Iris Posterior Synechiae After Descemet Membrane Endothelial Keratoplasty in Asian Eyes: Prevention and Management of Posterior Synechiae.

OBJECTIVES: To evaluate the efficacy of a mydriatic agent for posterior synechiae after phacoemulsification and intraocular lens (IOL) implantation followed by Descemet membrane endothelial keratoplasty (staged DMEK). METHODS: In this prospective study, the outcomes of DMEK with or without mydriasis (0.5% tropicamide and 0.5% phenylephrine hydrochloride [Mydrin-P; Santen, Osaka, Japan]) after the DMEK procedure were analyzed. Patients underwent IOL implantation approximately 4 weeks before DMEK. Six months after DMEK, the iris posterior synechiae severity score was evaluated based on the extent of posterior synechiae affecting the eight areas (45° each) of the pupillary rim (posterior synechiae score; grades 0-8). Best spectacle-corrected visual acuity, central corneal thickness, endothelial cell density, axial length, and the amount of air at the end of the surgery were also evaluated. RESULTS: Fifteen eyes of 15 patients (mydriatic: n=8, control: n=7) were eligible for inclusion. Iris posterior synechiae were detected in all seven eyes (100.0%) in the control group, whereas they were noted in two eyes in the mydriatic group (25%). The mean iris posterior synechiae score was 0.69±1.20 in the mydriatic group and was significantly lower than that in the control group (4.57±0.90; P<0.001). There was no significant difference in other clinical factors. Although the incidence and scores of posterior synechiae in the control group were higher, the incidence was significantly reduced with the use of a mydriatic agent (in the mydriatic group). CONCLUSIONS: Use of a mydriatic agent is an effective measure to prevent postoperative synechiae after DMEK.

Prevalence and characteristics of plateau iris configuration among American Caucasian, American Chinese and mainland Chinese subjects.

BACKGROUND: To investigate the prevalence, risk factors and characteristics of plateau iris configuration (PIC) among American Caucasian, American Chinese and mainland Chinese. METHODS: This multicentre, cross-sectional study of non-glaucomatous subjects (40-80 years) included 111 American Caucasian, 116 American Chinese and 110 mainland Chinese. Prevalence of PIC based on ultrasound biomicroscopy imaging was compared among the different ethnic groups. Risk factors and anterior segment optical coherence tomography-measured iris and angle parameters in eyes with PIC were compared. RESULTS: The prevalence of PIC was 25.2% in American Caucasian, 24.1% in American Chinese and 20.9% in mainland Chinese (p=0.73). The presence of PIC was associated with more positive spherical equivalence (OR=1.31, p=0.002) and shorter axial length (OR=0.75, p=0.04). There were significant differences in angle recess area (ARA) (p=0.04), IT750 (p=0.007) and IT2000 (p<0.001) between Chinese and Caucasians who have PIC. CONCLUSIONS: The prevalence of PIC did not differ among American Caucasian, American Chinese and mainland Chinese. PIC was associated with non-myopia and shorter axial length. Chinese eyes with PIC had smaller ARA and thicker irides than Caucasian ones. PIC might be a physiological variation of the iris and ciliary body that exists in normal eyes, both in Chinese and Caucasians.

Korean patients taking α1-adrenergic receptor antagonists show lower incidence of intraoperative floppy iris syndrome than western patients.

