Sildenafil-induced bilateral ciliochoroidal effusion syndrome: Case report.

PURPOSE: To report a case of bilateral ciliochoroidal effusion syndrome associated with sildenafil use. CASE REPORT: A 41-year-old male presented with a five-day history of bilateral blurred vision, elevated intraocular pressure, and myopic shift. Ultrasound biomicroscopy radial scans showed closed angles and 360 degrees of ciliochoroidal effusion in both eyes. Anterior segment coherence tomography angiography showed bilateral shallow anterior chamber. Further questioning revealed that the patient had taken sildenafil several times just a few days before symptoms appeared. Since then, the patient stopped dosing sildenafil. After treatment of anti-inflammation and shifting the lens-iris diaphragm posteriorly, the patient's visual acuity improved and intraocular pressure decreased. Follow-up ultrasound biomicroscopy and anterior segment coherence tomography angiography revealed resolution of ciliochoroidal effusion and increase of anterior chamber depth in both eyes. CONCLUSIONS: The patient demonstrated a rare case of sildenafil-induced bilateral ciliochoroidal effusion syndrome. This case report shows that sildenafil should be added to the possible causative agents of ciliochoroidal effusion syndrome.

Dynamic angle closure following pars plana vitrectomy with perfluoropropane gas.

Purpose: To report the clinical course of an aphakic patient who developed positional secondary angle closure glaucoma following pars plana vitrectomy (PPV) with perfluoropropane (C3F8) gas tamponade. Observations: A 23-year-old male presented due to a two-year history of vision loss in the left eye. Best-corrected visual acuity (BCVA) was 20/200 and intraocular pressure (IOP) was 12 mm Hg OS. Exam revealed iridodonesis and aphakia of both eyes, and a total RRD in the left eye. The patient underwent scleral buckle plus PPV with 15 % C3F8 gas and was instructed to maintain face-down positioning for 5 days. On post-operative day 1, IOP was 32 mm Hg and exam revealed significant diffuse corneal edema, a large epithelial defect, and 85 % C3F8 fill of the vitreous cavity. Patient was started on IOP-lowering drops but continued to have elevated IOP and corneal epithelial sloughing over the next 3 weeks. He was taken for a superficial keratectomy, but when placed supine under the microscope, a large new gas bubble was visualized overlying the pupil in a now shallow anterior chamber (AC) and IOP was 52 mm Hg. The patient was positioned back upright and the gas bubble migrated posteriorly out of the AC with return of IOP to 25 mm Hg. The dynamic nature of his IOP raised concerns for intermittent angle closure by C3F8 induced by supine positioning. Thus, a pars plana aspiration of the C3F8 gas was performed and resulted in normalization of the IOP. Conclusions and importance: Dynamic, positional secondary angle closure glaucoma can occur after vitrectomy with C3F8 in the setting of aphakia. This is the first report to capture C3F8 gas migration causing intermittent acute angle closure in real-time. Due to its intermittent nature however, the diagnosis may not be initially apparent at the slit lamp. Thus, we suggest this potential complication should be carefully monitored for and discussed when advising post-vitrectomy positioning in aphakic patients.

Secondary angle closure glaucoma due to iatrogenic big bubble formation in manual DALK for stromal degeneration: An unusual presentation.

A 65-year-old male was planned for Deep anterior lamellar keratoplasty (DALK) to improve his visual quality from the underlying spheroidal degeneration along the visual axis. An attempt for a big bubble was futile, hence converted to a manual DALK. On postoperative day 1, he developed secondary angle closure glaucoma due to reverse pupillary block by the host DM. Decompression of the big bubble was done and angle closure was resolved with a good visual outcome at 1-month post-op. We present the first case of secondary angle closure glaucoma due to reverse pupillary block by a big bubble in a rigid cornea. Abbreviations: DALK = Deep anterior lamellar keratoplasty, OD = oculus dexter, OS = oculus sinister, DS = Diopters Sphere, DC = Diopters cylinder, AS-OCT = anterior segment optical coherence tomography, DM = Descemet's membrane, IOP - Intraocular pressure, GHJ = Graft-host junction, BSS = Balanced salt solution.

Surgical management of glaucoma in microspherophakia using quadruple procedure.

