Twenty-Four-Hour Intraocular Pressure in Chronic Primary Angle-Closure Disease

PRCIS

Primary angle closure and primary angle closure glaucoma may exhibit normal intraocular pressure. Twenty-four-hour intraocular pressure fluctuation is highest in primary angle closure glaucoma. The degree of peripheral anterior synechiae was associated with a 24-hour intraocular pressure pattern in primary angle-closure disease without laser iridotomy.

PURPOSE

The purpose of this study was to study 24-hour intraocular pressure (IOP) patterns in eyes with chronic primary angle-closure disease and evaluate associations between peripheral anterior synechiae (PAS) and 24-hour IOP pattern.

PATIENTS AND METHODS

In this prospective cohort study, 59 eyes of 35 Asian patients with chronic primary angle-closure disease underwent complete ocular examinations at Ramathibodi Hospital, Mahidol University. Twenty-four-hour IOP records were obtained using Goldmann applanation tonometry at 2-hour intervals. Peak, mean, and trough 24-hour IOP values and 24-hour IOP fluctuation (difference between peak and trough values) were compared among groups. None of the participants received any treatment before complete data collection.

RESULTS

Even univariable analysis demonstrated a significant difference in peak, mean, and trough IOP and 24-hour IOP fluctuation between the 3 groups; the magnitude of trough IOP was not higher than 21 mmHg in all groups. In multivariable analysis, PAC and PACG eyes showed significantly higher peak IOP ( P =0.020 and 0.006, respectively) and 24-hour IOP fluctuation ( P =0.048 and 0.001, respectively) compared with PACS eyes. In comparison between combined PACS and PAC eyes versus PACG eyes, PACG eyes revealed significantly higher 24-hour IOP fluctuation. The degree of PAS was associated with peak and mean IOP values and with 24-hour IOP fluctuation in PAC and PACG eyes.

CONCLUSIONS

Twenty-four-hour IOP fluctuation was highest in PACG eyes. Although PAC and PACG eyes showed higher peak IOP and 24-hour IOP fluctuation values, compared with PACS eyes, trough IOP in PAC and PACG eyes were mostly below 21 mmHg. In addition, the degree of PAS was associated with a 24-hour IOP pattern in either PAC or PACG eyes.

Parapapillary choroidal microvascular density in acute primary angle-closure and primary open-angle glaucoma: an optical coherence tomography angiography study

BACK GROUND/AIMS

To determine whether parapapillary choroidal microvasculature (PPCMv) density, measured by optical coherence tomography angiography, differed between acute primary angle-closure (APAC), primary open-angle glaucoma (POAG) and controls.

METHODS

This is a prospective, cross-sectional, observational study. Data from 149 eyes from two academic referral centres were analysed. Automated PPCMv density was calculated in inner and outer annuli around the optic nerve region in addition to the peripapillary superficial vasculature, using customised software. A generalised estimating equation was used to compare vessel densities among groups, adjusted for confounders.

RESULTS

Data from 40 eyes with APAC, 65 eyes with POAG and 44 eyes in healthy controls were gathered and analysed. Global radial peripapillary capillary densities were reduced in eyes with APAC and POAG compared with controls (p=0.027 and 0.136, respectively). Mean outer annular PPCMv density in the POAG group was lower vs the APAC group by 3.6% (95% CI 0.6% to 6.5%) (p=0.018) in the multivariable model adjusted for confounders. The mean difference in inner and outer superior PPCMv between the POAG and APAC groups was 5.9% and 4.4% (95% CI 1.9% to 9.9% and 1.0% to 7.7%, respectively; both p<0.010). Furthermore, POAG and APAC groups both had significantly lower PPCMv compared with controls (both, p<0.001).

CONCLUSIONS

While superficial peripapillary vessels were affected to similar degrees in POAG and APAC, PPCMv drop-out was greater with POAG versus APAC, suggesting that choroidal vessel density may be affected to a lesser extent following an acute increase in intraocular pressure before glaucoma develops.

Light and electron microscopic features of preclinical pseudoexfoliation syndrome

PURPOSE

This study sought to explore the features of the anterior lens capsule in patients with preclinical pseudoexfoliation syndrome (pPEX) via light microscopy (LM) and transmission electron microscopy (TEM).

DESIGN

Cross-sectional, prospective, and observational case series.

METHODS

We recruited consecutive patients with and without pPEX who underwent routine cataract surgery at Ramathibodi Hospital, between April 2018 and November 2020. pPEX can be characterized by pigmented spoke-wheel deposition (P) on the anterior lens capsule, midperiphery cleft/lacunae (C), faint central disc present within the photopic pupil (D), white-spoke pattern (W) noted at the midperiphery, and a combination of at least two signs (Co). LM and TEM were used to examine anterior lens capsule specimens for the presence of characteristic pseudoexfoliation material (PXM). The features of the anterior lens capsule in pPEX explored via LM and TEM were recorded.

