Glauco-Claw: A novice implant for chronic angle-closure glaucoma

This article describes 1-year outcomes of a new intra-ocular implant, “Glauco-Claw,” in refractory chronic angle-closure glaucoma (ACG). Glauco-Claw is a novice polymethylmethacrylate implant with a central ring and five claws placed circumferentially. It was placed in the anterior chamber and the peripheral iris was tucked into the claws, thus causing goniosynechialysis and preventing the reformation of goniosynechiae. It was implanted in five eyes of five patients, and they were followed up for 1 year. Target intra-ocular pressure was achieved and maintained in all the patients till the last follow-up. Two patients did not require any anti-glaucoma medication. No significant complications were observed in any patient. Glauco-Claw could be another armamentarium in the management of refractory chronic ACG.

Gonioscopic angle evaluation and its correlation with graft survival and post-operative ocular hypertension in patients of Descemet’s stripping endothelial keratoplasty

Purpose: To evaluate the gonioscopic changes in patients receiving Descemet’s stripping endothelial keratoplasty (DSEK) without pre?existing ocular hypertension (OHT) and to report its correlation with post?surgery OHT, graft survival, and visual outcomes. Methods: Adult patients who underwent DSEK surgery from April 2014 to March 2018 with at least 2 years of follow?up were analyzed in this retrospective study. Demographic details, indication of DSEK, necessary anterior and posterior segment findings, and the post?DSEK OHT details were documented. Results: A total of 58 patients (23 males and 35 females) with a mean age of 61.44 ± 8.8 years were included in the study. The most common etiology for DSEK surgery was pseudophakic bullous keratopathy in 47 eyes (81.03%). A total of 22.41% (13/58) eyes showed elevated intra?ocular pressure (IOP) following DSEK surgery. The most common cause of IOP elevation was steroid?induced OHT in seven eyes (12.06%). Gonioscopy examination revealed areas of peripheral anterior synechiae (PAS) in 17 (29.3%) eyes. OHT was found in 4/17 (23.5%) eyes having PAS. Three of these cases required trabeculectomy + goniosynechiolysis (GSL), and the fourth case required GSL alone to control IOP. These four cases also required repeat DSEK for failed grafts. The mean pre?operative best corrected visual acuity was 1.62 logMAR (range 1.17–1.77), which gradually improved to 0.79 logMAR (range 0.3–1.77) after 2 years (p < 0.00001). Conclusion: PAS was found to be an important factor associated with post?DSEK ocular hypertension in our study. OHT in PAS cases required definitive surgical treatments to control IOP. It adversely affected the graft survival and in turn affected visual outcomes also.

Comparision between Simultaneous Intracameral and Intravitreal Injection and Intravitreal Injection of Bevacizumab in Neovascular Glaucoma

PURPOSE: To compare the clinical efficacy of simultaneous intracameral and intravitreal injection and intravitreal single injection of bevacizumab in patients with neovascular glaucoma (NVG). METHODS: The medical records of 43 eyes of 43 patients, who had treated with simultaneous intracameral and intravitreal injection (Group I) or intravitreal single injection (Group II) of bevacizumab 1.25 mg from January 2010 to December 2012, were retrospectively reviewed. The best corrected visual acuity (BCVA), intraocular pressure (IOP), regression time of new vessel in the iris (NVI) and anterior chamber angle (NVA), progression of peripheral anterior synechiae (PAS), and corneal parameters were measured preoperatively and one day, three days, 1 week, 1 month, and 3 months postoperatively. RESULTS: There was significant changes of IOP between the two groups at 1, 3 days postoperatively (p = 0.001, p < 0.001). The regression time of NVI and NVA in Group I was significantly faster than Group II (p = 0.026, p = 0.033). In the phakic eyes, regression time of NVI and NVA was significantly longer than aphakic and pseudophakic eyes in group II (p = 0.006, p = 0.005). Also, in the phakic NVG patients, the formation of PAS in Group I was significantly less than in Group II for the postoperative three months (p = 0.020). CONCLUSIONS: Simultaneous intravitreal and intracameral injection of bevacizumab seem to be more effective for the early lowering of IOP and regression of NVI and NVA, and inhibiting further PAS formation in NVG patients, especially in the phakic eyes. Therefore, simultaneous intracameral and intravitreal injection of bevacizumab may be considered as an adjunct to management of NVG in the phakic eyes.

Evaluation of blotchy pigments in the anterior chamber angle as a sign of angle closure.

