The spike of acute angle closure after the epidemic downgrade of COVID-19 management: a hospital-based comparative study from China.

PURPOSE: To analyse and compare the clinical characteristics and treatment outcomes of patients with acute angle closure (AAC) who presented before the COVID-19 pandemic, during the COVID-19 management and after their downgrading. METHODS: Consecutive AAC patients were recruited from our hospital and divided into three groups: those treated before the COVID-19 pandemic (Group1), during the COVID-19 management (Group2) and after the management downgrade (Group3). The demographic variables, clinical characteristics, treatment methods and therapeutic outcomes of the groups were compared. RESULTS: When compared to Groups1 and 2, Group3 showed a significantly higher incidence of AAC (0.27%, P < 0.001), a longer time from symptoms to treatment (TST; 160.88 ± 137.05 h, P = 0.031) and worse uncorrected visual acuity (P = 0.009) at presentation. In Group3, 68.9% had a history of COVID-19 and 28.5% developed ocular symptoms of AAC after taking medication for COVID-19 symptoms. The average time from the onset of COVID-19 to the appearance of eye symptoms was 3.21 ± 4.00 days. CONCLUSIONS: The COVID-19 has had a multifaceted impact on the incidence of AAC. Therefore, it is crucial to strengthen health education on glaucoma, especially AAC. The prevention and timely treatment of AAC should be emphasised to combat global blindness.

Diagnosis of Marfan Syndrome Following Progressive Myopia and Secondary Lens-Induced Angle Closure Crisis.

Marfan syndrome (MFS) is a well-described genetic connective tissue disease that heightens the risk of cardiovascular, ocular, pulmonary, and other emergencies in affected individuals. The wide range of phenotypic presentations, spanning from mild, chronic, and asymptomatic to acute and life-threatening, can pose challenges in diagnosing MFS when disease manifestations are subtle. We report a pathogenetic variant of MFS characterized by subtle systemic findings that was identified only after the patient presented with visual changes and pain associated with angle closure, despite a medical history indicating other pathologies linked to this condition. This case underscores the importance of recognizing the varied and sometimes subtle clinical features of MFS. Vigilance in identifying the constellation of findings associated with MFS can enhance its diagnosis and treatment outcomes by enabling appropriate and timely referrals for prophylactic evaluation and care to address potentially life-threatening complications.

Topiramate-induced ocular complications: case series.

Several ocular adverse effects have been attributed to Topiramate, a sulfonamide derivative. It can cause problems in the eye such as choroidal effusion syndrome, acute angle closure glaucoma, myopic shift, visual field defects, and Myokymia. If not identified early, it can be vision-threatening. It is commonly used for migraine prophylaxis, partial onset, and generalized tonic-clonic seizures. It has also been prescribed for bipolar disorder and alcoholism. The risk of adverse reactions with this drug is 3%. The prognosis is favorable if it is discontinued early and prompt therapy is initiated. OBJECTIVE: This article reported a case series of topiramate-induced ocular complications. MATERIALS AND METHODS: The patients presented with high intraocular pressure and blurred vision following a topiramate prescription for headache. CONCLUSION: Timely recognition and intervention can prevent potential visual loss in such cases.

Secondary Angle Closure Caused by Anterior Displacement of Capsular Tension Ring and Intraocular Lens Due to Aqueous Misdirection.

A capsular tension ring (CTR) is used for support to stabilize the capsular bag and intraocular lens (IOL) during and after cataract surgery. Although complications involving the CTR-IOL complex are not uncommon, cases of anterior displacement leading to complications are rare. This report presents a case of secondary angle closure caused by anterior displacement of the CTR-IOL complex due to aqueous misdirection and reports unique findings noted on anterior segment optical coherence tomography (AS-OCT). The patient, a 69-year-old woman, developed an acute angle closure crisis (AACC) and underwent cataract surgery with the implantation of a CTR and IOL. Post-surgery, there was an improvement in the central depth of the anterior chamber, but the patient experienced intermittent spikes in intraocular pressure. AS-OCT revealed a flat center of the iris and a closed anterior chamber angle which are plateau-iris-like findings. Secondary angle closure was caused by the CTR-IOL complex which was anteriorly displaced and pushed the peripheral iris owing to aqueous misdirection syndrome. Three weeks after the initial surgery, the patient underwent CTR removal, anterior vitrectomy, and intrascleral lens fixation. After the second surgery, intraocular pressure was normalized without any medications, and the anterior chamber angle was enlarged. This case provides a better understanding of secondary angle closure caused by the anterior displacement of the CTR-IOL complex and highlights the importance of AS-OCT in the detection of such complications.