RESULTS

This study included a total of 96 patients (101 excised anterior lens capsules); among them, 34 (35 excised anterior lens capsules) exhibited pPEX signs (pPEX group) but 62 (66 excised anterior lens capsules) did not (control group). The patients had a mean age of 74 ± 7 (range, 58-89) years. LM and TEM revealed no definite PXM in any patient. In the pPEX group, LM analysis identified two capsule specimens with suspected PXM; PXM precursors were observed in 1 of the 34 excised capsule specimens analyzed via TEM. Furthermore, 39 eyes (59.09%) exhibited signs of true exfoliation syndrome (TEX) in LM analysis (12.82%, 25.64%, 10.26%, 10.26%, and 41.03% for patients exhibiting P, D, C, W, and Co, respectively). However, no TEX signs were observed in the control group. We found that the anterior lens capsules exhibiting C and D were significantly associated with TEX (odds ratio = 5.4 and 7.9; P = 0.007 and 0.004, respectively).

CONCLUSIONS

LM analysis revealed no definite PXMs were detected in the excised anterior lens capsules, whereas TEM analysis showed PXM precursors in one specimen (2.94%). Notably, a significant association was observed between C and D signs and TEX.

Pseudophakic Angle Closure Due to Vitreous Block Following Ureteroscopic Lithotripsy

Background

Here, we describe a patient who exhibited pseudophakic angle closure due to vitreous block following ureteroscopic lithotripsy under general anesthesia.

Case Presentation

A 57-year-old Thai man presented with sudden eye pain and blurring of vision in the left eye following ureteroscopic lithotripsy under general anesthesia. The patient had a history of coconut hit into his left eye which resulted in traumatic anterior lens subluxation, for which he had undergone phacoemulsification and scleral-fixated intraocular lens implantation in the left eye. Prior scleral fixation procedure, anterior vitrectomy was not performed. Clinical examination showed mushroom-shaped vitreous in the anterior chamber with absolute pupillary block, which had resulted in acute angle closure. Thus, topical and oral antiglaucoma medications were administered to achieve normal intraocular pressure in the left eye, followed by laser peripheral iridotomy in that eye. The anterior chamber depth was successfully increased. Limited anterior vitrectomy by a pars plana approach was performed to prevent recurrent angle closure. The patient’s vision improved and his intraocular pressure remained controlled without any antiglaucoma medication.

Conclusion

Vitreous block can occur in patients with pseudophakia, especially in the presence of a ruptured posterior capsule. Cautious intraoperative anterior vitrectomy and surgical iridectomy are warranted. General anesthesia may contribute to the onset of vitreous block in susceptible patients.

Peripapillary Perfused Capillary Density in Acute Angle-Closure Glaucoma: An Optical Coherence Tomography Angiography Study

PURPOSE

To compare peripapillary perfused capillary density (PCD) on optical coherence tomography angiography among resolved acute angle-closure (AAC), primary open-angle glaucoma (POAG), and control eyes.

DESIGN

Prospective, cross-sectional, observational study.

METHODS

All patients with resolved AAC or POAG of varying severity and controls were enrolled. We obtained 4.5 × 4.5 mm2 optical coherence tomography angiography images of the optic nerve head. PCD was analyzed using customized software with major vessel removal. Continuous variables were assessed using the analysis of variance and Bonferroni correction test. A marginal model of generalized estimating equations was used to adjust for confounding factors and interocular correlation.

RESULTS

The study included 44 eyes with resolved AAC (mean duration of elevated intraocular pressure, 8.1 ± 10.9 days), 69 eyes with POAG, and 49 control eyes. PCD showed a similar decrease between AAC and POAG eyes (P > 0.99). After adjusting for age and sex, the mean difference in global PCD between each of the POAG stage groups and the AAC group was the highest in the severe POAG group (-3.43; 95% confidence interval [CI], -11.38 to 2.52; P = 0.211), followed by the mild POAG (0.68; 95% CI, -3.26 to 4.62; P = 0.735) and moderate POAG (0.20; 95% CI, -5.21 to 5.61; P = 0.942) groups. The duration of increased intraocular pressure did not affect PCD (P = 0.258 and 0.168 for global and annular PCDs, respectively).

CONCLUSIONS

The degree of microvascular attenuation in AAC eyes was not different from that in POAG eyes.

Peripapillary perfused capillary density in true versus pseudoexfoliation syndrome: An OCTA study

PURPOSE

To compare peripapillary perfused capillary density (PCD) among eyes with true exfoliation syndrome (TEX), eyes with pseudoexfoliation syndrome (PEX), and healthy control eyes.

MATERIALS AND METHODS

In this observational cross-sectional study, eyes with and without TEX or PEX were assessed by optical coherence tomography angiography (OCTA) imaging. Bilateral OCTA images (4.5 × 4.5 mm2) centered at the optic nerve head were obtained using a commercial spectral domain OCTA system. Optic nerve head perfusion was quantified using the split-spectrum amplitude decorrelation angiography algorithm. Categorical and continuous variables were compared using the chi-squared test and one-way analysis of variance, respectively. The generalized estimating equation was used to adjust for confounding factors and determine inter-ocular associations.

