Acute Primary Angle Closure Attack Research Articles

Long-term prognosis of acute primary angle closure in an east asian cohort

PurposeTo provide an updated analysis of the long-term outcomes of patients with acute primary angle closure (APAC) and to investigate the risk factors for visual field (VF) loss progression.Study DesignRetrospective, clinical cohort studyMethodsOne hundred and forty-six APAC patients with a minimum of 1-year follow-up were included. The presenting features and the treatment utilized were recorded. The visual and intraocular pressure (IOP) outcomes were analyzed. The main outcome measures were the proportion of blindness and IOP at the final visit. A subset of patients with sufficient VF results was divided into a stable and progressive group based on mean deviation (MD) loss rate. Univariate and multivariate logistic regression analyses were performed to identify predictors of progression.ResultsNine patients (6.2%) were blind, and 76.0% (111/146) had final decimal visual acuity greater than or equal to 0.5. All patients had normal final IOP, and 65.1% (95/146) were medication-free. 64.4% (94/146) underwent cataract surgery at a median 4 months after their APAC attack. The use of topical hypotensive medications (OR = 8.029, P = 0.012) was the only significant predictor of fast MD loss in the multivariate regression.ConclusionsThe long-term outcomes of APAC in recent years have been more promising. All patients maintained normal IOP several years following their APAC attack, and fewer than half required hypotensive agents. The incidence of blindness was low. These findings suggest that current practice patterns in the management of APAC are beneficial.

Bilateral acute angle closure attack in Weill–Marchesani syndrome: A case report

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.

The Outbreak of Acute Primary Angle-Closure Cases During the COVID-19 Omicron Variant Pandemic at a Tertiary Eye Center in Shanghai.

This study aimed to investigate the outbreak of acute primary angle-closure (APAC) during the COVID-19 Omicron variant pandemic in Shanghai. This single-center retrospective observational study included all newly diagnosed patients with APAC in Eye, Ear, Nose, and Throat Hospital of Fudan University from December 15, 2022, to January 14, 2023 (pandemic group) during the COVID-19 pandemic of Omicron Variant, and from November 15, 2021, to February 14, 2022 (control group) when the infection rate of COVID-19 is very low in Shanghai. Demographic features, intraocular pressure, axial length, anterior chamber depth, lens thickness and pupil diameter were compared between the two groups. A total of 223 patients (261 eyes) were included in the pandemic group and 75 patients (82 eyes) in the control group. The number of APAC patients and eyes in the pandemic group is 8.92-fold and 9.55-fold of the monthly average number in the control group. The onset dates of acute angle-closure were mainly between December 17 and December 31, 2022. In the pandemic group, 72.65% of patients with APAC had a recent COVID-19 infection. Among the COVID-19-positive patients, 72% suffered APAC attacks within 24h of the occurrence of COVID-19 symptoms and 92% within 3 days. The pandemic group showed a longer time from symptoms to treatment and larger pupil diameter than the control group (7.92 ± 6.14 vs 3.63 ± 2.93 days, p = 0.006; 4.53 ± 1.17 vs 3.78 ± 1.24 mm, p = 0.003, respectively). An outbreak of APAC attack was observed in our eye center during the COVID-19 Omicron variant pandemic in Shanghai. There may be a correlation between the onset of APAC and new COVID-19 Omicron variant infection, but the exact reason needs to be investigated further.

Evaluation of the Manchester Triage System in Patients with Acute Primary Angle Closure Attack: A Retrospective Study

