Idiopathic elevated episcleral venous pressure and open-angle glaucoma

Aqueous humor as eye lymph: A crossroad between venous and lymphatic system

Aqueous humor (AQH) is a transparent fluid with characteristics similar to those of the interstitial fluid, which fills the eyeball posterior and anterior chambers and circulates in them from the sites of production to those of drainage. The AQH volume and pressure homeostasis is essential for the trophism of the ocular avascular tissues and their normal structure and function. Different AQH outflow pathways exist, including a main pathway, quite well defined anatomically and referred to as the conventional pathway, and some accessory pathways, more recently described and still not fully morphofunctionally understood, generically referred to as unconventional pathways. The conventional pathway is based on the existence of a series of conduits starting with the trabecular meshwork and Schlemm's Canal and continuing with a system of intrascleral and episcleral venules, which are tributaries to veins of the anterior segment of the eyeball. The unconventional pathways are mainly represented by the uveoscleral pathway, in which AQH flows through clefts, interstitial conduits located in the ciliary body and sclera, and then merges into the aforementioned intrascleral and episcleral venules. A further unconventional pathway, the lymphatic pathway, has been supported by the demonstration of lymphatic microvessels in the limbal sclera and, possibly, in the uvea (ciliary body, choroid) as well as by the ocular glymphatic channels, present in the neural retina and optic nerve. It follows that AQH may be drained from the eyeball through blood vessels (TM-SC pathway, US pathway) or lymphatic vessels (lymphatic pathway), and the different pathways may integrate or compensate for each other, optimizing the AQH drainage. The present review aims to define the state-of-the-art concerning the structural organization and the functional anatomy of all the AQH outflow pathways. Particular attention is paid to examining the regulatory mechanisms active in each of them. The new data on the anatomy and physiology of AQH outflow pathways is the key to understanding the pathophysiology of AQH outflow disorders and could open the way for novel approaches to their treatment.

Radius-Maumenee syndrome: A case series with a long-term follow-up

The aim of the case series is to highlight the surgical challenges experienced like failed intervention, choroidal effusion, a postoperative cystoid macular oedema, and describe treatment options for Radius-Maumenee syndrome. Authors reported on 3 bilateral cases of Radius-Maumenee syndrome which underwent medical treatment, trabeculectomy with Mitomycin C, implantation with XEN45, Ahmed glaucoma valve, Baerveldt glaucoma implant, and cyclophotocoagulation.

Outcomes of medical and surgical management in eyes with idiopathic elevated episcleral venous pressure

Purpose

Idiopathic elevated episcleral venous pressure (IEEVP) is a rare cause of secondary glaucoma and is a diagnosis of exclusion. The aim of this study was to describe the clinical presentation and analyze the outcomes of medical and surgical management in eyes diagnosed with idiopathic elevated episcleral venous pressure.

Methods

A retrospective analysis of eyes diagnosed with IEEVP over a 5-year period between April 2012 and March 2016 was performed. The demographic details, medical history, and clinical course of the cases were obtained from the medical records. Data pertaining to the severity of glaucomatous damage, response to medical management, need for surgical intervention, and their outcomes were analyzed.

Results

Fifteen eyes of 13 patients were included. Thirteen eyes (86.6%) had open angle configuration. Among the 13 eyes that had glaucoma, eight eyes (61.5%) had severe glaucoma, four eyes (30.7%) had moderate glaucoma, and one eye (7.6%) had mild glaucoma. The median follow-up was 210 days. Seven of the 15 eyes (46.6%) required a glaucoma filtration procedure, and three underwent prophylactic sclerotomies. 71.4% of these eyes had complete success. One out of the seven operated eyes required choroidal drainage post-operatively.

Conclusion

IEEVP is an extremely rare condition and presents with raised intra-ocular pressure and tortuous episcleral vessels. The management of IEEVP is similar to that of primary open angle glaucoma. Uveal effusion is to be anticipated, and hence, combining trabeculectomy with prophylactic sclerotomies is advisable.

Effects of Consumption of Alcohol on Intraocular Pressure: Korea National Health and Nutrition Examination Survey 2010 to 2011

This study researched the association between alcohol consumption, intraocular pressure (IOP), and risk of open-angle glaucoma (OAG) using nationwide population-based cross-sectional data from the Korean population based survey. Information on alcohol intake was obtained by questionnaire and comprehensive ophthalmic examinations were performed. Among a total of 6057 participants, the prevalence of OAG was 4.4% (6.0% for men and 3.0% for women). Multivariate adjusted models showed that alcohol consumption showed significant relationship with changes in IOP. In sex-stratified analyses, alcohol consumption more than 2 times per week was associated with increased IOP in men without OAG, while in women with OAG drinking alcohol more than 4 times per week was associated with increased IOP. This study showed significant differences between men and women without glaucoma who consumed alcohol more than four times per week (p-value: 0.03). Our results suggest that alcohol consumption is associated with risk of elevated IOP depending on sex and presence of glaucoma in Koreans. Therefore, patients who need to control IOP should consider the effects of alcohol consumption.

