Glaucoma de ângulo fechado devido a síndrome de íris em platô / Primary angle closure glaucoma due to plateau íris syndrome

Resumo Objetivo: Descrever um caso de glaucoma de ângulo fechado devido a síndrome de íris em platô. Descrição do caso: Paciente do sexo feminino, de 50 anos de idade, que há 13 meses foi tratada de fechamento angular primário a esquerda com sucesso com iridotomia periféria com Nd:YAG laser, compareceu ao serviço com queixa de embaçamento visual e dor intermitentes no olho esquerdo. Ao exame, observou-se fechamento angular à esquerda que se desfazia à gonioscopia de identação e pressão intraocular (PIO) de 16 e 42mmHg. O exame do ângulo da câmara anterior pela tomografia de coerência óptica evidenciou iridotomia patente em ambos os olhos e à esquerda o fechamento aposicional. Pelo estudo das imagens do ângulo foi possível identificar a configuração íris em platô, caracterizando a síndrome de íris em platô à esquerda. Foi procedida a goniosplastia com laser de argônio em ambos os olhos, o que permitiu a correção da configuração da íris e controle da PIO. Após o tratamento, foi realizado exame de campo visual que foi normal à direita e à esquerda identificou escotoma arqueado superior. O fundo de olho mostrou disco óptico normal a direita (0,2),e glaucomatoso à esquerda (0,6). Um ano após a gonioplastia, a acuidade visual foi de 20/30 sem correção por ambos os olhos, PIO de 12 e 13mmHg, sem medicações, com fundo de olho e campos visuais inalterados. Conclusão: A configuração íris em platô deve sempre ser considerada frente a casos de fechamento angular primário, sendo a tomografia de coerência óptica valiosa ferramenta para corroborar no seu diagnóstico.

Abstract Objective: To present a case of closed-angle glaucoma due to Plateau iris syndrome. Case Description: Female Patient, 50 years old, that 13 months ago was treated for primary angular closure to the left successfully with iridotomy with Nd: YAG Laser. She attended the service complaining of visual haze and intermittent pain in the left eye. On examination, it was observed angle closure in the left that could be openned with identation. Intraocular pressure (IOP) of 16 and 42mmHg respectively. The examination of the anterior chamber angle by optical coherence tomography showed patent iridotomy in both eyes and on the left the apositional angle closure. By studying the angle images it was possible to identify plaeau iris configuration, characterizing the iris syndrome of plateau iris. Gonioplasty with argon laser was performed in both eyes, which allowed the correction of iris configuration and control of IOP. After treatment, visual field examination was performed, which was normal to the right and to the left identified superior arcuate scotoma. The Fundus showed a normal right optical disc (0.2), and glaucomatous left (0.6). One year after gonioplasty, visual acuity was 20/30 without correction by both eyes, PIO of 12 and 13mmHg, without medications, with unaltered visual fields and optic discs. Conclusion: The Iris configuration in Plateau should always be considered in front of cases of primary angle closure, being the optical coherence tomography valuable tool to corroborate in its diagnosis.

Opciones quirúrgicas en el cierre angular primario por iris en meseta / Surgical options for the primary angle closure in a plateau iris case

Se describen dos casos clínicos (hermanos), con el objetivo de mostrar diferentes opciones terapéuticas en el glaucoma por cierre angular primario por iris en meseta. El primer caso representa una paciente femenina con antecedentes de iris en meseta e iridectomía periférica quirúrgica, quien presentaba cifras de tensión intraocular elevadas y progresión del daño glaucomatoso, por lo que se decidió realizar trabeculectomía en ambos ojos, con evolución satisfactoria. El segundo caso se trata de un paciente masculino, con antecedentes de salud, quien acudió por molestias oculares. Tras examen físico oftalmológico se constató glaucoma por cierre angular por iris en meseta, con presión intraocular elevada y opacidad del cristalino asociada, por lo que se realizó trabeculectomía en ojo derecho más extracción del cristalino en ambos ojos. Como complicaciones posoperatorias presentó desprendimiento coroideo y edema macular, resueltos con tratamiento médico. La trabeculectomía luego de la extracción del cristalino en ojo derecho falló, por lo que actualmente se encuentra compensado con tratamiento médico. La elección de la terapéutica adecuada debe tener en cuenta los factores fisiopatológicos involucrados y la forma de presentación(AU)

