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PubMed2000

Angle-closure glaucoma in an urban population in southern India. The Andhra Pradesh eye disease study.

OBJECTIVE: To assess the prevalence and features of angle-closure glaucoma (ACG) in an urban population in southern India. DESIGN: A population-based, cross-sectional study. PARTICIPANTS: A total of 2522 (85.4% of those eligible) persons of all ages, including 1399 persons 30 years of age or older, from 24 clusters representative of the population of Hyderabad city. TESTING: The participants underwent an interview and detailed eye examination that included logarithm of minimum angle of resolution visual acuity, refraction, slit-lamp biomicroscopy, applanation tonometry, and gonioscopy; pupil dilatation and stereoscopic fundus evaluation was performed if the risk of angle-closure as a result of dilatation was not believed to be imminent. Humphrey threshold 24-2 visual fields (Humphrey Instruments Inc., San Leandro, CA) were performed when indicated by standardized criteria for disc damage or if intraocular pressure (IOP) was 22 mmHg or more. MAIN OUTCOME MEASURES: An occludable angle was defined as pigmented posterior trabecular meshwork not visible by gonioscopy in three quarters or more of the angle circumference. Manifest primary angle-closure glaucoma (PACG) was defined as IOP of 22 mmHg or more or glaucomatous optic disc damage with visual field loss in the presence of an occludable angle. An IOP of 22 mmHg or more or glaucomatous optic disc damage in the presence of an occludable angle secondary to an obvious cause was defined as secondary ACG. RESULTS: Manifest PACG and occludable angles without ACG were present in 12 and 24 participants, respectively, with age- and gender-adjusted prevalence (95% confidence interval [CI]) of 0.71% (0.34%-1.31%) and 1.41% (0.73%-2.09%) in participants 30 years of age or older, and 1.08% (0.36%-1.80%) and 2.21% (1.15%-3.27%) in participants 40 years of age or older, respectively. With multivariate analysis, the prevalence of these two conditions considered together increased significantly with age (P < 0.001); although not statistically significant, these were more common in females (odds ratio 1.70; 95% CI, 0.82-3.54) and in those belonging to lower socioeconomic strata as compared with middle and upper strata (odds ratio, 1.82; 95% CI, 0.88-3.74). The odds of manifest PACG were higher in the presence of hyperopia of more than 2 diopters ([D]; odds ratio, 3.69; 95% CI, 0.89-15.2). Only four of 12 participants (33.3%) with manifest PACG had been previously diagnosed, and one of 12 (8.3%) had peripheral iridotomy performed previously. Manifest PACG had caused blindness in one or both eyes in five of these 12 participants (41.7%); best-corrected distance visual acuity less than 20/400 in one or both eyes in four patients, and acuity less than 20/200 in one eye in another patient. Most (83.3%) of those with manifest PACG could be classified as having chronic form of the disease. We may have underestimated manifest PACG because visual fields were per- formed only on those with clinical suspicion of optic disc damage. Secondary ACG was present in two participants. CONCLUSIONS: The prevalence of PACG in this urban population in southern India is close to that reported recently in a Mongolian population. A large proportion of the PACG in this population was undiagnosed and untreated. Because visual loss resulting from PACG is potentially preventable if peripheral iridotomy or iridectomy is performed in the early stage, strategies for early detection of PACG could reduce the high risk of blindness resulting from PACG seen in this urban population in India.

Adolescent↗
PubMed2001

Iris melanoma: risk factors for metastasis in 169 consecutive patients.

