PURPOSE: To report a case of acute angle-closure glaucoma secondary to spontaneous suprachoroidal hemorrhage in a hemodialysis patient. CASE SUMMARY: A 71-year-old man visited our clinic after 3 days of vision loss and ocular pain in the right eye. He had been treated with hemodialysis using heparin due to diabetic nephropathy. Visual acuity (VA) was hand motion in the right eye and 0.2 in the left eye. The intraocular pressure (IOP) was 58 mmHg in the right eye and 15 mmHg in the left eye. Gonioscopic examination revealed a closed angle in the right eye. Fundus examination of the right eye showed a massive hemorrhagic retinal detachment and ultrasound sonography revealed a dome-shaped retinal detachment with suprachoroidal hemorrhage in the right eye. The patient was treated with topical aqueous suppressants and cycloplegics. After two weeks of medical treatment, VA in the right eye was still hand motion and IOP was 8 mmHg. Gonioscopic examination showed a wide-open angle in the right eye. During the two-month observation period, VA in the right eye did not recover, however there was no sign of IOP elevation or symptoms of ocular pain. CONCLUSIONS: Spontaneous suprachoroidal hemorrhage can occur in patients who receive hemodialysis with heparin. This spontaneous suprachoroidal hemorrhage can be subsequently accompanied by acute angle-closure glaucoma. Spontaneous decrease of suprachoroidal hemorrhage, loss of angle-closure, and decline of IOP can be expected by treating with topical aqueous suppressants and cycloplegics.
Aged ; Diabetic Nephropathies ; Glaucoma, Angle-Closure* ; Hand ; Hemorrhage* ; Heparin ; Humans ; Intraocular Pressure ; Mydriatics ; Renal Dialysis ; Retinal Detachment ; Ultrasonography ; Visual Acuity

BACKGROUNDPrimary angle-closure glaucoma (PACG) is a major cause of visual morbidity in East Asia. Dark-room provocative test (DRPT) has been used to determine which narrow angles have the risk to develop angle closure. However, the accuracy of DRPT might be altered because that after emerging from the dark room, the configuration of the angle is affected by the light of the slit-lamp and the appositionally closed angle reopens. The aim of this study was to examine the pupillary diameter in different light conditions and use it as a parameter to assess the accuracy of dark-room provocative test.

METHODSPatients with suspected primary angle-closure glaucoma undergoing DRPT were recruited. The anterior chamber angle was examined by anterior segment optical coherence tomography under the following conditions: (1) in standard room illumination; (2) after short-term dark-adaptation and (3) after DRPT. Mean values of pupil size and numbers of appositionally closed angle under different conditions were compared.

RESULTSA total of 47 eyes of 47 patients were analyzed. The pupil size after DRPT was smaller than that after short-term dark-adaptation (P < 0.001) and smaller than that in standard room illumination (P = 0.026). The numbers of appositionally closed angles after short-term dark-adaptation were significantly larger than those after DRPT (P < 0.001). There was no significant difference between the numbers of appositionally closed angles in standard room illumination and after DRPT (P = 0.157).

CONCLUSIONSConstriction of pupil size immediately after prolonged dark room provocative test may lead to change in the angle configuration, which may lead to false negative results. We suggest a modified protocol of recording intraocular pressure immediately after DRPT and performing gonioscopy following short-term dark adaptation to improve the accuracy of angle closure assessment.

Adult ; Aged ; Dark Adaptation ; Diagnostic Techniques, Ophthalmological ; Female ; Glaucoma, Angle-Closure ; diagnosis ; diagnostic imaging ; Humans ; Male ; Middle Aged ; Sensitivity and Specificity ; Ultrasonography

INTRODUCTION: Simultaneous bilateral angle-closure glaucoma is a potentially blinding disease. From 2001 to 2007, over 100 cases of Topiramate-associated bilateral acute angle glaucoma (TA-ACG) were reported. We report the first known case in the Philippines.