Background: Blotchy pigments in the anterior chamber (AC) angle are considered diagnostic of primary angle closure (PAC). But there are no reports either on the prevalence of blotchy pigments in AC angles or the validity of this sign. Aims: To determine the prevalence of blotchy pigments in AC angles and to evaluate their relationship with glaucomatous optic neuropathy (GON) in eyes with occludable angles. Setting and Design: Cross-sectional, comparative study. Materials and Methods: Gonioscopy was performed in 1001 eyes of 526 subjects (245 eyes of 148 consecutive, occludable angle subjects and 756 eyes of 378 non-consecutive, open angle subjects), above 35 years of age. Quadrant-wise location of blotchy pigments was documented. Statistical Analysis: Odds of blotchy pigments in occludable angles against that in open angles were evaluated. Relationship of GON with blotchy pigments in occludable angle eyes was evaluated using a multivariate model. Results: Prevalence of blotchy pigments in occludable angles was 28.6% (95% CI, 22.9-34.3) and in open angles was 4.7% (95% CI, 3.2-6.3). Blotchy pigments were more frequently seen in inferior (16%) and superior quadrants (15%) of occludable angles, and inferior quadrant of open angles (4%). Odds of superior quadrant blotchy pigments in occludable angles were 33 times that in open angles. GON was seen in 107 occludable angle eyes. Blotchy pigments were not significantly associated with GON (odds ratio = 0.5; P = 0.1). Conclusions: Blotchy pigments were seen in 28.6% of occludable angle eyes and 4.7% of open angles eyes. Presence of blotchy pigments in the superior quadrant is more common in occludable angles. Presence of GON in occludable angle eyes was not associated with blotchy pigments.

Paracentesis as an initial intervention in Malay Indonesian eyes with acute primary angle closure.

Background: Acute primary angle closure (APAC) is one of the causes of blindness in Department of Ophthalmology Cipto Mangunkusumo General Hospital. Management of APAC is still controversial. Laser peripheral iridotomy is difficult to be done due to corneal edema as a result of persistent high intraocular pressure (IOP). It is believe that paracentesis will lower IOP immediately. The objective of the study was to assess outcome of paracentesis as the initial management in Malay Indonesian eyes with APAC. Methods: This intervention study was conducted at the Eye Clinic of Cipto Mangunkusumo Hospital and Jakarta Eye Center commencing in January 2005 until December 2007. Malay Indonesian eyes with APAC were included in this study in accordance with the new Asia Pacific consensus. All APAC eyes underwent paracentesis to lower IOP. The presenting and post-paracentesis IOP and peripheral anterior synechiae were noted. The outcome was termed as good when IOP was ≤ 21 mmHg and poor when IOP was > 21 mmHg. Results: A total of 45 APAC eyes were recruited. Thirty-eight of these belonged to women; mean age was 54.6 ± 1.56 years. Meanwhile, average duration of symptoms was 13.15 ± 7.4 days and mean of extent of peripheral anterior synechiae (PAS) was 7.7 ± 3.1 hours. There was a strong correlation regarding duration of symptoms to the formation of PAS (r = 0.672; p < 0.001). The mean presenting IOP was 55 ± 13.37 mmHg and mean post-paracentesis IOP was 27 ± 12.78 mmHg. A decrease of 49% in IOP ( p < 0.001) was observed after paracentesis with good outcome in 19 eyes and poor outcome in 26 eyes. Conclusion: Paracentesis as an initial intervention in APAC eyes reduces the IOP immediately, but only as a temporary response.

Efficacy of bimatoprost 0.03% in reducing intraocular pressure in patients with 360° synechial angle-closure glaucoma: A preliminary study.

Context: Peripheral anterior synechiae (PAS; synechiae anterior to functional trabecular meshwork) formation in primary angle-closure glaucoma (PACG) hampers access to uveoscleral outflow. Thus, the role of bimatoprost in such patients with 360° synechiae was evaluated. Aims: To assess efficacy and safety profile of bimatoprost 0.03% in lowering intraocular pressure (IOP) in 360° synechial angle-closure glaucoma patients. Settings and Design: This was a prospective, non-randomized, non-comparative, selective analysis, single-center pilot study. Materials and Methods: A total of 23 eyes of 20 Indian chronic angle-closure glaucoma (CACG) patients with IOP greater than 21 mmHg, 360° PAS and no visual potential in the study eye underwent detailed eye examination. Baseline IOP was measured and YAG peripheral iridotomy was performed for complete angle-closure reconfirmation. Bimatoprost 0.03% was administered for 8 weeks as once-daily evening dose. IOP reduction within treatment group was determined with “paired t-test”. Results: The mean reduction in IOP from baseline to 8 weeks of bimatoprost therapy was 15.3 ± 9.5 mmHg (P < 0.001). The most commonly observed adverse event was conjunctival hyperemia (35%). Bimatoprost was well tolerated in the study. Conclusions: In this study, exclusively involving patients with 360° synechial angle-closure glaucoma and no visual potential, bimatoprost 0.03% treatment demonstrated a statistically significant IOP reduction. Hence, it can be inferred that bimatoprost 0.03% is an efficacious treatment modality in this subgroup of patients for reducing IOP.