OBJECTIVE: To identify risk factors that predict distant metastases of iris malignant melanoma. DESIGN: Retrospective case series. PARTICIPANTS: The participants included 169 consecutive patients with microscopically confirmed iris malignant melanoma managed on the Oncology Service at Wills Eye Hospital between 1974 and 1999. MAIN OUTCOME MEASURES: The main outcome measure was the development of distant tumor metastasis. Cox proportional regression models were used to calculate the risk of eventual metastatic spread. RESULTS: Of 1054 patients referred with suspicious iris melanocytic tumors (rule out malignant melanoma) over a 25-year period, 169 patients (16%) had microscopically proven iris melanoma, and the remainder (84%) had clinically diagnosed iris nevus. Of the patients with iris melanoma, the mean age at the time of diagnosis was 43 years (median, 45 years; range, 1-90 years). All patients were Caucasian. The mean tumor base was 6 mm (median, 5 mm; range, 1-17 mm), and mean tumor thickness was 2 mm (median, 2 mm; range, 1-4 mm). The mean number of clock hours of tumor involvement in the iris was four, tumor seeding on the iris was four, and tumor seeding into the anterior chamber angle was four. Extraocular extension was present in 10 eyes (6%). The tumor management consisted of local resection (iridectomy, iridocyclectomy, or iridocyclogoniectomy) in 102 patients (60%), enucleation in 51 (30%), plaque radiotherapy in 9 (5%), and observation in 7 patients (4%). Metastasis developed in nine patients (5%). Using Kaplan-Meier life table analysis, metastasis was found in 3% of patients at 5 years, 5% at 10 years, and 10% at 20 years. The clinical factors at initial evaluation predictive of eventual metastasis from iris melanoma included increasing age at diagnosis (P = 0.03), elevated intraocular pressure (P = 0.03), posterior tumor margin at angle or iris root (versus midzone) (P = 0.02), extraocular extension (P: = 0.02), and prior surgical treatment of the tumor elsewhere before referral (versus observation) (P = 0.006). The method of management (resection, radiotherapy, or enucleation) did not have an impact on metastasis. CONCLUSIONS: Microscopically confirmed iris melanoma demonstrates distant metastasis in 5% of patients at 10 years follow-up. Metastases are more likely to develop in those patients who are older and show tumor features of iris root/angle location with elevated intraocular pressure and extraocular extension.

Adolescent↗
PubMed2001

New surgical approach in the management of pseudophakic malignant glaucoma.

PURPOSE: To describe a new surgical approach in the management of pseudophakic malignant glaucoma. DESIGN: Noncomparative case series. PARTICIPANTS: Five consecutive patients with pseudophakic malignant glaucoma. METHODS: All patients underwent zonulo-hyaloido-vitrectomy. The procedure involves the performance of zonulectomy, hyaloidectomy, and anterior vitrectomy (zonulo-hyaloido-vitrectomy) through a peripheral iridectomy or iridotomy via the anterior chamber. MAIN OUTCOME MEASURES: Medications, visual acuity, intraocular pressure, and anterior and posterior segment findings were recorded before and after surgery. RESULTS: Resolution of the malignant glaucoma was achieved in all cases. No recurrences were observed after a median follow-up of 5.5 months (range, 1-9 months). In one patient with extensive anterior synechiae, bleb failure occurred after the resolution of the malignant glaucoma. This patient was treated successfully with a guarded filtration procedure supplemented with 5-fluorouracil. No other complications were observed. CONCLUSIONS: Zonulo-hyaloido-vitrectomy via the anterior segment appears to be an alternative option in the treatment of patients with pseudophakic malignant glaucoma.

Aged↗
PubMed2002

Primary phacoemulsification and intraocular lens implantation for acute angle-closure glaucoma.

