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.

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.

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.

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.

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.

[Painful anisocoria in a five-year-old child: A rare diagnosis which must not be missed]. / Anisocorie douloureuse chez un enfant de cinq ans : un diagnostic rare à ne pas méconnaître.

Congenital ectropion uveae (CEU) is a rare anomaly of the embryonic development of the anterior segment of the eye. We report the case of a 5-year-old child with an undiagnosed CEU who was treated urgently for an acute angle closure attack. CASE DESCRIPTION: A 5-year-old child was referred urgently for evaluation of anisocoria with mydriasis of the right eye and severe headache. Brain imaging with contrast injection was initially performed in the pediatric emergency department and ruled out central nervous system pathology. The initial examination of the right eye revealed an intraocular pressure (IOP) of 37mmHg, corneal edema, congenital ectropion uveae, mydriasis with pupillary block, a closed angle on gonioscopy, and a clear lens. The examination of the left eye was unremarkable, with no visible CEU. The initial management consisted of medical treatment with topical glaucoma drops and miotics and acetazolamide at 10mg/kg/d. Re-evaluation under general anesthesia showed persistent mydriasis and no resolution of the pupillary block. Filtering surgery was performed in the absence of a complete response to medical treatment, allowing control of IOP without drops and complete regression of the corneal edema. DISCUSSION: CEU is a rare malformation, and pressure complications represent an insignificant proportion of pediatric glaucoma cases. The acute presentation of acute angle closure in this potentially blinding short-term setting, however, makes detection and management difficult in very young children in a great deal of pain. Only one similar case has been reported in the pediatric literature. CONCLUSION: Acute angle closure complicating CEU is exceptional and difficult to diagnose in a pediatric context. Parents of children with this predisposing condition should be informed of the need to consult urgently when clinical signs of elevated intraocular pressure appear.

Spontaneous suprachoroidal haemorrhage in haemophilia coincident with ChAdOx1 nCoV-19 vaccine.

PURPOSE: To report a case of spontaneous suprachoroidal haemorrhage in a haemophilia patient immediately following ChAdOx1 nCoV-19 vaccination. CASE PRESENTATION: A 60-year-old man with haemophilia developed painful vision loss in his left eye a day following the ChAdOx1 nCoV-19 vaccination due to acute angle-closure glaucoma from a massive suprachoroidal haemorrhage. He had an extremely deranged coagulation profile; activated partial thromboplastin time (APTT): 89 s, normal range 29-35 s After factor VIII transfusion, ocular hypotensive therapy and systemic/topical steroids, the suprachoroidal haemorrhage and glaucoma resolved, but the vision remained poor. CONCLUSION: Spontaneous suprachoroidal haemorrhage may be seen in haemophiliacs with deranged coagulation profiles. In our case, it followed ChAdOx1 nCoV-19 vaccination, and we recommend caution and checking the coagulation profile in such patients apriori.

Bilateral choroidal effusions and angle closure in the setting of systemic capillary leak syndrome from HLA-directed vaccine and pembrolizumab therapy for squamous cell carcinoma.

Purpose: Immunotherapy has become an important addition to oncology treatment plans in recent years. As these therapies become more widely employed, many unique side effects have been reported. In ophthalmology the most well-documented side effects of immune checkpoint inhibitors (ICI) include uveitis, macular edema and dry eye syndrome. This manuscript describes a rare case of bilateral choroidal effusions and secondary angle narrowing in the setting of systemic capillary leak syndrome (SCLS) from an HLA-directed vaccine and an ICI, pembrolizumab, for the treatment of stage IV squamous cell carcinoma (SCC) of the lung. Observations: A 67-year-old male with a history of stage IV SCC of the lung status-post pneumonectomy presented to the emergency department due to functional decline, anasarca, and dyspnea after receiving an HLA-directed vaccine in combination with pembrolizumab. Extensive workup revealed that his symptoms were secondary to SCLS. Ophthalmology was consulted due bilateral choroidal detachments seen on magnetic resonance imaging. B-scan ultrasound and ultrasound biomicroscopy revealed large, non-appositional choroidal effusions with anterior rotation of the ciliary body. Given minimal response to oral steroid therapy, sub-Tenon's triamcinolone acetonide, atropine, and intraocular pressure-lowering eyedrops were initiated with a good response. Conclusions and Importance: Choroidal effusions and secondary angle closure can be rare complications of SCLS in the setting of ICIs. Clinicians must be aware of the potentials side effects of ICI therapy, as these medications become more commonly used.