CASE REPORT: A 42-year old Filipino woman diagnosed with migraine presented with the sudden blurring of vision, with generalized headache after her second dose of 25mg Topiramate. Visual acuity was decreased to 20/200 in each eye. Intraocular pressures  (IOP) were elevated to OD 50mmHg and OS 55mmHg with shallow anterior chambers and 360 degree angle closure on gonioscopy. Stat doses of mannitol, acetazolamide, brimonidine, and latanoprost were given. Topiramate was discontinued. Laser iridotomy was performed with note of an immediate drop in IOP to OD 24mmHg and OS 18 mmHg. On the day of discharge, the patient's third day of admission, IOP had returned to 12 mmHg OU and best-corrected vision had improved to 20/20 in both eyes. B-scan ultrasonography confirmed choroidal thickening in both eyes.

DISCUSSION: Topiramate associated acute angle closure glaucoma (TA-AACG) as an idiosyncratic adverse effect was first reported by Banta et al in July 20018 with shallow anterior chambers, relative lens thickening, and 360° ciliochoroidal detachments in both eyes on A- and B-scan ultrasonography. Angle-closure was believed to result from the anterior rotation of the ciliary process and not from pupillary block, rendering laser iridotomy ineffective. Signiñicant lens thickening has been shown in TA-AACG. It is thought to result in part from relaxation of the zonules due to anterior ciliary rotation and ciliary edema, and from a direct drug effect. Myopia resulting from this is characteristic of TA-AACG and may persist from days to weeks after discontinuation of topiramate. The management of TAAACG requires stopping the drug. As TA-AACG and transient myopia usually resolves within days to weeks after stopping Topiramate, medical treatment with topical cycloplegic agents, topical beta-blockers and oral pressure-lowering agents often suffice as an interim measure. However, more invasive options such as laser iridotomy should be considered when significant pupillary block angle closure is present.

SUMMARY: Topiramate may be associated with acute angle-closure glaucoma wherein, in the Filipino patient, pupillary block may be present and should be addressed by laser iridotomy when possible.

Human ; Female ; Glaucoma, Angle-closure ; Latanoprost ; Mydriatics ; Acetazolamide ; Intraocular Pressure ; Gonioscopy ; Topiramate ; Brimonidine Tartrate ; Mannitol ; Rotation ; Philippines ; Acceleratory Factor From Growth Hormone ; Prostaglandins F, Synthetic ; Fructose ; Migraine Disorders ; Visual Acuity ; Myopia ; Headache ; Ultrasonography ; Edema ; Anterior Chamber

PURPOSE: To determine the efficacy and safety of the dark-room prone-position test (DRPT) for intermittent angle closure (IAC) and to investigate the correlation between A-scan ultrasound biometric measurements and the results of DRPT. METHODS: Medical records were reviewed of 37 eyes in 24 patients who were diagnosed with IAC and received DRPT. The increase of intraocular pressure (IOP) induced by DRPT and the results from A-scan ultrasound biometric measurements were obtained. An increase in IOP of at least 8 mmHg from baseline was considered a positive result for DRPT. Associations between the increase of IOP induced by DRPT and the parameters of A-scan biometry were tested by linear regression analysis. RESULTS: The DRPT results were positive in 28 eyes of 19 patients. After DRPT, the IOP returned to near-baseline levels within 2 hours in all patients; some patients were treated with anti-glaucoma eye drops. Lens thickness was significantly correlated with the amount of IOP elevation induced by DRPT (r=0.338, p=0.041). CONCLUSIONS: DRPT is a safe and effective test in patients with IAC. DRPT can be used effectively to make a concrete diagnosis of IAC. Lens thickness appears to be associated with a positive response to DRPT.
Adult ; Aged ; *Darkness ; *Diagnostic Techniques, Ophthalmological/standards ; Female ; Glaucoma, Angle-Closure/*diagnosis ; Humans ; Male ; Middle Aged ; *Prone Position ; Ultrasonography

