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Objectives: This study aimed to determine the frequency of epiretinal membrane (ERM) in the long term after neodymium-doped yttrium aluminum garnet laser iridotomy (LI) using spectral domain optical coherence tomography (SD-OCT)., Materials and Methods: This retrospective study included 94 eyes that underwent LI for primary angle-closure glaucoma, were followed for at least 4 years, and had no ERM before the procedure. The control group consisted of 66 eyes that were followed for suspected glaucoma did not have a previous ERM. We compared the ERM frequencies of the groups at the last visit. Additionally, ERM frequencies were compared between those who had cataract surgery in the post-LI period and those who did not., Results: After a follow-up period of at least 4 years, ERM developed in 36 of 94 eyes (38.2%) in the LI group. Of these, 32 were stage 1 ERM (34.0%) and 4 were stage 2 ERM (4.2%). In the control group, ERM developed in 13 of 66 eyes (19.6%), 12 of which were stage 1 ERM (18.1%) and 1 was stage 2 ERM (1.5%) (p=0.012). ERM developed in 14 of 32 eyes (43.7%) who underwent phacoemulsification surgery after LI and in 22 of 62 eyes (35.4%) that underwent only LI without subsequent cataract surgery (p=0.435). ERM developed significantly more frequently in the 62 phakic eyes that underwent only LI than in the eyes in the control group (p=0.045)., Conclusion: LI appears to be a predisposing factor for the development of ERM, regardless of subsequent cataract surgery., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

Background: Posterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole., Case Presentation: A 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole., Conclusions: This case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye., (© 2024. The Author(s).)

Background: Secondary angle closure glaucoma (SACG) can be quite puzzling and can challenge even an experienced glaucoma surgeon. Unlike primary angle closure glaucoma, SACG can have various ocular and systemic associations. A careful review of the symptoms and past ocular and surgical history cannot be overemphasized. Some of the SACG can be refractory, requiring drainage devices. However, sometimes, all it takes is a prompt laser iridotomy. This can significantly reduce ocular morbidity and, in some situations, even blindness. Gonioscopy, often an underutilized technique, is critical in making the right diagnosis. With the advent of imaging techniques such as anterior segment optical coherence tomography and ultrasound biomicroscopy, one can easily pick up the etiology and treat early., Purpose: As many cases of SACG present acutely, it is critical that one makes a prompt diagnosis. We present here a video bouquet of illustrated examples of SACG and the steps to identify the cause by using different imaging techniques. Through this video, we aim to make the diagnosis of SACG a simpler, more streamlined, and logical process that will help in the accurate diagnosis and management., Synopsis: This video demonstrates various etiologies of secondary angle closure and methods to identify and treat the same., Highlights: Secondary angle closure can occur either with or without pupillary block. SACG with pupillary block involves mechanisms such as seclusio pupillae, aphakic/pseudophakic glaucoma, phacomorphic glaucoma, and silicon oil-induced glaucoma. In contrast, there are various other etiologies causing anterior pulling or posterior pushing mechanisms that contribute to non-pupillary block SACG. We discuss all of these, along with the imaging modalities needed to identify the same., Video Link: https://youtu.be/N0bIw7Uknww., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: To describe the clinical presentation and treatment outcomes of pupillary block glaucoma (PBG) following vitreoretinal surgery (VR surgery)., Material and Methods: Retrospective observational study of 6941 patients, who underwent VR surgery at a tertiary eye care centre in South India between January 2015 and December 2019. Amongst them, clinical data of 61 patients who developed PBG were taken for statistical analysis., Results: Mean (SD) age was 53.90 (13.4) years and the incidence of PBG was .87%. Median (IQR) time of onset of PBG following VR surgery was 3.33 (1.1-6.6) months and majority were pseudophakic (75%). PBG resolved with Nd:YAG laser peripheral iridotomy (LPI) alone in 50 (82%) patients, whereas 11(18%) patients required additional interventions like surgical iridectomy, trabeculectomy or diode laser cyclophotocoagulation (CPC) either as a stand-alone procedure or in combination with silicone oil removal (SOR). Mean (SD) intraocular pressure at the onset of PBG was 41.61 (14.5) mmHg, which reduced drastically following LPI to 24.28 (14.9) mmHg which further dropped significantly at 6 months follow up to 20.34 (13.9) mmHg., Conclusions: Incidence of secondary PBG after VR surgery was .87%, and we observed diabetes mellitus, combined cataract and VR surgery, use of 1000cs SO endotamponade, intraoperative endolaser and multiple VR surgical interventions as common associations. Majority of the patients with PBG after VR procedures resolved with LPI and medical management. Few individuals (18%) required additional laser or surgical intervention for IOP control.