OBJECTIVE: To evaluate the safety and efficacy of primary phacoemulsification and intraocular lens implantation (PPI) for acute angle-closure glaucoma (ACG). STUDY DESIGN: Prospective, nonrandomized comparative trial. PARTICIPANTS AND INTERVENTION: Forty-three eyes of 43 patients with acute ACG and uncontrolled intraocular pressure (IOP) were treated by PPI. Thirty-two eyes of 32 patients treated by conventional surgical iridectomy (CSI) constituted the control group. MAIN OUTCOME MEASURES: Postoperative visual acuity, IOP, number of antiglaucoma medications, complications, and secondary surgical interventions, if any, required for IOP control. RESULTS: Glaucoma control was achieved in 31 eyes (72%) in the PPI group and in 11 (35%) in the CSI group (P = 0.01). Mean preoperative IOP was 40.5 +/- 7.6 mmHg (standard deviation) and 39.7 +/- 7.8 mmHg, respectively (P = 0.46). Mean postoperative IOP was 17.8 +/- 3.4 mmHg (PPI group) and 20.1 +/- 4.2 mmHg (CSI group) after a mean follow-up of 10.2 +/- 3.4 months (P = 0.03). Postoperatively, the mean number of ocular hypotensive medications was 0.18 +/- 0.45 (PPI group) and 0.45 +/- 0.62 (CSI group) (P = 0.0001). Relative increase in postoperative best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 +/- 0.29 (PPI group) and 0.19 +/- 0.21 (CSI group), respectively (P = 0.0001). Additional surgery was necessary in 5 eyes (11.5%) in the PPI group and in 20 eyes (63%) in the CSI group (P = 0.01). Intraoperative and postoperative complications were few and manageable. CONCLUSIONS: CSI in patients with acute ACG was effective in reducing IOP initially but was associated with multiple surgical reinterventions. Conversely, primary PPI turned out to be safe and effective in reducing IOP and improving visual acuity. These results affirm that lens extraction may be considered the better procedure in uncontrolled ACG when faced with options of CSI or PPI.

Acute Disease↗
PubMed1978

Argon laser iridotomy in the treatment of patients with primary angle-closure or pupillary block glaucoma: a clinicopathologic study.

A "pulsed" argon laser was successful in 48 of 64 (75%) attempted laser iridotomies. Scanning and transmission electron microscopy performed on specimens taken at varying intervals following laser treatment revealed progressive scarring of iris tissue. The complications appear minimal at this time, but longer follow-up is required before it can be stated that laser and surgical peripheral iridectomies are comparable. However, the laser's simplicity and ease of administration appear to warrant its continued use at this time.

Argon↗
PubMed1981

Retrocorneal pigmentation secondary to iris stromal melanocytic proliferation.

A 40-year-old black man had two penetrating keratoplasties as a result of complications from alkali burns sustained many years earlier. Two further penetrating keratoplasties were performed for recurrent retrocorneal pigmentation. Both scanning and transmission electron microscopy demonstrated that the retrocorneal pigmented cells were iris melanocytes, based upon their fusiform or dendritic shapes and measurements of their cytoplasmic melanin granules. Repopulation of Descemet's membrane by the melanocytes was produced by a small remnant of atrophic iris. The pigment granules in the iris melanocytes were somewhat larger than those seen in similar cells from Caucasians or Orientals, but had identical measurements to those studied in an iridectomy specimen from another black patient. The retrocorneal iris melanocytes were able to synthesize banded basement membrane material, interrupted laminar basement membrane, and collagen fibrils. The cause of the exfoliation of the iris melanocytes onto the back of the cornea is unknown, but the discovery that iris melanocytes can proliferate in an ongoing fashion and secrete extracellular matrix provides new insight into the physiology of these cells.

Adult↗
PubMed1983

Laser trabeculoplasty and the glaucomas.

A standard 100-spot laser trabeculoplasty was applied to 137 eyes of 109 presurgical patients with a variety of primary, secondary, and postsurgical glaucomas. Average follow-up was 15.3 months. Laser therapy was most successful in eyes without prior surgery (chronic open-angle glaucoma (COAG), pseudoexfoliation, pigmentary dispersion) or with only one prior operation (iridectomy, trabeculectomy, or intracapsular cataract extraction). The mean range for pressure reduction was 6 to 12 mmHg. Failures were frequently seen in eyes with angle recession, uveitis, or more than one operation. Visual field deterioration was seen in 11% of successful COAG eyes. Asymmetric responses in bilaterally treated COAG patients were seen half the time. A drift downward of 5 mmHg or more at six months after laser reversed itself by 12 months in approximately one out of eight eyes from various categories.

Adult↗
PubMed1984

Complications of rigid anterior chamber implants.