Transient Optic Disc Swelling After Laser Iridotomy for the Treatment of Acute Angle Closure Glaucoma.

Acute angle closure glaucoma (AACG) is characterized by narrowing or closure of the anterior chamber angle of the eye. AACG typically presents in older, hyperopic patients who complain of blurred vision, ocular pain, halos around lights, headache, nausea, and vomiting. Optic disc swelling is known to be associated with intracranial hypertension, optic neuritis, anterior ischemic optic neuropathy, retinal vascular occlusion, and toxic optic neuropathy. There have been few reports of temporal relationships between laser iridotomy and optic disc swelling in patients with AACG. In this case report, we present a case of AACG where optic disc swelling was developed after sudden lowering of the intraocular pressure (IOP) by laser iridotomy. A 65-year-old woman presented with left eye pain and poor vision for one day. Slit-lamp examination revealed conjunctival injection, corneal edema, and a nonreactive and mid-dilated pupil in the left eye. Her best corrected visual acuity (BCVA) was 20/20 in the right eye and counting fingers in the left eye. IOP was 10 mmHg in the right eye and 54 mmHg in the left eye. A diagnosis of left AACG was made. A peripheral laser iridotomy was performed. The details of the optic disc were difficult to observe due to corneal edema, but there were no obvious abnormalities. The next day, the BCVA was 20/60 and the IOP had decreased to 9 mmHg in the left eye. Fundus examination demonstrated optic disc swelling in the left eye. Spectral-domain optical coherence tomography (SD-OCT) scanning revealed optic disc swelling in the left eye. One week after treatment, the BCVA was 20/50 and the IOP was 10 mmHg in the left eye. Fundus examination and SD-OCT scanning revealed mild improvement of optic disc swelling in the left eye. Four weeks after treatment, the BCVA was 20/50 and the IOP was 10 mmHg in the left eye. Fundus examination and SD-OCT scanning revealed an improvement in optic disc swelling in the left eye. After performing laser iridotomy, it is necessary to pay attention to changes in the optic disc as well as the IOP.

Novel diagnostic indicators for acute angle closure secondary to lens subluxation based on anterior segment and lens parameters.

Purpose: To explore stable and sensitive indicators for clinical diagnosis of acute angle closure (AAC) secondary to lens subluxation (LS) through quantitative analysis of CASIA 2 imaging.Design: A prospective cross-sectional study. Methods: Setting: Clinical practice.Participants: 23 patients with unilateral acute angle closure secondary to lens subluxation and 23 cataract patients without lens subluxation were recruited. Lens subluxation was confirmed by ultrasound biomicroscope diagnosis. The contralateral eyes without LS served as fellow control group. The cataract eyes without LS were enrolled in blank control group.Intervention: Participants underwent ophthalmologic examinations including slit-lamp biomicroscope, best corrected visual acuity, intraocular pressure, central corneal thickness measurement, axial length, gonioscopy, ultrasound biomicroscope and 360-degree anterior chamber and crystalline lens scan protocols of CASIA 2 system.Main outcome measures: Automated circumferential anterior segment and lens morphological parameters under anterior segment optical coherence tomography were analyzed via three-dimensional analysis. Results: Significant differences were found in the front and back radius of the lens, the front and back radius of steep curvature of the lens, lens thickness, lens decentration, lens diameter, iris-trabecular contact (ITC) index, ITC area, anterior chamber depth (ACD), lens vault (LV), and iris volume between LS and controls. Among these parameters, LV, the anterior radius of steep curvature of the lens and ACD demonstrated the highest prediction power (AUC = 0.87, 0.89, and 0.86, respectively). The prediction power of tilt/axis was much higher in the Gaussian Naive Bayes model (AUCs = 0.90) than in the logistic model (AUCs = 0.74). Combination of LV_mean, LV_std, tilt and tilt axis in Gaussian Naive Bayes model presented as most stable and excellent diagnostic markers for AAC secondary to LS (AUCs = 0.98). Conclusions: The combination of markers including lens tilt and lens vault in the mathematic model facilitate clinical work as it not only provides novel diagnostic indications and possible prompt treatment for AAC secondary to lens subluxations, but also enhances our understanding of the pathogenic role of zonulopathy in angle closure glaucoma.

