Occult hypotony maculopathy diagnosed with optical coherence tomography.
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OBJECTIVES: To investigate whether the presence of glaucomatous optic neuropathy affects the reduction of intraocular pressure (IOP) after phacoemulsification in postiridotomy eyes with primary narrow angles, and to evaluate the preoperative factors associated with postoperative IOP control in primary angle-closure glaucoma (PACG). METHODS: Patients with PACG undergoing phacoemulsification were prospectively enrolled and received a complete ophthalmic examination. Diurnal IOP was measured 1 day before and 3 months after surgery. For comparison, patients with primary angle closure or angle closure suspect (PAC/S) undergoing phacoemulsification were also enrolled. RESULTS: Postoperative reduction of IOP was significant in the PACG group (n = 29; P = .001) and in the PAC/S group (n = 28; P<.001), with no significant difference between the groups. The number of glaucoma medications used decreased in both groups (both, P<.001). Multiple regression analysis for the PACG group showed that there was a positive correlation between postoperative IOP and preoperative factors of mean IOP (P = .001) and the anterior chamber depth (P = .03). CONCLUSIONS: The reduction of IOP 3 months after phacoemulsification is significant and is similar in extent in postiridotomy eyes with and without glaucomatous optic neuropathy. A higher postoperative IOP in PACG is associated with a higher preoperative IOP and with a deeper preoperative anterior chamber depth.
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Pigment dispersion syndrome is characterized by iris transillumination defects, Krukenberg spindels, and dense trabecular pigmentation. Additional features are bilaterality, myopia, concavity of the peripheral iris, a higher incidence in men than in woman,and young age of onset. A mechanism of reverse pupillary block causes iridozonular friction. Laser iridotomy is recommended as treatment to prevent further pigment dispersion and pigmentary glaucoma.
BACKGROUND: It was investigated whether a very low target pressure could be achieved by modification of deep sclerectomy without losing the advantages of non penetrating surgery in comparison to conventional filtration surgery. PATIENTS AND METHODS: A total of 22 eyes from 22 patients with advanced open angle glaucoma were randomly assigned to receive a deep sclerectomy or a trabeculectomy. Both groups received 0.02% mitomycin C under the conjunctiva prior to preparation of the scleral flap. In the deep sclerectomy group at least parts of the outer trabecular meshwork were removed until an apparent filtration was achieved. A dry cross-linked hyaluronate served as an implant. In the other group a classical trabeculectomy was performed. RESULTS: The median intraocular pressure 12 months post-operation was 11.5 mm Hg in the deep sclerectomy group compared to 11 mm Hg in the trabeculectomy group; the median of the relative IOP reduction was -47% in the deep sclerectomy group, and -57% in the trabeculectomy group. The best corrected visual acuity was unchanged 12 months postoperatively in both groups. DISCUSSION: As a more aggressive IOP-lowering procedure (intended filtration, use of antimetabolites) deep sclerectomy proved to be as effective as trabeculectomy. Nevertheless, the advantages of the more difficult surgical procedure concerning visual acuity, complications and surgical interventions were lost postoperatively.
PURPOSE: Visualization of the anterior chamber angle is an important diagnostic method in patients with angle-closure glaucoma. In this study, optical coherence tomography (OCT) was used to image the angle width, the iris configuration, and the iris thickness in patients with angle-closure glaucoma. METHODS: Thirteen eyes of 11 patients suffering from angle-closure glaucoma were studied with slitlamp-adapted OCT. All patients were treated with Nd:YAG laser iridotomy. The angle width ( degrees ), the angle opening distance (AOD) (microm), and the iris thickness (microm) were measured with OCT. The configuration of the iris was classified as steeply convex, convex, or flat. RESULTS: The mean angle width was preoperatively 5.1+/-5.0 degrees (0-15 degrees ) and enlarged significantly (p=0.007) to 10.4+/-5.5 degrees (0-19 degrees ) postoperatively. The AOD changed from 71+/-55 microm (0-157 microm) preoperatively to 143+/-74 microm (0-256 microm) postoperatively (p<0.001). The mean iris thickness was 338+/-33 microm. With the exception of two eyes the predominant iris configuration changed from convex to flat. CONCLUSIONS: OCT allowed visualization and noninvasive assessment of the anterior chamber angle region in patients with angle-closure glaucoma. Our results suggest that goniometry with OCT could improve the evaluation in patients with narrow or closed anterior chamber angles.
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BACKGROUND: We report a case of sympathetic ophthalmia with systemic findings following resection of a malignant melanoma of the iris and ciliary body, and describe the treatment and clinical outcome. METHODS: A 49-year-old man underwent sector iridocyclectomy of a malignant iridociliary melanoma of the right eye. Five weeks later, he was diagnosed with sympathetic ophthalmia. Snellen's best-corrected visual acuity, fluorescein angiography, electroretinography, cerebrospinal fluid analysis and audiometry were performed. High-dose systemic steroid and immunosuppressive (cyclosporine and azathioprine) therapy was prescribed. Two months later chorioretinitis and macular edema persisted, and intravitreous triamcinolone was injected into the right eye. RESULTS: Five weeks after resection of an iridociliary melanoma, our patient had reported acute bilateral vision loss. Visual acuity was hand motion in both eyes. Examination showed bilateral granulomatous uveitis, diffuse choroiditis with Dalen-Fuchs nodules, papillitis and vitritis. On fluorescein angiography multiple hyperfluorescent dots, which coalesced in areas of exudative retinal detachment, were evident. The patient presented meningismus with pleocytosis on cerebrospinal fluid analysis, and sensorineural deafness. Sympathetic ophthalmia was diagnosed. High-dose intravenous steroids followed by oral prednisone at a tapering dose and immunosuppressive agents (cyclosporine and azathioprine), topical steroids in both eyes and intravitreal steroids in the right eye were administered. Phacoemulsification and intraocular lens implantation were performed to treat a dense cataract of the right eye. After 24 months of follow-up, best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left; no signs of intraocular inflammation were observed and neurological signs had resolved. Low maintenance doses of systemic steroids and immunosuppressive agents were administered up to month 18 of follow-up to avoid recurrence. CONCLUSIONS: Sympathetic ophthalmia is a rare, but severe disease that can occur after resection of iridociliary melanoma. High-dose steroid therapy and supplementation with immunosuppressive agents early in the course of the disease was effective in resolving the condition.