Despite accurate lens sizing, 100 eyes with rigid anterior chamber implants showed a high incidence of lens-related trauma postoperatively: pigment dispersion (pseudoguttata), angle recession, peripheral anterior synechiae, iris erosion/atrophy, iris holes from stretching, angle fibrosis, haptic tip erosion into sclera and iris, neovascularization of peripheral iris and angle, lens rotation through iridectomy and into ciliary body, lens tilting with corneal endothelial touch, high refractive cylinder with long intraocular lenses, pigment proliferation onto iris surface, partial slippage of the intraocular lens into vitreous following intracapsular procedure, and pupillary-block glaucoma. Vision results were good. Glaucoma and cystoid macular edema rates were low. Bullous keratopathy and retinal detachment didn't occur. High endothelial cell loss was associated with those lenses that "propellered" and those that tilted and touched endothelium. The adverse findings may be static or may represent a continuing process of tissue damage.

Adult↗
PubMed1985

Iris sphincterotomy, iridotomy, and synechiotomy by linear incision with the argon laser.

Linear cuts can be made across the iris fibers by multiple 0.01- to 0.05-second duration argon laser burns delivered through an Abraham iridectomy lens. Intrinsic iris tension will then cause the linear cuts to spread apart. This allows enlargement, reshaping, or repositioning of the pupil and large laser iridotomies with minimal burn energies and a very high percentage of success. The technique minimizes risk to the retina and eliminates the need for stretch burns in laser iridotomy. It requires the use of the Abraham lens and an argon laser, which generates a small spot of high power density. Posterior synechiae can be incised by using a line of low-power 0.01- or 0.02-second burns applied to the adherent pigment epithelium along the iris margin.

Adult↗
PubMed1985

Spontaneous intrastromal iris cyst. A case report with immunohistochemical and ultrastructural observations.

A 39-year-old man had an enlarging intrastromal iris cyst that obstructed the chamber angle inferotemporally and abutted the cornea. No history of ocular trauma or previous surgery was present. Iridocyclectomy with en bloc resection of the cyst was performed. The cyst was lined by one to three cell layers of focally pigmented epithelium that ultrastructurally exhibited desmosomes, tonofilaments, terminal bars, and apical microvilli. Additionally, membrane-bound melanin granules (melanosomal complexes) consistent with phagocytized uveal melanin granules were observed. Immunohistochemistry confirmed intracellular keratin. We conclude that the non-traumatic cyst reported herein is of surface ectodermal origin and suggest that such cysts be removed en bloc by sector iridectomy or iridocyclectomy if the lesion has been proven to enlarge.

Adult↗
PubMed1988

Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery.

Complicated retinal detachments (RDs) were successfully managed in 150 eyes of 170 consecutive patients by one surgeon (JLF) using silicone oil in conjunction with modern pars plana vitrectomy. Long-term postoperative complications were observed between 6 months and 5 years of follow-up. Cataracts developed in all phakic eyes and all corneas with oil-endothelial touch showed band keratopathy within 6 months. Recurrent detachments were noted in 22% of eyes during silicone oil tamponade and occurred in 13% of eyes after the oil had been removed. Other complications associated with the use of oil for vitreous surgery included pupillary block glaucoma (3%), closure of the inferior iridectomy (14%), fibrous epiretinal and subretinal proliferations (15%), pain (5%), and subconjunctival deposits of oil (3%). Without exception, within a period of 1 year the intraocular silicone oil showed some degree of emulsification, suggesting that the physicochemical characteristics of the oil injected may be an important variable in long-term complications.

Cataract↗
PubMed1989

Angle-closure glaucoma complicating ciliochoroidal detachment.

