Management Of Angle-closure Glaucoma Research Articles

Management of angle-closure glaucoma with X-linked retinoschisis: a case report

BackgroundX-linked retinoschisis (XLRS), due to mutations in the RS1 gene, is a common genetically determined form of macular degeneration. This report describes an unusual case of angle-closure glaucoma (ACG) with XLRS and discusses the treatment.Case presentationA 39-year-old Chinese man with an X chromosome-recessive inherited c.489G > A variant in the RS1 gene was diagnosed as XLRS and ACG, presenting with cystic macular lesions, shallow anterior chamber depth (ACD), and angle-closure with uncontrolled intraocular pressure (IOP). Malignant glaucoma occurred following trabeculectomy combining phacoemulsification with intraocular lens (IOL) implantation and goniosynechialysis. Subsequent anterior vitrectomy and irido-zonulo-hyaloid-vitrectomy (IZHV) effectively lowered IOP and deepened ACD, but the cystic cavity became larger.ConclusionsThere is a potential risk of malignant glaucoma in ACG patients with XLRS after filtering surgery. Although anterior vitrectomy can effectively resolve aqueous misdirection, the macular retinoschisis may get worse. Awareness of this risk may aid in surgical planning and postoperative management in these patients.

Phacoemulsification with double-in-bag intraocular lens implantation in nanophthalmic eyes with angle-closure glaucoma.

To report the outcomes of phacoemulsification with piggyback intraocular lens (IOL) implantation, with double-in-bag IOLs in the management of angle-closure glaucoma (ACG) in nanophthalmic eyes. This is a retrospective case series on nanophthalmic eyes with variable presentations of ACG. Phacoemulsification with double-in-bag IOL implantation was done for the included eyes. Baseline and follow-up corrected distance visual acuity (CDVA), spherical equivalent (SE), intraocular pressure (IOP), and the number of glaucoma medications were evaluated. Surgical details were extracted, and complications were recorded. Six eyes of three patients were included. The mean axial length was 17.24 ± 1.02mm. The mean preoperative IOP was 20 ± 2.7mmHg with medical treatment. The mean preoperative CDVA (logMar) was 0.83 ± 0.37 with mean SE 12.7 ± 1.77 diopters. The mean postoperative IOP at 3-month and 1-year follow-ups was 14 ± 5.3mmHg and 15.5 ± 4.1mmHg, respectively. Postoperative CDVA was 0.78 ± 0.41, with mean SE -0.04 ± 2 diopters. No significant intraoperative or postoperative complications were reported. One eye developed posterior capsule opacification (PCO), and another eye developed visually insignificant inter-lenticular opacification (ILO). In the evaluated nanophthalmic eyes with ACG, lens extraction with double-in-bag IOL implantation showed promising results regarding the IOP control as well as the visual and refractive outcomes.

Management of Angle Closure Glaucoma in a Myopic Pregnant Woman during the COVID-19 Pandemic – A Case Journey

Introduction: We present a case of a young Caucasian myopic patient with secondary ACG and the management during her pregnancy amidst the COVID-19 pandemic. Angle closure glaucoma (ACG) is an uncommon condition in younger myopic individuals. Thus, ACG in pregnancy is not well researched and no definitive guidelines exist for its treatment. Case Report: This 27-year-old female patient had been diagnosed with hypertensive uveitis and referred to the glaucoma clinic where peripheral anterior synechiae (PAS) was noticed on gonioscopy. As she had subacute angle closure glaucoma symptoms, she had been started on topical pilocarpine drops. She remained stable and under our regular follow up (dates). At her review in January 2021, she notified us that she was 27 weeks pregnant. She had continued pilocarpine drops once a day. Pilocarpine is a category C drug (with potential foetal risk though lack of human studies). Pilocarpine was advised to be stopped in the clinic as intra-ocular pressure is known to stabilise during pregnancy. She was further reviewed in the third trimester and had an uneventful delivery with a healthy baby. Her last review was post-pregnancy. She remained asymptomatic and her intra-ocular pressures were stable for the entire duration. Conclusion: Our case was an unusual presentation of subacute angle closure secondary to PAS in a young myopic female. Her management of pregnancy in the COVID-19 pandemic when secondary to the social distancing rules was challenging as the clinic reviews are limited. We successfully managed timely reviews without risking the patient or the baby of any potential side effects to pilocarpine or COVID-19.

