Treatment approaches for affected eyes in hospitalized patients with acute primary angle-closure glaucoma: a multicenter retrospective analysis

Background: Lens thickness is one of the factors that influence the mechanism of acute primary angle closure glaucoma (PACG). The thicker lens usually results in a shallower anterior chamber angle (ACA), and the gradual and progressive increase in lens thickness with age results in exaggerated shallowing of the ACA. Because lens thickness has an important role in acute PACG mechanism, prophylactic treatment like lens extraction might prevent PACG in early stages. This study aimed to describe the difference in lens thickness in acute and chronic PACG.
 Methods: The research was a cross-sectional study with samples conducted in Dr. M. Djamil General Hospital from September-December 2019. The number of eyes that fulfilled the inclusion criteria were 50 eyes from 50 patients consisting of 25 eyes with acute PACG and 25 eyes with chronic PACG. Subjects were examined with ocular biometry using A-scan biometry to evaluate lens thickness. Data were processed and analyzed using a computer program with a chi-square test.
 Results: Mean of lens thickness in acute PACG is 5.02 ± 0.45, while in chronic PACG is 4.86 ± 0.40. The difference in lens thickness in acute and chronic PACG were statistically significant (p = 0,037).
 Conclusion: Lens thickness is thicker in acute PACG than in chronic PACG.

To study the corneal endothelium and pachymetry in eyes with different subtypes of primary angle closure glaucoma (PACG), as compared to controls. A cross-sectional study was conducted on 30 consecutive patients in each subtype of PACG, subacute, acute and chronic, and 30 age and refraction matched controls. The parameters recorded included gonioscopy, optic disc evaluation, applanation tonometry, specular microscopy and central ultrasonic pachymetry. The mean endothelial cell counts in the four groups were as follows: subacute PACG 2396 +/- 271 cells/mm2, acute PACG 1597 +/- 653 cells/mm2, chronic PACG 2229 +/- 655 cells/mm2 and controls 2461 +/- 321 cells/mm2. The mean endothelial cell count in the fellow eyes of subacute PACG, acute PACG and chronic PACG patients was 2294 +/- 305 cells/mm2, 2388 +/- 226 cells/mm2 and 2108 +/- 203 cells/mm2, respectively (NS). The acute PACG patients had significantly lower endothelial cell counts (P < 0.001) as compared to the other three groups. Eyes in which the acute attack of angle closure persisted for less than 72 h had a mean endothelial cell count of 2016 +/- 306 cells/mm2, as compared to 759 +/- 94.4 cells/mm2 in eyes with an attack lasting for 72 h or more (P < 0.001). The endothelial count was also significantly lower in eyes with chronic PACG as compared to control eyes (P < 0.001). There was increased pleomorphism and polymegathism of the corneal endothelial cells seen in eyes with resolved acute and chronic PACG. The mean central corneal thickness was 531.4 +/- 25.3 microm in eyes with subacute PACG, 567.9 +/- 37.3 microm in eyes with acute PACG, 526.4 +/- 31.9 microm in eyes with chronic PACG and 525 +/- 12.6 microm in control eyes. The acute PACG eyes had a significantly higher corneal thickness (P < 0.001) when compared to all the other groups. There is a significant decrease in the corneal endothelial cell density in eyes that have had an acute attack of angle closure glaucoma and in eyes with chronic PACG. The endothelial cell population in eyes with sub-acute PACG and in the fellow eyes of all subtypes of PACG is not significantly different from the normal population.

To investigate the long-term clinical course of acute primary angle closure (APAC) and acute primary angle-closure glaucoma (APACG) in Japanese patients. We retrospectively reviewed our records of 66 consecutive APAC or APACG eyes observed between February 1992 and December 2003 (mean follow-up, 42.1 months). Immediately after the diagnosis, all patients had received similar medications to halt the acute attack. Subsequently, laser iridotomy or surgical peripheral iridectomy and/or laser iridoplasty were conducted. If intraocular pressure (IOP) control was poor under maximum tolerable ocular hypotensive agents, trabeculectomy with adjunctive mitomycin C (MMC) was undertaken. After laser therapy, the probability of success, defined as an IOP of <21 mmHg with or without medications, was 81.2% +/- 6.2%. In the ten eyes that were trabeculectomized, the probability of success based on the same criterion was 40.0% +/- 29.7%. Multivariate analysis revealed that the degree of synechial angle closure (P = 0.029) and the preexistence of chronic glaucomatous optic neuropathy (P = 0.015) significantly influenced the need for subsequent filtering surgery. Without the intervention of filtering surgery, 84.6% of eyes with APAC or APACG maintained IOP control with or without antiglaucoma medications. However, APAC and APACG eyes that eventually received trabeculectomy were predisposed to an uncontrollable IOP, even with the intraoperative application of MMC. The severity of APAC or APACG in Japanese may be affected by an underlying creeping angle closure.