Acute primary angle closure attack is an ophthalmological emergency. The aim of this study was to describe the cases diagnosed in the Emergency Department, by correlating the initial complaint with the Manchester triage level and ultimately the time needed until ophthalmological evaluation and iridotomy. Retrospective analysis of the electronic medical records of patients with acute primary angle closure attack that attended the Ophthalmology Emergency Department of our tertiary center between January 2010 and December 2020. Overall, 2228 Emergency Department episodes coded with the diagnoses glaucoma or ocular hypertension were retrieved, followed by screening of each episode for correct identification of true acute primary angle closure attacks. Clinical data was gathered, including Manchester triage level, presenting complaint, intraocular pressure at presentation, first medical specialty that observed the patient, time until observation by Ophthalmology and time until laser iridotomy. Among the 120 patients identified, 84 (70%) were female and the mean age was 68 ± 12 years. Mean intraocular pressure at admission was 53.4 ± 12.4 mmHg, and 9.2% of patients presented only non-ocular complaints, while 9.2% presented mixed complaints (ocular and non-ocular). Most patients (68.1%) with only non-ocular or mixed complaints were triaged to a non-ophthalmologist (p < 0.001). Concerning the triage system, at admission, most patients (66.7%) were labelled yellow (urgent), while 9.2% and none were labelled as orange (very urgent) or red (emergent), respectively. Most patients (83.3%) were directly sent to Ophthalmology (properly triaged), while the remaining were incorrectly assigned to a non-ophthalmologist. Median time until observation by Ophthalmology was 49 minutes in the properly triaged group (min. 15, max. 404), while it was 288 minutes (min. 45, max. 871) in those who were incorrectly triaged (p < 0.001). Likewise, median time until treatment with laser iridotomy was 203 minutes in the properly triaged group (min. 22, max. 1440) and 353 minutes in the incorrectly triaged group (min.112, max. 947) (p < 0.001). Most patients with acute primary angle closure attack were not properly triaged according to the level of the Manchester triage system. There was a significant delay in the diagnosis and treatment of those patients who were first assigned to non-ophthalmologists. There is a need to raise awareness regarding the presenting signs and symptoms of an acute primary angle closure attack in order to avoid preventable vision loss.

Anterior Lens Curvature Matters in the Course of Primary Angle Closure: An Analysis Based on Ultrasound Biomicroscopic Imaging.

Purpose To evaluate the effect of anterior lens curvature in primary angle closure (PAC) and find additional anatomical features of crystalline lens that may predispose primary angle closure to the acute course. Methods 435 eyes (263 subjects) were enrolled in this study. Four groups of eyes were included based on angle configurations and clinical features: (i) acute primary angle closure (APAC, 140 eyes); (ii) chronic primary angle closure (CPAC, 116 eyes); (iii) primary angle closure suspect (PACS, 84 eyes); and (iv) normal controls (95 eyes). All patients underwent thorough ophthalmic exams including applanation tonometry, gonioscopy, low-coherence interferometry, and ultrasound biomicroscopic imaging. Based on the panoramic anterior segment images from ultrasound biomicroscopic imaging measurements, the radius of anterior lens curvature (ALR) was calculated using the least-squares curve fitting technique. ALR, in addition to axial length (AL), anterior chamber depth (ACD), and lens thickness (LT), was compared among different groups using univariate and multivariate analysis with mixed effects linear model. Results APAC, CPAC, and PACS groups all had steeper ALR, shorter AL, shallower ACD, and thicker LT than normal control group. ACD and LT further differ between APAC and CPAC or PACS eyes. Moreover, a steeper ALR was also found in the APAC group as compared to CPAC, PACS, and normal control groups. Conclusions A steeper ALR may predispose the acute attack of PAC. In addition to the relative lens position and size, lens curvature is another variable that contributes to the pathophysiological mechanisms of primary angle closure.

Bruch's membrane opening - minimum rim width measurement after acute primary angle-closure.

To evaluate Bruch's membrane opening - minimum rim width (BMO-MRW) and peripapillary retinal nerve fiber layer thickness (RNFLT) following an acute primary angle-closure attack (APAC). Nine consecutive patients with unilateral APAC were included. Patients with a bilateral attack, with signs of glaucomatous optic nerve damage or evidence of a previous APAC in either eye were excluded. Three months after the attack, all eyes underwent BMO-MRW and RNFLT measurements with SDOCT. APAC eyes were compared to the contralateral eyes. Three months after the attack, mean BMO-MRWs were 281.22 ± 56.88 μm and 313.78 ± 43.48 μm (P = 0.009) and mean RNFLTs were 78 ± 15.36 μm vs 95.78 ± 10.81 μm (P = 0.008) in the APAC and contralateral eyes, respectively. RNFLT and BMO-MRW measurements had a strong positive correlation (R = 0.7436, P = 0.013). APAC eyes had a shorter axial length (21.85 ± 1.21 vs 22 ± 1.07, P = 0.042) and shallower anterior chamber depth (2.29 ± 0.21 vs 2.41 ± 0.12, P = 0.039) than contralateral eyes. IOP at presentation showed a strong negative correlation with both BMO-MRW (R = -0.7669, P = 0.009) and RNFLT measurements (R = -0.7723, P = 0.008). BMO-MRW and RNFLT measurements are significantly reduced 3 months after an APAC when compared to the contralateral eye. IOP at presentation may have an impact on the reduction of these parameters.