Importancia del diagnóstico por imágenes multimodales en glaucoma agudo de ángulo cerrado: reporte de caso / Importance of multimodal imaging diagnostics in acute angle closure glaucoma: Case report

Describir la historia natural y el manejo de un glaucoma de cierre angular agudo secundario a melanoma coroideo.Mujer de 70 años que presenta dolor agudo con presión intraocular elevada y catarata madura y que fue diagnosticada de glaucoma agudo de ángulo cerrado en el ojo derecho. Mediante estudios adicionales de diagnóstico por imagen se descubrió un melanoma coroideo que causaba el cierre agudo del ángulo. Se realizó enucleación, y actualmente la paciente se encuentra en estrecha vigilancia postoperatoria por parte de oftalmología y oncología.Este caso refleja la importancia del diagnóstico y el tratamiento precoz de los tumores intraoculares en la disminución de la incidencia de metástasis y el aumento de la supervivencia. En el glaucoma de ángulo cerrado agudo secundario, el tratamiento debe estar dirigido a resolver el factor desencadenante del glaucoma. (AU)

To describe the natural history and management of an acute angle closure secondary to choroidal melanoma.A 70-year-old female presented with pain, elevated intraocular pressure, mature cataract, and angle closure in right eye. With further studies she was found to have a choroidal melanoma causing the acute angle closure. Enucleation was performed and the patient is currently in close postoperative surveillance by ophthalmology and oncology.The importance of early identification and treatment of intraocular tumors to decrease incidence of metastasis. In secondary acute angle-closure glaucoma treatment should be targeted towards resolving the triggering factor of glaucoma. (AU)

Acute angle-closure related with choroidal metastasis from lung adenocarcinoma: A case report and literature review.

PURPOSE: Acute angle-closure is a rare manifestation of choroidal metastasis. We reported a case of choroidal metastasis from lung adenocarcinoma presenting with unilateral acute angle-closure attacks relieved with radiotherapy after failed conventional medical and laser treatments. This represented the first detailed report of treatments of secondary acute angle-closure attacks in patients with choroidal metastasis. CASE DESCRIPTION: A 69-year-old female without ocular history was diagnosed with metastatic lung adenocarcinoma. One month later, she complained of blurred vision and pain in the right eye that lasted 2 days. IOP was 58 mmHg and best-corrected visual acuity (BCVA) was counting finger in the right eye. Slit-lamp examination revealed corneal edema with ciliary congestion, extremely shallow anterior chamber both centrally and peripherally, mid-dilated pupil and moderate cataract in the right eye. While the left eye was normal. B-scan ultrasound and orbital computed tomography showed an appositional choroidal detachment with an underlying choroidal thickening suggesting choroidal metastasis in the right eye. There was limited effect of medical and laser therapy. IOP was 9 mmHg in the right eye after two months of palliative external beam radiotherapy in the right orbit. BCVA was hand motion in the right eye. Slit lamp examination revealed clear cornea, deep anterior chamber in the right eye. Regression of choroidal detachment and choroidal metastasis in the right eye were observed in B-scan ultrasound. CONCLUSION: This case demonstrated that patient with secondary acute angle-closure attacks from large bullous choroidal detachment related to choroidal metastasis could only be successfully treated with radiotherapy as both medical and laser therapy might not be capable of breaking angle-closure attacks.

Anatomical considerations for reducing ocular emergencies during spaceflight.

PURPOSE: The privatization of space travel is opening civilian spaceflight to an unprecedented number of individuals now and in the immediate future. The increase in the number and diversity of space travelers will mean increased exposure to both physiologic and pathologic changes observed during acute and prolonged microgravity. AIMS: In this paper, we describe the anatomic, physiologic, and pharmacologic factors to consider that impact acute angle-closure glaucoma risk during spaceflight. CONCLUSIONS: Based on these factors, we elaborate upon areas of medical considerations and provide future recommendations that may aid in reducing the risk of acute angle-closure glaucoma in the next era of spaceflight.

Importance of multimodal imaging diagnostics in acute angle closure glaucoma: Case report.

To describe the natural history and management of an acute angle closure secondary to choroidal melanoma. A 70-year-old female presented with pain, elevated intraocular pressure, mature cataract, and angle closure in right eye. With further studies she was found to have a choroidal melanoma causing the acute angle closure. Enucleation was performed and the patient is currently in close postoperative surveillance by ophthalmology and oncology. The importance of early identification and treatment of intraocular tumors to decrease incidence of metastasis. In secondary acute angle-closure glaucoma treatment should be targeted towards resolving the triggering factor of glaucoma.

Use of Diuretics and Risk of Acute Angle Closure: A Case-Control Study.

