Leonard Pek-Kiang Ang

Long-term clinical course of primary angle-closure glaucoma in an Asian population

PURPOSE To study the long-term clinical course of patients with primary angle-closure glaucoma (PACG). DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Sixty-five consecutive patients who were diagnosed with PACG at one Singapore hospital from January 1990 through December 1994. METHODS Primary angle-closure glaucoma was defined as the presence of glaucomatous optic neuropathy and compatible visual field loss associated with a closed angle in the same eye. All study eyes underwent laser peripheral iridotomy (LPI). There were two groups of patients studied. Group A consisted of those with a past documented history of an episode of acute angle closure (that had resolved after LPI). Group B consisted of those with no previous acute episode. The presenting features, management, and subsequent long-term intraocular pressure (IOP) outcome were analyzed. MAIN OUTCOME MEASURES Intraocular pressure and the need for further glaucoma treatment. RESULTS The follow-up period was 63 +/- 29 months (mean +/- standard deviation). The mean presenting IOP was 40 +/- 16 mmHg, and the presenting vertical cup-to-disc ratio was 0.6 +/- 0.2. Of the 83 eyes, only five eyes (6%) did not require any treatment after LPI in the long term. In group A (35 eyes), all eyes required further treatment with antiglaucoma medications. Twenty-two eyes (62. 9%) eventually underwent filtering surgery at a mean of 7.3 months after the commencement of treatment. In group B (48 eyes), 43 eyes (89.6%) underwent further medical therapy, of which 22 eyes (45.8%) eventually underwent filtering surgery at a mean of 18.4 months after the commencement of treatment. CONCLUSIONS Despite the presence of a patent LPI, most eyes with established PACG require further treatment to control IOP. Medical therapy fails in most cases, necessitating filtering surgery. Patients risk experiencing further glaucomatous visual damage if this trend is not detected.

Acute primary angle closure in an Asian population : long-term outcome of the fellow eye after prophylactic laser peripheral iridotomy

PURPOSE To study the long-term outcome of fellow eyes of Asian patients with acute primary angle closure (APAC) who underwent prophylactic laser peripheral iridotomy (LPI). DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Ninety-six consecutive patients with APAC at presentation to one Singapore hospital from January 1990 through December 1994. METHODS The presenting features of the fellow eye were recorded, and the subsequent long-term intraocular pressure (IOP) outcome after LPI was analyzed. All fellow eyes were initially treated with pilocarpine 2% eyedrops four times daily before LPI, which was performed within 1 week of presentation. For any eye, a rise in IOP during follow-up was defined as a rise in IOP requiring treatment by medication or surgery. MAIN OUTCOME MEASURES Incidence of acute angle closure and IOP. RESULTS The mean follow-up period was 50.8 months (range, 9-99 months). Of the 96 patients, 15 patients had bilateral APAC, and APAC developed in one fellow eye before LPI could be performed. The remaining 80 fellow eyes were studied. No cases of APAC developed after prophylactic LPI. Seventy-one fellow eyes (88.8%) were successfully treated with LPI alone without the need for additional glaucoma treatment in the long term. Seven eyes (8.8%) had IOPs of 21 mmHg or less on presentation, but a rise in IOP developed on follow-up despite the presence of a patent LPI. Two fellow eyes (2.5%) had signs of preexisting chronic angle closure glaucoma at presentation and required further glaucoma treatment even after LPI. There were no significant complications from the procedure in any of the fellow eyes studied. CONCLUSIONS In this Asian population with APAC, prophylactic LPI is safe and effective in preventing acute angle closure in fellow eyes. In addition, prophylactic LPI prevents long-term rise in IOP in 88.8% of fellow eyes (with approximately 4 years of follow-up). However, because a small proportion of fellow eyes did experience a rise in IOP within the first year, despite the presence of a patent LPI, close monitoring is still advised in the follow-up of fellow eyes of patients with APAC.