Seasonal variations and climatic factors on acute primary angle-closure admission in southern China: a 5-year hospital-based retrospective study.

To delineate the seasonality of acute primary angle-closure (APAC) admission in a coastal city of southern China and its association with climatic factors. A total of 1155 Chinese subjects with principal diagnosis of APAC attack were recruited from 2012 to 2016, and their medical records were retrieved. Monthly climatic factors were obtained from the Meteorological Bureau of Shantou. Monthly and seasonal APAC admissions were compared, and its correlation with climatic factors was evaluated. APAC admission was higher in female subjects (75.9%) with an overall mean age of 64.7±9.3years. APAC admission was highest in summer with the peak onset in June. The peak of APAC admission for female subjects aged≤65years was in June, and that for>65years was in July. The peak of APAC admission for male subjects aged >65years was in August. Precipitation was positively correlated with APAC admission rate for both aged≤65 (β=0.415, p=0.001) and >65years old (β=0.364, p=0.004) female subjects. In contrast, surface temperature was positively correlated with APAC admission rate for male subjects aged >65years (β=0.441, p<0.001). No climatic factor was correlated with APAC admission rate for male subjects≤65years. This study revealed the peak season of APAC admission in summer, and surface temperature and precipitation are the associated factors. Close monitoring of climate changes could help to reduce the incidence of APAC attack.

Vessel density and retinal nerve fibre layer thickness following acute primary angle closure

BackgroundTo evaluate changes in circumpapillary vessel density (cpVD) and retinal nerve fibre layer (cpRNFL) thickness after a successfully treated episode of acute primary angle closure (APAC) and to identify factors...

Acute primary angle-closure in Sturge-Weber syndrome

PurposeSturge-Weber syndrome (SWS) is a neurocutaneous disorder characterized by facial cutaneous venous dilatation (port-wine stain), leptomeningeal angioma, and ocular abnormalities. Here we report a case of SWS who experienced acute primary angle-closure in the same side of the nevus flammeus. ObservationsA 64-years-old female patient with SWS port wine stain on the left side of her face was referred to our ER for acute primary angle-closure (PAC). The IOP was 64 mmHg in the left eye (12 mmHg in OD) and the visual acuity was 20/100. The acute PAC was aborted after medical treatment with intravenous Mannitol and oral Acetazolamide, but laser iridotomy (LI) was not performed because of the risk of bleeding. After the acute episode, her IOP remained stable in midteen under 3 topical medications. However, the patient reported several subacute attacks in the following month. We arranged phacoemulsification and intraocular lens (IOL) implantation two months after the initial PAC attack. The post-op condition was smooth with 20/20 visual acuity, and the angle opened dramatically on anterior segment optical coherence tomography (AS-OCT). Her IOP was around 13 mmHg without medication and there was no more acute PAC attack. ConclusionsSWS with ipsilateral acute PAC has seldom been reported. Lens extraction and IOL implantation can be an option in treating such patients since conventional laser iridotomy may cause bleeding.

Long-term outcomes after acute primary angle closure of Caucasian chronic angle closure glaucoma patients.

There is a lack of information about long-term results of chronic angle closure glaucoma following an acute primary angle closure attack in Caucasian patients. The aim of the study was to report morphological and functional long-term data of chronic angle closure eyes following a monolateral primary angle closure attack and to provide a comparison with their fellow eyes. Observational retrospective case series. Fifty-seven consecutive patients (114 eyes) underwent long-term follow-up analysis. Patients underwent ophthalmic assessment more than 5years since the angle closure attack. Intraocular pressure, best-corrected visual acuity, angle assessment, vertical C/D ratio and standard automated perimetry were the main outcome measures. Comparisons were made between angle closure attack eyes and fellow eyes and between phakic and pseudophakic eyes. Mean follow-up time was 5.86±1.19years. A significant greater damage in the angle closure eyes compared with fellow eyes in both structural (mean C/D 0.61 ± 0.16; P < 0.001) and functional (mean deviation: -7.98 ± 6.46 vs. -4.83 ± 4.95 dB; P < 0.001) terms was present. Mean IOP was 13.44 ± 2.78 and 13.89 ± 2.60 mmHg in angle closure and fellow eyes (P = 0.11). Thirty of 57 (53%) fellow eyes developed chronic angle closure (mean deviation: -7.74 ± 5.21 dB) even if prophylactic iridotomy was promptly performed. Our study prompts ophthalmologists to closely follow patients after an APAC attack to prevent potential glaucoma damage in both APAC and fellow eye.

