Variación de la presión intraocular posterior a la facoemulsificación en pacientes con cierre angular primario / Variation in intraocular pressure after phacoemulsification in patients with primary angle closure

RESUMEN El glaucoma por cierre angular primario constituye una enfermedad de rápida evolución con efectos negativos sobre la visión si no es tratada oportunamente. Objetivo: Identificar las variaciones de la presión intraocular posterior a la facoemulsificación del cristalino transparente en pacientes con cierre angular primario, y los factores relacionados con su reducción. Métodos: Se realizó un estudio descriptivo longitudinal prospectivo en la provincia de Pinar del Río, entre enero del año 2013 y agosto de 2016, que incluyó a 67 pacientes con cierre angular primario y cristalino transparente, quienes fueron sometidos a la facoemulsificación. El análisis estadístico se realizó con el programa SPSS. Resultados: La presión intraocular promedio preoperatoria fue de 27,14 ± 2,90 mmHg y a los 2 años de 14,61 ± 1,68 mmHg, con reducción de 46,17 por ciento. La variación fue estadísticamente significativa (p< 0,001), independiente de los valores preoperatorios (< 30 mmHg o ≥ 30 mmHg). Los factores relacionados con la reducción de la presión intraocular fueron la presión intraocular preoperatoria (p< ; 0,001), la amplitud angular (p< 0,001) y la ausencia de sinequias anteriores periféricas (p< 0,001). El análisis multivariado arrojó que mientras mayor es el valor de la presión intraocular preoperatoria (p< 0,001) y menor es la presencia de sinequias anteriores periféricas (p= 0,008), mayor es el porcentaje de reducción. Conclusión: La facoemulsificación del cristalino transparente en pacientes con cierre angular primario produce variación significativa de la presión intraocular, la cual se relaciona con una mayor reducción de esta, mayor presión intraocular preoperatoria y menor presencia de sinequias anteriores periféricas(AU)

ABSTRACT Primary angle closure glaucoma is a rapidly evolving disease with negative effects on vision if it is not treated timely. Objective: To identify the variations of intraocular pressure after phacoemulsification of the transparent lens in patients with primary angular closure, and the factors related to its reduction. Methods: A prospective longitudinal descriptive study was conducted at the province of Pinar del Río, between January 2013 and August 2016, which included 67 patients with primary and transparent crystalline angular closure, who underwent phacoemulsification. Statistical analysis was performed with the SPSS program. Results: The preoperative average intraocular pressure was 27.14 ± 2.90 mmHg and at 2 years 14.61 ± 1.68 mmHg, with a reduction of 46.17%. The variation was statistically significant (p< 0.001), independent of preoperative values (< 30 mmHg or ≥ 30 mmHg). The factors related to the reduction of intraocular pressure were preoperative intraocular pressure (p< 0.001), angular amplitude (p< 0.001) and the absence of peripheral anterior synechiae (p< 0.001). The multivariate analysis showed that the high value of preoperative intraocular pressure (p< 0.001) and the low presence of peripheral anterior synechiae (p= 0.008), meant a great percentage reduction. Conclusion: Phacoemulsification of the transparent lens in patients with primary angular closure produces significant reduction of intraocular pressure, greater preoperative intraocular pressure and less presence of peripheral anterior synechiae(AU)

Non-pupillary block angle-closure mechanisms: a comprehensive analysis of their prevalence and treatment outcomes / Mecanismos de fechamento angular sem bloqueio pupilar: análise de prevalência e resultados terapêuticos

Purpose: To assess the prevalence and treatment outcomes of angle-closure mechanisms other than pupillary block in a population of Brazilian patients. Methods: A retrospective chart review was conducted to evaluate patients who had undergone laser peripheral iridotomy (LPI) due to occludable angles at a single institution between July 2009 and April 2012. An occludable angle was defined as an eye in which the posterior trabecular meshwork was not visible for ≥180° on dark-room gonioscopy. Key exclusion criteria were any form of secondary glaucoma and the presence of >90° of peripheral anterior synechiae. Collected data were age, race, gender, angle-closure mechanism (based on indentation goniocopy and ultrasound biomicroscopy), intraocular pressure (IOP), number of antiglaucoma medications and subsequent management during follow-up. If both eyes were eligible, the right eye was arbitrarily selected for analysis. Results: A total of 196 eyes of 196 consecutive patients (mean age 58.3 ± 11.6 years) who underwent LPI were included. In most of the patients [86% (169 patients; 133 women and 36 men]), LPI sucessfully opened the angle. Mean IOP was reduced from 18.3 ± 6.4 mmHg to 15.4 ± 4.5 mmHg after LPI (p<0.01). Among the 27 patients with persistent occludable angles, the most common underlying mechanisms were plateau iris (56%) and lens-induced component (34%). Most of these patients (85%) were treated with argon laser peripheral iridoplasty (ALPI); approximately 90% showed non-occludable angles following the laser procedure (mean IOP reduction of 18.9%), with no significant differences between patients with plateau iris and lens-induced components (p=0.34; mean follow-up of 11.4 ± 3.6 months). Conclusion: Our findings suggest that, in this population of Brazilian patients, several eyes with angle closure were not completely treated with LPI. In the present large case series involving middle-age patients, plateau iris was the ...