Purpose: Acute angle-closure is a rare manifestation of choroidal metastasis. We reported a case of choroidal metastasis from lung adenocarcinoma presenting with unilateral acute angle-closure attacks relieved with radiotherapy after failed conventional medical and laser treatments. This represented the first detailed report of treatments of secondary acute angle-closure attacks in patients with choroidal metastasis., Case Description: A 69-year-old female without ocular history was diagnosed with metastatic lung adenocarcinoma. One month later, she complained of blurred vision and pain in the right eye that lasted 2 days. IOP was 58 mmHg and best-corrected visual acuity (BCVA) was counting finger in the right eye. Slit-lamp examination revealed corneal edema with ciliary congestion, extremely shallow anterior chamber both centrally and peripherally, mid-dilated pupil and moderate cataract in the right eye. While the left eye was normal. B-scan ultrasound and orbital computed tomography showed an appositional choroidal detachment with an underlying choroidal thickening suggesting choroidal metastasis in the right eye. There was limited effect of medical and laser therapy. IOP was 9 mmHg in the right eye after two months of palliative external beam radiotherapy in the right orbit. BCVA was hand motion in the right eye. Slit lamp examination revealed clear cornea, deep anterior chamber in the right eye. Regression of choroidal detachment and choroidal metastasis in the right eye were observed in B-scan ultrasound., Conclusion: This case demonstrated that patient with secondary acute angle-closure attacks from large bullous choroidal detachment related to choroidal metastasis could only be successfully treated with radiotherapy as both medical and laser therapy might not be capable of breaking angle-closure attacks., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background/purpose: The purpose of this study was to report an atypical presentation of postoperative endophthalmitis after cataract surgery that initially presented as angle-closure glaucoma and to discuss challenges with the case management because of the unusual presentation and patient noncompliance., Methods: This was an observational case report. B-scan ultrasound and ultrasound biomicroscopy., Results: A 69-year-old White man with a 1-week history of uncomplicated cataract surgery was referred to our glaucoma clinic because of vision loss and concern for angle-closure glaucoma. Anterior segment examination showed 360 degrees of flat anterior chamber with no hypopyon. A diagnosis of postoperative endophthalmitis was established when a B-scan ultrasound showed dense vitreous opacities. The patient underwent a pars plana vitrectomy, anterior chamber reformation, peripheral iridectomy, and intravitreal injection of antibiotics for treatment of endophthalmitis in the presence of an angle-closure glaucoma with good visual recovery., Conclusion: A low threshold for suspicion of endophthalmitis is needed after any routine intraocular procedure. An atypical presentation may masquerade as another pathology that delays the true diagnosis and treatment. Timely intervention in postoperative endophthalmitis is crucial in preserving vision.

YAG-laser interventions are associated with the risk of complications, including in the cornea., Purpose: This study evaluates the condition of the cornea after laser discission (LD) of secondary cataracts (SC) and laser iridectomy (LI) using corneal confocal microscopy (CCM)., Material and Methods: Group 1 included patients with the diagnosis "Pseudophakia, secondary cataract", they underwent LD of SC. Patients of group 1 were divided into 2 subgroups depending on the initial state of the cornea: group 1A included patients with unaltered corneas; group 1B - with changes in the corneas. Group 2 included patients diagnosed with angle-closure glaucoma (ACG) or suspected ACG, they underwent LI. CCM was performed on the Heidelberg HRT-III system. Laser treatment was performed using the Nd:YAG-laser LPULSA SYL-9000, λ=1.064 µm., Results: Immediately after treatment, subgroup 1A exhibited singular hyperreflective deposits and negligible endothelial cell loss (ECL). After 1 month, CMM findings revealed no changes in this subgroup. In subgroup 1B, a post-LD reduction in endothelial cell density led to increased polymegathism, decreased pleomorphism, heightened endothelial cell nucleus reflectivity, and moderate hyperreflective deposits after 1 month. In the second group, significant hyperreflective deposits of various sizes, increased nucleus reflectivity, and notable endothelial cell density reduction were observed immediately and 1 month after LI., Conclusion: The results of this study show that the possibility of developing corneal complications after photo destructive laser interventions is to a certain extent related to the initial state of the cornea. The risk of developing corneal damage increases with decreasing distance between the cornea and the irradiated structure. An increase in the level of laser radiation energy and its total values also contributes to damage to the cornea, which is possible with dense secondary cataracts and thick irises.