Background The circulating endothelial progenitor cells (EPCs)play an important role in postnatal vasculogenesis and restoration of endothelial injury.Previous investigation illustrated that a reduced ocular blood flow and vascular dysfunction caused by endothelial dysfunction plays a role in the pathogenesis of glaucoma.However,endothelial system accommodation is accomplished with the circulating EPCs. Objective The present trail was to investigate EPCs change in patients with primary acute angle-closure glaucoma (PACG)and explore the role of EPCs in the pathogenesis of PACG. Methods A prospective cohort study was designed.Thirty patients with PACG were enrolled in Tianjin Medical University General Hospital as PACG group,and 20 normal subjects served as control group.Periphery blood samples were obtained from all the patients and then stained with saturating concentrations of monoclonal antibodies,FITC-conjugated anti-CD34 and CD133 mAb.EPCs identified by CD34,CD133 were enumerated by flow cytometry,and the correlation between EPCs change and its relative factors was analyzed.Informed consent was obtained from each subject before any medical procedure. Results No significant differences were found in age,gender,vascular-related risk factor,blood biochemical indicators between PACG group and normal contol group(P＞0.05 ),but a higher intraocular pressure( IOP)was displayed in PACG group compared with normal control group ( P =0.00 ).The numbers of EPCs were ( 48 ± 22 ) cells/ml in PACG group and ( 65 ± 20 )cells/ml in normal control group with a significant difference between them (P=0.004).In PACG group,the numbers of EPCs were(60± 19 )cells/ml and (34 ±7 )cells/ml respeetively in phase 1 and phase 3 of optical nerve damage (Z=-3.015,P=0.002 ).There was a negative correlation between EPCs numbers and baseline IOP within a certain range( r=-0.835,P＜0.05 ).However,no obvious correlations were seen between EPCs numbers and blood lipid Level,blood glucose level or glaucoma course ( r =0.343,P =0.227 ; r =-0.203,P =0.419 ; r =0.198,P =0.610 ).The EPCs numbers in PACG patients with cardiovascular disease were(56±22)cells/ml and that of without PACG were (35± 15 ) cells/ml( P =0.005 ). Conclusions The numbers of EPCs decrease in PACG patient.These results imply that EPCs might play role during the restore of the optical nerve damage in PACG eye. Key words: Endothelial progenitor cell; Acute angle-closure glaucoma; Flow cytometry

Objective To measure quantitatively and analysis the differences in the anterior segment biological parameters between the normal subject and patients suffering primary angle closure glaucoma (PACG), as well as the distinction among different stages of PACG by using anterior segment optical coherence tomography (OCT). Methods A retrospective case series study was designed.Medical records of 217 cases (217 eyes) from The Second Hospital of Hebei Medical University from December 2013 to December 2014 were recruited, including 5 groups as follows: 35 cases (35 eyes) with pre-clinical stage acute primary angle closure glaucoma (APACG), 32 cases (32 eyes) with remission period of APACG, 35 cases (35 eyes) with early stage of chronic primary angle closure glaucoma (CPACG), 35 cases (35 eyes) with progress period of CPACG and 80 cases (80 eyes) coming for regular eye health examination in general clinic.The anterior segment biological parameters of each group was measured by Heidelberg Spectralis OCT, including the anterior chamber width (ACW), angle opening distance (AOD), trabecular iris area (TISA), iris thickness (IT) and crystalline lens rise (CLR). Results The IT and CLR of APACG and CPACG were significantly greater than normal control group, while other anterior segment parameters were significantly smaller, with significant differences between them (all at P 0.05). Compared with progress period of CPACG, the IT of the early stage of CPACG was thicker, while the CLR was smaller (both at P 0.05). The IT750, IT2 000 and ITmax of the pre-clinical stage of APACG were significantly thicker than those of progress period of CPACG (all at P 0.05). Conclusions Compared with normal people, the PACG patients have a more crowding anterior segment structure, smaller AOD, smaller TISA, thicker IT and more anterior located lens.The APACG patient at remission period has a more crowding anterior segment structure, smaller AOD, smaller TISA, thicker IT and more anterior located lens than APACG patient at per-clinic stage.The CPACG patient at progress period has a higher CLR, but thinner IT than patient at early stage.The APACG patients at per-clinic stage has thicker IT and a more crowding anterior segment structure than the CPACG patient at early stage, and the APACG patient at remission period has thicker IT than CPACG patient at progress period. Key words: Angle-closure glaucoma; Anterior segment; Optical coherence tomography; Anterior segment biological parameters

Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle-closure glaucoma: A prospective, randomized, controlled trial

Uveal effusion in primary angle-closure glaucoma

Objective To compare the prevalence of plateau iris in acute primary angle closure glaucoma (APACG) and chronic angle closure glaucoma (CACG) after laser peripheral iridotomy.Methods 37 cases (37 eyes) with APACG and 29 cases (29 eyes) with CACG were enrolled in the study.In APACG group,the fellow eyes of the eyes with acute attack were studied.In CACG group,eyes with less than 90° PAS were studied.UBM was used for all cases at one month after laser peripheral iridotomy and stopping pilocarpine eyedrops more than one week.Platau iris in a quadrant was defined by anteriorly directed ciliary body,absent ciliary sulcus,steep iris root from its point of insertion followed by a downward angulation,flat iris plane,and irido-angle contact.At least two quadrants had to fulfill these UBM criteria for an eye to be classified as having platau iris.Results 12 of 29 (41.4％) cases in CACG group fulfilled all the criteria for platau iris,while in APACG group,7 of 37 (18.9％) cases were diagnosed as platau iris.The difference was statistically significant (P =0.045) after laser peripheral iridotomy.Conclusion Platau iris has a higher prevalence in CACG than in APACG after laser peripheral iridotomy. Key words: Glacoma, angle closure, primary; Platau iris

Purpose: To evaluate the outcomes of trabeculectomy performed on eyes with medically uncontrolled acute angle closure glaucoma (AACG). Methods: The authors reviewed 31 eyes of 30 acute primary angle-closure glaucoma patients who had undergone trabeculectomy. The eyes were divided into two groups: eyes which did not respond to medical and/or laser treatment (Group A, 16 eyes) and those which initially responded to medical and/or laser treatment and later had an intraocular pressure (IOP) increase (Group B, 15 eyes). Complete success was defined as a final IOP below 21 mmHg without medication, and qualified success was defined as a final IOP below 21 mmHg with medication. Patients whose postoperative IOP was 22 mmHg or greater on at least two serial measurements or who required additional glaucoma surgery were classified as failures. Results: The mean follow-up was 43.132.3 months. The five-year qualified success rate was 56.3% in Group A and 100% in Group B (log-rank test, p=0.02). The preoperative IOP was significantly higher in Group A (38.011.5 mmHg) than in Group B (21.812.2 mmHg) (p 0.05). Conclusions: The medically uncontrolled AACG appears to have an adverse effect on the outcome of trabeculectomy. Success of trabeculectomy in AACG seems to be inversely related with elevated preoperative intraocular pressure.

