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Changes in Anterior Segment Morphology After Laser Peripheral Iridotomy in Acute Primary Angle Closure

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Changes in Anterior Segment Morphology After Laser Peripheral Iridotomy in Acute Primary Angle Closure Changes in Anterior Segment Morphology After Laser Peripheral Iridotomy in Acute Primary Angle Closure SASAN MOGHIMI, REBECCA CHEN, MOHAMMADKARIM JOHARI, FAEZEH BIJANI, MASSOOD MOHAMMADI, ALIREZA KHODABANDEH, MINGGUANG HE, AND SHAN C. LIN PURPOSE: To evaluate the anterior segment biomet- different between groups with and without exaggerated ric changes measured by anterior segment optical LV after LPI. coherence tomography (AS-OCT) in acute primary CONCLUSION: This study confirms that LPI results in a angle closure (APAC) after laser peripheral iridotomy significant increase in the angle width, ACD, and ACA as (LPI). well as flattening of the iris in APAC eyes. The extent of DESIGN: Prospective interventional study. angle deepening is inversely related to baseline angle width. METHODS: In this clinic-based study, 52 eyes of 52 The lens shifts posteriorly after resolution of attack, espe- patients with resolved APAC attack who underwent cially in those with greater lens vault. (Am J LPI were enrolled. Subjects underwent complete Ophthalmol 2016;166:133–140. Ó 2016 Elsevier Inc. ophthalmic examination and AS-OCT imaging before All rights reserved.) and 6 weeks after LPI. Anterior chamber depth (ACD), anterior chamber area (ACA), iris thickness (IT), iris area, iris curvature, lens vault (LV), anterior vault, angle opening distance (AOD500, AOD750), and trabecular RIMARY ANGLE CLOSURE DISEASE IS CHARACTER- iris space area (TISA500, TISA750) were measured in ized by a crowded anterior segment and synechial qualified images and compared before and after LPI. A P or appositional closure of the angle. Angle closure linear mixed-model analysis was performed for potential can have several different presentations. Acute primary predictors of change in AOD750. Main outcome measure angle closure (APAC) is characterized by sudden intraoc- was change in AOD750 after LPI. ular pressure (IOP) rise and its consequences, such as RESULTS: The mean age of participants was 60.7 ± 9.2 corneal edema, decreased vision, seeing halos around years. Mean angle width (Shaffer grade) changed from lights, sluggish mid-dilated pupil, headache, eye pain, 1–3 0.25 ± 0.34 at baseline to 1.22 ± 0.86 after LPI (P < and eye redness. This condition is an ophthalmologic .001). However, 25 nasal angles (48.0%) and 28 tempo- emergency; untreated, APAC may lead to potentially ral angles (53%) had iridotrabecular contact after LPI. sight-threatening complications. Its treatment has 2 All angle parameters (AOD500, AOD750, TISA500, arms: IOP reduction and relief of angle closure. The TISA750; P £ .03), ACD (P [ .001), and ACA (P most common underlying mechanism of primary angle < .001) increased significantly after LPI. Iris curvature closure in this presentation is pupil block, which can be and LV were reduced (P [ .01 for both) after LPI, but relieved with laser peripheral iridotomy (LPI) in most 3,4 there was no significant change in IT and iris area. After cases. multivariate analysis, pre-LPI AOD750 was the only fac- A lens-induced mechanism in the development of APAC has tor associated with change in AOD750 (b [ L0.992, also been suggested. Lens vault (LV) is an important anatomic P [ .02). Exaggerated LV, defined as LV greater than risk factor and was previously regarded as one of the strongest pre- 3,5–8 one-third of the anterior vault (sum of LV and ACD), dictors of primary angle closure glaucoma (PACG). This was present in 61.5% of the cases (32 eyes). The extent mechanism of angle closure, called the ‘‘exaggerated lens vault 8 of change in angle parameters was not significantly mechanism,’’ was found to be predominant in half of APAC eyes in a study by Moghimi and associates.9 Although various investigators have studied factors Supplemental Material available at AJO.com. predicting LPI success in drainage angle opening among 1,4,10–17 Accepted for publication Mar 23, 2016. patients with primary angle closure/suspect, few From Farabi Eye Hospital, Tehran University of Medical Sciences, studies are performed on APAC eyes with a high Tehran, Iran (S.M., M.J., F.B., M.M., A.K.); Koret Vision Center, 18 University of California, San Francisco Medical School, San Francisco, proportion of exaggerated LV. The present study eval- California (S.M., R.C., S.C.L.); and Department of Ophthalmology, uates the effect of LPI on anterior segment morphology University of Melbourne, Melbourne, Australia (M.H.). and investigates potential predictors of LPI success in Inquiries to Shan C. Lin, Koret Vision Center, University of California, San Francisco Medical School, San Francisco, CA 94143; e-mail: [email protected]. angle opening in terms of gonioscopy and biometric edu findings. 0002-9394/$36.00 Ó 2016 ELSEVIER INC.ALL RIGHTS RESERVED. 