris syndrome after cataract extraction.Case presentationWe report two cases of recurrent acute angle-closure attack in 2 Chinese patients with plateau iris syndrome. The first patient was a 69 year-old woman who received bilateral argon laser peripheral iridoplasty and cataract extraction 2 years prior to the latest acute angle-closure with right eye intraocular pressure 48 mmHg. The attack was aborted medically. Peripheral iridotomy was patent and argon laser peripheral iridoplasty marks were mostly at peripheral 2/3 of the iris. Anterior segment optical coherence tomography confirmed bilateral plateau iris configuration. Use of long term pilocarpine or repeated argon laser peripheral iridoplasty to prevent recurrent angle-closure attack was discussed but she opted for observation. The second patient was a 64 year-old man presented with acute angle-closure after cataract extraction despite placement of laser peripheral iridotomy. Plateau iris syndrome was confirmed by anterior segment optical coherence tomography and he received argon laser peripheral iridoplasty.ConclusionsAcute angle-closure due to plateau iris syndrome can still occur despite previous cataract extraction and argon laser peripheral iridoplasty. These are the first reported cases of recurrent acute angle-closure attack due to plateau iris syndrome following cataract extraction, with or without previous argon laser peripheral iridoplasty. Repeated treatment with argon laser peripheral iridoplasty or pilocarpine could be considered although the long term efficacy is questionable. Argon laser peripheral iridoplasty should be applied as peripheral as possible so as to open up the drainage angle effectively.

PurposeThe purpose of this study was to identify whether it was possible to subdivide subjects with primary angle-closure glaucoma (PACG) based on anterior segment optical coherence tomography (ASOCT) imaging, and to determine the characteristics of such subgroups.MethodsWe evaluated 210 subjects with PACG. All subjects underwent gonioscopy and ASOCT imaging. Customized software was used to measure ASOCT parameters. An agglomerative hierarchical clustering method was first used to determine the optimum number of parameters to be included in the determination of subgroups. Then, the best number of subgroups was determined using Akaike Information Criterion (AIC) and Gaussian Mixture Model (GMM) methods.ResultsThe mean age of the subjects was 67.9 years, and 53.3% were female. Following the hierarchical clustering, four parameters (iris area, anterior chamber depth (ACD), anterior chamber width (ACW), and lens vault (LV)) were chosen to be representative of related parameters. The optimal number of subgroups using GMM analysis and AIC was 3. Subgroup 1 (N=89; 42.4%) was characterized by a large iris area, subgroup 2 (N=24; 11.4%) by a large LV and a shallow ACD, whereas subgroup 3 (N=97; 46.2%) displayed only intermediate values across iris area, LV, and ACD.ConclusionsWe identified three distinct subgroups of PACG subjects based on ASOCT imaging.