Background/aims: Prophylactic laser peripheral iridotomy (LPI) is performed in primary angle-closure suspect (PACS) eyes to prevent acute angle-closure attacks. However, accelerated cataractogenesis is a potential risk of the procedure that may result in decreased visual acuity. We aimed to assess the long-term impact of LPI on cataract formation in Chinese PACS., Methods: In the Zhongshan Angle Closure Prevention Trial, eligible bilateral PACS participants received LPI in one randomly selected eye, while the fellow eye remained untreated. Cataract was graded using the Lens Opacity Classification System III, and progression was defined as an increase in grade by at least two units in any category or cataract surgery., Results: In total, 889 participants were randomly assigned to LPI in one eye only (mean age 59±5 years, 83% female). At 72 months, treated eyes had slightly higher average nuclear grades (p<0.001). However, there were no differences between eyes for predefined cataract progression (cumulative probability at 72 months: 21.2% in LPI vs 19.4% in control, p=0.401) or cataract surgery (1% for both). While LPI-treated eyes had a 10% higher risk of progression over 6 years (HR=1.10 (95% CI 0.88 to 1.36)), this was not statistically significant. Visual acuity at 72 months was similar in treated and untreated eyes (p=0.43)., Conclusion: Although lenses were graded on average as slightly more opaque in laser-treated eyes, prophylactic neodymium:yttrium-aluminum-garnet LPI did not cause significant cataract progression. Our results suggest that LPI treatment of asymptomatic narrow angles does not increase the risk of developing clinically meaningful cataract worsening over time., Trial Registration Number: ISRCTN45213099., Competing Interests: Competing interests: DS-TC and JAK are employees of Genentech Inc., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To report three cases that developed acute angle-closure glaucoma on the background of hyponatremia due to COVID 19 infection., Methods: Data of patients with positive PCR result for COVID 19 infection and concurrent findings of acute angle-closure glaucoma were analysed retrospectively., Results: The common characteristic of all cases was positive PCR test for COVID 19 infection taken from the nasopharyngeal swab 4 or 5 days ago. Their serum sodium levels were lower than 135 mmol / L. At the initial ophthalmic examination, all cases had diffuse corneal edema with shallow anterior chambers and mid-dilated non-reacting pupils.The choroid was evaluated as normal by ocular ultrasonography. Intraocular pressures (IOP) of the first, second, and third cases were 35 mmHg, 44 mmHg, and 40 mm Hg, respectively. 5-10 cc/kg mannitol was given to all patients intravenously within 30 min. Simultaneously, they began to use oral acetazolamide, topical pilocarpine, beta-blocker, and prednisolone acetate drops.After stabilization of IOP, Neodymium-doped yttrium aluminum garnet;(ND: YAG) Laser iridotomy was performed on all patients. No additional fluid therapy was given to the patients other than mannitol, and it was determined that the blood sodium level remained at normal levels after diuresis., Discussion: Hyponatremia is the most common electrolyte disorder in COVID 19 infection. Hyponatremia may cause an angle-closure attack in patients with shallow anterior chamber angles.Therefore, one should be aware of the possibility of angle-closure glaucoma in patients who develop hyponatremia due to COVID 19 disease. Suspected patients should be referred to the ophthalmology department.

Purpose: To describe a case of bilateral ciliochoroidal effusion with secondary angle closure and myopic shift early in course of Dengue Fever., Case Description: A 36-year-old, female complaints of painless loss of vision few days after being diagnosed dengue fever. Her best corrected visual acuity is 6/6 with refractive correction of -3.00 DS and -2.75 DS in right and left eye respectively. On examination her anterior chambers are shallow with closed angles on anterior segment optical coherence tomography and high intraocular pressure. Fundus examination revealed macular striae with peripheral choroidal oedema suggestive of ciliochoroidal effusion with angle closure and acute myopic shift. Few days after starting on topical intraocular pressure lowering drugs, cycloplegics and topical steroid eye drops along with low dose systemic steroids her condition improved with resolution of choroidal effusion and return of vision to normal levels., Discussion: This case report represents interesting patient who developed transient loss of vision due to accumulation of fluid in suprachoroidal space resulting in secondary angle closure and myopia after being diagnosed with dengue fever, for which one should have high index of suspicion to facilitate timely management.

Neovascular glaucoma (NVG) is a rare, aggressive, blinding secondary glaucoma, which is characterized by neovascularization of the anterior segment of the eye and leading to elevation of the intraocular pressure (IOP). The main etiological factor is retinal ischemia leading to an impaired homeostatic balance between the angiogenic and antiangiogenic factors. High concentrations of vasogenic substances such as vascular endothelial growth factor (VEGF) induce neovascularization of the iris (NVI) and neovascularization of the angle (NVA) that limits the outflow of aqueous humor from the anterior chamber and increases the IOP. NVG clinical, if untreated, progresses from secondary open-angle glaucoma to angle-closure glaucoma, leading to irreversible blindness. It is an urgent ophthalmic condition; early diagnosis and treatment are necessary to preserve vision and prevent eye loss. The management of NVG requires the cooperation of retinal and glaucoma specialists. The treatment of NVG includes both control of the underlying disease and management of IOP. The main goal is the prevention of angle-closure glaucoma by combining panretinal photocoagulation (PRP) and antiangiogenic therapy. The aim of this review is to summarize the current available knowledge about the etiology, pathogenesis, and symptoms of NVG and determine the most effective treatment methods.