Different therapeutic options for the primary angle closure glaucoma by plateau iris were described in two clinical cases. The first one was a female patient with a a history of plateau iris and peripheral iridectomy. Elevation of intraocular pressure and progression to glaucoma was confirmed, so it was decided to perform trabeculectomy in both eyes and the result was satisfactory. The second case was a male patient with history of health problems, who suffered with eye disturbances. After ophthalmological exam, a primary angle closure glaucoma caused by plateau iris was confirmed with marked eye hypertension and associated crystalline lens opacity. Trabeculectomy of right eye and lens extraction in both eyes was applied. Choroidal detachment and macular edema were the postoperative complications, but the medical treatment managed to solve this situation. After the lens extraction, trabeculectomy in the right eye failed and today it is compensated with medical treatment. The right therapeutic choice should take into consideration the physiopathologic factors and the form of presentation(AU)

Clinical and Anterior Segment Anatomical Features in Primary Angle Closure Subgroups Based on Configurations of Iris Root Insertion

PURPOSE: To compare the clinical and anterior segment anatomical features in primary angle closure sub-groups based on configurations of iris root insertion. METHODS: Primary angle closure patients were imaged using anterior segment optical coherence tomography. Anterior chamber depth, iris curvature, iris thickness (IT) at the scleral spur and 500, 750, and 1,500 µm from the scleral spur (IT(0), IT(500), IT(750), and IT(1500)), lens vault, iris area, angle opening distance (AOD(500)), angle recess area (ARA(750)), and trabecular iris space area (TISA(750)) were measured. Iris root insertion was categorized into a non-basal insertion group (NBG) and basal insertion group (BG). RESULTS: In total, 43 eyes of 39 participants belonged to the NBG and 89 eyes of 53 participants to the BG. The mean age of participants was greater in the NBG than the BG (62.7 ± 5.7 vs. 59.8 ± 7.3 years, p = 0.043), and the baseline intraocular pressure was higher in the BG than the NBG (16.4 ± 4.4 vs. 14.9 ± 3.3 mmHg, p = 0.037). The BG showed a greater IT(0) (0.265 ± 0.04 vs. 0.214 ± 0.03 mm, p < 0.001) and iris area (1.59 ± 0.24 vs. 1.52 ± 0.27 mm2, p = 0.045), lower ARA(750) (0.112 ± 0.08 vs. 0.154 ± 0.08 mm2, p = 0.017) and AOD(500) (0.165 ± 0.07 vs. 0.202 ± 0.08 mm, p = 0.014) compared to the NBG. CONCLUSIONS: The BG had a narrower anterior chamber angle, thicker peripheral iris, and higher pretreatment intraocular pressure.

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 ...

Cierre angular agudo bilateral inducido por benzodiazepinas / Bilateral acute angle closure induced by benzodiazepins

El cierre angular agudo o glaucoma agudo como es conocido mundialmente es un cuadro clínico característico producido por un cierre angular brusco, constituye una urgencia oftalmológica que pone en peligro la función visual si no es resuelto satisfactoriamente en las primeras horas de instaurado. El mecanismo fisiopatológico más frecuente es el bloqueo pupilar primario y el tratamiento de elección es la iridotomía láser periférica. Se debe realizar el diagnóstico diferencial con el bloqueo pupilar secundario y con otras causas sin bloqueo pupilar en las que la iridotomía no es suficiente. El cierre angular agudo es generalmente unilateral aunque se puede presentar de forma bilateral desencadenado por el empleo de drogas que producen dilatación pupilar como en el caso clínico que se describe a continuación