Acute angle-closure glaucoma complicating ciliochoroidal detachment developed in eight eyes of six patients. The clinical presentation was uniform: extremely shallow central anterior chamber depth, flat peripheral anterior chamber, closed angle, and elevated intraocular pressure (IOP). There were three patients with uveal effusion syndrome, two with posterior scleritis, and one with an arteriovenous malformation. Cycloplegia, along with aqueous suppressants and corticosteroids, successfully resolved the acute glaucoma in all eyes. This rare, secondary glaucoma must be differentiated from primary angle-closure glaucoma, because the treatment is markedly different. Although primary angle-closure glaucoma is treated with miotics and peripheral iridectomy, such therapy may worsen the glaucoma in eyes with angle-closure glaucoma due to a ciliochoridal detachment.

Aged↗
PubMed1991

Management of late-onset angle-closure glaucoma associated with retinopathy of prematurity.

Late-onset angle-closure glaucoma secondary to retinopathy of prematurity (ROP) occurred in ten eyes of ten patients. The age at presentation ranged from 12 to 45 years (mean, 32 years). Eight eyes had nonneovascular mechanisms for the angle closure while two had neovascular angle closure. Treatment of eyes with this form of secondary angle closure included medical management alone, peripheral iridectomy, trabeculectomy, lensectomy, alloplastic tube shunt implantation, and cilioablative procedures. Three eyes required more than one of these treatments. The choice of therapy was based on the initial intraocular pressure and vision, degree of lens opacity and intumescence, presence of anterior segment neovascularization, and the gonioscopic appearance of the anterior chamber angle. The clinical features of this condition are described and a proposed mechanism and therapeutic approach are presented.

Adolescent↗
PubMed1993

Corneal trabeculectomy without conjunctival incision. Extended follow-up and histologic findings.

BACKGROUND: Corneal trabeculectomy, a guarded filtration procedure without conjunctival incision but with an iridectomy, was developed in 30 eyebank and 20 rabbit eyes before being applied to humans. METHODS: Corneal trabeculectomy was performed in one eye and conventional trabeculectomy in the contralateral eyes of six rabbits. Sequential postoperative histologic examinations were performed on these eyes at various times after surgery. Corneal trabeculectomy also was performed in 20 eyes of 18 patients with glaucoma for control of their intraocular pressure (IOP). RESULTS: Results of histologic examination on these rabbit eyes showed less subconjunctival inflammation and fibrosis after corneal trabeculectomy than conventional trabeculectomy. In the eight patients with glaucoma who had had their surgery at least 1 year previously, the mean IOP decreased from 31 mmHg (preoperatively) to 14 mmHg. Eighty-eight percent have IOPs less than or equal to 18 mmHg without medications or revision. CONCLUSION: Extended follow-up shows that corneal trabeculectomy is a low-tech, relatively atraumatic filtration procedure without conjunctival incision, which produces diffuse and persistent blebs and controls IOP. Results of sequential postoperative histologic examination in rabbit eyes suggest that corneal trabeculectomy may incite less subconjunctival inflammation than conventional trabeculectomy.

Adult↗
PubMed1993

Incidence and management of glaucoma in Vogt-Koyanagi-Harada syndrome.

BACKGROUND: The Vogt-Koyanagi-Harada syndrome is a bilateral panuveitis associated with neurologic and dermatologic manifestations. METHODS: The authors reviewed the charts of all patients with Vogt-Koyanagi-Harada syndrome seen at their institution over the past decade to determine the incidence of glaucoma, as well as the results of medical and surgical therapy for glaucoma, in this group of patients. FINDINGS: Of 42 patients diagnosed with Vogt-Koyanagi-Harada syndrome, evidence of glaucoma requiring either medical or surgical intervention occurred in 16 patients (38.1%). Of these, nine (56.3%) had open-angle glaucoma and seven (43.7%) had angle-closure secondary to pupillary block. In 5 (31.3%) of the 16 patients, medical therapy alone was sufficient to control intraocular pressure. Eleven patients (68.7%) required surgical intervention, consisting of laser iridotomy, surgical iridectomy, trabeculectomy with or without 5-fluorouracil, and/or Molteno implantation. CONCLUSION: The relative success of each of these procedures in this group of patients is discussed. Glaucoma is a common complication in the Vogt-Koyanagi-Harada syndrome, and one that is often difficult to control.