Purpose: To determine the prevalence, clinical characteristics, and mechanisms of secondary glaucoma in Vogt-Koyanagi-Harada (VKH) disease., Methods: This retrospective, longitudinal observational study analyzed the demographic data, disease stage, glaucoma development, intraocular pressure, best-corrected visual acuity, lens status, optic nerve, gonioscopy, management, and visual outcomes of VKH disease. Clinical features were used to categorize the stage of VKH disease. VKH eyes were divided into two groups, with or without glaucoma, undergoing further analysis, including statistical analysis., Results: 305 eyes of 155 patients with VKH disease with a median follow-up of 22 months were included. Secondary glaucoma developed in 67 (22%) eyes, most of which (64.2%) had chronic recurrent VKH at presentation. Angle-closure was present in 55 (82.1%) of glaucoma eyes. Peripheral anterior and posterior synechiae were present in 58 (86.6%) and 51 (76.1%) eyes, respectively. Pupillary block and posterior synechiae resulted in iris bombé in 17 (25.4%) eyes with glaucoma. At the last visit, visual acuity was worse in eyes with glaucoma (p < 0.001)., Conclusion: We found that angle-closure disease is a significant cause of secondary glaucoma in VKH. Eyes with glaucoma were more likely to present in the chronic recurrent stage of the disease., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Background and Objectives: The aim of our study was to identify risk factors associated with phacomorphic glaucoma (PG) by comparing the biometric parameters of contralateral eyes of patients with PG with the eyes of patients with a mature cataract. Methods: This retrospective case−control study included 71 eyes affected with PG, 311 eyes of control participants, and 71 contralateral eyes of patients with PG. All participants were ethnically Kazakh. Axial lengths (AL), anterior chamber depths (ACD), and lens thicknesses (LT) were measured using A-scan ultrasound biometry. To determine the threshold value of the A-scan parameters associated with PG, we performed ROC analysis. Results: The eyes with PG had smaller AL and ACD values and larger LT values, followed by the fellow eyes with PG and the control eyes. There were no differences in age and sex between patients with PG and mature cataracts. After adjustment for age and other A-scan parameters, continuous measures of ACD and LT were associated with PG (OR 0.57, 95% CI 0.38−0.73, p < 0.001; OR 3.36, 95% CI 1.64−6.912, p = 0.001). When A-scan parameters were dichotomized according to the identified threshold, an ACD of less than 2.5 mm (OR 3.113, 95% CI 1.562−6.204, p = 0.001) and an LT thicker than 4.75 mm (OR 26.368, 95% CI 9.130−76.158, p < 0.001) were found to be related to PG. Conclusions: We found that a thicker lens and, possibly, a shallow ACD are risk factors for PG.

Rationale: Angle closure glaucoma (ACG) is one of the most emergent types of glaucoma in clinical practice. Laser peripheral iridotomy (LPI) could minimize pupillary block and prevent ACG from an acute attack. However, recurrent increase in intraocular pressure (IOP) may still occur despite successful LPI. The aim of this study is to highlight the importance of postLPI pilocarpine use and larger LPI size as well as to share some experiences of cataract surgery in patients with ACG., Patient Concerns: A 63-year-old female was referred to our hospital for headache, and poor control of IOP in the right eye for 3 hours., Diagnoses: The patient was diagnosed ACG in the right eye. Recurrence of ACG in the right eye and new-onset and recurrent ACG in the left eye were noted during follow-up, despite successful LPI. The diagnosis was confirmed through slit lamp and gonioscope examination., Interventions: The LPI size was enlarged and pilocarpine use was maintained at 2% (1 drop 4 times a day) in both the eyes. Finally, cataract surgery was performed in both the eyes., Outcomes: No recurrence of ACG was noted during postLPI pilocarpine use in both the eyes. The postoperative IOP was stable for >6 months after cataract surgery without any surgical intervention or antiglaucoma medication use. No discomfort or major complication was observed., Conclusion: This report highlights the importance of postLPI pilocarpine use and larger LPI size in patients with refractory ACG., Competing Interests: The authors of this work have no conflict of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: None

Objective: To review the literature devoted to the search of predictors of primary angle closure (PAC) progression as an important link in the pathogenesis of primary angle-closure glaucoma. This part presents a cluster analysis, describes the mechanisms of PAC development, and considers the studies aimed at discovering the risk factors for the progression of primary angle closure suspect into true angle closure. The results of the analyzed literature are ambiguous, indicating the need for further research that would involve strict inclusion criteria, and a standard approach to defining the primary angle closure disease and expanding the diagnostic parameters, in which a key role belongs to anterior segment optical coherence tomography (AS-OCT).