Femtosecond laser-assisted cataract phacoemulsification combined with goniosynechialysis in the treatment of primary acute angle-closure glaucoma with cataract / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the clinical efficacy of femtosecond laser-assisted phacoemulsification combined with goniosynechialysis in the treatment of acute angle-closure glaucoma complicated with cataract.METHODS: A total of 53 patients(60 eyes)with primary acute angle closure glaucoma complicated with cataract admitted to our hospital from April 2020 to February 2021 were selected. They were divided into two groups according to the surgical method, with 28 cases(30 eyes)who were treated with femtosecond laser-assisted phacoemulsification combined with goniosynechialysis in group A, and 25 cases(30 eyes)who were treated with traditional cataract phacoemulsification combined with goniosynechialysis in group B. The effective phacoemulsification time(EPT)and cumulative dissipated energy(CDE)during surgery in two groups were recorded. Patients were followed up to 3mo after surgery, and the intraocular pressure, anterior chamber depth(ACD), best corrected visual acuity, corneal endothelial cell loss rate(ECL)and surgical complications were observed in both groups.RESULTS: The postoperative intraocular pressure was significantly decreased and ACD was significantly increased(all P<0.05), and there was no difference between the two groups(all P>0.05). The postoperative best corrected visual acuity of the two groups was significantly better than that before surgery(P<0.05), and group A was significantly better than group B at 1d after surgery(P<0.05). The EPT, CDE, ECL and incidence of complications(7% vs. 27%)in group A were significantly lower than those in group B(all P<0.05).CONCLUSION: Femtosecond laser-assisted cataract phacoemulsification combined with goniosynechialysis in the treatment of primary acute angle-closure glaucoma combined with cataract has a significant therapeutic effect, which can effectively improve surgical safety, reduce the rate of corneal endothelial cell loss, and have fewer complications.

[Superior vena cava syndrome associated with bilateral angle closure glaucoma]. / A vena cava superior szindrómához társuló kétoldali zárt zugú glaucoma.

Superior vena cava syndrome is a set of symptoms resulting from partial or complete blockage of the superior vena cava. In the majority of cases, it develops secondary to lung tumors and lymphoma. It is characterized by edema of the head, neck, and upper limbs, large veins, and dyspnoea. Ophthalmological changes related to the syndrome rarely occur: eyelid swelling, conjunctival chemosis and suffusion have been described previously, and in one case, elevated episcleral pressure was also reported. Our 57-year-old female patient's superior vena cava syndrome was resolved with stent placement, and her small cell lung tumor was treated with chemotherapy. As part of the syndrome, he complained of bilateral blurred vision with a history of 4 months. During his examination, we found a bilateral closed angle, an intraocular pressure of 60 mmHg on both sides, and severe visual impairment. We performed a lens exchange combined with better semolysis, which achieved a significant reduction in intraocular pressure and managed to preserve the remaining visual acuity. After Nd:YAG laser iridotomy on the left eye, we started antiglaucoma drop treatment to reduce pain. After phacoemulsification, the morphology of the anterior chamber in the right eye improved significantly, which could be quantified by anterior segment optical coherence tomography. The ophthalmic parameters remained stable during the treatment of the underlying disease. The purpose of this publication is to draw attention to the ophthalmic symptoms of vena cava syndrome as well as to present the ophthalmic condition that sometimes accompanies the syndrome causing rapid, severe visual impairment, which, to our knowledge, has not been described before. Orv Hetil. 2022; 163(49): 1967-1971.

Pigmented paravenous retinochoroidal atrophy with acute angle-closure glaucoma and posterior subcapsular cataract: a case report.

