Angle Closure Glaucoma in Retinitis Pigmentosa

Archive of Clinical Cases, 2016

We present the clinical case of a 43 years old female patient, referred to our clinic for a red, painful left eye. Multiple bilateral similar attacks were reported by the patient in the last 2 years, for which a diagnosis of conjunctivitis or anterior uveitis was established. At current presentation we found bilateral marked inflammatory reaction in the anterior segment (extensive peripheral iris synechiae, inflammatory membrane in the pupillary area, iris "bombe", pigment dispersion, but no keratic precipitates or cells in the anterior chamber. Intraocular pressure (IOP) was 12 mmHg in OD and 40 mmHg in OS, under topical treatment, started 24 before the current visit. Gonioscopy showed closed angle in both eyes, "openable" in various grades after indentation in all quadrants. Anterior segment ocular coherence tomography (AS-OCT) and ultrasonic biomicroscopy (UBM) suggested anatomical causes for acute angle closure, revealing multiple rolling folds on the iris surface, high insertion onto the scleral wall. Multiple laboratory investigations excluded any potential cause of uveitis, therefore the anatomical theory remained in discussion related to a disproportion between anterior structures leading to angle closure attacks. We performed laser peripheral iridotomy, in this patient with positive outcome: IOP decrease, deepening of the AC, open angle in gonioscopy. Misleading issues in this case confused the initial diagnosis and delayed the adequate treatment.

Open Access Journal of Ophthalmology

Pigmentary Glaucoma is a bilateral process characterized by the deposit of pigment granules throughout the anterior segment that causes an increase in intraocular pressure due to pigmentary obstruction and injury to the trabeculum. We present a patient with a previous history of elevated intraocular pressure treated with timolol 0.5 % that arrives to consultation with blurred vision. Ophthalmological examination revealed a compound hypermetropic astigmatism with elevated intraocular pressures, the presence of guttas in the endothelium and narrowing of the anterior chamber, deposits of endothelial pigments and in the lens also opacified and in the trabeculum, with angular closure. In the fundus of the eye, asymmetry was observed in the excavations and visual alterations appeared in the field. The IOL Master 700 corroborated that it is a patient with small eyes and narrow cameras, something that is not frequent in Pigmentary Glaucoma, for which an angular closure is also proposed.

Journal of Evolution of Medical and Dental Sciences, 2016

BACKGROUND Sixty million people are affected with glaucoma worldwide and more than 20 million have PACG. Of these, more than 5 million with PACG are blind, which is twice more than POAG. Early detection and timely treatment with Nd.YAG laser iridotomy and associated complications determine visual outcome. OBJECTIVES To study efficacy of Nd.YAG laser iridotomy in controlling intraocular pressure in primary angle closure glaucoma patients. To study role of prophylactic Nd.YAG laser iridotomy in the fellow eyes of primary angle closure glaucoma patients. To study anatomical changes in the angle of anterior chamber following peripheral iridotomy and complications of Nd.YAG laser iridotomy. METHODS A prospective study of 100 cases of primary angle closure glaucoma was conducted in Basaveshwar Teaching and General Hospital (Attached to M.R. Medical College), Kalaburagi. A detailed ophthalmic examination was performed. IOP was measured by Goldmann applanation tonometry. Gonioscopy was done by Goldmann 3 mirror lens. Nd.YAG laser was performed on all affected eyes and 82 fellow eyes of 100 patients and followed up for six months. RESULTS Among the patients included in the study 73 (73%) patients were females and 27 (27%) were males. In our study most of the patients were 40 to 60 years of age group. Our study included 57 (57%) with PAC, 28 (28%) with PACG and 15 (15%) PACS. There was improvement of 2 Shaffer's grades in 65%, 1 Shaffer's grades in 25% of patients. In my study 53 (92.2%) of 57 PAC (Acute and sub-acute) patients had improved with stable visual acuities and good control of IOP at followup visits; 20 (71.4%) of 28 PACG (Chronic) patients had good control of IOP at followup visits with improvement of stable visual acuities. All the PACS eyes and the fellow eyes with prophylactic laser iridotomy were with good IOP control and visual acuities; 6 (3.4%) eyes out of 172 eyes which underwent iridotomies were found closed at follow-up visits with shallow anterior chamber and narrow angles. Transient elevation of IOP was noted in 38 (38%) patients and iris bleeding was noted in 19 (19%) patients. In our study, 28.5% eyes with PACG and 5.2% eyes with primary angle closure were classified as failures in controlling IOP and maintaining stable or improvement in visual acuity. INTERPRETATION AND CONCLUSION Nd. YAG laser iridotomy has now become treatment of choice in angle closure glaucoma. Efficacy of iridotomy depends on IOP at presentation, presence or absence of PAS, stage of the disease and pre-existing glaucomatous optic neuropathy. Effective screening and early intervention may improve visual outcomes.