Analysis of the effectiveness of preventative phacoemulsification (PE) in anatomically short eyes with an increased risk of an acute glaucoma attack in thickened lens can help in choosing the optimal management tactics for these patients., Purpose: To study the changes in morphometric parameters of the anterior segment of anatomically short eyes with an increased risk of acute glaucoma attack before and after preventative PE., Material and Methods: The study included 70 patients (70 eyes) with a high risk of acute glaucoma attack in short anatomical axial length and thickened lens, with posterior and middle positions of the ciliary body. They were divided into 2 groups: the main group consisted of 45 patients who agreed to undergo PE; the comparison group consisted of 25 patients who refused to undergo PE due to good visual functions and no complaints about vision. B-mode ultrasound examination of the anterior segment of the eye was used to evaluate the cross-sectional surface area of the lens (CSAL) and the cross-sectional surface area of the anterior chamber (CSAAC)., Results: In the main group, on day 2-3 after PE the anterior chamber depth increased in all eyes, the CSAAC index increased, the anterior chamber angle (ACA) widened to Schaffer grade to II-III. After 1-3 years and 4-5 years, the anterior chamber depth, the CSAAC index and the width of the ACA remained stable. In the comparison group, after 1-3 years the anterior chamber depth and the CSAAC index significantly decreased, the ACA narrowed, and the intraocular pressure increased; after 4-5 years, there was a progressive increase in the CSAL index, the ACA was completely closed (0°)., Conclusion: In all cases of timely performed preventative PE, already on days 2-3 after surgery there was a statistically significant improvement in the main morphometric parameters of the eye, which remained stable for 4-5 years.

Purpose: To study features of anatomical and morphometric parameters of the structures of anterior eye segment in young patients with moderate and high hyperopia in order to identify the signs of an increased risk of developing primary angle-closure glaucoma (PACG) and its acute attack., Material and Methods: The study included 160 eyes (80 patients) with axial length (AL) of less than 23 mm. Patients with moderate or high hyperopia were divided into two groups according to their age ranges (the 1 st - 27 patients (54 eyes) under 40 years old; the 2 nd - 27 patients (54 eyes) of 41-50 years old, the comparison group - 26 patients (52 eyes) of 42-50 years old with the initial stage of PACG. AL of the eyes, anterior chamber (AC) depth in the central zone, lens thickness (LT) in the optical zone were measured using IOL Master 700 («Carl Zeiss Meditec AG», Germany). AC volume and peripheral AC depth were measured using rotating Scheimpflug camera Pentacam («Oculus», Germany)., Results: While the average values of AL in patients of the 1 st and 2 nd groups were comparable, a statistically significant decrease in AC depth and a significant increase in LT were revealed in the 2 nd group. There was a statistically significant increase in LT, a decrease in peripheral AC depth and AC volume in the comparison group relative to the 2 nd group. In the 1 st group: in 2 eyes of one 38-year-old patient the maximum proximity of all 3 indices to the median values of the group of patients with PACG was found; in 4 eyes of two other patients (35 and 38 years old), a combination of small AC volume with increased LT or small AC volume with small AC on the periphery was noted., Conclusion: Significant differences in terms of LT, peripheral AC depth and AC volume were found between age-comparable (41-50 years old) healthy individuals with short eyes and patients with initial PACG. In 11% of the eyes of healthy patients with hyperopia aged 21 to 40 years, there was a combination of two or three of the studied morphometric signs, which may indicate the risk of developing PACG.

Purpose: Vogt-Koyanagi-Harada (VKH) is an autoimmune disease with bilateral granulomatous uveitis and various systemic manifestations. Bilateral acute angle closure glaucoma (AACG) can be a rare initial manifestation of VKH that may be misdiagnosed as primary angle closure glaucoma (PACG)., Case Report: A 62-year-old woman with bilateral painless loss of vision referred to Qingdao Municipal Hospital. She had been diagnosed as PACG before admission and prescribed with anti-glaucoma treatment which did not improve her symptom. She had severe bilateral uveitis, optic disk swelling, and serous retinal detachment in both eyes. Intraocular pressure (IOP) was 20 mmHg in the right eye and 23 mmHg in the left eye, and her best corrected visual acuities (BCVAs) were 0.02 in both eyes. She was treated with oral corticosteroid therapy on a tapering schedule. One month after the therapy, the IOP remained well-controlled with deepened anterior chamber. Her visual acuity and symptom were improved., Conclusions: We experienced a case of VKH disease with an unusual presentation of bilateral secondary AACG. It is important for ophthalmologists to know about this rare cause of painless loss of vision so that it could be treated properly.

Objective: To review the literature devoted to the problem of primary anterior chamber angle closure (PAC) and the development of this pathology from glaucoma suspect to primary angle closure glaucoma. The paper includes a trend analysis of the studies concerning primary angle closure suspects (PACS). The concept of this review is conditioned by the conflicting strategies for treating patients with initial PAC without glaucomatous optic neuropathy. Solving the problem of angle closure plays a key role in preventing the development of PAC glaucoma, which is the world's leading cause of irreversible blindness. This part of the review provides information on the frequency and rate of disease progression in PACS. The analyzed literature data is contradictory and indicates the need for further search that would consider a standardized approach to defining the concept of PAC disease, demographic factors and unified examination methods for generalizing and systematizing data in order to draw out unified treatment recommendations.