PURPOSE: To examine the possible link between acute angle closure (AAC) with use of diuretics. METHODS: A nested case-control study (NCC) was conducted among a cohort of diuretic users using the PharMetrics Plus database from 2006 to 2020. Cases were identified as the first international classification of diseases 9th and 10th editions (ICD-9/10) code for ACC. For each case, 4 controls were selected and matched to the cases by age and sex using density-based sampling. A conditional logistic regression model was used to compute rate ratios (RRs) adjusted for the drugs topiramate, bupropion, sulphonamide antibiotics, acetazolamide, and sulfasalazine. The RRs for a negative control drug, amlodipine, was also assessed. RESULTS: From the initial cohort of 713 574 diuretics users, 1 553 cases and 6 212 controls were identified. No increase in the risk of AAC with current users of diuretics was found (RR = 1.06, (95% CI: 0.81-1.37) for all diuretics; RR = 0.97, (95% CI: 0.71-1.32) for thiazides; RR = 1.24, (95% CI: 0.90-1.73) for loop diuretics; RR = 0.99, (95% CI: 0.73-1.36) for potassium sparing). CONCLUSION: We found no increase in the risk of acute angle closure with use of diuretics. Future studies are needed to confirm these findings.

An Atypical Presentation of Relapsing Polychondritis Manifesting As Acute Angle Closure.

Relapsing polychondritis (RPC) is a rare autoimmune disease characterized by recurrent inflammation of cartilaginous and proteoglycan-rich tissues throughout the body. The most commonly affected sites are the auricular pinna, nose, and joints with ocular tissue involvement occurring in up to 50% of patients. The most common ocular manifestations are scleritis, episcleritis, uveitis, and conjunctivitis. Less common ocular issues include keratitis, retinopathy, optic neuropathy, extraocular muscle palsy, and orbital inflammation. Due to the variable clinical presentation and rarity of the disease, the diagnosis of RPC is often delayed or it is misdiagnosed. It is important that ophthalmologists be aware of relapsing polychondritis because ocular symptoms may present as the initial manifestation of the disease.

Post-Operative Delirium Masking Acute Angle Closure Glaucoma.

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA). Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline. Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

Factors associated with severe corneal endothelial damage following acute primary angle closure in Chinese subjects.

PURPOSE: To investigate the corneal endothelial damage caused by acute primary angle closure (APAC) and related risk factors for severe corneal endothelial cell damage in Chinese subjects. METHODS: In this multicentre retrospective study, 160 Chinese patients (171 eyes) diagnosed with APAC were recruited. Endothelial cell density (ECD) and morphological changes short after APAC were studied. Univariate regression and multivariate regression were used to identify risk factors associated with the extent of ECD reduction, including age, gender, education level, patients' location, systemic diseases, APAC duration (hours), highest recorded intraocular pressure (IOP), and presenting IOP. Factors associated with the probability of severe corneal damage (ECD lower than 1000/mm2) were analysed based on a linear function. RESULTS: After one APAC episode, 12.28% eyes had ECD lower than 1000/mm2, 30.41% had ECD between 1000 and 2000/mm2, and 57.31% had ECD more than 2000/mm2. Attack duration was the only factor associated with severe endothelial damage (p < 0.0001). If the attack were to be subsided within 15.0 h, possibility of ECD lower than 1000/mm2 could be controlled under 1%. CONCLUSION: Shortly after the abortion of APAC, 12.28% patients experienced severe endothelial cell damage with ECD less than 1000/mm2. The only factor associated with severe ECD decrease was attack duration. Immediate and effective treatment is pivotal for preserving corneal endothelial function in APAC patients.

Unilateral pigmented paravenous retinochoroidal atrophy with acute angle-closure glaucoma: a case report.

BACKGROUND: Pigmented paravenous retinochoroidal atrophy (PPRCA) is an uncommon fundus disease characterized by perivenous aggregations of pigment clumps and retinochoroidal atrophy distributed along the retinal veins. We report a Chinese female case of unilateral PPRCA with acute angle-closure glaucoma (AACG). CASE PRESENTATION: A 50-year-old Chinese female presented with vision loss and elevated intraocular pressure (IOP) in the right eye and then underwent trabeculectomy. She referred to our clinic for further evaluation and treatment. The funduscopic examination revealed grayish retinochoroidal atrophy and osteocyte-like pigment clumping lesions along the retinal veins and peripapillary preretinal hemorrhage in the right eye. The patient also presented with AACG in the same eye on the basis of past medical history of acute attack, shallow anterior chamber depth (ACD), narrow angle showed by ultrasound biomicroscopy (UBM) and glaucomatous neuropathy identified by optical coherence tomography (OCT). Other examinations like fluorescein fundus angiography (FFA), electroretinogram (ERG) and electrooculography (EOG) all confirmed the aforementioned diagnose. CONCLUSION: PPRCA is a rare disease, uncommon in females and symmetrical in both eyes. We present a rare case of unilateral PPRCA accompanied with AACG.