Changes in Iris Stiffness and Permeability in Primary Angle Closure Glaucoma.

PurposeTo evaluate the biomechanical properties of the iris by evaluating iris movement during pupil constriction and to compare such properties between healthy and primary angle-closure glaucoma (PACG) subjects.MethodsA total of 140 subjects were recruited for this study. In a dark room, the anterior segments of one eye per subject were scanned using anterior segment optical coherence tomography imaging during induced pupil constriction with an external white light source of 1700 lux. Using a custom segmentation code, we automatically isolated the iris segments from the AS-OCT images, which were then discretized and transformed into a three-dimensional point cloud. For each iris, a finite element (FE) mesh was constructed from the point cloud, and an inverse FE simulation was performed to match the clinically observed iris constriction in the AS-OCT images. Through this optimization process, we were able to identify the elastic modulus and permeability of each iris.ResultsFor all 140 subjects (95 healthy and 45 PACG of Indian/Chinese ethnicity; age 60.2 ± 8.7 for PACG subjects and 57.7 ± 10.1 for healthy subjects), the simulated deformation pattern of the iris during pupil constriction matched well with OCT images. We found that the iris stiffness was higher in PACG than in healthy controls (24.5 ± 8.4 kPa vs. 17.1 ± 6.6 kPa with 40 kPa of active stress specified in the sphincter region; P < 0.001), whereas iris permeability was lower (0.41 ± 0.2 mm2/kPa s vs. 0.55 ± 0.2 mm2/kPa s; p = 0.142).ConclusionsThis study suggests that the biomechanical properties of the iris in PACG are different from those in healthy controls. An improved understanding of the biomechanical behavior of the iris may have implications for the understanding and management of angle-closure glaucoma.

Deep learning algorithms to isolate and quantify the structures of the anterior segment in optical coherence tomography images

Background/AimsAccurate isolation and quantification of intraocular dimensions in the anterior segment (AS) of the eye using optical coherence tomography (OCT) images is important in the diagnosis and treatment of many...

Role of Anterior Segment OCT in the Management of Primary Narrow Angle Disease

Purpose: To highlight the role of anterior segment OCT, in complementing gonioscopic findings in the management of angle closure glaucoma.&#x0D; Study Design: Descriptive observational case series.&#x0D; Study Place and Duration: Study was conducted at Eye department of Shifa International Hospital, from January 2019 to March 2019.&#x0D; Methods: After taking informed consent from the patients, the study was conducted at Shifa International Hospital Islamabad. Patients were selected by convenient sampling technique. Patients were diagnosed on the basis of history and clinical examination. Patients with angle closure on Gonioscopy were included in this series. Detailed ocular examination including visual acuity for distance and near, tonometry, Gonioscopy and anterior segment OCT were performed. Data was collected and presented as case series.&#x0D; Results: The median age 57 years with 50% more than 60 years and 50% less than 60 years of age. Presenting IOP was less than 21 mmHg in 50% and higher in remaining 50%. On examination 37.5% were categorized as PACS, 12.5% having PAC and 50% as PACG. After definitive treatment 12.5% still needed medical treatment to prevent progression in PACG and none in PACS and PAC.&#x0D; Conclusion: In narrow angle disease, treatment is designed not only to control intraocular pressure (IOP) but also to keep angle open as much as possible. Appositional closure or peripheral anterior synechiae (PAS) can damage the trabecluar meshwork. Iridoplasty, peripheral Iridotomy (PI) and early lens extraction can defer the need for filtration procedure if done well in time.&#x0D; Key Words: OCT anterior segment, Narrow angle, Optic nerve head.

Pathogenic role of the vitreous in angle-closure glaucoma with autosomal recessive bestrophinopathy: a case report

BackgroundAutosomal recessive bestrophinopathy (ARB) is caused by homozygous or compound heterozygous mutations in the BEST1 gene and always accompanied with refractory angle-closure glaucoma (ACG). The exact mechanism for the pan-ocular abnormalities in ARB is still unknown and the management of ACG in these cases is challenging.Case presentationA 26-year-old patient with a novel autosomal–recessively inherited c.1 A > G variant in BEST1 diagnosed as ARB and ACG, presented as widespread vitelliform deposits in the posterior pole, retinoschisis in the macula, vitreoretinal interface abnormalities, shallow anterior chamber depth (ACD) and angle closure with uncontrolled intraocular pressure (IOP). Combined phacoemulsification, intraocular lens implantation and goniosynechialysis did not improve any clinical presentation. However, low dose transscleral cyclophotocoagulation with subsequent vitreous liquefaction effectively lowered IOP, deepened ACD, and rehabilitated retinoschisis in both eyes.ConclusionsThis case implied vitreous condition may play a pathogenic role in formation of retinoschisis and ACG in the patients with ARB. Treatments that induce vitreous liquefaction could be used to treat young ACG patients with ARB or other kinds of ACG to avoid vision-threatening post-operative complications.