Chronic angle-closure with glaucomatous damage: Long-term clinical course in a north american population and comparison with an asian population☆

PURPOSE To study the long-term clinical course of North American chronic angle-closure glaucoma (CACG) patients with optic disc damage and visual field loss in the presence of an angle closed at least partially by peripheral anterior synechiae and to compare it with a similar group of Singaporean patients. DESIGN A retrospective, interventional case-control study series. PARTICIPANTS Fifty-one patients (80 eyes) diagnosed with CACG with glaucomatous optic nerve head and visual field damage at a New York hospital from January 1990 through December 1994. All study eyes underwent laser peripheral iridotomy (LPI). METHODS The presenting features, management, and subsequent long-term intraocular pressure (IOP) outcome were analyzed and compared with 65 Asian patients (83 eyes) from a Singapore hospital who were similarly diagnosed during the same period. MAIN OUTCOME MEASURES The long-term outcome after LPI was assessed in terms of IOP and the requirement for additional therapy. RESULTS The mean presenting IOP was higher in the Singapore eyes (40 +/- 15 mmHg) compared with the New York eyes (31 +/- 12.5 mmHg). All 80 New York eyes (100%) and 78 of 83 Singapore eyes (94%) required further treatment to control IOP during follow-up. Of the eyes with a subsequent rise in IOP, 33 of 80 eyes (41.3%) compared with 34 of 83 eyes (41.0%) of the Singapore patients were controlled with additional topical medication. Of the New York eyes, 25 of 80 (31.3%) eventually underwent filtering surgery, compared with 44 of 83 (53.0%) in the Singapore study. The other 22 eyes (27.5%) in the New York group went on to additional laser procedures, peripheral iridoplasty, laser trabeculoplasty, or a combination thereof, after which IOPs were controlled and no surgery was required. There was no similar comparison for the Singapore group, because these eyes went directly on to surgery. CONCLUSIONS Despite the presence of a patent LPI, most eyes with CACG presenting with elevated IOP and having both optic disc and visual field damage in both populations required further treatment to control IOP. Results in the American population are similar to that reported in Asian patients.

Endogenous Klebsiella endophthalmitis.

Purpose To report 4 cases of endogenous Klebsiella endophthalmitis. This disease is a rare but devastating complication of Klebsiella sepsis. Familiarity with its varied clinical presentations would aid in early diagnosis and institution of appropriate therapy.Methods We report 5 eyes of 4 patients with endogenous Klebsiella endophthalmitis from December 1995 to September 1996 and review the literature regarding previously successfully treated cases.Results The mean age of the patients was 67.5 years (range 37–85 years). One patient had bilateral involvement. At presentation, 3 eyes had a visual acuity of no perception of light (NPL) and the 1 patient with bilateral involvement had an acuity of counting fingers in one eye and 20/40 in the other. The primary source of sepsis was the pulmonary system in 2 patients, the hepatobiliary system in 1 patient and the urinary tract in 1 patient. One patient had coexisting diabetes mellitus. Two patients had a pupillary hypopyon. Local and systemic treatment with an aminoglycoside and cephalosporin was initiated. Despite treatment, 2 eyes remained NPL. One eye developed a globe perforation and was eviscerated. The patient with bilateral involvement was treated within 8 h and recovered fully with a final visual acuity of 20/20 in both eyes.Conclusion It is important to have a high index of suspicion in patients with septicaemia presenting with intraocular inflammation, especially in diabetics with suppurative liver disease, urinary tract infection or pulmonary infection. As the visual prognosis for patients with Klebsiella endophthalmitis is generally poor, early diagnosis and treatment with intravenous and intravitreal antibiotics may improve the visual outcome.

A case of episcleral neurofibroma.

Purpose: To report a rare case of episcleral neurofibroma and discuss the possible differential diagnoses. Methods: Case report of a 36-year-old man who presented with a painless epibulbar mass of the left eye. We describe the clinical and histopathologic features of the tumour and compare it with other tumours which may have a similar clinical presentation. Results: An excisional biopsy of the tumour was performed. Histopathologic examination revealed the tumour to be an isolated episcleral neurofibroma. Conclusion: It is often difficult to clinically differentiate this tumour from other conditions. Because of the slow growth of neurofibromas and its slow risk of malignant transformation, these lesions may be observed periodically for progression. Surgical excision may be performed if the lesion is found to be progressively enlarging in size.

Herpes zoster ophthalmicus. (Singapore National Eye Center, Singapore) J Pediatric Ophthalmology Strabismus. 2001;38:174–176.

This case report discussed 2 children with herpes zoster ophthalmicus as the first manifestation of varicella-zoster virus infection. Both childrens mothers had varicella while they were pregnant, but the children did not have a history of clinical varicella following birth. The authors concluded that the children were infected transplacentally with complete resolution of the features of the disease at the time of delivery. Such cases of childhood herpes zoster without a history of clinical varicella infection are rare in literature.