Ultrasound biomicroscopic analysis of pseudophakic pupillary block glaucoma induced by Soemmering's ring

AIM: To perform ultrasound biomicroscopic analysis of pseudophakic pupillary block glaucoma induced by lens capsule and a Soemmering's ring and its resolution, and to elucidate the pathophysiology of this glaucoma. METHODS: A woman with pseudophakic pupillary block glaucoma underwent successful neodymium:YAG (Nd:YAG) laser photodisruption of the lens capsule through a laser iridotomised coloboma with resolution of the pupillary block. The Humphrey ultrasonic biomicroscope model 840 was employed to observe the anterior segment before and after laser photodisruption. RESULTS: Ultrasound biomicroscopic examination revealed the intraocular lens (IOL) was displaced forward, shallowing the central anterior chamber. The anterior hyaloid face was relatively posterior to the posterior capsule. The iris was in apposition to the anterior capsule, which was in touch with the IOL optics. A massive Soemmering's ring, which extended from the IOL optics to the ciliary processes, was displaced anteriorly. The Soemmering's ring consisted of several tightly packed layers. The ciliary processes rotated anteriorly. After Nd:YAG laser photodisruption of the capsule, ultrasound biomicroscopic images showed the resolution of the pupillary block and the anterior rotation of the ciliary process. The Soemmering's ring moved posteriorly, and the layers in the ring became loose. CONCLUSIONS: A massive Soemmering's ring may one of potential causes of pupillary block after cataract surgery. Ultrasound biomicroscopy is potentially useful as a non-invasive diagnostic technique for clinical diagnosis and differentiation between Soemmering's ring induced pupillary block glaucoma and other forms of pupillary block.     

Imaging late capsular block syndrome: ultrasound biomicroscopy versus Scheimpflug camera

We describe 2 patients with late capsular block syndrome whose anterior chamber morphology was evaluated with ultrasound biomicroscopy and Scheimpflug imaging before and after neodymium:YAG laser capsulotomy. Pretreatment ultrasound biomicroscopy examination showed significant capsular bag distension in both patients. Scheimpflug imaging failed to capture the posterior capsule displaced far behind the intraocular lens. Automatic anterior chamber depth measurements were incorrect with Scheimpflug imaging in 1 patient. Ultrasound biomicroscopy seems to be superior to Scheimpflug imaging in eyes with extremely distended capsular bags. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.     

Pupil block glaucoma after neodymium:YAG capsulotomy in a patient with a partially subluxated posterior chamber intraocular lens

A 73-year-old-woman presented following neodymium:YAG capsulotomy for posterior capsular opacification with acute glaucoma. Previous cataract surgery had left her with a subluxated lens. Cornea edema obscured detail of the anterior chamber, but the edge of the lens could be seen clearly within the pupillary space. This produced a diagnostic dilemma because no obvious cause for pupil block could be seen. She failed to respond to medical therapy and had a laser iridotomy, following which her symptoms resolved. We believe this case demonstrates the importance of a laser iridotomy to exclude pupil block glaucoma when adequate visualization of the pupillary space is obscured.     

Ultrasound biomicroscopy in pupillary block glaucoma secondary to ophthalmic viscosurgical device remnants in the posterior chamber after anterior chamber phakic intraocular lens implantation

A 25-year-old woman developed pupillary block glaucoma in the right eye after implantation of an angle-supported phakic intraocular lens despite a preexisting moderate-sized iridectomy. Ultrasound biomicroscopy (UBM) showed ophthalmic viscosurgical device retention in the posterior chamber and a full-thickness, patent-appearing iridectomy at 12 o'clock. The intraocular pressure gradually decreased to normal after a neodymium:YAG laser iridotomy was performed midperipherally at 9 o'clock. To our knowledge, this is the first report of UBM findings of this complication.     