Background: Microspherophakia is a rare developmental lens anomaly with increased anteroposterior and reduced equatorial diameter. It presents with refractive myopia, shallow anterior chamber, and angle closure glaucoma. It is associated with subluxated or dislocated lens, progressive myopia, defective accommodation, and glaucoma. Glaucoma is the most common vision-threatening complication and mostly requires surgical management that includes trabeculectomy, lensectomy, and drainage implant. A staged or combined procedure can be performed. The purpose of this video is to highlight the advantages of combining parsplana vitrectomy (PPV) with parsplana lensectomy (PPL), scleral fixated intraocular lens (SFIOL), and Aurolab aqueous drainage implant (AADI) in a young patient with advanced glaucoma and gross subluxation. Drainage implants are preferred over filtering surgeries in eyes undergoing vitreoretinal procedures due to the risk of bleb fibrosis and hypotony seen in the latter. The combined procedures should be tailored according to the lens status and severity of glaucoma in each patient. Purpose: The purpose of this video is to illustrate a combined quadruple procedure (PPL, PPV, SFIOL, and AADI) in microspherophakic patients with unstable glaucoma and video-based skill transfer to a novice surgeon. Synopsis: This video illustrates quadruple surgery in a microspherophakic patient with secondary angle closure glaucoma. The authors also emphasize the advantages of a combined quadruple procedure over staged procedure or combined PPL with filtering procedure. Highlights: Quadruple procedure can be performed in young microspherophakic patients with advanced glaucoma or at risk of progression and losing central vision along with gross subluxation of lens. It eliminates the need for multiple procedures, the risk of hypotony, and bleb-related complications. Video link: https://youtu.be/KdFjb7acXCI.

Analysis of choroidal thickness on optical coherence tomography in a patient with sudden-onset bilateral myopia, macular striae, and shallow anterior chamber after topiramate use.

This patient presented with sudden onset myopia, shallow anterior chamber, and radial macular folds in both eyes after using topiramate. Ocular parameters including increased choroidal thickness normalized after cessation of topiramate.

The high-pressure bleb.

A 45-year-old male presented with a slowly progressive, painless swelling in his right eye for the past 6 months. He had undergone an open globe injury repair 10 years back and an eventful cataract surgery 5 years back. The presenting visual acuity in the affected eye was perception of light with inaccurate projection of rays. The intraocular pressure was 44 mm Hg with advanced glaucomatous cupping. The swelling was identified to be a communicating sub-tenon cyst secondary to scleral wound dehiscence from secondary angle closure glaucoma. Wound re-suturing, cyst excision and diode laser cyclophotocoagulation was performed in a single sitting, with explained poor visual prognosis.

Case Report: Vogt-Koyanagi-Harada Syndrome Mimicking Acute Angle-Closure Glaucoma in a Patient Infected With Human Immunodeficiency Virus.

Vogt-Koyanagi-Harada disease (VKH) is a rare multisystemic inflammatory autoimmune disorder. Glaucoma secondary to VKH frequently occurs during the recurrent phase of anterior uveitis; however, acute angle-closure glaucoma (ACG) secondary to both VKH and human immunodeficiency virus (HIV) infection has rarely been reported. We describe a case of secondary acute ACG involving VKH, characterized by sudden vision loss, moderately elevated intraocular pressure (IOP), shallow anterior chamber, and fully or partially closed angle, in an HIV-infected patient. Both VKH and HIV infection contributed to the occurrence of ACG due to the leakage and forward rotation of the ciliary body, as well as choroidal effusion. The deterioration of IOP and serous macular detachment were observed after initial corticosteroid therapy. Visual acuity and IOP were improved with subretinal fluid absorption after continued corticosteroid therapy. Understanding the response of IOP and serous macular detachment after corticosteroid therapy is important for clinical practice.

Secondary angle-closure glaucoma as an ocular presentation of systemic lupus erythematosus: a case report.

Systemic lupus erythematosus (SLE) is a chronic idiopathic autoimmune disease. SLE can involve almost any part of the eyes. However, bilateral angle-closure glaucoma due to lupus choroidopathy that is accompanied by polyserositis and nephropathy is rare. We report a 21-year-old woman whose clinical manifestations were diagnosed as bilateral angle-closure glaucoma caused by ciliochoroidal effusion. Subsequently, SLE and lupus nephritis were diagnosed on the basis of malar rash, photosensitivity, proteinuria, positive anti-Smith and anti-DNA antibodies, and a renal histopathological biopsy. After 1 month of treatment with steroids and immunosuppressive drugs, the patient's intraocular pressure returned to normal, visual acuity improved, and lupus nephritis was effectively controlled. Bilateral secondary acute angle closure caused by SLE choroidal disease can be an ocular manifestation of SLE, and is usually accompanied by polyserositis and nephropathy. High-dose steroids and immunosuppressive therapy should be immediately and actively provided for this condition.