Uveal effusion following acute primary angle-closure: a retrospective case series.

To evaluate the morphological changes in anterior segment in Chinese patients with uveal effusion (UE) after the attack of acute primary angle-closure (APAC) using ultrasound biomicroscopy (UBM), and to assess the clinical course and prognosis of the disease. In a retrospective case series, 26 eyes in 26 consecutive patients diagnosed with UE after the treatment of intraocular pressure (IOP)-lowering medication for the attack of APAC were enrolled. The unaffected fellow eyes served as controls. The morphological changes were observed by ultrasonography, slit lamp microscopy and gonioscopy. UBM was used to assess the degree and extent of effusion based on the analysis of parameters associated with UE. The mean IOP was 9.2 (SD 2.1) mm Hg at the diagnosis of UE after IOP-lowering medication, while 14.1 (SD, 2.6) mm Hg in the fellow eyes (P=0.000). The anterior chamber depth (ACD) (P=0.000), angle opening distance at 500 µm (AOD500) (P<0.01) and anterior chamber angle (ACA) (P<0.05) were decreased significantly, while ciliary body thickness (CBT) (P<0.05) increased significantly in UE eyes. UE grade analysis showed 7 eyes in grade 1, 9 eyes in grade 2, and 10 eyes in grade 3. Quadrant scores were performed of 4 eyes in 1 quadrant, 3 eyes in 3 quadrants, and 19 eyes in 4 quadrants. There was the positive correlation between grade and quadrant score (r=0.644, P=0.000). The effusion on all eyes were recovered after medication, which mean IOP was 13.9 (SD, 2.8) mm Hg. UE is a frequent complication in Chinese patients after the attack of APAC, partially associated with hypotony. The severity of UE is correlation with height of effusion, extent of detachment, and shallower ACD.

Immediate Anterior Chamber Paracentesis with a 30-Gauge Needle for Acute Primary Angle Closure

Background: Primary angle-closure glaucoma (PACG) is more common among Asians than among Caucasians. Acute primary angle closure (APAC) is a serious associated complication in PACG patients. When conventional treatment fails, Anterior Chamber Paracentesis (ACP) can be performed to decrease IOP. Although slit knives are commonly used for performing ACP, other techniques can also be used to perform this procedure. Objective: To investigate the efficacy and safety of immediate anterior chamber paracentesis using a 30-gauge needle combined with conventional topical and systemic medications for the treatment of APAC. Materials and methods: This prospective study was conducted in 15 consecutive primary angle-closure glaucoma patients that presented with and who were treated for acute primary angle closure (APAC) at the Department of Ophthalmology, Siriraj Hospital, (Bangkok, Thailand) during the January 2015 to December 2015 study period. Patients were included if they were older than 18 years of age, if this was their first known attack of APAC, and if they had an IOP ≥ 40 mmHg. Results: Mean age of the 15 included participants (3 males, 12 females) was 61 years. Mean presenting IOP ± SD was 54.3 ± 11.6 mmHg. Twelve of 15 eyes had visual acuity worse than 6/18. Immediately after ACP, mean IOP ± SD was 7.5 ± 5.1 mmHg. None of the 15 included eyes were reactive to light prior to ACP. Mean pupil diameter was significantly reduced from baseline at 60 minutes after ACP (p=0.004) and was significantly smaller than baseline at 24 h after ACP (p=0.03). BCVA was improved to ≥ 6/18 in 11 and 12 eyes at 1 and 24 h after ACP, respectively. All patients had relief from symptoms immediately following ACP. No ACP-related complications were observed in any patient in this study. Conclusion: Immediate APC with a 30-guage needle is a safe and effective initial treatment for APAC. APC should be combined with conventional treatment with topical and/or systemic medications. APC yields rapid IOP reduction, dramatic relief of symptoms, and corneal clarity. APC may also improve response to further treatment, improve IOP control, and may reduce or eliminate the need for systemic medication.