BACKGROUND: Pigmented paravenous retinochoroidal atrophy (PPRCA) is a rare fundus disease characterized by the presence of osteoblast-like pigment, atrophy of retinal pigment epithelium (RPE), and choroid deposition along the large retinal veins. CASE PRESENTATION: A 55-year-old Chinese female presented with right eye distention and bilateral vision loss. Osteocyte-like pigmentation and retinal choroidal atrophy distributed along the large retinal veins were seen in the fundus of bilateral eyes. The atrophy in the left eye was more severe compared to the right eye. The patient also presented with bilateral acute angle-closure glaucoma (AACG) and posterior subcapsular cataract (PSC) accompanied with anterior segmental manifestations, similar to the complications of retinitis pigmentosa (RP). The patient underwent ultrasound biomicroscopy (UBM), Humphrey field analyser (HFA), optical coherence tomography (OCT), fundus autofluorescence (FAF), fluorescein fundus angiography (FFA), electroretinogram (ERG), and electrooculography (EOG), all of which confirmed the aforementioned diagnose. CONCLUSION: PPRCA is a rare disease of unknown etiology. The patient in this case presented with complications similar to those of RP, and the two conditions may share a genetic basis. Further studies are needed to confirm this relationship.

Acute angle-closure glaucoma after total knee replacement surgery: case report and literature review.

An early and correct diagnosis improves the prognosis of post-operative Acute angle closure glaucoma (AACG). A 65 years-old monophtalmus man was operated for a total knee replacement surgery, under general anaesthesia without any adverse events. The day after, the patient described recurrent periorbital pain in his eye, with ocular hyperaemia, and reduced visual acuity. A diagnosis of AACG was made and conservative treatment was started to reduce the intraocular pressure. In the post-operative AACG, several predisposing local factors including genetic predisposition, female gender, hypermetropia, increased lens thickness and small corneal diameter, can be added to a pupillary block induced by adrenergic and anticholinergic drugs used in anaesthetic procedures as risk factors. An acute and intensive periorbital or ocular pain, with or without visual disturbance, must aware the physician.

Bilateral Choroidal Detachment in the Absence of Previous Intraocular Surgery.

The aim of this report was to present a case of bilateral choroidal detachment following treatment with topical therapy dorzolamide/timolol without history of previous surgery. An 86-year-old woman, with intraocular pressures of 40.00/36.00 mm Hg, was treated with preservative-free double therapy with dorzolamide/timolol. One week later, she presented with bilateral vision loss and irritative symptoms in the face, scalp, and ears, with well controlled pressures. The anterior exam showed LOCS III N4C3 cataracts, and the fundus and ultrasound exams revealed a bilateral infero-temporal choroidal detachment in the absence of neoplasia or other systemic cause. One week in absence of hypotensive treatment and receiving topical prednisolone, she showed reattachment of the choroidal detachment. Six months after cataract surgery, the patient remains stable, without choroidal effusion regression. Hipotensive treatment following chronic angle closure can lead to choroidal effusion similar to cases of acute angle closure treated with oral carbonic-anhydrase inhibitors. The combined strategy of removing hipotensive treatment and topical corticosteroids could be useful for the initial management of choroidal effusion. Also, performing cataract surgery after choroidal reattachment can help with stabilization.

Bilateral acute angle closure glaucoma as an initial presentation of Vogt-Koyanagi-Harada syndrome: A clinical case report.

PURPOSE: Vogt-Koyanagi-Harada (VKH) is an autoimmune disease with bilateral granulomatous uveitis and various systemic manifestations. Bilateral acute angle closure glaucoma (AACG) can be a rare initial manifestation of VKH that may be misdiagnosed as primary angle closure glaucoma (PACG). CASE REPORT: A 62-year-old woman with bilateral painless loss of vision referred to Qingdao Municipal Hospital. She had been diagnosed as PACG before admission and prescribed with anti-glaucoma treatment which did not improve her symptom. She had severe bilateral uveitis, optic disk swelling, and serous retinal detachment in both eyes. Intraocular pressure (IOP) was 20 mmHg in the right eye and 23 mmHg in the left eye, and her best corrected visual acuities (BCVAs) were 0.02 in both eyes. She was treated with oral corticosteroid therapy on a tapering schedule. One month after the therapy, the IOP remained well-controlled with deepened anterior chamber. Her visual acuity and symptom were improved. CONCLUSIONS: We experienced a case of VKH disease with an unusual presentation of bilateral secondary AACG. It is important for ophthalmologists to know about this rare cause of painless loss of vision so that it could be treated properly.

Acute angle closure glaucoma precipitated by homeopathic eyedrops containing Atropa belladonna.