Epithelial downgrowth after femtosecond laser-assisted cataract surgery.

PURPOSE: To present the case of a 72-year-old female with epithelial downgrowth after femtosecond laser-assisted cataract surgery. OBSERVATIONS: The patient previously underwent YAG vitreolysis after uncomplicated femtosecond laser-assisted cataract surgery and presented 1 year later with epithelial downgrowth causing complete pupillary block and severe angle closure glaucoma. Subsequent management with nd:YAG peripheral iridotomies failed rapidly leading to a confusing presentation with a flat anterior chamber and high intraocular pressure ultimately requiring surgical management. CONCLUSIONS: We describe the occurrence of epithelial downgrowth after femtosecond laser-assisted cataract surgery and illustrate the utility of ultrasound biomicroscopy to differentiate between severe pupillary block and malignant glaucoma.

Ciliochoroidal effusion syndrome with central serous-like chorioretinopathy and secondary angle closure following exogenous testosterone use.

PURPOSE: To report a unique presentation of ciliochoroidal effusion syndrome with central serous-like chorioretinopathy and secondary angle closure following exogenous testosterone use. OBSERVATIONS: A 37 year-old man presented with a two week history of blurred vision, elevated intraocular pressure, and myopic shift in his right eye. Gonioscopy showed angle closure. After YAG iridotomy, ultrasound biomicroscopy (UBM) showed ciliochoroidal effusion and anterior rotation of the ciliary processes. Subsequent color fundus photography, enhanced depth imaging optical coherence tomography (EDI-OCT) and near-infrared reduced-illuminance autofluorescence imaging (NIR-RAFI) showed macular striae, choroidal folds, and increased choroidal thickness without presence of subretinal fluid (SRF) or pigment epithelial detachment (PED). Further questioning revealed the patient was using dermal testosterone gel for six months for treatment of hypogonadism. The patient stopped using the testosterone gel, and his visual acuity and intraocular pressure significantly improved six weeks later. Follow-up UBM showed significant improvement of the ciliochoroidal effusion, and repeat multimodal images demonstrated resolution of the macular striae and choroidal folds, and slightly improved choroidal thickness. CONCLUSIONS AND IMPORTANCE: Our patient demonstrates a rare case of ciliochoroidal effusion, central serous-like chorioretinopathy, and secondary angle closure that dramatically improved with cessation of testosterone. We believe that this unique clinical constellation is the first to be reported associated with exogenous testosterone use.

Clinical and pathological correlation of cotton wool spots in secondary angle closure glaucoma.

PURPOSE: Cotton Wool Spots (CWS) are a commonly described retinal finding in the posterior segment associated with an extensive number of systemic diseases. The appearance of a CWS in the setting of glaucoma has rarely been reported and has not been correlated with pathology to localized loss of the nerve fiber layer previously. In this case report, we augment a previous report of an 18 year old female with a diagnosis of low grade ciliary body melanoma. This patient experienced eventual mechanical angle closure with a CWS appearing in the posterior pole in the setting of acute elevation of intraocular pressure (IOP). This eye underwent enucleation and pathology evaluation. OBSERVATIONS: Fundus photography documented a CWS in the posterior segment during a period of acute elevation in IOP. Subsequently the eye was enucleated due to pain from refractory angle closure glaucoma secondary to low grade iris-ciliary body ring melanoma. The specific site of the prior CWS was studied with 1µ Epon retinal step sections stained with a novel AgNO3 solution. Light microscopy demonstrated a retinal nerve fiber layer scar and inner nuclear layer collapse in the prior location of the CWS. Light microscopy and transmission electron microscopy shortly after enucleation had demonstrated temporal quadrant laminar optic nerve (ON) retrograde axonal transport block. CONCLUSIONS AND IMPORTANCE: Although not commonly associated with glaucoma, CWS can present in the setting of acute elevations of IOP and may be associated with loss of nerve fiber layer. This loss of nerve fiber layer can confound the ability to judge glaucoma progression based on nerve fiber layer thickness via optical coherence tomography and changes in disc contours. Patient care may benefit from care provider's awareness of this possible phenomenon in the setting of angle closure.

Ring melanoma of the anterior chamber angle as a mimicker of pigmentary glaucoma.