Objetivo: Reportar a prevalência e os resultados terapêuticos em casos de fechamento angular por outros mecanismos além de bloqueio pupilar em uma população de pacientes brasileiros. Métodos: Realizou-se um estudo retrospectivo para avaliar pacientes apresentando ângulo oclusível submetidos à iridotomia periférica a laser (LPI), em uma única instituição, entre julho/2009 e abril/2012. Ângulo oclusível foi definido pela não observação do trabeculado posterior em mais de 180° à gonioscopia sem identação. Olhos com glaucomas secundários ou >90º de sinéquia anterior periférica foram excluídos. Foram coletados os seguintes dados: idade, raça, sexo, mecanismo de fechamento angular (com base na gonioscopia e biomicroscopia ultrassônica), pressão intraocular (PIO), número de medicações antiglaucomatosas e manejo subsequente durante o seguimento. Sempre que ambos os olhos eram elegíveis, o olho direito foi escolhido arbitrariamente para análise. Resultados: Foram incluídos 196 olhos de 196 pacientes (58,3 ± 11,6 anos) que foram submetidos à LPI. Na maioria dos casos [86% (169 pacientes; 133 mulheres e 36 homens), a LPI foi capaz de abrir o ângulo. A PIO média foi reduzida de 18,3 ± 6,4 para 15,4 ± 4,5 mmHg após a LPI (p<0,01). Entre os 27 casos que persistiram com ângulo oclusível, os mecanismos mais comuns envolvidos foram íris em platô (56%) e induzido por componente cristaliniano (34%). A maioria desses casos (85%) foram tratados com iridoplastia periférica a laser (ALPI). Aproximadamente 90% tornaram-se não oclusíveis após a ALPI (redução média da PIO de 18,9%), não havendo diferença significativa entre os pacientes com componentes de íris em platô ou cristaliniano (p=0,34; seguimento médio de 11,4 ± 3,6 meses). Conclusões: Nossos resultados sugerem que, nessa população de pacientes brasileiros, parte dos olhos com fechamento angular não foi completamente tratada com LPI. Nesta série de pacientes de meia-idade, a presença de íris em ...

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.

Prevalence of plateau iris configuration in primary angle closure glaucoma using ultrasound biomicroscopy in the Indian population.

Purpose: To report the prevalence of plateau iris in patients with primary angle closure glaucoma (PACG), in North India. Materials and Methods: The patients with PACG, attending the glaucoma services at a tertiary care center in North India were included in the study. All patients had undergone Nd-YAG laser peripheral iridotomy at least four weeks prior to inclusion in the study. Four weeks prior to inclusion in the study, none of the patients had used pilocarpine. Ultrasound Biomicroscopy (UBM) images were qualitatively evaluated and plateau iris configuration was defined in an eye if the following criteria were fulfilled in two or more quadrants: anteriorly directed ciliary process supporting the peripheral iris, steep rise of iris root from its point of insertion followed by a downward angulation from the corneoscleral wall, absent ciliary sulcus, and iridotrabecular contact in the same quadrant. Results: One hundred and one eyes were included in the study. There were 63 (62.4%) females and 38 (37.6%) males. The mean age of the patients was 57.8 ± 9.5 years (range: 42 to 78 years). The mean axial length in the study population was 22.2 ± 1.1 mm. The mean spherical equivalent refraction was 0.06 ± 1.12 D. The mean intraocular pressure was 18.5 ± 4.7 mmHg (range: 12 – 24 mmHg). Twenty-nine (28.7%) subjects were diagnosed with plateau iris on the basis of above-defined criteria. Of the 29 eyes, 18 (62.1%) subjects had plateau iris in two quadrants, nine (31.03%) in three quadrants, and two (6.8%) had this configuration in all the four quadrants. Conclusions: Approximately 30% of the eyes with PACG had plateau iris on UBM. Plateau iris was very often the cause for residual angle closure following laser peripheral iridotomy in Indian eyes with PACG.