Phacoemulsification with Peripheral Iridectomy and Trabeculectomy: Comparing the Two Procedures in Management of Angle-Closure Glaucoma

Background: glaucoma was ranked as one of the major causes of blindness worldwide. Angle-closure glaucoma (ACG) is a type of glaucoma characterized by narrowing or closure of the anterior chamber angle. Objective: to compare the clinical outcomes of phacoemulsification (Phaco) with peripheral iridectomy versus trabeculectomy in management of ACG. Patients and Methods: this study was a prospective, follow-up nonrandomized clinical trial, carried out on 50 eyes with ACG. Patients were divided into two groups: group A (n= 25); eyes underwent phacoemulsification with peripheral iridectomy, and group B (n= 25); eyes underwent sub-scleral trabeculectomy. Intraocular pressure (IOP), visual outcomes and postoperative complications were assessed. Patients were followed-up for 6 months. Results: postoperative visual acuity was significantly improved in phaco group compared to that of trabeculectomy group (P <0.001). The mean postoperative IOP was reduced significantly (P < 0.05) in both groups at all time intervals compared to their preoperative values. Anterior chamber depth increased significantly postoperatively in group (A) (p<0.001) however, almost no change was noticed in group (B). Meanwhile, postoperative angle opening distance was increased (p<0.001) in both groups. No significant differences were found between both procedures in Rim area, Rim volume, cup/disc area ratio and maximum cup depth. Eight cases (32.0%) in group (A) and 7 cases (28.0%) in group (B) suffered from postoperative complications with insignificant difference. Conclusion: both procedures are effective in lowering IOP in patients with ACG, but phacoemulsification with peripheral iridectomy significantly improved visual acuity compared to sub-scleral trabeculectomy with almost the same rate of complications.

Phacoemulsification with Peripheral Iridectomy and Trabeculectomy: Comparing the Two Procedures in Management of Angle-Closure Glaucoma

Background: glaucoma was ranked as one of the major causes of blindness worldwide. Angle-closure glaucoma (ACG) is a type of glaucoma characterized by narrowing or closure of the anterior chamber angle. Objective: to compare the clinical outcomes of phacoemulsification (Phaco) with peripheral iridectomy versus trabeculectomy in management of ACG. Patients and Methods: this study was a prospective, follow-up nonrandomized clinical trial, carried out on 50 eyes with ACG. Patients were divided into two groups: group A (n= 25); eyes underwent phacoemulsification with peripheral iridectomy, and group B (n= 25); eyes underwent sub-scleral trabeculectomy. Intraocular pressure (IOP), visual outcomes and postoperative complications were assessed. Patients were followed-up for 6 months. Results: postoperative visual acuity was significantly improved in phaco group compared to that of trabeculectomy group (P <0.001). The mean postoperative IOP was reduced significantly (P < 0.05) in both groups at all time intervals compared to their preoperative values. Anterior chamber depth increased significantly postoperatively in group (A) (p<0.001) however, almost no change was noticed in group (B). Meanwhile, postoperative angle opening distance was increased (p<0.001) in both groups. No significant differences were found between both procedures in Rim area, Rim volume, cup/disc area ratio and maximum cup depth. Eight cases (32.0%) in group (A) and 7 cases (28.0%) in group (B) suffered from postoperative complications with insignificant difference. Conclusion: both procedures are effective in lowering IOP in patients with ACG, but phacoemulsification with peripheral iridectomy significantly improved visual acuity compared to sub-scleral trabeculectomy with almost the same rate of complications.

An update on therapeutic modalities for the prevention of angle closure glaucoma.