A 19-year-old man noticed blurred vision in his right eye. He had an intraocular pressure of 60 versus 12 mmHg in the fellow eye. He was initially diagnosed with an atypical, advanced pigmentary glaucoma. The intraocular pressure did not respond to maximal medication, deep sclerectomy, goniopuncture, and 2 cyclophotocoagulations. Sixteen months after presentation, malignancy was first suspected, and the eye was enucleated. A ring melanoma of the anterior chamber angle was confirmed by the histopathologic examination. Normal nuclear staining for breast cancer 1 gene (BRCA1)-associated protein 1 suggested that the tumor was likely of disomy 3 type with a favorable prognosis. No local or systemic recurrence has developed within 4 years. A literature review of this rare type of minimal volume diffuse uveal melanoma identified 18 additional patients. The initial diagnosis in 18 of the 19 patients with a ring melanoma of the anterior chamber angle was unilateral glaucoma with a median intraocular pressure of 40 mmHg and an age range of 16-76 years. Liver metastasis developed in 5 of 12 patients older than 45 years. This rare subtype is estimated to account for 0.05%-0.16% of all uveal melanomas.

Secondary Angle-Closure Glaucoma Due to Posterior Synechiae of Iris Following Combined Phacoemulsification and 23-Gauge Transconjunctival Vitrectomy.

PURPOSE: To describe the clinical characteristics of eyes with secondary angle-closure glaucoma following combined phacovitrectomy. METHODS: Retrospective case series. RESULTS: Nine eyes developed angle-closure glaucoma due to iris posterior synechiae with an incidence rate of 1.82% (95% CI: 0.64 - 3%) among 493 eyes following phacovitrectomy. PDR with TRD was the most common surgical indication. Single piece IOL insertion and silicone oil were present in all cases. Fibrin in the anterior chamber was found in six eyes postoperatively. Mean degree of iris bombe was 310±79.37° at 3.55±1.87 weeks with a mean IOP of 32.56±5.89 mm of Hg. Systemic diabetes and grade of cataract were the only significant risk factors (r2 =1; p= 0.016 and 0.049, respectively). Nd:YAG laser PI relieved the angle-closure attack in all cases. CONCLUSION: Systemic diabetes and advanced grade of cataract are significant risk factors for secondary angle-closure glaucoma following combined phacovitrectomy.

Current concepts in the treatment of vitreous block, also known as aqueous misdirection.

Vitreous block (VB), a rare secondary angle-closure caused by anterior rotation of the ciliary body, occurs in a variety of settings, but most frequently after glaucoma filtering surgery. The etiology remains unclear, but choroidal expansion and anterior vitreous abnormalities have been proposed. In the past, treatment of VB has yielded high rates of failure and recurrence. Advancements in surgical techniques, however, have led to improved visual outcomes. We review the history of this condition and present a stepwise approach to its diagnosis and treatment using modern imaging modalities and surgical techniques.

Phacoemulsification using Iris Hook in Patients with Secondary Angle-Closure Glaucoma Associated with Lens Subluxation

PURPOSE: To evaluate the effect on the intraocular pressure after the phacoemulsification on the secondary angle-closure glaucoma associated with lens subluxation. METHODS: We reviewed the clinical records of 8 patients (9 eyes) prospectively who's intraocular pressure (IOP) didn't controlled with medication, so received the lens removal by the phacoemulsification. We reviewed their intraocular pressure, visual acuity, and complications before and after the surgery. RESULTS: The patients' mean age was 60.4 +/- 11.9. Initial mean IOP was 41.2 +/- 15.0 mmHg with mean of 1.1 +/- 1.8 medication and mean preoperative IOP was 30.4 +/- 11.2 mmHg with mean of 1.2 +/- 1.1 medication. Postoperative IOP was 16.2 +/- 2.8 mmHg with usage of 0.6 +/- 0.9 medication during the follow-up of 4.6 +/- 1.4 months, and the IOP of 6 eyes (66.7%) were controlled under 21 mmHg without any medication. With anti-glaumatic medication, the IOP of all patients were controlled under 21 mmHg. The best corrected visions were also improved after the surgery in all patients. The complications occurred in 5 eyes (55.6%), temporarily increased IOP in 4 eyes (44.4%), and hyphema in 1 eye (11.1%). CONCLUSIONS: The phacoemulsification in the secondary angle-closure glaucoma with the lens subluxation showed relatively satisfactory results, but thorough follow-up would be needed due to the recurrence of elevated IOP afterward.