PURPOSE: To assess the present state of examination procedures and treatments for angle-closure glaucoma (ACG) in Japan. METHODS: A nationwide questionnaire survey was conducted, targeting 1237 registered facilities to Japanese Ophthalmological Society. RESULTS: Valid replies were obtained from 754 of 1232 facilities (61.2%). Primary ACG comprised a small percentage of the glaucoma types diagnosed in outpatient examinations. More than 50% of the laser iridotomy (LI) procedures were prophylactic at 52.9% of the facilities. Gonioscopy was most frequently used for determining indications for prophylactic LI. Specular microscopy was always performed prior to LI in 7.8% of the facilities. Prophylactic LI resulted in complications at 20.5% of the surveyed facilities, although the incidence was low. The following residual complications were reported at 82.9% of the facilities when treating ACG attacks: cataract, persistent elevation of intraocular pressure, and bullous keratopathy. One-third of the facilities experienced inadequate treatment of an ACG attack by physicians other than ophthalmologists. CONCLUSIONS: The incidence of LI-induced complications was higher in ACG eyes than in narrow-angle eyes. However, prophylactic LI sometimes results in persistent ocular complications.
PURPOSE: To compare the effects of brimonidine 0.2% and apraclonidine 1% on intraocular pressure (IOP) and pupil size in patients undergoing laser peripheral iridotomy (LPI). METHODS: Forty patients (40 eyes) with occludable angle or angle-closure glaucoma requiring LPI were recruited. Patients were randomized to receive either brimonidine 0.2% or apraclonidine 1% before and after LPI. The IOPs were measured at 1, 2 and 3 h after LPI, and pupil size was measured before and at 45 min after eyedrop instillation. Both parameters were analyzed using the t test. RESULTS: There were 20 patients in each group. The baseline IOP was 17.1 +/- 3.2 mmHg for the brimonidine group and 16.7 +/- 2.8 mmHg for the apraclonidine group (P = 0.67) (t test). The mean IOP 3 h after laser treatment was 18.2 +/- 7.8 mmHg for the brimonidine group and 15.7 +/- 5.6 mmHg for the apraclonidine group (P = 0.25) (t test). There was no statistically significant difference between the two groups in the mean IOP changes at 1, 2, or 3 h after LPI. The mean change in pupil size after brimonidine was -0.33 +/- 0.37 mm and after apraclonidine was +0.90 +/- 0.87 mm. The difference was significant (P < 0.001). CONCLUSION: Brimonidine 0.2% was found to have an efficacy comparable to that of apraclonidine 1.0% in preventing post LPI IOP spikes. Apraclonidine 1.0% tends to have a pupil dilating effect while brimonidine 0.2% tends to constrict the pupil.
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PURPOSE: To report the use of argon laser peripheral iridoplasty in the treatment of plateau-like iris configuration as a result of iris and ciliary body cysts. DESIGN: Case report. METHODS: A 43-year-old male with plateau iris syndrome was demonstrated by high frequency ultrasound biomicroscopy (UBM), to have numerous iris and ciliary body cysts. Bilateral argon laser peripheral iridoplasty was performed. RESULTS: Argon laser iridoplasty opened the drainage angle in both eyes. CONCLUSION: Argon laser iridoplasty is an effective and safe treatment for plateau iris syndrome and may also prove valuable in the treatment of plateau-like iris configuration resulting from iridociliary cysts.
PURPOSE: To describe the clinical features, natural course, management and histopathologic features of iris melanocytoma. DESIGN: Single-center retrospective case series. METHODS PATIENT POPULATION: Forty-seven consecutive patients (47 eyes) with iris melanocytoma. INTERVENTION PROCEDURE: Data regarding patient and tumor features were analyzed for their impact on the main outcome measures using univariate and multivariate regression models. Kaplan-Meier estimates were used to analyze the main outcomes as a function of time. MAIN OUTCOME MEASURES: Increased intraocular pressure (IOP), tumor seeding, and tumor growth. RESULTS: Associated findings at initial presentation included iris stromal seeds in 20 patients (43%), and anterior chamber angle seeds in 12 (26%). Intrinsic vascularization and sector cataract were not seen in any eyes. The management at presentation included observation in 39 patients (83%), tumor removal by sector iridectomy/iridocyclectomy in 7 (15%), and enucleation for blind painful eye with secondary increased IOP in 1 (2%). The diagnosis was confirmed by histopathologic examination in 11 patients (23%). The mean follow-up was 58 months. Using Kaplan-Meier estimates, clinical evidence of growth was observed in 23% at 5 years, 48% at 10 years, and 74% at 15 years. New tumor seeds developed in 34% at 5 years, 63% at 10 years, and 75% at 15 years. Increased IOP was observed in 11% at 5 years, 11% at 10 years, and 55% at 15 years. CONCLUSIONS: Iris melanocytoma represented only 3% of all iris nevi. Related iris stromal and anterior chamber angle seeds were common, and secondary glaucoma occurred in 11% at 5 years. Growth was observed in 23% at 5 years but no malignant transformation was found.