Angle closure glaucoma is a prominent burden for the worldwide health system. Because this disorder is commonly asymptomatic, and can lead to irreversible blindness, the proper screening and early management of this disease can be critical. The definitions of angle closure and consequently its treatment guidelines have been dynamically modified and updated in the past decades. Surgical and laser techniques have been adapted to address the different mechanisms involved in the manifestation of the disease and properly prevent its progression in different stages. In this review, we will assess the most recent techniques and their indications in the prevention and management of angle closure disorders. Recent trends in surgical and laser procedures in the management of angle closure glaucoma are often geared toward combination strategies, to target different mechanisms. Targeting the lens and the angle structures and adjacent tissues simultaneously may be a promising approach in both the prevention of further angle closure, modulating the pressure, and prevention of cataract progression. Modifying your therapeutic modalities and thresholds for treatment based on updated angle closure disorder definitions and guidelines, as well as innovative screening techniques, may be beneficial to your patients, in regards to both prevention and reduction of disease progression.

Surgical Treatment of Angle-Closure Glaucoma.

Advances in anterior segment imaging modalities have contributed new insights towards a better understanding of the various mechanisms of angle-closure glaucoma (ACG). This development is key to good decision making when confronted with angle-closure patients needing appropriate therapy. Surgical management of ACG remains an integral part of glaucoma patient care. The distinctive anatomy of angle-closure eyes and the few objective lines of evidence to support the effectiveness of the different surgical treatment options present a challenge to glaucoma surgeons.

Case-based approach to managing angle closure glaucoma with anterior segment imaging

This is a case-based approach to the diagnosis and management of angle closure glaucoma of a variety of causative factors, with a special emphasis on the use of advanced anterior segment imaging including ultrasound biomicroscopy and anterior segment optical coherence tomography. Although all angle closure is caused by iridotrabecular contact, the cause of angle closure glaucoma is classified based on the site of primary blockage of aqueous movement from anterior to posterior: pupillary block, plateau iris, lens-related, and posterior causative factors. Although gonioscopy is traditionally used to visualize the angle structures and estimate the angle width, objective and reproducible measurement of the anterior chamber angle can best be obtained with advanced anterior segment imaging. In this review article, we demonstrate the utility of anterior advanced imaging to identify underlying mechanisms in cases of angle closure glaucoma in guiding directed management.

Management of angle closure glaucoma

Primary angle closure glaucoma (PACG) is equally prevalent in Indian in Asian population as the primary open angle glaucoma. Eighty-six percent of people with PACG are in Asia, with approximately 48.0% in China, 23.9% in India and 14.1% in southeast Asia. To understand PACG, it is mandatory to understand its classification and type of presentation with the underlying pathophysiology. The treatment options are medical, laser and/or surgical. The present article provides an overview of PACG.

Management of angle-closure glaucoma in East Asian eyes: a response to argon laser iridotomy-induced bullous keratopathy, a growing problem in Japan

We were suitably impressed to read the article entitled “Argon laser iridotomy-induced bullous keratopathy—a growing problem in Japan” by Ang et al ,1 advocating a change in management of primary...

Non-phacoemulsification small incision extracapsular cataract extraction and goniosynechialysis on management of angle closure glaucoma

目的 评价手法小切口晶状体囊外摘出联合房角分离术治疗闭角型青光眼的疗效.方法 回顾分析2004年6月至2006年6月住院治疗的闭角型青光眼85例(98眼),分别对54例(63眼)行小切口晶状体囊外摘出、31例(35眼)行超声乳化晶状体吸出联合房角分离后房型硬性人工晶状体植入治疗闭角型青光眼,进行分析比较.结果 术后1月眼压,小切口组: 0.05).术后1周最佳矫正视力,小切口组:≥0.5者41眼、0.1～0.4者16眼、 0.05).结论 小切口晶状体囊外摘出联合房角分离术治疗闭角型青光眼与超声乳化晶状体吸出联合房角分离联合后房型硬性人工晶状体植入术,效果相近,可有效治疗闭角型青光眼。

The management of angle-closure glaucuoma by phacoemulsification

目的 探讨晶状体超声乳化白内障摘出治疗闭角型青光眼合并白内障的临床疗效.方法 本组临床观察对象为闭角型青光眼29例(37眼).均有不同程度的晶状体浑浊.行巩膜隧道切口晶状体超声乳化白内障摘出折叠式人工晶状体植入术.随访1-21个月(平均13.9月).结果 术后平均眼压(11.25±2.50)mmHg,比术前用药后平均眼压(19.50±10.26)mmHg明显降低,差异有统计学意义(P＜0.05),中央前房深度由术前的(1.47±0.32)mm增加到术后(2.35±0.34)mm,两者比较差异有统计学意义(P＜0.05).术后视力均有不同程度提高.结论 闭角型青光眼并白内障行晶状体超声乳化联合后房型折叠式人工晶状体植入术,在一定程度上可得到有效的治疗。