Bilateral phacomorphic angle-closure glaucoma in a highly myopic patient secondary to isolated spherophakia

BackgroundAngle closure most commonly occurs in older hyperopic patients as a result of primary relative pupil block. Less frequently, angle closure occurs in highly myopic patients with conditions other than primary relative pupil block. This report presents the diagnosis, pathophysiologic mechanism, and management of a patient with both high myopia and bilateral advanced phacomorphic angle-closure glaucoma caused by isolated spherophakia.CaseA 40-year-old asymptomatic man with very high myopic astigmatism presented with chronic angle closure and an intraocular pressure of 42 mmHg in both eyes. Additionally there was a nonmyopic fundus and 24-mm axial length, with a clear crystalline lens protruding through the pupillary plane in each eye, confirmed by B-scan ultrasonography. Gonioscopy and A-scan and B-scan ultrasonography identified the pathogenesis of intraocular pressure elevation, angle closure, and high myopia to be lenticular in origin. Initial medical therapy and subsequent laser iridotomy relieved the pupil block angle closure and successfully lowered intraocular pressure.ConclusionAngle closure can occur in highly myopic eyes. Careful gonioscopy and ultrasonography can lead to the correct diagnosis and tailored management for these eyes. Phacomorphic angle-closure glaucoma from spherophakia is associated with Weill-Marchesani syndrome as well as a few other uncommon syndromes. Isolated pseudophakia is a rarely reported cause of phacomorphic angle closure.     

Ultrasound biomicroscopy in glaucoma

Ultrasound biomicroscopy (UBM) is a high-resolution ultrasound technique that allows noninvasive in vivo imaging of structural details of the anterior ocular segment at near light microscopic resolution and provides detailed assessment of anterior segment structures, including those obscured by normal anatomic and pathologic relations. We summarize UBM applications in glaucoma. In some cases UBM elucidates the mechanism of elevated intraocular pressure by showing the relationship between the peripheral iris and the trabecular meshwork. It can be used to study the causes of secondary glaucoma, for example, the pigment dispersion syndrome, lens-induced glaucomas, ciliary block, cysts, and solid tumors of the anterior segment. It can also assess the effects of various interventions such as laser iridotomy, trabeculectomy, and non-penetrating drainage surgery. Precise quantitative evaluation of the anterior chamber angle structures can help in diagnosis and management of various pathologies related to glaucoma.     

Role of ultrasound biomicroscopy in managing pseudophakic pupillary block glaucoma

We describe a case of anterior capsule adherence to the iris that occurred after phacoemulsification with in-the-bag intraocular lens (IOL) implantation. This adherence led to the development of pseudophakic pupillary block glaucoma. There were no synechias at the pupillary margin associated with the capsule-iris adherence. Ultrasound biomicroscopy, used to evaluate the anterior segment in vivo, clarified the mechanism of pseudophakic pupillary block. The pupillary block was relieved by a single laser iridotomy.     

Anterior segment imaging using optical coherence tomography and ultrasound biomicroscopy in secondary pigmentary glaucoma associated with in-the-bag intraocular lens

A 43-year-old man with high myopia developed unilateral pigmentary glaucoma with recurrent episodes of painless blurred vision in the left eye following uneventful phacoemulsification. Bilateral cataract surgery was performed with capsular bag implantation of a +4.00 diopter AcrySof MA60 intraocular lens (IOL) (Alcon Laboratories) followed by a neodymium:YAG laser capsulotomy. Secondary iatrogenic dispersion syndrome in the left eye with subsequent intraocular pressure elevation was suspected in the presence of anterior chamber pigmented cells, circular epithelial iris loss around the pupil, and trabecular hyperpigmentation. Close contact between the edge of the IOL and the posterior pigmented iris epithelium, which was clinically suggested by anterior biomicroscopy, was documented by ultrasound biomicroscopy and optical coherence tomography of the anterior segment.     

Ultrabiomicroscopic-histopathologic correlations in individuals with autosomal dominant congenital microcoria: three-generation family report

Background

Congenital microcoria (CMC) is due to a maldevelopment of the dilator pupillae muscle of the iris, with a pupil diameter of less than 2 mm. It is associated with juvenile open angle glaucoma and myopia. We report on a three-generation Mexican-Mestizo family with CMC. The eldest member''s iris biopsy proved muscle anomalies. Further, we analyzed novel ultrasound biomicroscopy findings in the family members who did not require surgery.

Patients and Methods

A 62-year-old woman, her 41-year-old son and her 9-year-old grandson affected with microcoria since birth, documented by clinical examination and ultrasound biomicroscopy. The eldest member underwent phacoemulsification, and a biopsy of the iris and the anterior capsule of the lens was taken.