Adolescent↗
PubMed1995

Bilateral diffuse iris nodular nevi. Clinical and histopathologic characterization.

BACKGROUND: Diffuse nodular nevus of the iris is an uncommon condition that presents with multiple verrucous excrescences distributed diffusely on the iris surface. METHODS: The authors describe 30 patients with bilateral diffuse iris nodular nevi and report associations with bilateral congenital cataract, neurofibromatosis, oculodermal melanocytosis, congenital ptosis, morning glory anomaly, Axenfeld anomaly, or Peters anomaly. RESULTS: Iris nodules were uniform in size and distribution and were brown, as was the surrounding iris. Light and electron microscopy of iridectomy specimens from one patient showed elevated plaques composed of aggregates of plump, lightly pigmented nevoid cells interwoven with mature, densely pigmented spindle-shaped uveal melanocytes. CONCLUSIONS: The authors report the largest clinical series and first ultrastructural description of bilateral diffuse iris nodular nevi, which represents a variant of neural crest development. No ocular complications could be attributed to the iris nodules, which should be differentiated from Lisch nodules and other pathologic iris lesions.

Adolescent↗
PubMed1995

Iris retraction syndrome after intraocular surgery.

BACKGROUND: The authors report the postoperative development of iris retraction syndrome in two individuals. This is a rare syndrome that can present with pupillary block after an unrepaired rhegmatogenous retinal detachment. PATIENTS: The authors report two patients who had the iris retraction syndrome shortly after intraocular surgery. One patient had pupillary block that developed 6 months after cataract extraction and posterior chamber intraocular lens implantation. A second patient had uveitis, hypotony, and pupillary seclusion 4 weeks after pars plana vitrectomy. RESULTS: Both patients were treated successfully with a scleral buckling procedure and peripheral iridectomy. CONCLUSION: Postoperative uveitis that occurs with iris retraction and pupillary seclusion should alert the physician of an occult retinal detachment and warrant a thorough dilated funduscopic examination. Features unique to this report include the development of iris retraction syndrome in the presence of a pseudophakos, the rapidity of onset of this disorder after retinal detachment, and its masquerade as a persistent postoperative uveitis.

Aged↗
PubMed1996

Multicenter clinical experience using an erbium:YAG laser for vitreoretinal surgery.

PURPOSE: To evaluate the advantages, disadvantages, safety, complications, and surgical applicability of an erbium:YAG laser system for maneuvers in vitreoretinal surgery. METHODS: A prospective, consecutive trial of 68 eyes in 66 patients undergoing vitreoretinal surgery in which an erbium:YAG laser with graduated output from 0.2 to 5.0 mJ per pulse, repetition rate of 2 to 30 Hz, and equipped with a flexible fiber optic and interchangeable 20-gauge intraocular fiber optic endoprobes was used to perform specific maneuvers, including transection, incision, and ablation of membranes, retinotomy, vessel coagulation, iridectomy, and lens tissue ablation. The patients were treated in five centers in contemporary vitreoretinal surgical settings for surgical indications, including proliferative diabetic retinopathy, proliferative vitreoretinopathy, epiretinal membrane, and retinopathy of prematurity. RESULTS: One hundred seventy-four maneuvers were performed with an overall surgical efficacy rating of excellent or good in 84% of maneuvers, ranging from a high of 100% for subretinal membrane transection to a low of 25% for coagulation of blood vessels. Complications included retinal break or photocoagulative injury in 5% of epiretinal membrane incisions, minor bleeding from transected retinal vessels during 29% of retinotomies, and intraocular lens damage during two posterior capsulotomies. The most significant limitation was the cautious pace used during maneuvers near the retinal surface. CONCLUSION: The erbium:YAG laser is capable of versatile new approaches offering precise tissue cutting and ablation in vitreoretinal surgical maneuvers with a high degree of safety. The main limitation encountered was the slow speed of certain critical maneuvers near the retina.

Adult↗