The acute angle closure or acute glaucoma as it is worldwide known is a characteristic clinical picture that is caused by sudden angle closure, It represents ophthalmological emergency that endangers the visual function if not satisfactorily solved in the first hours of occurrence. The most frequent physiopathological mechanism is primary pupil blocking and the treatment of choice is peripheral laser iridotomy. The differential diagnosis must be made with the secondary pupil blocking and with other causes without pupil blocking in which iridotomy is not enough. The acute angular closure is generally unilateral, although it may appear bilaterally and be caused by the use of drugs that give rise to pupil dilation like the clinical case which was described here

Laser Peripheral Iridotomy with Iridoplasty in Primary Angle Closure Suspect: Anterior Chamber Analysis by Pentacam

PURPOSE: To compare conventional laser peripheral iridotomy (LPI) and LPI combined with laser peripheral iridoplasty in eyes with primary angle closure suspect (PACS) by assessment of anterior chamber dimensional changes using a Pentacam. METHODS: Forty-eight eyes of 24 subjects with bilateral PACS were recruited consecutively. Each eye was randomly allocated to treatment with conventional LPI, argon LPI only, or LPI plus iridoplasty, which consisted of simultaneous argon LPI and peripheral iridoplasty. Anterior chamber measurements were performed on each eye using a Pentacam, both before and after treatment. Mean anterior chamber depth (ACD), anterior chamber volume (ACV), and anterior chamber angle were measured, and topographic ACD analysis was performed. Results were compared between the two treatment groups. RESULTS: After treatment with either conventional LPI or LPI plus iridoplasty, the mean ACD and ACV increased significantly. Topographic ACD analysis revealed that the mid-to-peripheral ACD increase was significantly greater in the LPI plus iridoplasty group than in eyes treated with conventional LPI. Intraocular pressure changes and post-LPI complications did not differ between the groups. CONCLUSIONS: Compared with conventional LPI, our study showed that LPI plus iridoplasty improved the mid-to-peripheral ACD increase. This procedure may have a role as an adjunct for reducing angle closure by simultaneously eliminating pupillary and non-pupillary block components.

Recurrent Occlusion of Laser Iridotomy Sites After Posterior Chamber Phakic IOL Implantation

We report a case of recurrent occlusion of laser iridotomy (LI) sites after a Visian ICL (Implantable contact lens version 4, Staar Surgical AG, Nidau, Switzerland) implantation. A 45-year-old woman had bilateral ICL implantation after placement of two peripheral LI sites in each eye to prevent pupillary block. At one month after the operation, severe narrowing or occlusion of four LI sites occurred. After this, although she received four additional LIs at postoperative months 1, 6, 9 and 10 in both eyes, the narrowing or occlusion recurred. Mild chronic anterior chamber inflammation was observed intermittently throughout the follow-up period. We performed clear lens extraction in both eyes (at postoperative month 11 in the left eye and month 26 in the right eye) due to recurrent occlusion of the LI sites and excess trabecular meshwork pigment deposition presumably caused by the four repeated LIs. Recurrent obstruction of LI sites can occur after ICL implantation. These problems were unresolvable despite four repeated laser iridotomies. The risks associated with anterior uveitis must be considered when planning an ICL implantation.

Síndrome de Íris Plateau: relato de 17 casos / Iris Plateau syndrome: case report of 17 cases