PURPOSE: To evaluate the incidence and clinical manifestations of intraoperative floppy iris syndrome (IFIS) according to iris alterations in Korean patients taking α1-adrenergic receptor antagonists (α1-ARAs). METHODS: This is a prospective observational study. Two surgeons performed cataract surgery in 758 eyes of 596 patients over a period of 12 months. Past medical history was reviewed, especially whether patients had been taking systemic α1-ARAs. Ultrasound biomicroscopy was performed to measure the iris thickness of the dilator muscle region (DMR) at half the distance between the scleral spur and the pupillary margin. Pupil diameter was measured and the occurrence of IFIS was recorded. Measurements of the α1-ARA group were compared with those of a control group matched for age and sex. RESULTS: IFIS occurred only in six eyes of four patients on systemic α1-ARA medications (0.8%). Pupil diameter in the α1-ARA medication group and the control group was not significantly different. The difference in mean DMR thickness in patients taking an α1-ARA and in the control group was also not statistically significant (p=0.641). However, within the α1-ARA population, the DMR thickness of IFIS cases was significantly lower than that of non-IFIS cases (p=0.013) CONCLUSIONS: The overall incidence of IFIS was far lower in Korean patients than that reported for western patients. IFIS patients taking α1-ARAs showed significantly greater iris DMR thinning than non-IFIS patients taking α1-ARAs. Our findings indicate that the interaction between α1-ARAs and melanin, which results in iris DMR atrophy and IFIS, is less strong in Korean patients (with dark irises) than western patients.

Plateau iris in Whites versus Asians.

PURPOSE: To evaluate the prevalence of plateau iris diagnosed by ultrasound biomicroscopy after laser peripheral iridotomy in Whites as compared to Asians in a U.S. clinic setting. METHODS: This was a prospective, observational study of narrow angle patients (n=55) who underwent laser peripheral iridotomy. Ultrasound biomicroscopy was performed in 4 quadrants of only one eye of each patient 4~6 weeks before and after surgery. The images were randomized and interpreted qualitatively by a single observer. Plateau iris was diagnosed in eyes with persistent appositional angles after laser peripheral iridotomy when at least 2 quadrants fulfilled the following criteria: 1. The ciliary process was directed anteriorly. 2. The ciliary sulcus was absent. 3. The central iris plane was flat. RESULTS: Twenty eight subjects (50.1%) were Whites, and 27 subjects (49.0%) were Asians. Plateau iris was assessed in 18 subjects (32.7%): 9 of 28 Whites (32.1%) and 9 of 27 Asians (33.3%). The proportion of plateau iris did not differ between Whites and Asians (P>0.99) CONCLUSION: The prevalence of plateau iris did not differ between Whites and Asians. Both groups had a substantial proportion of narrow angle patients with this clinical entity.

Impact of liver transplantation on transthyretin-related ocular amyloidosis in Japanese patients.

OBJECTIVE: To evaluate the long-term impact of liver transplantation on ocular manifestations of familial amyloid polyneuropathy (FAP) in Japanese patients. METHODS: Medical records were retrospectively reviewed in a long-term follow-up study. Of 52 patients with FAP amyloidogenic transthyretin Val30Met, 22 patients underwent liver transplantation. We assessed ocular manifestations, including amyloid deposition at the pupillary border, pupillary border with irregularity, vitreous opacities, and glaucoma, in patients who underwent liver transplantation. In addition, we compared the clinical characteristics of vitreous opacities-the most common ocular manifestation of FAP-in patients who underwent liver transplantation and those who did not to determine the effect of transplantation on the progression of ocular amyloidosis. RESULTS: Mean time after FAP onset was 10 years and after liver transplantation was 7 years in patients who underwent liver transplantation. All ocular manifestations increased with time after transplantation. Eight patients (36%) developed vitreous opacities and 4 patients (18%) developed glaucoma during follow-up. Mean time from FAP onset to vitreous opacities onset was significantly shorter in patients with early-onset disease who underwent liver transplantation than in those who did not. CONCLUSIONS: Patients with FAP who undergo liver transplantation continue to have a long-term risk of severe ocular manifestations, especially vitreous opacities and glaucoma, which can restrict their daily lives, even after liver transplantation.

Primary iris stromal cyst with rapid growth.