A 72-year-old female patient developed bilateral secondary iridocorneal angle-closure glaucoma with uveal effusion syndrome after uncomplicated cataract surgery. The postoperative intake of acetazolamide was identified as causative for the development of the effusion syndrome. Taking a sulfonamide-free systemic and local intraocular pressure lowering and anti-inflammatory treatment into account, a rapid improvement of the ocular manifestation was achieved. The case illustrates a rare but clinically severe adverse effect of acetazolamide and outlines efficient treatment options., (© 2020. The Author(s).)

Purpose: To investigate the etiologies and the clinical characteristics of angle-closure glaucoma (ACG) patients younger than 40 years old in Chinese., Methods: Inpatients with diagnosis of ACG and diagnosed age younger than or equal to 40 years old, who were admitted in Eye, Ear, Nose, and Throat Hospital Fudan University from 2002 to 2017, were included in this retrospective non-comparative case series. The underlying causes and clinical features for all the patients were analyzed by comprehensive review of medical charts., Results: A total of 298 patients (463 eyes) met the criteria, including 153 females (51.3%) and 145 males (48.7%); the mean age was 25.6 ± 13.0 years. Primary angle-closure glaucoma (PACG), uveitis, and anterior segment dysgenesis (ASD) were the top three etiologies in our patients, which accounted for 32.6%, 20.3%, and 15.1% of the total patients respectively. PACG mainly occurs after 30 years of age and ASD is the top reason of ACG in patients younger than 20 years old. Other known etiologies include iridocorneal endothelial syndrome, neovascular glaucoma, nanophthalmos, retinitis pigmentosa, spherophakia, bestrophinopathy, persistent fetal vasculature, iridociliary cysts, congenital retinoschisis, Marfan's syndrome, retinopathy of prematurity, familial exudative vitreoretinopathy, congenital retinal folds, Coat's disease, and neurofibromatosis., Conclusions: We described the uncommon presentation of ACG in Chinese young patients. Although unusual, most of the etiologies could be identified. Therefore, more careful and comprehensive examinations are needed for early detection and timely treatment for young ACG patients., (© 2021. The Author(s).)

We report a case of bilateral acute angle closure glaucoma developing after prone position ventilation for severe COVID-19 pneumonia. A 53-year-old diabetic and hypertensive male developed blurred vision and ocular discomfort in both eyes after prone position ventilation for severe COVID-19 pneumonia. At initial examination he was noted to have diffuse corneal edema with shallow anterior chambers and mid dilated non reacting pupils. His intraocular pressure was 48 and 54 mm Hg in right and left eye, respectively. Following intravenous mannitol (20%) infusion, oral acetazolamide 250 mg 3 times daily, along with topical therapy with combination Brimonidine and Brinzolamide eye drops and Fluoromethalone eye drops his corneal edema resolved and subsequent to laser iridotomy his intraocular pressures lowered significantly and could be maintained below 16 mm Hg in both eyes with topical therapy alone. With prone position ventilation being a commonly used adjuvant treatment for acute respiratory distress syndrome associated with COVID-19 pneumonia, acute angle closure may be precipitated in these patients if they have pre-existing narrow angles. Awareness of the possibility and its recognition may allow prompt ophthalmic referral, early treatment and minimize visual consequences., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study aimed to investigate the relationship between corneal decompensation following laser peripheral iridotomy (LPI) and iridocorneal endothelial contact., Study Design: Retrospective observational case series., Methods: Specular microscopy images of LPI recipients with narrow angles were taken at the central cornea and the 8 midperipheral corneal regions at approximately 3 mm from the center. Eleven eyes of 11 patients had a minimum of  ≤ 1600 cells/mm 2 among 8 midperipheral corneal endothelial cell densities (ECDs). Radial scans of the angles in the 8 directions were taken with ultrasound biomicroscopy (UBM) in the supine and face-down positions. The minimum and maximum angle opening distance at 750 μm from the scleral spur of the 8 directions were defined as the narrowest and widest angles, respectively. The ECD of the narrowest angle direction was compared with the ECD of the widest angle direction., Results: When UBM was performed with the subject in the supine position, the iris and cornea at the narrowest angle were in contact in only 4 of 11 eyes, while in the face-down position, the iris and the cornea at the narrowest angle were in contact in 10 of the 11 eyes. In the face-down UBM, the midperipheral ECD of the narrowest angle direction was significantly smaller than the midperipheral ECD of the widest angle direction (P = 0.006)., Conclusion: The ECD of the narrow angle direction can decrease after LPI. This suggests that corneal endothelial cell damage following LPI may be due to mechanical damage from iridocorneal endothelial contact.