Objetivo: Relatar 17 casos diagnosticados como Síndrome da Íris Plateau (17 olhos), enfocando a apresentação clínica, abordagem diagnóstica e conduta. Métodos: Os pacientes foram diagnosticados como Síndrome de Íris Plateau, baseado nos exames de gonioscopia e biomicroscopia ultra-sônica (UBM), realizados após a iridectomia a laser. Todos os pacientes foram acompanhados por um período de tempo médio de 46,7 + 11,7 meses. Aforma completa da síndrome foi determinada pela presença de crise congestiva recidiva ou teste da prono-posição em quarto escuro positivo. Resultados: No primeiro grupo, oito olhos se apresentaram na primeira consulta com glaucoma agudo. Dois destes olhos apresentaram teste provocativo positivo (2) após a iridectomia e seis deles apresentaramcrise congestiva recidiva durante o tempo de seguimento - síndrome da íris em Plateau completa. No segundo grupo, nove olhos não apresentaram glaucoma agudo, antes ou após a iridectomia, e devido aos achados nos exames de gonioscopia e UBM foram diagnosticados como portadores do mecanismo da íris em Plateau – possíveis casos de síndrome da íris em Plateau incompleta. Mesmo após a realização da iridectomia,dois olhos do segundo grupo apresentaram progressão das sinéquias anteriores periféricas (SAP). Conclusão: Casos de síndrome da íris em Plateau podem evoluir apresentando crise congestiva recidiva e/ou progressão das SAP. A gonioscopia sempre deve ser realizada após a iridectomia a laser a fim de verificar a eficácia do procedimento em abrir o ângulo irido-corneano. Entretanto, estudos prospectivos longitudinais são ecessários para determinar quais os fatores de risco relacionados ao processo de fechamento angularsecundário ao mecanismo da íris em Plateau.

Objective: To report 17 cases of Plateau Iris Syndrome (17 eyes) focusing on clinical presentation, diagnosis approach and treatment. Methods: All patients were diagnosed as iris Plateau syndrome cases based on gonioscopy and ultrasound biomicroscopy (UBM) exam findings, performed after laser iridectomy. The mean follow up time was 46,7 + 11,7 months. The completeform of the syndrome was determined by the presence of recurrent acute angle closure episode or a positive darkroom prone position test. Results: In the first group, eight eyes had an acute angle closure episode at the time of thefirst evaluation. Two of them had a positive dark room prone position test even after iridotomy and six of themhad a recurrent acute angle closure episode during the follow-up period - complete plateau iris syndrome cases.In the second group, nine eyes that did not have an acute attack before or after iridotomy were included. All of themhad gonioscopy and UBM findings compatible with plateau iris mechanisms – possible incomplete plateau iris syndrome cases. We observe progression of peripheralanterior synechiae (PAS) in two eyes of the second group even after iridotomy. Conclusion: Plateau iris syndromecases may develop recurrent acute angle closure episodes and/or further PAS formation. The gonioscopy exam must always be performed after the iridotomy in order to verify the opening of the irido-corneal angle. Further studies should address the risk factors related to the maintenance of the angle closure process even after iridotomy.

Ultrasound Biomicroscopic Changes after Laser Iridotomy or Trabeculectomy in Angle-closure Glaucoma

This study was performed to demonstrate the ultrasound, biomicroscopic and dimensional changes of angle structure after laser iridotomy (LI) and primary trabeculectomy (PT) in primary angle-closure glaucoma (PACG). Angle-opening distance at a point 500 (m from the scleral spur (AOD500), trabecular-iris angle (theta1), trabecular ciliary process distance (TCPD), ciliary process-iris angle (CPI), iris thickness (ID1, ID3), length of iris-lens contact distance (ILCD) and anterior chamber depth (ACD) were assessed before and after each procedure. Thirteen patients with LI and 16 with PT were prospectively enrolled. There were statistically significant increases in AOD500, theta1, and ILCD in both groups. CPI was decreased in both groups. ACD, TCPD, and iris thickness were not changed significantly. The changes in angle configuration after LI or PT may result more from alterations in aqueous pressure gradients across the iris and the changes of configuration were greater in the iris roots without rotation of ciliary body. However, we didn't find any significant differences in the changes of parameters between the two procedures.

Scheie operation for aphakic glaucoma

Aiming at a more permanent results in lowering the ocular tension in cases of aphakic glaucoma due to delayed or non-formation of A.C., Scheie operation was done in 10 cases, in 4 of them after failure of repeated cyclodialysis and in the rest as a primary procedure. Results were very encouraging. The ocular tension was lowered to normal in 9 cases by one operation. Only ate case [case X] required a second intervention on nasal pillar with subsequent normalization of tension. Scheie operation is thus the operation of choice for cases of aphakic glaucoma being safe, easy and with high percentage of success