Attack Of Primary Angle Closure Research Articles

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.

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.

Rationale for early lens extraction in the treatment of primary angle closure disease

PURPOSE. To demonstrate the advisability of early lens extraction in the treatment of primary angle closure disease in clinical practice.METHODS. The study presents three clinical cases with patients at different stages of primary angle closure disease (PACD). The first one is related to the development of a bilateral acute attack of primary angle closure (PAC) that happened in the intensive care unit during treatment for acute respiratory distress syndrome (ARDS) associated with COVID-19 pneumonia in a patient with a previously undiagnosed PACD. The second case demonstrates the progression of glaucomatous optic neuropathy (GON) in early primary angle-closure glaucoma (PACG) after laser peripheral iridotomy (LPI) and delayed selective laser trabeculoplasty (SLT) in a patient with increased lens thickness. The third example illustrates the progression of advanced PACG in the right eye (OD) and moderate PACG in the left eye (OS) due to formation of goniosynechiae after bilateral LPI, which required transscleral diode cyclophotocoagulation (TSCP) in OD and trabeculectomy in OS. Subsequently, bilateral cataract phacoemulsification with intraocular lens implantation (CPE+IOL) and SLT were performed.RESULTS. In the first clinical case, advanced PACG developed in both eyes within 2 months. After bilateral LPI, trabeculectomy, compensation of intraocular pressure (IOP) was achieved, visual functions stabilized. In the second clinical case, 5.5 years after LPI and SLT, an increase in the thickness of the lens was revealed (in OD by 0.2 mm, in OS by 0.48 mm). GON did not progress in OD (thinning rate of the retinal nerve fiber layer was 0.94 µm/year, p=0.32) and the progression rate in OS was -1.04 µm/year (p=0.018). Taking into account the lens-involved mechanism of PACD progression, bilateral CPE+IOL was recommended. In the third clinical example, IOP remained elevated after bilateral LPI, TSCP in OD and trabeculectomy in OS as a result of goniosinechiogenesis, and therefore CPE+IOL also did not lead to its decrease. After bilateral SLT, compensation of IOP was achieved without local hypotensive therapy (IOP measured by Icare: OD 18.0 mm Hg, OS 15 mm Hg).CONCLUSION. In order to preserve visual functions, CPE+IOL is highly recommended at the very beginning of PACD, before the formation of GON and goniosynechiae. This is dictated by the dominant role of the lens-involved mechanism in PACD formation, as demonstrated in the described clinical examples.

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.

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.

In vivo Confocal Microscopy of Posner-Schlossman Syndrome: Comparison with herpes simplex keratitis, HLA-B27 anterior uveitis and acute attack of primary angle closure

To investigate in vivo confocal microscopy (IVCM) findings in patients with Posner-Schlossman Syndrome (PSS), we compared the IVCM findings from the eyes of patients with: PSS (44 eyes); herpes simplex keratitis (HSK) (45 eyes); HLA-B27 anterior uveitis (B27AU) (45 eyes); and with acute attack of primary angle closure (aPAC) (43 eyes). The central Langerhans cells (LCs) grade at the level of corneal basal epithelial cells of the PSS group (2.33 ± 0.55) was similar to that of the HSK group (2.63 ± 0.67) (χ2 = −1.435, P = 0.174) but was significantly higher than those of the B27AU group (1.80 ± 0.79) (χ2 = 2.311, P = 0.023) and the aPAC group (1.75 ± 0.46) (χ2 = 2.701, P = 0.022). The keratocyte activation grade of the PSS group (1.55 ± 0.76) was similar to that of the HSK group (1.65 ± 0.81) (χ2 = 1.104, P = 0.675) but was significantly higher than those of the B27AU group (1.00 ± 0.71) (χ2 = 2.364, P = 0.025) and aPAC group (1.75 ± 0.46) (χ2 = 2.532, P = 0.027). The LCs and keratocyte activation grades observed by IVCM in patients with PSS were higher than those in patients with B27AU and with aPAC, but they were similar to those in patients with HSK. This implies that PSS might be related to viral infection.

ACUTE PRIMARY ANGLE CLOSURE ATTACK DOES NOT CAUSE AN INCREASED CUP-TO-DISC RATIO

Wills Eye Institute Philadelphia, PA Original study reprint requests: Helen V. Danesh-Meyer, MD, Department of Ophthalmology, University of Auckland, Private Bag 92019, Auckland 1023, New Zealand. Chew et al. Primary Angle Closure Attack and Increased Cup-to-Disc Ratio 259.

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.

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.

Re: Laser Peripheral Iridoplasty as Initial Treatment of Acute Attack of Primary Angle-Closure: A Long-Term Follow-Up Study: Reply to Letter to the Editor

Re: Laser Peripheral Iridoplasty as Initial Treatment of Acute Attack of Primary Angle-Closure: A Long-Term Follow-Up Study: Reply to Letter to the Editor

Scanning laser polarimetry in patients with acute attack of primary angle closure

Purpose To compare the retinal nerve fiber layer measurements of attacked eyes with their fellow eyes after a single unilateral attack of acute primary angle closure (APAC). Methods Patients with a single episode of APAC in 1 eye, successfully treated with laser peripheral iridotomy, were recruited. Eyes with persistently raised intraocular pressure (IOP) after resolution of the acute attack were excluded. Scanning laser polarimetry was carried out at 6 months after remission of the acute attack. The various parameters between the attacked and the fellow eyes were compared using the Student t-test. Results Twenty-six patients (24 female and 2 male, mean age 66.9±8.1 years) were recruited. The duration of the APAC ranged from 5 to 98 hours (mean, 36.3 hours). The mean presenting IOP during the acute attack was 62.0±9.4 mm Hg. Only the mean inferior ratio and the ellipse modulation showed a statistically significant difference between the attacked and the fellow eyes among the 12 standard scanning laser polarimetry measurement parameters. Conclusion No severe retinal nerve fiber layer damage was documented in eyes that suffered a single episode of APAC with duration of attack up to 48 hours. With duration of attack longer than 48 hours, retinal nerve fiber layer damage was detected.