PURPOSE: To investigate the correlation between peripheral anterior synechia (PAS) and the quantitative anterior chamber angle parameters measured by ultrasound microscopy (UBM) in angle-closure glaucoma suspect (ACGS) eyes. METHODS: Eyes were defined ACGS as having occludable angles and intraocular pressure less than 21 mm Hg without glaucomatous optic nerve head. The gonioscopic criteria for ACGS were the trabecular meshwork invisible in 3 or more quadrants of the entire angle and the angular width less than 20 degrees by Shaffer classification. Twenty-seven eyes of 20 patients underwent anterior chamber angle and ciliary body imaging with UBM. Angle opening distance (AOD500), angle recess area (ARA), trabecular-ciliary process distance (TCPD) and trabecular-iris angle (TIA) were measured from the UBM images at each quadrant. RESULTS: The AOD500, ARA, and TIA were not significantly different between the eyes with PAS (9 eyes) and without PAS (18 eyes) at each quadrant. However, the TCPD was significantly shorter in the superior quadrant when compared with the eyes without PAS (mean: 405.3+/-70.9 micrometer vs 536.4+/-140.5 micrometer) (p<0.05). CONCLUSIONS: The results suggest that the shorter distance from trabecular meshwork to ciliary body or the anterior placement of ciliary process may play a role in the development of PAS in ACGS eyes.
Aged ; Anterior Chamber/*ultrasonography ; Ciliary Body/pathology/ultrasonography ; Cross-Sectional Studies ; Female ; Follow-Up Studies ; Glaucoma, Angle-Closure/pathology/*ultrasonography ; Gonioscopy ; Humans ; Male ; Microscopy, Acoustic/*methods ; Middle Aged ; Prognosis ; Retrospective Studies ; Severity of Illness Index ; Trabecular Meshwork/pathology/ultrasonography

PURPOSE: To compare the measured values of anterior chamber depth and angle in glaucoma patients using Ultrasound Biomicroscopy (UBM) and Orbscan(TM) IIz Topography. METHODS: We measured the anterior chamber depth and angles of four directions in 26 eyes of 13 primary open angle glaucoma (POAG) patients, 26 eyes of 13 normal tension glaucoma (NTG) patients, and 20 eyes of 10 angle closure glaucoma (ACG) patients, with UBM and Orbscan. RESULTS: The values of anterior chamber depth did not show any difference between UBM and Orbscan. The values for anterior chamber angle in POAG and NTG eyes were not different between UBM and Orbscan, but the values for all anterior chamber angles except the superior angle, measured with UBM were significantly larger than those for ACG measured by Orbscan. CONCLUSIONS: Both UBM and Orbscan showed similar results in the measurement of anterior chamber depth and angle in POAG and NTG patients, but showed different results in the anterior chamber angle for ACG patients. UBM will be more useful in evaluating the anterior chamber angle in ACG patients because it can assess the structures of the anterior chamber angle objectively.
Anterior Chamber* ; Glaucoma ; Glaucoma, Angle-Closure ; Glaucoma, Open-Angle ; Humans ; Low Tension Glaucoma ; Microscopy, Acoustic* ; Ultrasonography*

PURPOSE: To identify the essential morphologic characteristics concerned with angle closure in chronic primary angle-closure glaucoma (PACG) and to assess the changes in quantified values for angle relationships after laser iridotomy (LI) in them using ultrasound biomicroscopy (UBM). METHODS: Anterior segment imaging and quantitative assessment of angle relationships were obtained in 25 eyes of 25 patients with chronic PACG using UBM (UBM plus2000 system, Paradigm(R) Inc., Utah, USA) before and 2 weeks after LI. RESULTS: The mean anterior chamber depth (ACD), anterior chamber angle (ACA), angle-opening distance (AOD500), and trabecular-iris distance (TID) were 2.16 mm, 12.73 degrees, 0.128 mm, and 0.101 mm, respectively. All our results were significantly smaller than previously reported quantified values in normal adult. In comparison between before and after LI, ACD and iris thickness (IT) did not change significantly, whereas ACA, AOD500, AOD250, and TID all significantly increased after LI. CONCLUSIONS: Using UBM, we identified the essential morphologic characteristics concerned with angle closure in chronic PACG and quantitatively demonstrated the result of treatment based on the changes of angle relationships after LI.
Adult ; Anterior Chamber ; Glaucoma, Angle-Closure* ; Humans ; Iris ; Microscopy, Acoustic ; Ultrasonography* ; Utah