Elevated episcleral venous pressure and its implications: A case of Radius-Maumenee syndrome

We report a rare case of dilated episcleral veins with unilateral secondary open-angle glaucoma. Our case highlights the possible differentials to be considered and the systematic investigations to be done while ruling out the etiologies. Radius–Maumenee syndrome is a diagnosis of exclusion. Raised IOP can remain refractory to the medical therapy and conventional trabeculectomy carries higher risk of complications. Here, we discuss the choice of surgical treatment and its implications on management of this secondary open-angle glaucoma.

Radius-Maumenee syndrome: Beyond a diagnostic and therapeutic challenge

Radius-Maumenee syndrome (SRM) or idiopathic episcleral venous hypertension (HVEI) is an uncommon disorder that occurs with a dilation of the episcleral vessels and an increase in intraocular pressure (IOP). It is a syndrome that constitutes a diagnostic and therapeutic challenge for the ophthalmologist. A case is presented in which, despite making an early diagnosis and trying to plan a treatment aimed at avoiding choroidal effusion, its appearance was unavoidable, having to treat it twice with good functional results so far.

Idiopathic elevated episcleral venous pressure in a teenager

Purpose

To report a case of unilateral idiopathic elevated episcleral venous pressure (IEEVP) in a 15-year-old patient. We reviewed and summarized published case reports of IEEVP to determine how to manage this challenging and rare condition.

Observations

A 15-year-old Caucasian male presented with elevated intraocular pressures (IOP), blood in Schlemm canal in the left eye, and asymmetric cupping with corresponding glaucomatous findings on testing. We diagnosed the patient with IEEVP and describe successful surgical intervention with deep sclerectomy and viscocanalostomy.

Conclusions and Importance

IEEVP is a diagnosis of exclusion and based on clinical findings of dilated episcleral veins, blood in Schlemm canal and glaucomatous changes. If glaucomatous progression occurs with medication, filtration surgery is usually required, and most patients have good results in the literature. Care should be taken to prevent post-operative hypotony and serous choroidal detachment.

Advanced glaucoma secondary to bilateral idiopathic dilated episcleral veins - a case report

Background

Idiopathic elevated episcleral venous pressure (IEEVP) or idiopathic dilated episcleral veins (IDEV) is a rare abnormality, and thus therapeutic treatment for this condition rarely is discussed. We report a case of a patient with bilateral glaucoma secondary to IDEV for whom intraocular pressures (IOPs) were controlled successfully by trabeculectomy.

Case presentation

A 50 year-old female with a complaint of persistent red eyes for over 30 years, presented with numerous tortuous and engorged episcleral vessels in both eyes (OU), open angles OU with spontaneous blood in Schlemm’s canal 360 degrees bilaterally. Orbital color Doppler examination showed the superior ophthalmic veins to be of normal calibre, with no reversal of flow. Head MRI with contrast and cerebral angiography were negative for arteriovenous fistula. Coronary angiography, color Doppler echocardiography and chest radiographs were within normal limits. A diagnosis of secondary glaucoma and IDEV was made. Neither anti-glaucoma medications, nor laser trabeculoplasty reduced the patent’s IOP effectively. Only after trabeculectomy was performed in each eye, were IOPs successfully controlled.

Conclusions

This case serves to remind clinicians of the importance of identifying and evaluating thoroughly patients with episcleral vessel dilation in non-inflamed eyes with no known cause. A misdiagnosis or missed diagnosis of long-term elevated intraocular pressure may result in significant damage to the optic nerve. In addition, when performing filtration surgery it is crucial that the ophthalmologist control the IOP and make an effort to prevent choroidal effusion.

Outflow enhancement by three different ab interno trabeculectomy procedures in a porcine anterior segment model

PURPOSE

To evaluate three different microincisional ab interno trabeculectomy procedures in a porcine eye perfusion model.

METHODS

In perfused porcine anterior segments, 90° of trabecular meshwork (TM) was ablated using the Trabectome (T; n = 8), Goniotome (G; n = 8), or Kahook device (K; n = 8). After 24 h, additional 90° of TM was removed. Intraocular pressure (IOP) and outflow facility were measured at 5 and 10 μl/min perfusion to simulate an elevated IOP. Structure and function were assessed with canalograms and histology.