133 http://dx.doi.org/10.1016/j.ajo.2016.03.032 METHODS TABLE 1. Anterior Segment Parameters Measured THE STUDY PROTOCOL WAS APPROVED BY THE INSTITU- by Anterior Segment Optical Coherence Tomography and tional review board of Farabi Eye Hospital, Tehran, Iran. Their Definitions This was a prospective study in which, after complete Parameter Definition explanation, all patients gave written informed consent to participate in this research protocol. Angle opening The distance between the posterior The participants were recruited from the glaucoma clinic distance at 500 and corneal surface and the anterior iris 750 mm (AOD500, surface on a line perpendicular to the of Farabi Eye Hospital, Tehran, Iran, which is a tertiary care AOD750) trabecular meshwork, 500 and center, as part of the Farabi Angle Closure Study. All 750 mm from the scleral spur, patients had an APAC attack, defined by the presence of respectively the following: (1) at least 2 of the following symptoms of Trabecular iris space The surface area of a trapezoid with the an acute episode of IOP rise: ocular pain or headache, area at 500 and following boundaries: anteriorly, the nausea or vomiting, decreased vision, and rainbow- 750 mm (TISA500, angle opening distance at 500 or colored halos around lights; (2) IOP at presentation of at TISA750) 750 mm from the scleral spur; least 30 mm Hg by Goldmann applanation tonometry; posteriorly, a line drawn from the (3) examination findings such as conjunctival injection, scleral spur perpendicular to the corneal epithelial edema, fixed mid-dilated pupil, and plane of the inner scleral wall to the shallow anterior chamber; and (4) shallow anterior cham- iris; superiorly, the inner corneoscleral wall; and inferiorly, the iris surface ber and narrow angle in the other eye. APAC attacks were Anterior chamber The axial distance from the corneal broken within 24 hours of the onset of symptoms with depth (ACD) endothelium to the anterior lens intravenous mannitol or oral glycerin, oral acetazolamide, surface and topical timolol. The APAC attack was defined as Anterior chamber The cross-sectional area of the anterior broken when IOP was less than 21 mm Hg (with or without area (ACA) chamber bordered by the posterior medication) and when signs and symptoms of acute IOP surface of the cornea, the anterior rise had subsided. Eyes whose attack could not be broken surface of the iris, and the anterior with these medications were excluded from the study and surface of the lens within the pupil received further interventions. Iris area (I-Area) Region defined as the cross-sectional Individuals with history of ocular trauma, uveitis, sur- area of the iris from the scleral spur to gery, or laser therapy were excluded from the study. Eyes the pupil Iris curvature (I-Curv) The perpendicular distance from a line with iris or angle neovascularization, pseudoexfoliation, between the most central to the most secondary angle closure, or any iris or corneal abnormalities peripheral points of the iris pigment were also excluded. Miotic or mydriatic medications were epithelium to the posterior iris surface not used in any of the patients prior to imaging. at the point of greatest convexity Slit-lamp examination of the anterior segment, Iris thickness (IT) Iris thickness at 750 mm from the scleral Goldmann applanation tonometry, and gonioscopy (with spur (IT750) and without indentation) in dark conditions, using a Lens vault (LV) The perpendicular distance from the Zeiss-style 4-mirror goniolens (Model G-4; Volk Optical, anterior pole of the lens to the Mentor, Ohio, USA) with a narrow 1-mm beam of light horizontal line between the scleral were conducted for all the patients before LPI and 6 weeks spurs later. The Shaffer grading system was used to evaluate the Anterior vault (AV) The perpendicular distance from the corneal endothelium to the horizontal angle on gonioscopy. The angle was considered ‘‘closed’’ line between the scleral spurs when posterior trabecular meshwork was not visible on gonioscopy of that quadrant. ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRA- Two experienced ophthalmologists (S.M., M.M) deter- phy: Anterior segment optical coherence tomography mined scleral spur location in each image. The principal (AS-OCT) (Visante OCT; Carl Zeiss Meditec, Dublin, investigator (S.M.) validated all the images for quality and California, USA) was performed before LPI and again scleral spur location. After identifying the scleral spur, 6 weeks later in dark ambient lighting. Scans were centered the software automatically measures anterior segment on the pupil and were obtained along the horizontal axis parameters, including anterior chamber depth (ACD), ante- using the Enhanced Anterior Segment Single protocol. rior chamber area (ACA), iris thickness (IT), iris area, iris Three images were captured, and the highest-quality image curvature, LV, lens thickness, and anterior vault (AV); and was used for analysis using the Zhongshan Angle Assess- angle parameters, including angle opening distance at 500 ment Program (ZAAP; Zhongshan Ophthalmic Center, and 750 mm from the scleral spur (AOD500, AOD750) Guangzhou, China). and trabecular iris space area at 500 and 750 mmfromthe 134 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2016 scleral spur (TISA500, TISA750).
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