Purpose: The aim of the study was to report an infectious cause of congenital pupillary-iris-lens membrane with secondary angle closure glaucoma in an infant., Design: This was a case report., Methods: Institutional review board exemption for this report was obtained from the Institutional Ethics Committee, Aravind Eye Hospital, Tirunelveli. Informed consent was obtained.A 3-month-old female infant presented to us with congenital pupillary-iris-lens membrane, iris bombe and raised intraocular pressure in the left eye. She underwent trabeculotomy and trabeculectomy along with membranectomy for the same. An aqueous tap performed a month later was suggestive of coexisting Toxoplasma gondii infection detected by polymerase chain reaction., Result: The study provides a description of the course of management of angle closure glaucoma secondary to congenital pupillary-iris-lens membrane with an associated infection. Intraocular pressure reduced from 40 to 20 mm Hg in the left eye., Conclusion: This condition is a rare entity of unknown etiology with an increased risk of glaucoma and visual loss. A multidisciplinary approach is needed for the management of these eyes. Infectious associations with these membranes should be ruled out by an aqueous tap with polymerase chain reaction and a close postoperative follow-up is mandatory., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Down syndrome is a genetic disease caused by trisomy of chromosome 21 that is characterized by numerous systemic abnormalities including intellectual disability, stereotypical facies, and congenital heart malformations. Ocular abnormalities are commonly seen with Down syndrome including corneal disease (keratoconus), refractive error, and atypical irides (Brushfield spots). We report the first case of aqueous misdirection in a patient with Down syndrome after trabeculectomy. Patients with Down syndrome often have small, hyperopic eyes with narrow iridocorneal angles and may be at increased risk for aqueous misdirection associated with surgical procedures. Awareness of this risk may aid surgical planning and postoperative management., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Ocular complications are common in the critical care setting but are frequently missed due to the focus on life-saving organ support. The SARS-CoV-2 (COVID-19) pandemic has led to a surge in critical care capacity and prone positioning practices which may increase the risk of ocular complications. This article aims to review all ocular complications associated with prone positioning, with a focus on challenges posed by COVID-19., Materials and Methods: A literature review using keywords of "intensive care", "critical care", "eye care", "ocular disorders", "ophthalmic complications," "coronavirus", "COVID-19," "prone" and "proning" was performed using the electronic databases of PUBMED, EMBASE and CINAHL., Results: The effects of prone positioning on improving respiratory outcomes in critically unwell patients are well established; however, there is a lack of literature regarding the effects of prone positioning on ocular complications in the critical care setting. Sight-threatening ophthalmic disorders potentiated by proning include ocular surface disease, acute angle closure, ischemic optic neuropathy, orbital compartment syndrome and vascular occlusions., Conclusions: COVID-19 patients may be more susceptible to ocular complications with increased proning practices and increasing demand on critical care staff. This review outlines these ocular complications with a focus on preventative and treatment measures to avoid devastating visual outcomes for the patient.

Purpose: The purpose of the study was to report a small case series of patients with iridoschisis seen at our hospital over a period of 5 years., Methods: Retrospective review of all those files over the past 5 years whereby the diagnosis of iridoschisis/iris atrophy/iris fibrils in anterior chamber (AC) was made., Results: In our case series, the average age at presentation was 49 years (range: 23-85 years). The pathology was bilateral in 57% of patients in our series. Our most common presentations were angle closure glaucoma and cataract. Younger individuals can also manifest iridoschisis., Conclusion: The iridoschisis can be an incidental finding, and gonioscopy should be performed in all the cases, as occludable or synechiael angle closure may be present in these cases., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Middle East African Journal of Ophthalmology.)

Background: Ultrasound cycloplasty (UCP) is a non-invasive procedure for glaucoma treatment. Using high-intensity focused ultrasound to work on the ciliary body, the generation of aqueous humor can be reduced and the drainage of aqueous humor through the uveoscleral pathway can be enhanced. Recently, this therapy is gradually gaining clinical recognition. We report a case of a patient with glaucoma who accepted UCP in another hospital, but because of a worsening of a preexistent cataract and an insufficient IOP lowering effect, finally underwent cataract surgery in both eyes in our hospital, during the surgery we observed the unusual opacities probably due to UCP mistreatment., Case Presentation: Patient was diagnosed as chronic angle closure glaucoma and catacract, accepted UCP on both eyes in another hospital 4 months ago. After the UCP therapy, the pupil was vertical ellipse, the UCP didn't have a sufficient effect on IOP and forced us to do cataract surgery to lower IOP. During the cataract surgery, some unusual white opacities in the peripheral cortex with clear boundary were found. Inaccurate WtW measurement was the most likely cause of the injury, which resulted in the use of the small-size UCP probe and the downward movement of the UCP probe., Conclusion: UCP should not be a first line treatment in a patient with cataract and angle closure glaucoma, cataract extraction is a better choice. The appropriate case selection needs to be more strict and the preoperative indexes measurements need to be more accurate.