Objective To measure macular retinal thickness parameters in acute primary angle-closure glaucoma (APACG) patients and to compare them to normal subjects using three dimensional Optical Coherence Tomography (3D-OCT) and discuss the possible mechanism.Methods The prospective analysis included 26 participants with APACG affected 30 eyes (including 22 patients with unilateral affected eyes and 4 patients with bilateral eyes) and 40 healthy subjects in control group.3D-OCT was used to measure and compared the macular retinal thickness in both two groups' eyes.Results Comparison of the macular retinal thickness between the groups showed that the thickness in the APACG eyes were significantly greater than in healthy eyes at fovea and at lmm from the fovea (t =4.07,3.30; both P =0.00),while there were no statistic difference in macular inner-ring retinal thickness and outer-ring retinal thickness (both P ＞0.05).The retinal thickness at fovea and at lmm from the fovea in APACG eyes were (238.38±51.77)μm,(248.31±40.79)μm,while in healthy eyes were (195.73±16.38)μm,(220.15±-18.61)μm.Conclusions Macular retinal thickness in the APACG eyes is significantly greater than in healthy eyes at fovea and at lmm from the fovea,presumably because of macular edema.The innovation of OCT technology may probably help us to learn more about the pathogenesis of acute angle-closure glaucoma. Key words: Acute primary angle-closure glaucoma; Macular; Optical coherence tomography

To establish the profile of patients with acute primary angle-closure glaucoma (APACG) and to assess comparatively clinical and morphometric parameters between eyes with APACG and contralateral eyes (CLEs). Prospective study including patients attended from September 2005 to March 2007. diagnosis of APACG. presence of cataract (except for "glaukomflecken") that may cause low visual acuity or myopization, secondary glaucoma, previous APAGC or surgical procedure in the (CLE), no possibility to control the acute crisis of glaucoma clinically, plateau iris. The following were evaluated: incidence of APACG, age, gender, race, family history of glaucoma, corrected visual acuity (CVA) and uncorrected visual acuity (UVA), spherical equivalent (SE), cup/disc ratio (C/D), gonioscopy, keratometry (K), central corneal thickness (CCT), and echobiometric data [anterior central chamber depth (ACCD), axial length (AL), lens thickness (LT)] and relation between lens thickness and axial length (LT/AL). One thousand and three hundred and forty-three patients were examined from September 2005 to March 2006; 28 (2.1%) had the diagnosis of APACG. The incidence of the APACG was 20.8 cases per 1000 patients. The patients with APACG were manly white women with a negative familial history of glaucoma and with an average age of 59.6 years. When clinical aspects were compared between eyes with APACG and CLEs, statistical significance was observed: UVA (APACG: 0.27 +/- 0.32; CLE: 0.57 +/- 0.33, p=0.000); CVA (APACG: 0.53 +/- 0.44; CLE: 0.88 +/- 0.23, p=0.000); SE (APACG: +0.49 +/- 1.98; CLE: +1.21 +/- 2.03, p=0.007); C/D (APACG: 0.51 +/- 0.28; CLE: 0.42 +/- 0.20; p=0.031). Also, by gonioscopy, eyes with APACG demonstrated more frequently angle closure than CLEs. The eye of the crisis showed the following characteristics: average K of 45.21 +/- 1.96 D, average CCT of 534.46 +/- 34.15 mm, average ACCD of 2.43 +/- 0.28 mm, average AL of 21.68 +/- 0.96 mm, average LT 4.85 +/- 0.32 mm and average LT/AL of 2.24 +/- 0.16. The CLE presented average K of 44.92 +/- 1.86 D, average CCT of 533.18 +/- 31.41 microm, average ACCD of 2.51 +/- 0.29 mm, average AL of 21.82 +/- 0.92 mm, average LT 4.85 +/- 0.36 mm and average LT/AL of 2.23 +/- 0.18. There were statistically significant differences only in two parameters (K and ACCD) when affected and the CLE were compared. The incidence of the APACG was 20.8/1000. It was more frequent in white women, leu kodermics, without family history of glaucoma and with an age average of 59.6 years. The eyes with APACG showed, with statistical significance, worse visual acuity, higher C/D, lower hypermetropic SE, higher average K, and lower ACCD than CLEs.