Journal of Clinical & Experimental Ophthalmology, 2012

Pupillary block is the most common mechanism responsible for angle closure [9], but the anatomical configuration which causes a plateau iris may be a more common mechanism than was previously thought. Pupillary block mechanism In pupillary block, the resistance to aqueous flow from the posterior to anterior chamber is at the level of the pupil, creating a pressure gradient that causes forward bowing of the peripheral iris and closure of the angle [10,11]. Aqueous humor flow from the posterior chamber into the anterior chamber is regulated by a differential pressure between the anterior and the posterior chamber. This pressure differential may increase greatly when the dimensions of the iris-lens channels are changed. As this pressure increment increases, the iris becomes more convex and can close angle. Extreme anterior iris-bulging, iris bombé would be expected with pressure differentials of 10-15 mm Hg [12]. The variables that influence the flow through the ''pinch region'' (iris-lens channels) and influence the pressure differential and related iris contour have been studied extensively [12-16]. Changes in pupillary size, increased channel length and decreased height, movement of the iris insertion posteriorly or of the lens anteriorly, were associated with an expected increase in the pressure differential. Other variables exist and interact to determine the iris contour, including eye size, especially the dimensions of the anterior segment, lens size and position, iris stroma and iris musculature characteristics, ciliary body anatomy, and physiologic parameters including aqueous humor flow rate, facility of outflow, vitreousaqueous fluid flow, and the effects of accommodation and blinking [9].

Journal of Glaucoma, 1999

International Ophthalmology, 1993

Twenty eyes of 19 patients presenting with acute angle closure glaucoma (AACG) which failed to respond to medical treatment were treated with laser iridoplasty. In all 20 eyes, laser peripheral iridectomy (PI) was prevented by a hazy cornea. In all cases, iridoplasty resulted in a rapid and significant reduction in intraocular pressure. Laser iridoplasty appears to have a useful role in the management of medically unresponsive AACG, particularly in those cases where laser peripheral iridotomy (PI) has failed or is not possible to perform.

Biomedical Research-tokyo, 2017

Objective: This research was aimed to explore the effects of surgical treatment on acute angle closure glaucoma with persistent high Intraocular Pressure (IOP). Methods: A total of 80 cases (89 eye cases) with acute angle closure glaucoma with persistent high IOP were selected (44 eyes in penetration group while 45 eyes in extraction group). Patients in penetration group were given anterior chamber penetration and trabeculectomy. Patients in extraction group were given vitreous aspiration and trabeculectomy. Treatment effects and treatment safety conditions of patients in two groups were analysed. Results: Compared with extraction group, there were no significant differences in eye pressure of patients in penetration group before surgery and during hospital discharge, eyesight, functional filter blebs and formation rate of non-functional filter blebs (P>0.05). Complications rate of patients in penetration group was lower than that in the extraction group (P<0.05). Conclusion: ...

Survey of Ophthalmology, 2009

Primary angle-closure glaucoma is a major cause of blindness worldwide. It is a disease of ocular anatomy that is related to pupillary-block and angle-crowding mechanisms of filtration angle closure. Eyes at increased risk for primary angle-closure are small with decreased axial length, anterior chamber depth, and filtration angle width, associated with a proportionately large lens. Angle-closure glaucoma afflicts Asian and

Journal of American Association for Pediatric Ophthalmology and Strabismus, 2005

Laser photocoagulation is the current treatment standard for severe retinopathy of prematurity (ROP). Uncommon, but well recognized complications include cataract, and vitreous and retinal hemorrhage. Angleclosure glaucoma after laser photocoagulation for ROP is rare. The purpose of this study was to identify additional cases of angle-closure glaucoma following laser treatment for ROP. Methods: Five eyes of four patients with angle-closure glaucoma following laser treatment for ROP were identified by three ophthalmologists at separate institutions between 1997 and 2001. Demographic and clinical data were obtained from medical records. Clinical and surgical findings associated with the diagnosis and management of angle-closure glaucoma following ROP laser were evaluated. Results: The following data were collected (mean (range)): gestational age, 26.8 (24 to 29) weeks; birth weight, 833 (570 to 1062) g; age at laser treatment for ROP, 35 (33 to 37) weeks; number of laser burns, 1598 (930 to 2400); and time to diagnosis of angle-closure glaucoma, 3.6 (2 to 5) weeks. Three of five eyes had objective data for intraocular pressure (IOP) and corneal diameter with mean IOP 41 mm Hg (35 to 44) and mean corneal diameter 11.1 mm (10.25 to 11.5). Initial treatment included topical and systemic medications. Three eyes required surgical intervention. Angle-closure resolved in all cases with normalization of IOP. Follow-up (5 months to 3.6 years) showed that affected eyes tended to be more myopic than unaffected fellow eyes (mean spherical equivalent Ϫ6.5 vs Ϫ4.7 diopters). Conclusions: Angle-closure glaucoma can develop following laser treatment for severe ROP. Medical, and frequently surgical, intervention provides effective management.

British medical bulletin, 2010