Acute angle closure glaucoma is a sight-threatening condition that may lead to blindness. This is a case report of a woman who presented to the emergency department (ED) with acute angle closure glaucoma following use of an over-the-counter (OTC) homeopathic eye drop containing atropa belladonna (deadly nightshade). A 55-year-old woman presented to the ED with a 5-day history of left eye redness, swelling, tearing, and foreign-body sensation that had acutely worsened in the last two days. Her exam revealed mild left conjunctival injection with watery tearing and a hazy appearance of her left cornea. Fluorescein staining was negative, while tonometry revealed elevated intraocular pressure on the left, suggestive of acute angle closure glaucoma. She was urgently referred to ophthalmology. The etiology of the acute angle closure glaucoma was initially unclear however, with additional prompting, she revealed that two days prior she had started using homeopathic OTC eye drops. Inspection of the eyedrop's ingredients revealed that atropa belladonna was the primary ingredient and likely precipitated her isolated episode of acute angle closure glaucoma. A high level of clinical suspicion and focused ophthalmic exam including tonometry is essential to identify acute angle closure glaucoma in the ED. We present a case report of acute angle closure glaucoma associated with the use of homeopathic belladonna-containing eyedrops. Our report reinforces the necessity to perform thorough medication and supplement history given the prevalence of physiologically active substances available in OTC medications.

Levels of IL-8 and IL-12p70 in the aqueous humor of patients with primary acute angle-closure glaucoma and its clinical significance / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To measure the levels of IL-8 and IL-12p70 in the aqueous humor of patients with primary acute angle-closure glaucoma(AACG)and age-related cataract(ARC), and to investigate the clinical significance.<p>METHODS:Totally 29 eyes of 29 AACG patients, and 17 eyes of 17 ARC patients were enrolled in the study from October 2019 to December 2020. The levels of IL-8 and IL-12p70 were measured in the aqueous humor using Cytometric Beads Array. The clinical information was recorded in the same time for the correlation.<p>RESULTS:The level of IL-8 in AACG group was statistically elevated compared with the control group(Z= -5.384, P<0.05). However the IL-12p70 level did not differ in AACG group compared with ARC group(Z= -1.587, P=0.112). The IL-8 level was positively correlated with the duration of acute attack(rs=0.387, P=0.038). The concentrations of IL-8 and IL-12p70 in the filtration surgery group were significantly increased than that of the non-filtration surgery group(P<0.05).<p>CONCLUSION: The level of the inflammatory factor IL-8 in the aqueous humor of patients with AACG was significantly elevated. With the progression of the disease, the concentration of the immune-related factor IL-12p70 increased differentially. Both inflammation and immunity may play an important role in the pathogenesis of AACG.

Aqueous humor proteomic analysis of acute angle-closure glaucoma with visual field loss.

BACKGROUND: Acute angle-closure glaucoma (AACG) is an ophthalmic emergency that occurs over the course of hours or days and may cause irreversible blindness if not treated immediately. In most cases, optic nerve damage is the cause of visual field (VF) loss in AACG. There has been no reliable biomarker found to evaluate optic nerve damage to date. Aqueous humor (AH) proteome analysis might reveal the proteomic alterations in AACG and provide helpful clues in the search for an AH biomarker of optic nerve damage and VF loss. METHODS: In this study, we used the AH proteome to explore the functions of differentially expressed proteins (DEPs) during disease progression. The AH proteins from the early-stage group and late-stage group were extracted and analyzed by the data-independent acquisition (DIA) method. The DEPs functions were annotated, and parallel reaction monitoring (PRM) was used to validate the key DEPs. RESULTS: A total of 87 DEPs were found. Gene Ontology analysis showed that most DEPs were enriched in immunology, hemodynamics, and apoptosis. Ingenuity pathway analysis found that vascular endothelial growth factor (VEGF) signaling, the production of reactive oxygen species (ROS) in macrophages, and the nuclear factor erythroid 2-related factor 2 (NRF2)-mediated oxidative stress response were active pathways in the late stage of AACG. The mechanism of retinal ganglion cell (RGC) death was hypothesized on the basis of DEP functional analysis. A total of 20 DEPs were validated by using PRM, and prostaglandin-H2 D-isomerase was found to have the potential to evaluate optic nerve damage. CONCLUSIONS: This study showed that AH proteomic analysis could reveal the proteomic alterations in the pathogenesis of VF loss in AACG and help to provide objective protein biomarkers to evaluate VF loss. These findings will benefit the application of the AH proteome to clinical research.