RESULTS

At 5 μl/min infusion rate, T resulted in a greater IOP reduction than G or K from baseline (76.12% decrease versus 48.19% and 47.96%, P = 0.013). IOP reduction between G and K was similar (P = 0.420). Removing another 90° of TM caused an additional IOP reduction only in T and G but not in K. Similarly, T resulted in the largest increase in outflow facility at 5 μl/min compared with G and K (first ablation, 3.41 times increase versus 1.95 and 1.87; second ablation, 4.60 versus 2.50 and 1.74) with similar results at 10 μl/min (first ablation, 3.28 versus 2.29 and 1.90 (P = 0.001); second ablation, 4.10 versus 3.01 and 2.01 (P = 0.001)). Canalograms indicated circumferential flow beyond the ablation endpoints.

CONCLUSIONS

T, G, and K significantly increased the outflow facility. In this model, T had a larger effect than G and K.

Bimatoprost sustained-release intracameral implant reduces episcleral venous pressure in dogs

OBJECTIVE

To determine the effect of a bimatoprost sustained-release intracameral implant (Bimatoprost SR) on episcleral venous pressure (EVP) in normal dogs.

METHODS

Normotensive beagle dogs were randomized to receive Bimatoprost SR 30 μg (n = 7) or sham injection (needle insertion only, n = 7) in one eye on day 1. EVP was measured with an episcleral venomanometer through day 65. Episcleral aqueous outflow vessels were identified using fluorescence imaging following intracameral injection of indocyanine green in one additional animal. A separate cohort of dogs that had been trained for conscious intraocular pressure (IOP) measurements received Bimatoprost SR 30 μg (n = 8) in one eye; IOP was evaluated through day 66.

RESULTS

Baseline mean EVP was 10.0 mmHg in the Bimatoprost SR group and 10.4 mmHg in the sham group. Eyes treated with Bimatoprost SR exhibited a transient increase in mean EVP that peaked at day 8, followed by a decrease to levels below baseline. From day 29 to day 65, the change in mean EVP from baseline ranged from -2.4 to -3.9 mmHg (P < 0.05 vs. sham). Baseline mean IOP in eyes treated with Bimatoprost SR was 14.9 mmHg, and a steady IOP reduction was maintained through day 66. Bimatoprost SR-treated eyes exhibited a selective, sustained dilation of aqueous outflow vessels that was not observed in sham-treated eyes.

CONCLUSIONS

In normal dogs, Bimatoprost SR was associated with a transient increase in EVP followed by a sustained decrease. Changes in EVP were accompanied by a sustained dilation of aqueous outflow vessels.

Radius-Maumenee syndrome: a rare cause of glaucoma

Case presentation of a 41-year-old woman with long-standing bilateral eye injection whose clinical findings included bilateral episcleral vessel engorgement and tortuosity, raised intraocular pressure with open iridocorneal angles and left optic disc cupping. All remaining objective examination was normal. She underwent cranial and orbits CT and CT-angiography scans which were unremarkable. Optical coherence tomography of the peripapillary nerve fibre layer and automated perimetry were compatible with advanced glaucomatous damage on the left eye. The patient was diagnosed with idiopathic elevated episcleral venous pressure or Radius-Maumenee syndrome. If medical therapy is unable to prevent disease progression, left eye filtering surgery will be proposed.

Intraocular pressure in children after congenital heart surgery: A single-center study

Background:

The impact of varied cardiac physiologies on intraocular pressure (IOP) among children undergoing heart operations is unknown.

Aim:

The aim of this study was to determine the IOP among children with varying cardiovascular physiologies and varying hemodynamics after their heart operation.

Setting and Design:

This was a prospective, observational study.

Materials and Methods:

Patients ≤18 years undergoing congenital heart surgery were included in this study. IOP measurement was performed by Icare® tonometer between 3 and 14 days after heart operation.

Statistical Analysis:

Summary statistics were estimated for all demographic, anthropometric, and clinical data.

Results:

A total of 116 eyes from 58 children were included. The mean and standard deviation age was 28.4 (45.8) months. Single-ventricle anatomy was present in 26 patients (45%). Despite similar heart rate and blood pressure, the mean IOP among the patients with single-ventricle anatomy was significantly elevated as compared to patients with two-ventricle anatomy (18 mm Hg vs. 12 mm Hg, P < 0.001). There was no difference in IOP measurements based on the complexity of operation performed. We noted that patients undergoing surgical palliation with central shunt (21 mm Hg), Fontan operation (19 mm Hg), bidirectional Glenn operation (19 mm Hg), Norwood operation (19 mm Hg), or definitive repairs such as tetralogy of Fallot repair (17 mm Hg), and atrioventricular canal repair (19 mm Hg) were associated with the highest IOPs in the study cohort.

Conclusions:

This study demonstrates that IOPs vary with varying cardiovascular physiology after pediatric cardiac surgery.

Spontaneous Resolution of Presumed Idiopathic Elevated Episcleral Venous Pressure

PURPOSE

To report a case of presumed idiopathic elevated episcleral venous pressure (EVP) initially requiring medical management.