Changes in Anterior Segment Morphology After Laser Peripheral Iridotomy in Acute Primary Angle Closure

To evaluate the anterior segment biometric changes measured by anterior segment optical coherence tomography (AS-OCT) in acute primary angle closure (APAC) after laser peripheral iridotomy (LPI). Prospective interventional study. In this clinic-based study, 52 eyes of 52 patients with resolved APAC attack who underwent LPI were enrolled. Subjects underwent complete ophthalmic examination and AS-OCT imaging before and 6weeks after LPI. Anterior chamber depth (ACD), anterior chamber area (ACA), iris thickness (IT), iris area, iris curvature, lens vault (LV), anterior vault, angle opening distance (AOD500, AOD750), and trabecular iris space area (TISA500, TISA750) were measured in qualified images and compared before and after LPI. A linear mixed-model analysis was performed for potential predictors of change in AOD750. Main outcome measure was change in AOD750 after LPI. The mean age of participants was 60.7 ± 9.2 years. Mean angle width (Shaffer grade) changed from 0.25 ± 0.34 at baseline to 1.22 ± 0.86 after LPI (P < .001). However, 25 nasal angles (48.0%) and 28 temporal angles (53%) had iridotrabecular contact after LPI. All angle parameters (AOD500, AOD750, TISA500, TISA750; P ≤ .03), ACD (P= .001), and ACA (P < .001) increased significantly after LPI. Iris curvature and LV were reduced (P= .01 for both) after LPI, but there was no significant change in IT and iris area. After multivariate analysis, pre-LPI AOD750 was the only factor associated with change in AOD750 (β=-0.992, P= .02). Exaggerated LV, defined as LV greater than one-third of the anterior vault (sum of LV and ACD), was present in 61.5% of the cases (32 eyes). The extent of change in angle parameters was not significantly different between groups with and without exaggerated LV after LPI. This study confirms that LPI results in a significant increase in the angle width, ACD, and ACA as well as flattening of the iris in APAC eyes. The extent of angle deepening is inversely related to baseline angle width. The lens shifts posteriorly after resolution of attack, especially in those with greater lens vault.

Long-term outcomes after acute primary angle closure in a White Caucasian population.

IntroductionVery limited data is available on the morbidity and progression to primary angle closure glaucoma (PACG) in White Caucasian individuals following acute primary angle closure (APAC).Our aim is to identify the number of eyes who developed PACG following an APAC attack and to determine the risk factors for PACG development in a White Caucasian population in the United Kingdom (UK). We assessed the rate of blindness and visual impairment in the affected eye as defined by the World Health Organisation.MethodsRetrospective observational study including 48 consecutive eyes of 46 White Caucasian subjects who presented with APAC to a tertiary referral unit in the United Kingdom.Eyes affected by glaucomatous optic neuropathy at presentation were excluded. We included in our analysis socio-demographic variables, ophthalmic findings, investigations and treatment.ResultsThe mean final follow up period was 27 months ± 14 standard deviation (SD). Seven (15 %) eyes developed PACG. Statistical analysis showed that the following factors were linked to a higher risk of progression: length of symptoms before presentation and time taken to break the attack. The intraocular pressure (IOP) was significantly higher in the group who developed PACG at the one- and six-month visit compared to the group which did not develop the disease.At the final visit 3 (6 %) eyes were blind while 5 (10 %) were visually impaired. PACG was responsible for visual impairment in 2 (4 %) eyes but not for any case of blindness.ConclusionsDelayed presentation, length of time taken to break the attack and poor IOP control can result in PACG development and visual impairment. APAC causes a low long-term visual morbidity in White Caucasians.

Objective Assessment of Progression after Acute Primary Angle Closure Using HRT and GDx

Irreversible damage to the optic nerve can follow the rapid increase of IOP during an Acute Primary Angle Closure (APAC). Despite the development of advanced imaging technology, there is still a lack of good longitudinal studies assessing patients after an acute attack. The aim of this study was to assess the progression of patients using different objective optic nerve head and retinal imaging parameters following APAC. Twenty patients with a single attack of APAC, were retrospectively assessed in this study. Patients were assessed with the Heidelberg Retinal Tomography (HRT3) and Scanning Laser Polarimeter (GDx-VCC) as well as Humphrey Visual Field (HVF) repeatedly up to eighteen months after the acute attack. Progression for each imaging modality was assessed with multiple parameters. All patients showed Retinal Nerve Fibre Layer (RNFL) and optic disc changes over time. At 18 months, 67% of patients showed progression in 4/5 GDx parameters, and 33% in all 5. HRT analysis similarly showed progression in 4/5 parameters in 70% of patients, and 30% in all 5. This study shows that structural progressive changes to RNFL and ONH occur following APAC confirming that APAC patients need long-term follow-up after the acute attack.