PURPOSE: To describe the clinical features and the surgical management of primary iris stromal cyst with rapid growth. METHODS: A 14-year-old Chinese-Mongolian girl was referred to us with a 1-month history of obstructed vision and photophobia. On an examination, a semitransparent cyst with a densely pigmented posterior wall was revealed in the anterior chamber of the left eye. The information regarding the location and extent of the cyst was further analyzed by anterior segment optical coherence tomography and ultrasound biomicroscopy. It arose within the iris stroma, measuring 7.52 x 3.60 mm. Blood vessels on the surface of the lesion were revealed by iris angiography. There was no history of amniocentesis, birth trauma, antecedent ocular injury, or maternal illness during gestation. The diagnosis of primary iris stromal cyst was made. A combination of needle aspiration, piecemeal resection of cyst wall, cryotherapy, and argon laser photocoagulation with overlapped spots was used. RESULTS: Histopathology of the cyst wall revealed nonkeratinized, multilayered, stratified squamous epithelium with clusters of goblet cells. Complete resolution of the cyst was successfully achieved. The visual acuity improved to 20/25 from counting fingers. At 6 months of follow-up, there was no recurrence. CONCLUSIONS: Complete eradication and devitalization of any remaining epithelial cells are the key factors for preventing recurrence and diffuse epithelialization of the anterior chamber.

Clinical findings in Japanese patients with Waardenburg syndrome type 2.

PURPOSE: To determine the visual characteristics of Japanese subjects with the Waardenburg syndrome type 2. METHODS: The visual functions of 11 albino patients who were identified from the screening of 240 children attending a school for children with a hearing deficit were studied. The ophthalmological examinations included eye position, visual acuity, biomicroscopy, ophthalmoscopy, visual field by confrontation or Goldmann's perimetry, stereoacuity by the Titmus test, and color vision by the Ishihara pseudoisochromatic plates. RESULTS: A combination of congenital sensory deafness and partial ocular albinism without lateral displacement of the lacrimal puncta was observed in 11 (4.6%) of the students with hearing deficit. All these children had sectorial heterochromia irides with local retinal hypopigmentation. Lid deformities were not present. The retinal vasculature was normal, and macular hypoplasty was not found. Other than 1 eye with hyperopic amblyopia, no serious visual disturbance was found in these patients. CONCLUSIONS: The 11 students were classified as having Waardenburg syndrome type 2. None had a critical visual deficit, and all had partial heterochromia irides and retinal hypopigmentation.

Iridocorneal endothelial syndrome in Thai patients: clinical variations.

OBJECTIVE: To evaluate the spectrum of iridocorneal endothelial syndrome, to our knowledge, never studied previously in Orientals. METHODS: From 1986 to 1998, we examined 60 consecutive patients (20 men, 40 women) with characteristic signs of iridocorneal endothelial syndrome and compared the clinical manifestations to those reported in white patients. RESULTS: Cogan-Reese syndrome (CRS) was most common (38 patients), while 14 patients had Chandler syndrome (CS), and 8 had progressive iris atrophy. Three patients initially classified as having CS and 1 as having progressive iris atrophy progressed to CRS. Glaucoma occurred in 46 patients (76.7%), most commonly in patients with progressive iris atrophy or CRS. Ten patients had slow progression of disease during the follow-up period of up to 12 years. Three patients (2 with CRS, 1 with CS) had asymptomatic localized islands of "hammered-silver" appearance and 11 (8 with CRS, 2 with CS, and 1 with progressive iris atrophy) had subclinical abnormal endothelium in the contralateral eyes. A translucent membrane was commonly seen on the brown iris surface. Total endothelial involvement was present in 49 patients, while 6 (4 with CRS, 2 with CS) had focal endothelial abnormalities with sharp demarcation from adjacent normal endothelium. CONCLUSIONS: Iridocorneal endothelial syndrome occurs in Orientals. Cogan-Reese syndrome is the most common form and is strongly associated with glaucoma. Although several clinical manifestations were similar between whites and Orientals (mean age of onset, sex predilection, iris changes, peripheral anterior synechiae formation, or corneal edema), CRS was most prevalent; a translucent membrane were more noticeable in Orientals.