Results

Ultrasound biomicroscopy confirmed the CMC diagnosis showing iris thinning and a pupil diameter of less than 2 mm. Histopathology of the iris showed a significant reduction of smooth muscle cells, but no alterations of the anterior lens capsule.

Discussion

Although CMC is a rare disorder, which is due to a maldevelopment of the dilator pupillae muscle of the iris, it could be associated with juvenile open angle glaucoma and myopia; therefore, precise diagnosis is required. Ultrasound biomicroscopy could be a great option to confirm the disorder.Key Words: Microcoria, Ultrasound biomicroscopy, Iris, Histopathology     

YAG laser iridotomy treatment for primary angle closure in east Asian eyes

AIM: To assess the efficacy of Nd:YAG laser iridotomy as initial treatment for primary angle closure in a community setting in rural Mongolia. METHODS: Subjects with occludable drainage angles in two glaucoma prevalence surveys in Mongolia (carried out in 1995 and 1997) were treated with YAG laser iridotomy at the time of diagnosis. These patients were re-examined in 1998. Patency of iridotomy, intraocular pressure (IOP), visual acuity, and gonioscopic findings were recorded. Iridotomy was classified unsuccessful in eyes where further surgical intervention was required or in which there was a loss of visual acuity to <3/60 from glaucomatous optic neuropathy. RESULTS: 164 eyes of 98 subjects were examined. Patent peripheral iridotomies were found in 98.1% (157/160) of eyes that had not undergone surgery. Median angle width increased by two Shaffer grades following iridotomy. Iridotomy alone failed in 3% eyes with narrow drainage angles and either peripheral anterior synechiae or raised IOP, but normal optic discs and visual fields. However, in eyes with established glaucomatous optic neuropathy at diagnosis iridotomy failed in 47%. None of the eyes with occludable angles that were normal in all other respects, and underwent iridotomy, developed glaucomatous optic neuropathy or symptomatic angle closure within the follow up period. CONCLUSIONS: Nd: YAG laser iridotomy is effective in widening the drainage angle and reducing elevated IOP in east Asian people with primary angle closure. This suggests that pupil block is a significant mechanism causing closure of the angle in this population. Once glaucomatous optic neuropathy associated with synechial angle closure has occurred, iridotomy alone is less effective at controlling IOP.     

Descemet membrane detachment after sequential argon-neodymium:YAG laser peripheral iridotomy

PURPOSE: To report a case of Descemet membrane detachment after sequential argon-neodymium (Nd):yttrium-aluminum-garnet (YAG) laser peripheral iridotomy.DESIGN: Interventional case report.METHODS: A 72-year-old Chinese man presented with acute primary angle-closure in the left eye. In the fellow right eye, a localized Descemet membrane detachment developed after prophylactic sequential argon-Nd:YAG laser peripheral iridotomy. Ultrasound biomicroscopy pictures were taken.RESULTS: The Descemet membrane detachment reattached gradually without intervention. The cornea remained clear and the vision was unchanged.CONCLUSION: In sequential argon-Nd:YAG laser peripheral iridotomy, the shock wave formed during photodisruption may produce linear cracks at the level of Descemet membrane, resulting in detachment. This complication can occur irrespective of the color of the iris.     

Histology of the lens in the Weill-Marchesani syndrome.

The Weill-Marchesani syndrome is a rare systemic connective tissue disease characterised by small stature, brachydactyly, ectopia lentis, and spherophakia. Three siblings with typical manifestations of this syndrome were reported. The ophthalmological findings in all these cases were spherophakia, severe myopia, a shallow anterior chamber, and narrow angle glaucoma. Two cases underwent laser iridotomy and drug treatment. In the third case the lens was removed from the eye because of injury, and this lens was examined by light and electron microscopy.     