Quantification of Retinal Nerve Fiber Layer Thickness After Unilateral Acute Primary Angle Closure in Asian Indian Eyes

To determine retinal nerve fiber layer thickness (RNFLT) using Spectral optical coherence tomography/scanning laser ophthalmoscope (Spectral OCT/SLO) in Asian Indian eyes after single, unilateral attack of acute primary angle closure (APAC). Thirty-two patients with unilateral attack of APAC with normal optic disc and normal visual field, unaffected fellow eyes, and 35 age-matched normal control eyes were enrolled for the study. Six weeks after the remission of acute attack, peripapillary average, quadrant, and clock-hour RNFLT were compared between 3 groups using Spectral OCT/SLO. APAC patients had mean IOP of 51.3±13.3 mm Hg (range, 40-74) at the time of presentation with acute attack in the affected eye and 14.9±2.9 mm Hg at 6 weeks after resolution of APAC. Duration of symptoms of acute attack was 35.9±23.8 hours. Significant differences were found between RNFLT in APAC and fellow eyes for most the parameters except for 1, 4, 6, and 7-o'clock-hour sector. Most of the RNFLT parameters showed statistically significant difference between APAC and normal control eyes except for temporal quadrant, 6, 7-o'clock-hour sectors. Statistically significant differences were found between RNFLT in unaffected fellow and normal control eyes for most of the parameters except for 6, 7, 11 o'clock-hour sectors. RNFLT was found to be significantly thinner in APAC and unaffected fellow eyes when compared with normal age-matched controls. Hence, patients with APAC should be monitored carefully to determine its long-term effects on optic disc, RNFLT, and visual fields. Longitudinal studies can determine whether the RNFLT measurements remained stable or showed progression in these patients.

A comparison of two approaches to managing acute primary angle closure in Asian eyes

PurposeTo review the management regimes of acute primary angle closure (APAC) in two hospitals in Singapore, and to identify the incidence of and risk factors for progression to glaucomatous optic neuropathy.MethodsWe conducted a retrospective review of 40 patients from National University Hospital (NUH) and 52 patients from Singapore National Eye Centre (SNEC) who were diagnosed with APAC. Patients were treated with similar protocols of intensive medical therapy until laser peripheral iridotomy could be performed. In the event of failed medical treatment, patients at NUH only underwent laser iridoplasty. The 1-year outcomes were reviewed.ResultsThe demographic features of patients and presenting intraocular pressures (IOP) were similar in both centers. More patients from NUH presented within 3 days of symptom onset, compared to those from SNEC (90.0% versus 71.2%, respectively) (P = 0.037). The mean ± standard deviation time to break the attack was 18.2 ± 32.9 hours at SNEC and 9.80 ± 10.6 hours at NUH (P = 0.11). The mean follow up duration was 18.8 ± 14.0 months. Nineteen patients (36.5%) from SNEC and six patients (22.5%) from NUH developed raised IOP (P = 0.032) within 1-year of the attack. Of these, glaucomatous optic neuropathy developed in thirteen patients (68.4%) from SNEC and all six patients (100%) from NUH. At final review, the mean IOP of the APAC eye was 14.8 ± 4.3 mmHg from SNEC and 13.4 ± 3.0 mmHg from NUH. There was no significant difference in final visual acuity or IOP between both groups.ConclusionTreatment strategies in both centers were effective in aborting an APAC attack. The development of raised IOP appears to be associated with a longer period of attack suggesting that greater urgency in aborting APAC attacks may entail better long term outcomes.