Exudative Retinal Detachment and Ciliochoroidal Effusion in Preeclampsia.

Purpose: To describe a novel case of focal exudative retinal detachment, choroidal effusion, and acute angle closure in preeclampsia. Methods: A case report is presented. Results: A 37-year-old woman at 38 weeks gestation presented with 2 weeks of progressive blurred vision in the left eye. She had a visual acuity (VA) of 20/800 and an intraocular pressure (IOP) of 26 mm Hg in the left eye (compared with 17 mm Hg in the right eye). Examination showed subretinal fluid in the posterior pole, ciliochoroidal effusion, and angle closure in the left eye without pathology in the right eye. She was found to have hypertension and proteinuria consistent with preeclampsia. The visual symptoms resolved after delivery. At the 1-month follow-up, she had a VA of 20/60 OS, symmetric IOPs, and resolved subretinal and choroidal effusions. Conclusions: To our knowledge, this is the first reported case of ciliochoroidal effusion in the setting of preeclampsia. It may aid in the diagnosis of preeclampsia's ocular manifestations and broaden pathophysiological understanding.

Effects of the periocular botulinum toxin on the ocular surface and anterior chamber: a prospective study in patients with hemifacial spasm and blepharospasm.

PURPOSE: To analyze using Pentacam®, the corneal and anterior chamber changes following periocular botulinum toxin injection in patients with facial dystonia. METHODS: Prospective study that included patients with facial dystonia that were going to receive a periocular botulinum toxin injection for the first time or six months or more after the previous injection. A Pentacam® examination was carried out in all patients before and 4 weeks after the injection. RESULTS: Thirty-one eyes were included. Twenty-two had a diagnosis of blepharospasm and nine of hemifacial spasm. Analysis of corneal and anterior chamber parameters revealed a significant decrease in iridocorneal angle after botulinum toxin injection (from 35 ± 10º to 33.8 ± 9.7º, p = 0.022). No other corneal or anterior chamber parameters changed significantly after the injection. CONCLUSIONS: Periocular botulinum toxin injection causes narrowing of the iridocorneal angle.

Glaucoma and Systemic Disease.

Glaucoma is the leading cause of irreversible blindness in the world. Due to its potential to cause permanent vision loss, it is important to understand how systemic conditions and their respective treatments can be associated with or increase the risk for developing glaucoma. In this review, we examined the literature for up-to-date discussions and provided commentary on glaucoma, its pathophysiology, and associated risk factors. We discuss systemic diseases and the impact, risk, and mechanism for developing glaucoma, including pharmacologically induced glaucoma; inflammatory and auto-immune conditions; infectious, dermatologic, cardiovascular, pulmonary, renal, urologic, neurologic, psychiatric and systemic malignancies: intraocular tumors; as well as pediatric, and genetic conditions. The goal of our discussion of systemic conditions including their commonality, mechanisms, treatments, and associations with developing glaucoma is to emphasize the importance of ocular examinations and follow-up with the multidisciplinary teams involved in the care of each patient to prevent unnecessary vision-loss.

Highlights on Genetic Polymorphism Associated with Thromboembolic Risk; Implications in Ophthalmic and Autoimmune Disorders-A Review.

The present paper explores genetic polymorphism and its association with thromboembolic retinal venous disorders, such as central/hemi-retinal vein occlusion, as well as possible correlations with other ocular findings, such as closed angle glaucoma, but also with autoimmune general disorders. In this review, we are highlighting the importance of establishing a correspondence between all of the above, since they all have complex etiopathogeneses; sometimes, when all coexist together, they could generate effects that may be very difficult to manage. There are studies supporting that genetic polymorphism, such as the variant MTHFR A1298C, may increase the risk for developing glaucoma, especially in the heterozygote model. Being aware of all these aspects may prove to be useful in patients with several associated diseases, as a combined effort between several medical specialties may prove to the benefit of these patients. Our review, completed with an exemplifying clinical case, shows that it is necessary to raise awareness of all aspects of a complex medical situation, including the genetic one, of a patient being at risk for thromboembolic episodes, for preventing them or managing them promptly and properly in the future.