Objective To explore the differences in anatomic structures of primary acute angle closure glaucoma (PAACG).Methods sixty eyes of 30 cases of PAACG and 60 eyes of 30 cases of normal eyes were enrolled in the study.For PAACG patients,anatomical structural data were obtained before and after trabeculectomy surgery.Then the results were compared with the data of normal eyes.Observational items included anterior chamber depth,lens thickness,vitreous cavity length,axial length and corneal diameter.The relative location of lens was calculated by the formula (anterior chamber depth + 1/2 lens thickness) over axial length.The coefficient of lens thickness over axial length was calculated and analyzed.Results Compared with normal eyes,PAACG patients had shallower anterior chamber,thicker lens,shorter axial length,forward shifting of lens position,smaller corneal diameter and larger coefficient of lens thickness/axial length.The differences were statistically significant (P ＜ 0.05).Conclusion PAACG patients have shallower anterior Chamber,thicker lens,shorter axial length and smaller corneal diameter.The relative location of lens and coefficient of lens thickness/axial length are the early indicators for PAACG. Key words: Glaucoma, angle closure, acute; Structure, anatomic ; Ultrasonography; Trabeculectomy

To evaluate the anterior segment parameters in the subtypes of primary angle closure glaucoma (PACG) using ultrasound biomicroscopy. Five groups, each comprising 30 consecutive patients, diagnosed to have subacute PACG, acute PACG, chronic PACG, primary open angle glaucoma (POAG), and healthy controls were included in the present study. All patients underwent slit-lamp biomicroscopy, direct ophthalmoscopy, 90D fundus examination, gonioscopy, applanation tonometry, visual field testing, A-scan biometry, and ultrasound biomicroscopy (UBM). The anterior segment parameters recorded included: trabecular-iris angle, angle opening distance, trabecular ciliary process distance, and the iris thickness among other parameters. On ultrasound biomicroscopy the trabecular iris angle of control and POAG groups was more than all the subtypes of PACG (P < 0.001). The trabecular iris angle of subacute PACG (P < 0.001) and chronic PACG (P = 0.003) was more than acute PACG. Angle opening distance of controls and POAG group was significantly more than acute PACG and chronic PACG (P < 0.001). The trabecular ciliary process distance of POAG group and controls was more than subacute PACG, acute PACG, and chronic PACG. The trabecular ciliary process distance of subacute PACG (P < 0.001) and chronic PACG (P < 0.001) was more than acute PACG. Eyes with acute PACG had the least iris thickness at the three different positions tested. There was a positive correlation between the anterior chamber angle (trabecular iris angle) and the following parameters: trabecular ciliary process distance, angle opening distance, anterior chamber depth, and the axial length (r = 0.57). Eyes with primary angle closure glaucoma have a thinner iris with a shorter trabecular iris angle, angle opening distance, and trabecular ciliary process distance. The eyes with acute primary angle closure glaucoma have the narrowest angle recess.

Purpose:To study ultrastructural changes of the trabecular meshwork in acute and chronic primary angle closure glaucoma (PACG) and primary open angle glaucoma (POAG) eyes by scanning electron microscopy.Materials and Methods:Twenty-one trabecular meshwork surgical specimens from consecutive glaucomatous eyes after a trabeculectomy and five postmortem corneoscleral specimens were fixed immediately in Karnovsky solution. The tissues were washed in 0.1 M phosphate buffer saline, post-fixed in 1% osmium tetraoxide, dehydrated in acetone series (30-100%), dried and mounted.Results:Normal trabecular tissue showed well-defined, thin, cylindrical uveal trabecular beams with many large spaces, overlying flatter corneoscleral beams and numerous smaller spaces. In acute PACG eyes, the trabecular meshwork showed grossly swollen, irregular trabecular endothelial cells with intercellular and occasional basal separation with few spaces. Numerous activated macrophages, leucocytes and amorphous debris were present. Chronic PACG eyes had a few, thickened posterior uveal trabecular beams visible. A homogenous deposit covered the anterior uveal trabeculae and spaces. Converging, fan-shaped trabecular beam configuration corresponded to gonioscopic areas of peripheral anterior synechiae. In POAG eyes, anterior uveal trabecular beams were thin and strap-like, while those posteriorly were wide, with a homogenous deposit covering and bridging intertrabecular spaces, especially posteriorly. Underlying corneoscleral trabecular layers and spaces were visualized in some areas.Conclusions:In acute PACG a marked edema of the endothelium probably contributes for the acute and marked intraocular pressure (IOP) elevation. Chronically raised IOP in chronic PACG and POAG probably results, at least in part, from decreased aqueous outflow secondary to widening and fusion of adjacent trabecular beams, together with the homogenous deposit enmeshing trabecular beams and spaces.

Acute Primary Angle Closure Structural Damage