Acute Primary Angle Closure Attack Does Not Cause an Increased Cup-to-Disc Ratio

To determine if an increased cup-to-disc ratio (CDR) and retinal nerve fiber layer (RNFL) loss occur after acute primary angle closure (APAC). Prospective, observational case series. Twenty participants with unilateral APAC provided 20 affected eyes and 20 fellow eyes (controls) for analysis. After initial presentation, participants attended 3 further assessments over a 12-month period (visit 2, within 2 weeks; visit 3, 2-3 months; and visit 4, 6-12 months), in which they underwent the following investigations: Heidelberg Retinal Tomography (Heidelberg Engineering, Dossenheim, Germany), optical coherence tomography of the RNFL and macula, and automated perimetry. Cup-to-disc ratio, optic cup area, neuroretinal rim area, RNFL thickness, macular thickness, and volume. There was no change from visits 2 to 4 in CDR (0.46 ± 0.17 vs. 0.47 ± 0.20; P = 0.94), neuroretinal rim area (1.64 ± 0.55 vs. 1.64 ± 0.57; P = 0.96), or other optic nerve head parameters analyzed in eyes with APAC. The mean overall RNFL thickness decreased from 106.6 ± 17.9 μm to 92.9 ± 18.3 μm between visits 2 and 3 (P<0.01) in affected eyes. The superior quadrant RNFL thickness decreased from 134.8 ± 25.9 μm to 113 ± 25.7 μm (P<0.01), and the inferior quadrant RNFL thickness decreased from 139.1 ± 28.4 μm to 115.6 ± 24.9 μm (P<0.01). There was no significant change in macular thickness or volume. This study demonstrated that an increase in CDR does not occur after APAC that is treated promptly, although RNFL loss does occur.

Optical Coherence Tomography Measurement of Retinal Nerve Fiber Layer After Acute Primary Angle Closure With Normal Visual Field

To detect retinal nerve fiber layer (RNFL) thickness after a single acute primary angle closure (APAC) attack with normal visual field. Prospective, observational case study. Twenty-eight patients who had a single unilateral APAC attack associated with normal visual fields at three months after remission and 28 single eyes from normal controls were enrolled. Duration of APAC attack was 5.9 +/- 2.7 hours. Comparisons of average RNFL thickness and RNFL thickness in four quadrants and in 12-o'clock-hour segments of the attacked eyes, unaffected fellow eyes, and normal controls were made using fast RNFL thickness (3.4) of Stratus optical coherence tomography. Significant differences were demonstrated comparing the inferior-quadrant RNFL thicknesses for the attacked eyes with those of the normal controls (P = .02) and fellow eyes (P = .02) using one-way analysis of variance with Tukey's tests. Inferior region RNFL thickness was significantly decreased in the attacked eyes after an APAC episode associated with normal visual field.

Long-term outcomes in asians after acute primary angle closure

Purpose To determine the long-term outcome of Asian eyes with an acute attack of primary angle closure (APAC) and to identify risk factors at presentation associated with the development of glaucomatous optic nerve damage. Design Cross-sectional observational case series. Participants Ninety individuals who were initially seen with APAC 4 to 10 years previously at 2 Singapore hospitals. Methods All subjects underwent a complete eye examination, including visual acuity, visual field testing, dilated eye examination, and optic nerve head photography. The optic discs were judged clinically and photographically as to whether there was glaucomatous optic neuropathy present, and visual fields were assessed for corresponding visual field loss. All visual fields and optic nerve photographs underwent a second evaluation by an experienced, but masked, glaucoma specialist, who assessed whether the changes were compatible with glaucoma. Main outcome measures The main outcome measures were blindness (defined as best-corrected visual acuity worse than 6/60 and/or central visual field of less than 20° in the attack eye) and glaucomatous optic neuropathy (GON). Results A total of 90 of 170 eligible subjects (65.2%) were examined. All subjects were Asian and were predominantly Chinese (78 subjects [86.7%]). There were 61 females (67.8%), and the age of the subjects was 62.0±9.0 years (mean ± standard deviation) at the time of APAC, with a mean duration of 6.3±1.5 years from the time of the APAC episode to the study examination. Sixteen (17.8%) subjects were blind in the attack eye; half of the cases of blindness were caused by glaucoma. Forty-three subjects (47.8%) had GON, with 13 eyes (15.5%) having markedly cupped optic discs (cup-to-disc ratio >0.9). Thirty-eight eyes (58%) had best-corrected vision worse than 6/9, with cataract responsible for close to half the cases of poor vision. There were no identifiable risk factors related to the APAC episode that were significantly associated with the presence of GON. Conclusions Several years after being seen with APAC, 17.8% of subjects examined were blind in the attack eye, and almost half had glaucomatous optic nerve damage. Vision was also reduced in a large number of individuals, largely from unoperated cataract. Subjects with APAC would benefit from regular follow-up to monitor for visual field decline and glaucoma development.