RESULTS

We enrolled 39 eyes with TEX, 31 eyes with PEX, and 32 control eyes. There were no significant differences among the three groups regarding age, intraocular pressure, cup-to-disc ratio, blood pressure, or axial length (all p>0.05). There were significant differences in global PCD among the three groups (p = 0.01). There were significant differences in annular PCD between the TEX and PEX groups (p = 0.027).

CONCLUSIONS

While both global and annular PCDs did not differ between the TEX and control groups, greater loss of annular PCD in the PEX group than in the TEX and control groups suggests more pronounced microvascular disturbance in PEX.

SYNOPSIS/PRECIS

Greater microvascular attenuation in PEX compared with TEX and normal control measured by OCTA.

Comparison of Two Tube-Modification Techniques in Baerveldt Glaucoma Implantation in Refractory Glaucoma

Importance

To compare treatment outcomes among a stent group, ligature group and combined group in eyes with refractory glaucoma.

Background

Various techniques have been used intra-operatively to restrict the aqueous flow in Baerveldt glaucoma implantation.

Design

Retrospective chart review.

Participants

All glaucoma patients aged over 18-years old who had Baerveldt implantation in Ramathibodi Hospital, Bangkok, Thailand, between October 2011 and February 2018 were included for analysis.

Methods

Retrospective interventional research was conducted. All glaucoma patients who underwent drainage device implantations were retrospectively reviewed from medical records and divided into three groups: stent group, ligature group, and combined group. The primary outcome was post-operative intraocular pressure (IOP) changes and BCVA (logMAR) change. The secondary outcome is treatment failure. Repeated measurements with mixed models and multi-level parametric survival model stratified by propensity score and eye side were used to compare the primary and secondary outcomes between stent group and ligature group.

Main Outcome Measures

Treatment failure between two groups.

Results

A total of 163 patients with a mean age of 57.11 ± 19.04 years, implanted with Baerveldt tube, were eligible. There were no significant differences between stent and ligature groups in terms of post-operative IOP changes [mean difference with 95% confidence interval = 0.53 (−0.49, +1.55) vs −0.02 (−0.84, +0.81); P = 0.411] and post-operative BCVA (logMAR) change (0.02 (−0.13, +0.18) vs –0.05 (−0.18, +0.07); P = 0.465). The hazard ratio and 95% confidence interval of treatment failure in ligature group were 2.57 (0.72–9.19) compared with the stent group.

Conclusion

This study suggests a trend toward a better result in the stent group compared with the ligature group. Further research with a larger sample size and randomized control trial is warranted.

Atypical central retinal artery occlusion as the first presentation of POEMS syndrome: a case report

Background

POEMS syndrome is a plasma cell disorder, which clinically manifests from paraneoplastic syndrome: polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes. The most common ocular manifestation is optic disc swelling, whereas other ocular manifestations; cystoid macular edema, serous macular detachment, venous sinus thrombosis, infiltrative orbitopathy, uveitis, neovascularization of the disc, peripapillary choroidal neovascularization and optic disc drusen, had also been reported.

Case presentation

A 52-year-old Thai man presented with 5-day sudden painless visual loss in the left eye. Ocular examination revealed visual acuity of 20/20 and no light perception in the right and left eye, respectively. Right fundoscopic examination was significant for hyperemic generalized optic disc swelling. Left fundoscopic examination revealed opaque and edematous entire retina giving the appearance of central retinal artery occlusion (CRAO) along with pallid “chalky white” optic disc swelling. Fluorescein angiography showed profound leakage of bilateral optic nerve heads and arteriolar filling defect in macular area along with leakage of small retinal arterioles in the left eye. Indocyanine green angiography demonstrated choroidal filling defect in the left eye only. Neuroimaging showed enhancement and luminal narrowing of left internal carotid artery, early subacute watershed infarctions in the left cerebral hemisphere and pachymeningeal enhancement. Cerebrospinal fluid analysis revealed high protein level with normal opening pressure. Intravenous methylprednisolone was initially started without any benefit. After extensive investigations, diagnosis of “POEMS syndrome” was made based on polyneuropathy, elevated lambda light chain level, elevated plasma vascular endothelial growth factor (VEGF), hepatomegaly, spinal sclerotic bone lesions, and thrombocytosis. Furthermore, sural nerve biopsy demonstrated neuropathy and positive VEGF staining. He was treated with eight cycles of bortezomib, cyclophosphamide and dexamethasone (BorCyDex). Polyneuropathy and thrombocytosis had remarkably improved after 2nd cycle, whereas, visual impairment had shown no recovery. Hepatomegaly was significantly reduced after the completion of BorCyDex. Our case eventually received autologous hematopoietic stem cell transplantation with high dose melphalan.

Conclusions

To our knowledge, we illustrated the first patient given CRAO as the first presentation and ocular finding ever reported in POEMS syndrome. Both cerebral and ocular infarctions were presumably the result of VEGF-induced cranial vasculopathy as evidenced by neuroimaging.