Evolución y resultados del glaucoma por cierre angular primario / Evolution and results of the glaucoma caused by primary angular closing

Objetivo: Evaluar la evolución y resultados finales de los pacientes con diagnóstico de glaucoma por cierre angular primario. Métodos: Se realizó un estudio observacional, descriptivo, prospectivo en 21 pacientes con diagnóstico de glaucoma por cierre angular primario que acudieron al Servicio de Oftalmología del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez, de Matanzas, en el período comprendido entre noviembre de 2008 a enero de 2010, con un seguimiento mínimo de 3 meses. Se analizaron las variables clínico-epidemiológicas, examen oftalmológico y tiempo de inicio del tratamiento. Los datos recogidos fueron procesados en Microsoft Excel. Resultados: El grupo etáreo que predominó fue el de 60 a 69 años. Hubo un control de la presión intraocular en el 85,7 por ciento de los pacientes y el 76,2 por ciento obtuvo buena agudeza visual, correspondiendo este grupo con un inicio precoz del tratamiento médico-quirúrgico. Las secuelas invalidantes estuvieron presentes en un bajo por ciento de los casos, quienes iniciaron el tratamiento médico-quirúrgico pasadas las 48 horas. Conclusiones: El diagnóstico oportuno y el tratamiento inmediato de la enfermedad, determina el control adecuado de la presión intraocular y evita en muchos casos una pérdida visual irreversible.

Objective: Evaluating the evolution and final results of the patients with glaucoma by primary angular closing. Methods: We made an observational, descriptive, prospective study in 21 patients diagnosed with glaucoma by primary angular closing who assisted the Service of Ophthalmology of the Clinical Surgical Teaching Hospital Comandante Faustino Pérez, of Matanzas, in the period from November 2008 to January 2010, with a minimal follow-up of 3 months. We analyzed the clinical-epidemiologic variables, the ophthalmologic examination and the time the treatment began. The collected data were processed in Microsoft Excel. Results: The predominant age group was the 60-69 years-old one. There was a control of the ocular pressure in 85,7 percent of the patients, and the 76,2 percent had good visual acuity, in correspondence with a precocious beginning of the medical-surgical treatment. There were invaliding sequels in a low percent of the cases, corresponding to those patients who began the medical-surgery treatment after 48 hours. Conclusions: The on-time diagnosis and immediate treatment of the disease leads to the adequate control of the intraocular pressure and, in many cases, avoids an irreversible visual lost.

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.

An Indian perspective on primary angle closure and glaucoma.

Aim: To provide a synopsis of primary angle closure disease in India, and Indian studies on the same. Results: Primary angle closure glaucoma forms almost half of all adult primary glaucomas seen in a hospital setting in India. Anatomically, corneal diameters and anterior chamber depths were least in acute and chronic PACG eyes as compared to subacute eyes and controls. Besides relative pupillary block, a Valsalva maneuver during activities of daily living may be responsible for intermittent angle closure and raised IOP in predisposed eyes. Iridotomy alone, controlled the intraocular pressure in 66.7% of subacute eyes and 12.9% of the acute. Medical therapy was additionally required for 35.5% of the acute eyes, 12.1% of the subacute and 30.0% of the chronic cases. There was a greater mean and peak IOP reduction, achieved with 0.005% latanoprost once daily, 8.2 ± 2.0 mm Hg, compared with 0.5% timolol twice daily, 6.1 ± 1.7 mm Hg2. A progression of PACS to PAC was seen in 22%, PAC to PAC OHT in 38.7% and PAC OHT to PACG in 30.7% over 5 years. Conclusions: Primary angle closure disease is common in India, and can be managed well with iridotomy, followed by an appropriate control of IOP.

Importance of population-based studies in clinical practice.

In the last decade, there have been reports on the prevalence of glaucoma from the Vellore Eye Survey, Andhra Pradesh Eye Diseases Survey, Aravind Comprehensive Eye Survey, Chennai Glaucoma Study and West Bengal Glaucoma Study. Population-based studies provide important information regarding the prevalence and risk factors for glaucoma. They also highlight regional differences in the prevalence of various types of glaucoma. It is possible to gather important insights regarding the number of persons affected with glaucoma and the proportion with undiagnosed disease. We reviewed the different population-based studies from India and compare their findings. The lacunae in ophthalmic care that can be inferred from these studies are identified and possible reasons and solutions are discussed. We also discuss the clinical relevance of the various findings, and how it reflects on clinical practice in the country. Since India has a significantly high disease burden, we examine the possibility of population-based screening for disease in the Indian context.