PURPOSE: To clarify the ciliary body and choroidal detachment after panretinal photocoagulation and to inspect complications by ciliary body and choroidal detachment after panretinal photocoagulation. METHODS: A dynamic, in vivo examination using ultrasound biomicroscope (UBM) was performed on 12 eyes of 11 patients before, immediately after, and 3 and 7 days after panretinal photocoagulation. IOP measurement was performed on each occasions, and the spot size, and spot number of laser applications of each patient was measured. RESULTS: Three days after photocoagulation, ciliochoroidal detachment was observed in 6 of the 12 eyes, but none was observed at 7 days. The retinal surface area that had been treated was associated with the development of detachment. No significant IOP change according to the ciliochoroidal detachment was present. CONCLUSIONS: Although ciliochoroidal detachment was asymptomatic and transient in this study, potential hazards such as angle closure glaucoma necessitate careful attention in the planning of panretinal photocoagulation. UBM is a useful tool for the evaluation of ciliochoroidal detachment after photocoagulation.
Choroid* ; Ciliary Body* ; Glaucoma, Angle-Closure ; Humans ; Light Coagulation* ; Retinaldehyde ; Ultrasonography*

This study was performed to demonstrate the ultrasound, biomicroscopic and dimensional changes of angle structure after laser iridotomy (LI) and primary trabeculectomy (PT) in primary angle-closure glaucoma (PACG). Angle-opening distance at a point 500 (m from the scleral spur (AOD500), trabecular-iris angle (theta1), trabecular ciliary process distance (TCPD), ciliary process-iris angle (CPI), iris thickness (ID1, ID3), length of iris-lens contact distance (ILCD) and anterior chamber depth (ACD) were assessed before and after each procedure. Thirteen patients with LI and 16 with PT were prospectively enrolled. There were statistically significant increases in AOD500, theta1, and ILCD in both groups. CPI was decreased in both groups. ACD, TCPD, and iris thickness were not changed significantly. The changes in angle configuration after LI or PT may result more from alterations in aqueous pressure gradients across the iris and the changes of configuration were greater in the iris roots without rotation of ciliary body. However, we didn't find any significant differences in the changes of parameters between the two procedures.
Acute Disease ; Aged ; Aged, 80 and over ; Ciliary Body/surgery/*ultrasonography ; Female ; Glaucoma, Angle-Closure/surgery/*ultrasonography ; Humans ; Iridectomy/*methods ; Iris/surgery/*ultrasonography ; Laser Surgery ; Male ; Middle Aged ; Prospective Studies ; Trabecular Meshwork/surgery/*ultrasonography ; Trabeculectomy/*methods

In order to evaluate the morphologic types of appositional angle-closure glaucoma, biometric measurements were made in angle-closure glaucoma patients using Ultrasound biomicroscopy (UBM). Twenty-six patients with primary angle-closure glaucoma and 21 cataract patients with as a control group were examined. The angle-closure glaucomatous eyes were classified as type B in which the angle closure started at the bottom of the angle and type S in which the angle closure occurred in the vicinity of Schwalbe's line. The trabecular-ciliary process distance (TCPD, type B; 873.20+/-86.77 microm, type S; 832.52+/-82.96 microm, control; 1233.50+/-73.01 microm, p = 0.000) and the angle opening distance (AOD500, type B; 89.75+/-63.27 microm, type S; 88.85+/-72.95 microm, control; 304.40+/-104.30 microm, p = 0.000) were significantly shorter in patients with angle closure vice control group. No significant difference were noted in the three groups of patients in regards to iris thickness or ciliary process-iris angle. In this study, we have demonstrated that there are two types of appositional angle-closure and have shown the forward rotation of the ciliary process without changes of the ciliary process-iris angle in cases of angle-closure glaucoma.
Adult ; Aged ; Aged, 80 and over ; Anterior Chamber/*ultrasonography ; Comparative Study ; Female ; Glaucoma, Angle-Closure/*ultrasonography ; Gonioscopy/methods ; Human ; Male ; Middle Age ; Prospective Studies ; Weights and Measures