Pupillary block following posterior chamber intraocular lens implantation in adults

BACKGROUND: Pupillary block rarely occurs after cataract extraction with posterior chamber intraocular lens implantation. METHODS: A series of six patients (seven eyes) treated for pupillary block after posterior chamber intraocular lens implantation between 1990 and 2001 is described; in one eye, the attack occurred after phacoemulsification. RESULTS: The interval between pupillary block development and the cataract surgery ranged from 1 day to 5 years. In all eyes, treatment consisted of neodymium-YAG laser peripheral iridotomy. In four eyes, the laser peripheral iridotomy relieved the block (one procedure in two; two to three procedures in two). One patient was also treated with YAG capsulotomy, and two patients needed additional surgical intervention. CONCLUSION: Despite the rarity of the complication of pupillary block after posterior chamber intraocular lens implantation, physicians should be aware of the sometimes difficult course of recovery after treatment.     

Ultrasound biomicroscopic findings in hallerman-streiff syndrome

PURPOSE: To demonstrate the usefulness of ultrasound biomicroscopy in detecting the morphological changes in the lens caused by the spontaneous absorption of lens material and to detect fundus abnormalities in a patient with Hallermann-Streiff syndrome. METHODS: Case report of an infant diagnosed at the age of 2 months as having Hallermann-Streiff syndrome. RESULTS: Spontaneous lens absorption occurred during the course of follow-up and was detected only by ultrasound biomicroscopy after the patient was prepared for cataract surgery. The changes in the anterior chamber depth and lens shapes were documented by ultrasound biomicroscopy. Retinal folds that were barely observable by conventional ophthalmoscopy because of a dense cataract were clearly shown by ultrasound biomicroscopy. CONCLUSIONS: Ultrasound biomicroscopy can be used to examine the lenses of eyes that are not observable with conventional optical instruments. Ultrasound biomicroscopy can also be used to study the posterior segment of microphthalmic eyes. We recommend preoperative ultrasound biomicroscopy to prevent unnecessary anesthesia and surgical preparation.     

Lens opacity after neodymium: YAG laser iridectomy for phakic intraocular lens implantation

We describe a previously unreported complication of a posterior chamber intraocular lens (IOL) implanted in a phakic eye. The left eye of a 25-year-old patient with high myopia was treated prophylactically with neodymium: YAG (Nd: YAG) laser iridotomy prior to phakic IOL implantation. Slitlamp examination of the left eye disclosed an opacity of the anterior capsule of the crystalline lens under the iridotomy site. This case demonstrates a complication associated with Nd:YAG iridotomy prior to implantation of a phakic IOL.     

继发性瞳孔阻滞性青光眼的超声生物显微镜检查

目的　研究继发性瞳孔阻滞性青光眼超声生物显微镜的影像特征。方法　对 11例临床上疑似睫状环阻滞性青光眼 ,而经超声生物显微镜检查诊断为瞳孔阻滞性青光眼患者的影像特征进行分析。结果　 11例患者的超声生物显微镜检查并不表现为典型瞳孔阻滞性青光眼的影像特点 ,但是后房均存在 ,支持瞳孔阻滞性青光眼的诊断。瞳孔阻滞性青光眼的影像特点因原发疾病的不同而异 :外伤后晶状体半脱位的患者 ,晶状体和睫状突间的距离于脱位处增大 ,晶状体位置前移 ;虹膜睫状体炎的患者 ,具有严重的虹膜前、后粘连的特点 ;抗青光眼手术后引起的继发性瞳孔阻滞性青光眼的患者 ,其睫状突与晶状体赤道部间有明显的距离 ,有虹膜周边切除孔或滤过内口不通畅的特点。结论　超声生物显微镜检查对继发性瞳孔阻滞性青光眼的诊断及其与睫状环阻滞性青光眼的鉴别诊断有重要意义 ,后房存在与否为鉴别诊断的要点。     

Ultrasound biomicroscopy of anterior segment tumors.