Iris melanocytoma (IM) is a rare variant of iris nevus with distinctive clinical and histopathological features. A 66-year-old woman, with a history of right eye pigmented iris nevus, presented to us with a recent onset of visual acuity decrease in that eye. She had a melanocytic iris lesion with iridocorneal angle invasion, peripheral corneal adhesion, pupil corectopia, sectorial cataract and high intraocular pressure. Ultrasound biomicroscopy did not exclude malignant transformation, so excisional biopsy was performed revealing the presence of IM without signs of atypia. Subsequently, the patient underwent cataract surgery combined with iridoplasty and later an ab externo trabeculectomy. Most cases of IM remain stable and require no intervention, but in cases of unusual clinical course, with rapid growth or secondary glaucoma, surgical treatment is indicated as a diagnostic and therapeutic measure. This case report highlights the importance of a timely and multidisciplinary ophthalmological approach for a better visual outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Acute angle-closure glaucoma (AACG) caused by vitreous hemorrhage is a rare complication of intravitreal injection that often leads to permanent vision loss without prompt treatment., Case Report: This is a case of vitreous hemorrhage with secondary AACG in an 80-year-old man who presented to the emergency department (ED) with pain and vision loss in his left eye after undergoing intravitreal injection to treat exudative macular degeneration. The diagnosis was made with the use of point-of-care ultrasound after intraocular pressure (IOP) was found to be significantly elevated in the left eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should have a high level of suspicion for AACG in patients who are diagnosed with a vitreous hemorrhage after intravitreal injection and should immediately measure IOP for elevation upon presentation to the ED., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Two patients presented with angle closure many years after cataract extraction. The first patient presented with acute intraocular pressure (IOP) elevation and closed iridocorneal angle that resolved with a laser iridotomy. The second patient presented with an insidious course of high IOP and progressive narrowing of the iridocorneal angle, ultimately requiring a pars plana vitrectomy and glaucoma valve implant, with subsequent normalization of pressure and angle anatomy. Although rare, angle closure in eyes with posterior chamber intraocular lenses is a dangerous complication that can occur many years after cataract extraction. Retained lens fragments, and perhaps repeated intravitreal injections, might place susceptible patients at risk.

Case Report: A 6-month-old female presented with an iris cyst in the left eye, first identified at age 4 months. The patient was seen by an ophthalmologist at age 6 months and referred for further management. Our examination 2 weeks later demonstrated a 6 mm diameter iris cyst originating from the anterior surface of the inferior iris, occupying the inferior two thirds of the anterior chamber and obscuring the pupil. Intraocular pressure was normal and the remainder of the anterior chamber was formed. Because of concern for the development of amblyopia, the patient was scheduled for an examination under anesthesia and iris cyst removal 2 days later. In the intervening 2 days, the patient's mother noted worsening photophobia and tearing. At the time of surgery, the intraocular pressure was 51 mm Hg in the left eye. Anterior examination demonstrated interval development of shallowing of the anterior chamber with irido-corneal and cyst-corneal touch. The iris cyst had increased to 8 mm in size and filled the entire pupillary aperture. The iris cyst was excised, and histopathology confirmed the diagnosis of an iris stromal cyst., Conclusions: Congenital stromal cysts of the iris can enlarge, threatening amblyopia and secondary glaucoma in children. Although angle closure is a known theoretical complication of iris stromal cysts, actual cases are rare in the literature. This case demonstrates the importance of serial examinations to monitor progression of iris stromal cysts, particularly in young children.

Purpose: Stickler syndrome is associated with open-angle glaucoma, but no reports exist of adults presenting with acute angle closure. Here, we report the clinical associations and short-term outcomes in 2 patients with Stickler syndrome who presented with acute angle closure at a single tertiary referral center., Observations: A 36-year-old female with Stickler syndrome presented with acute onset of red and painful left eye with cloudy vision. Initial intraocular pressure (IOP) was measured to be 54 mm Hg. Gonioscopy revealed no angle structures or peripheral anterior synechiae in the left eye. Two laser peripheral iridotomies were created 5 days apart without adequate IOP lowering. Left eye cataract extraction with intraocular lens implantation and Ahmed glaucoma drainage device implantation were performed with resolution of ocular hypertension.A 35-year-old male with Stickler syndrome presented with intermittent right eye pain and blurry vision. IOP was 42 mm Hg and gonioscopy revealed 270 degrees of angle closure in the right eye. The patient underwent laser peripheral iridotomy in the right eye with resolution of ocular hypertension by the next day., Conclusions: Recognizing angle closure as a potential feature of Stickler syndrome can help providers adequately screen and manage patients with Stickler syndrome presenting with acutely elevated IOP.

Secondary angle closure in a pseudophakic eye due to pupillary block, more than a decade following phacoemulsification, has not been reported. We managed a 75-year-old female presenting with sudden, painful diminution of vision and raised intraocular pressure in the right eye. The key finding was an almost flat anterior chamber with intraocular lens in normal position clinically as well as on ultrasound biomicroscopy. The posterior chamber was ballooned up by vitreous, which was cleared surgically to restore the anatomy. Meticulous clinical examination augmented by ultrasound biomicroscopy findings helped us to diagnose and manage this case for satisfactory intraocular pressure and visual outcome.