METHODS

We present a case report of a 28-year-old white man presenting with eye redness and soreness as a referral to the glaucoma service. He was diagnosed with idiopathic elevated EVP after systematic workup.

RESULTS

Unilateral elevated intraocular pressure was detected along with dilated episcleral vessels, mild cupping of optic nerve head, and blood in Schlemm's canal, yet negative angiographic imaging and hypercoagulable labs. Topical antiglaucoma medication normalized intraocular pressure, which then maintained with resolution of episcleral vessel caliper and blood in Schlemm's canal after discontinuation of medication.

CONCLUSIONS

This is the first reported case of spontaneous resolution of presumed idiopathic elevated EVP, persisting after discontinuation of medical therapy and without surgical intervention.

Surgical management of glaucoma secondary to idiopathic elevated episcleral venous pressure

Idiopathic elevated episcleral venous pressure is characterized by dilated episcleral veins and open angle glaucoma. Trabeculectomies in these eyes are often complicated by uveal effusions (intraoperative or postoperative) at nonhypotonous pressures. We highlight the ability to avoid the need for sclerostomies by preventing intraoperative shallowing of the anterior chamber and the use of tight scleral sutures which should be adjusted postsurgery to gradually reach the target intraocular pressure in a step-wise manner.

Elevated Intraocular Pressure due to Arteriovenous Fistula between External Carotid Artery and Facial Vein

Aqueous outflow via the conventional outflow pathway is dependent on the pressure gradient between intraocular pressure (IOP) and episcleral venous pressure (EVP). Elevated IOP resulting from increased EVP is a well-known complication of arteriovenous fistulas, which are usually between the carotid artery and the cavernous sinus. Arteriovenous malformations usually occur spontaneously, after a trauma or from iatrogenic causes, and they manifest with findings of chemosis, dilatation of the conjunctival vessels, exophthalmos, and extraocular motility limitation. In this study, we present a case of elevated IOP due to facial arteriovenous malformations following a functional neck dissection surgery that caused intraocular pressure elevation.

Is Episcleritis Associated to Glaucoma?

OBJECTIVE

The aim of this study was to show possible connection between episcleritis and open-angle glaucoma.

DESIGN

This was a retrospective study.

MATERIALS AND METHODS

Data on 21 patients who suffered from episcleritis and had no previous attack of episcleritis or glaucoma were collected for a period of 8 years (from 2004 to 2011).

RESULTS

Six of the 21 patients of the study group (28.6%) were diagnosed as suffering from glaucoma. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and for 1 patient there was no record of conjunctival congestion. Two of the 6 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period.

CONCLUSIONS

This study suggests an association between episcleritis and open-angle glaucoma.

Idiopathic elevated episcleral venous pressure with secondary glaucoma

PURPOSE

Idiopathic elevated episcleral venous pressure (IEEVP) is a rare condition that can lead to glaucoma, which can be difficult to manage. This case report aims to educate clinicians on the importance of considering IEEVP in the differential diagnosis of elevated intraocular pressure (IOP) in the presence of engorged episcleral veins.

CASE REPORT

We describe a patient who presented to the office with high IOPs in the presence of engorged episcleral veins. We diagnosed the patient with glaucoma and referred the patient to a glaucoma specialist. The elevated IOP became difficult to manage medically, and the patient underwent a trabeculectomy in the right eye. We eventually diagnosed the patient with IEEVP.

CONCLUSIONS

Although rare, IEEVP should be considered when the patient presents with elevated IOP in the presence of engorged episcleral veins. Idiopathic elevated episcleral venous pressure is often difficult to manage both medically and surgically.

Increased intraocular pressure after extensive conjunctival removal: a case report

A 50-year-old woman, who had undergone extensive removal of conjunctiva on the right eye for cosmetic purposes at a local clinic 8 months prior to presentation, was referred for uncontrolled intraocular pressure (IOP) elevation (up to 38 mmHg) despite maximal medical treatment. The superior and inferior conjunctival and episcleral vessels were severely engorged and the nasal and temporal bulbar conjunctival areas were covered with an avascular epithelium. Gonioscopic examination revealed an open angle with Schlemm's canal filled with blood to 360 degrees in the right eye. Brain and orbital magnetic resonance imaging and angiography results were normal. With the maximum tolerable anti-glaucoma medications, the IOP gradually decreased to 25 mmHg over 4 months of treatment. Extensive removal of conjunctiva and Tenon's capsule, leaving bare sclera, may lead to an elevation of the episcleral venous pressure because intrascleral and episcleral veins may no longer drain properly due to a lack of connection to Tenon's capsule and the conjunctival vasculature. This rare case suggests one possible mechanism of secondary glaucoma following ocular surgery.