Incidência de glaucoma agudo primário no Serviço de Glaucoma do Hospital São Geraldo / Incidence of primary angle-closure glaucoma in the Glaucoma Service of the São Geraldo Hospital

OBJETIVOS: Determinar a incidência do glaucoma agudo primário no Serviço de Glaucoma do Hospital São Geraldo; estabelecer o perfil destes pacientes e identificar possíveis fatores de risco. MÉTODOS: Estudo transversal. Período de análise: setembro/2005 a agosto/2006. Inclusão: diagnóstico de glaucoma agudo primário. Exclusão: presença de catarata que acarrete baixa acuidade visual ou miopização, glaucomas secundários, íris em platô. Foram avaliados: número de atendimentos, incidência de glaucoma agudo primário, idade, sexo, raça, história familiar de glaucoma, ceratometria, e dados biométricos. RESULTADOS: Dentre 879 pacientes atendidos, 20 (2,3 por cento) tiveram o diagnóstico de glaucoma agudo primário, desse modo, a incidência de glaucoma agudo primário foi de 22,7 por 1000 atendimentos. Dos pacientes com glaucoma agudo primário: 6 (30,0 por cento) eram do sexo masculino e 14 (70,0 por cento) feminino; a idade variou de 40 a 73 anos (média: 60,4 ± 8,1 anos); 12 (60,0 por cento) eram leucodérmicos e 8 (40,0 por cento) feodérmicos; 5 (25,0 por cento) com história familiar positiva para glaucoma. O risco relativo para o sexo feminino foi de 1,44 (IC 95 por cento). Onze (55,0 por cento) pacientes tiveram glaucoma agudo primário no olho direito e 9 (45,0 por cento) no esquerdo. Não houve diferença estatisticamente significativa na comparação dos parâmetros biométricos e ceratometria entre os olhos afetados e os contralaterais. CONCLUSÕES: A incidência de glaucoma agudo primário no Serviço de Glaucoma do Hospital São Geraldo foi de 22,7 por 1000 atendimentos, sendo mais freqüente em mulheres, leucodérmicas, com história familiar negativa para glaucoma e média de idade de 60,4 anos. Os olhos afetados e olhos contralaterais foram semelhantes nos parâmetros biométricos.

PURPOSE: To determine the incidence of the primary angle-closure glaucoma at the Glaucoma Service of São Geraldo Hospital, to establish the profile of these patients and to identify the possible risk factors. METHODS: Transversal study. Period of assessment: from September/2005 to August/2006. Inclusion criteria: diagnosis of primary angle-closure glaucoma. Exclusion criteria: presence of cataracts that cause low visual acuity or index-myopia, secondary glaucoma, plateau iris. Number of visits, incidence of primary angle-closure glaucoma, age, gender, race, family history of glaucoma, keratometric, and biometric data were assessed. RESULTS: Of 879 attended patients, 20 (2.3 percent) had the diagnosis of primary angle-closure glaucoma, therefore, the incidence of the primary angle-closure glaucoma was 22.7 cases per 1000 attended. Of those patients with primary angle-closure glaucoma: 6 (30.0 percent) were men and 14 (70.0 percent) women; the age varied from 40 to 73 years (average: 60.4 ± 8.1 years); 12 (60.0 percent) were leukodermics and 8 (40.0 percent) pheodermics; 5 (25.0 percent) with positive familiar history of glaucoma. The relative risk for women was 1.44 (95 percent IC). Eleven (55.0 percent) patients had primary angle-closure glaucoma of the right eye and 9 (45.0 percent) of the left. When biometric data and keratometry were compared between the affected and contralateral eye, no statistical significant difference was observed. CONCLUSIONS: The incidence of the primary angle-closure glaucoma at the Glaucoma Service of São Geraldo Hospital was 22.7 cases per 1000 attended. It was more frequent in leukodermic women, without family history of glaucoma and with an average age of 60.4 years. The affected and contralateral eyes were biometrically similar.

Profile of the subtypes of angle closure glaucoma in a tertiary hospital in north India.

A prospective study of 500 consecutive patients of primary angle closure glaucoma was undertaken to study the clinical profile of the three subtypes: acute, subacute, and chronic. A record of age and sex distributions, symptomatology, the best corrected visual acuity, gonioscopy, visual fields, methods of control of intraocular pressure, and status of the second eye was maintained. Statistical analysis of these parameters and the subtypes of angle closure glaucoma was carried out using the chi-square test. Angle closure glaucoma constituted 45.9% of all primary adult glaucomas seen. 24.8% of these had acute angle closure glaucoma, 31.2% subacute, and 44% chronic glaucoma. Angle closure glaucoma occurred maximally in the sixth decade and females constituted 51.4% of those affected. The difference in symptoms among the subtypes was significant (p < 0.001). More than 80% of the chronic eyes had no significant symptoms. Visual field defects specific for glaucoma were seen in only 15.1% of chronic glaucoma eyes. Bilaterality was commonest in subacute angle closure glaucoma (95.5%) and least in acute angle closure 35.5%. Nd YAG iridotomy alone or with topical medication controlled the intraocular pressure in 48.3% of acute angle closure glaucoma, 78.8% of subacutes, and 30% of chronic eyes. Statistically, each parameter reviewed was significantly different among the subtypes. There are considerable differences as well as an overlap of clinical features in the subtypes of angle closure glaucoma, which suggest some anatomical differences or dissimilar pathogenic mechanisms in these eyes.