Distribution and Characteristics of Peripheral Anterior Synechiae in Primary Angle-Closure Glaucoma

PURPOSE: To evaluate the characteristics of peripheral anterior synechiae (PAS) in primary angle-closure glaucoma (PACG). METHODS: We reviewed the charts of 155 patients (244 eyes) with PACG. We divided these patients into one of four clinical subtypes: acute angle-closure glaucoma (ACG), chronic ACG, angle-closure hypertension, and ACG suspect. The prevalence, extent, and location of PAS were evaluated according to PACG subtypes. Correlation analysis was used to evaluate relationships between the highest IOP level without treatment and the extent of PAS. RESULT: The average degree of angle-closure with PAS was 14.6+/-9.1 in eyes that were classified as ACG suspect, 83.8+/-48.3 in angle-closure hypertension, 140.5+/-31.3 in acute ACG, and 180.3+/-31.9 in chronic ACG (ANOVA test, P<0.05). PAS was most frequently found in the superior part of the eye, especially from 12 to 1 o'clock. The incidence of broad PAS (PAS over 30 degrees in width) was highest in superior part, but the medium and narrow PAS (PAS limited to within 30 degrees in width) was distributed throughout all 12 sectors relatively equally. Prior to a laser iridotomy (LI) and other medical treatments, a positive correlation was found between the highest IOP (intraocular pressure) levels and the extent of PAS in chronic ACG (r=0.423, P<0.0001). However, statistically significant relationships were not found between the highest IOP levels before treatment and the extent of PAS in any of the other clinical subtypes. CONCLUSIONS: Our results suggest that acute and chronic ACG patients are most likely to have a greater extent of PAS than patients in the angle-closure hypertension or ACG suspect subtypes. PAS may be narrower in earlier stages and broader in later stages. PAS was also found most frequently in the superior part of the eye. The extent of synechial closure of the angle may play a role in raising IOP levels in later stages of the disease rather than early on.

Clinical Factors that Influence Intraocular Pressure Change after Cataract Surgery in Primary Open-Angle Glaucoma and Angle-Closure Glaucoma

PURPOSE: To evaluated the effect of cataract surgery on intraocular pressure (IOP) in primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG), and to find predictors for a favorable postoperative IOP after cataract surgery in patients with coexisting cataract and glaucoma. METHODS: Various clinical factors were evaluated in 68 patients (76 eyes) with well controlled primary glaucoma who had undergone cataract surgery. The differences in parameters between groups divided by postoperative IOP course were analyzed. RESULTS: For this study, successful IOP control was defined as an IOP between 6 mmHg and 21 mmHg without anti-glaucoma medication at last visit after cataract surgery. Eyes with the highest preoperative IOPs less than 28 mmHg in POAG and 42 mmHg in PACG had a significantly higher probability of success. In PACG, the probability of success was significantly higher, if fewer than three anti-glaucoma medications were given before surgery and if the areas of PAS before surgery were less than 4 hours. CONCLUSIONS: Primary small incision cataract surgery using phacoemulsification and foldable intraocular lens implantation could be considered the procedure of choice for a selective group of patients with coexisting glaucoma and visually significant cataract, with respect to IOP, the number of anti-glaucoma medications, and the area of peripheral anterior synechiae.

Relationship between the Extent of Peripheral Anterior Synechiae and the Severity of Visual Field Defects in Primary Angle-closure Glaucoma

We investigated the relationship between the circumferential extent of peripheral anterior synechiae (PAS) and the severity of visual field defects in primary angle-closure glaucoma (PACG). Correlations between visual field defects and the extent of PAS were analyzed in 73 eyes; 28 with and 45 without acute attacks. Spearman's correlation coefficient between the severity of visual field defects and the extent of PAS was 0.348 (P = 0.003) in all subjects (n = 73), 0.377 (P = 0.012) in the PACG eyes without acute attacks (n = 45), and 0.338 (P = 0.079) in the eyes with acute attacks (n = 28). Our results showed a statistically significant correlation between the extent of PAS and the severity of visual field damage in PACGoverall, and especially in PACG patients without a history of acute attacks.

Effect of YAG Laser Iridotomy on IOP in Chronic Angle-closure Glaucoma

The effect of YAG laser iridotomy on intraocular pressure was investigated in 24 eyes of 19 patients with chronic angle-closure glaucoma prospectively for 3 months. In most cases(75%) the intraocular presure was reduced and the mean amount of reduction was 4.33mmHg. The amount of pressure reduction has no significant correlation with the extent of peripheral anterior synechiae and visual field loss. This result shows that laser iridotomy should be considered in the management of chronic angle-closure glaucoma irrespective of the extent of peripheral anterior synechiae and visual field loss and some amount of intraocular pressure reduction may be expected after laser iridotomy.