Clinical study on the management of angle-closure glaucoma by phacoemulsification with foldable posterior chamber intraocular lens implantation

目的 评价透明角膜切口白内障晶状体超声乳化吸出后房人工晶状体植入术治疗原发性闭角型青光眼合并白内障的疗效.方法 回顾性分析闭角型青光眼伴白内障14例(27眼).单纯行透明角膜切口白内障晶状体超声乳化吸出联合后房型人工晶状体植入术,术后随访8～20个月.结果 所有患者术中术后无严重并发症,术后视力较术前明显提高,术后平均眼压(12.64±3.37)mmHg与术前用药后平均眼压(16.72±4.26)mmHg相比差异有统计学意义(配对t检验,P＜0.01),周边前房较术前明显加深,前房角均重新开放或部分开放增宽.结论 单纯透明角膜切口白内障晶状体超声乳化吸出后房型折叠人工晶状体植入术,可有效治疗合并白内障的闭角型青光眼。

Primary angle closure glaucoma: a developing world perspective

Primary angle closure glaucoma (PACG) is estimated to affect a significant proportion of the population worldwide. Of those affected, the majority reside in developing countries. In the developing world, more than 80% of the people afflicted with glaucoma are unaware that they have the disease, and visual impairment from PACG is more severe than from primary open-angle glaucoma. Considering the paucity of resources and competing opportunity costs, it is imperative that the developing world extrapolates current literature and exiting data sensibly, and develops cost-effective strategies for the detection and management of angle closure glaucoma. The number needed to treat (NNT) was used to extrapolate the trials for an individual patient. To extrapolate to the overall population (where applicable) the authors used the population attributable risk percentage (PAR%). For individual patient care, treatment of a primary angle closure suspect (PACS) has an NNT of 6 over 5 years to prevent one patient progressing to primary angle closure (PAC). The NNT for PAC to prevent PACG over 5 years is 5. The 'effective' PAR% for PACS is 56.4% and the 'effective' PAR% for PAC is 65%. This suggests both PACS and PAC are important health burdens but because of the absence of a good screening test and the opportunity costs involved, population-based screening will probably be unfeasible in developing countries.

Clinical study on the management of angle-closure glaucoma by phacoemulsification

目的 评价超声乳化白内障吸除联合后房型折叠式人工晶状体植入术治疗闭角型青光眼合并白内障的疗效.方法 52例(58眼)闭角型青光眼合并白内障患者入院后均行超声乳化白内障吸除联合后房型折叠式人工晶状体植入术,术后随访6个月至3年,平均(16.50±6.20)个月.结果 53只限术后最佳矫正视力均有不同程度提高.术后随访眼压(14.26±3.20)mm Hg,比术前用药后眼压(19.56±3.36)mm Hg明显降低,差异有统计学意义(P＜0.01).中央前房深度由术前(1.78±0.36)mm,增加到术后(2.83±0.28)mm,手术前、后差异有统计学意义(P＜0,001).结论超声乳化白内障吸除联合后房型折叠式人工晶状体植入术治疗闭角型青光眼是一种行之有效的手术方法。

Clinical study on the effect of phacoemulsification with foldable posterior chamber intraocular lens implantation in the management of angle-closure glaucoma

目的 观察超声乳化白内障吸除联合折叠式人工晶体植入术治疗急性闭角型青光眼合并白内障患者的临床疗效.方法收集2002年7月至2005年9月于中山眼科中心青光眼病区收治的急性闭角型青光眼合并白内障31例(31眼),患者均接受超声乳化白内障吸除联合折叠式人工晶体植入术,术后随访3个月.结果术后最佳矫正视力,较术前显著提高(P＜0.05);患者术后3个月眼压平均为(15.3±3.2)mmHg,较术前用药前后眼压相比均显著下降(P＜0.05);超声生物显微镜检查发现术后前房深度较术前均显著增加,平均为(3.01±0.47)mm(P＜0.05);术后患者房角均较术前增宽,房角粘连关闭象限不同程度开放.结论超声乳化白内障吸除联合折叠式人工晶体植入术可有效降低眼压、提高视力,为急性闭角型青光眼同时合并白内障患者安全有效的治疗途径。