BACKGROUND: Ultrasound biomicroscopy is a new method of imaging the anterior segment of the eye at microscopic resolution using high frequency ultrasound. METHODS: A prospective study was performed to evaluate the use of ultrasound biomicroscopy in imaging anterior segment tumors. Forty-five patients underwent clinical examination followed by slit-lamp photography, anterior segment B-scan ultrasonography, and ultrasound biomicroscopy according to an established protocol. RESULTS: All lesions were clearly imaged by ultrasound biomicroscopy, while only 17 were detectable by conventional B-scan ultrasound. Ultrasound biomicroscopy allowed precise measurement and visualization of subsurface features in small tumors. Differentiation between solid and cystic lesions was easily achieved. The margins of ciliary body tumors could be more accurately defined. Histopathologic correlation was possible in four cases managed surgically. Ultrasound biomicroscopy images compared favorably with low-power microscopy. No complications were encountered. CONCLUSION: Ultrasound biomicroscopy proved a valuable new noninvasive technique in the evaluation of anterior segment tumors.     

Deconstructing the mechanisms of angle closure with anterior segment optical coherence tomography

Background: To illustrate the common mechanisms of angle closure by observing the changes following a laser iridotomy and then cataract surgery with anterior segment optical coherence tomography. Design: Retrospective interventional case series. Participants: Four patients with iridotrabecular contact. Methods: The anterior chamber was imaged in different lighting conditions prior to and following a laser iridotomy and then cataract surgery. The images were superimposed on each other, using the interscleral spur line as a common baseline. Main Outcome Measures: Qualitative and quantitative analysis of the changes of the iris and the drainage angle. Results: Iridotrabecular contact was seen in dark conditions in all patients. Iridotrabecular contact related to pupil block was abolished after a laser iridotomy. Persistent iridotrabecular contact following a laser iridotomy, due to a lens‐induced mechanism, was abolished after cataract surgery. Iridotrabecular contact that persisted after a laser iridotomy and cataract surgery was due to a ‘pure’ plateau iris syndrome or peripheral anterior synechiae. These treatments lowered the height of the iris plane in the region posterior to the trabecular meshwork. Conclusion: Following a laser iridotomy and cataract surgery, there is posterior movement of the iris plane away from the trabecular meshwork, but iridotrabecular contact can persist due to the ciliary processes or peripheral anterior synechiae. These changes show that the risk of iridotrabecular contact depends on the height of the iris plane relative to the trabecular meshwork and the degree of physiologic pupil dilation, and that angle closure can be a multi‐mechanism disease rather than a pure one.     

Low-energy linear-incision neodymium: YAG laser iridotomy versus linear-incision argon laser iridotomy. A prospective clinical investigation

When the Q-switched neodymium: YAG (Nd: YAG) laser is focused through the Wise 103-diopter (D) iridotomy-sphincterotomy lens (103-D lens) at low energy levels, the peripheral iris fibers can be cut individually across the iris tension lines to produce large iridotomies of controllable size. Thirty patients had linear-incision Nd:YAG laser iridotomy in one eye and linear-incision argon laser iridotomy in the other. Two-hour post-laser IOP rises averaged 7.33 mmHg for the Nd:YAG laser and 8.64 mmHg for the argon laser. The argon laser produced lens burns in 9 of 30 eyes, including 7 of 9 blue eyes. No lens damage occurred with the Nd:YAG laser. No corneal or retinal damage was seen with either laser. Local oozing of blood inhibited optical breakdown and required a pause before completion in 5 of 30 eyes with Nd:YAG iridotomy, including 4 of 6 dark brown thick irides. Because the iris fibers must be cut by direct contact with the laser plasma, serial cutting of iris fibers by multiple low-energy plasmas is safer than a single-shot, high-power plasma occupying the full thickness of the iris. Because it is effective and because it avoids the hazards of argon laser iridotomy and of high-power Nd:YAG laser iridotomy, linear incision Nd:YAG laser iridotomy is recommended as the safest method of iridotomy.     

Treatment of late-onset capsular distension syndrome with a neodymium:YAG laser peripheral iridotomy and anterior capsulotomy

We describe a new approach to treat late-onset capsular distension syndrome in which the fluid in the capsular bag is cloudy and prevents a posterior neodymium:YAG (Nd:YAG) laser capsulotomy. A peripheral laser iridotomy is created through which the anterior lens capsule peripheral to the IOL optic is accessed. This opening in the iris provides an access point through which an anterior Nd:YAG laser capsulotomy can be performed. Following disruption of the anterior lens capsule, the capsular fluid is released into the anterior chamber and absorbed through the inherent drainage system of the eye. This approach avoids the need for a more invasive surgical intervention.