Luis Gustavo Biteli

Association between corneal biomechanical properties and optic nerve head morphology in newly diagnosed glaucoma patients

Background:  To investigate the association between corneal biomechanics and optic nerve head morphology in newly diagnosed primary open‐angle glaucoma patients.

Corneal viscoelasticity differences between diabetic and nondiabetic glaucomatous patients.

PurposeTo investigate corneal viscoelasticity in primary open-angle glaucoma patients with and without diabetes mellitus, and to correlate corneal hysteresis (CH) with central corneal thickness (CCT). MethodsIn this cross-sectional study, 44 primary open-angle glaucoma patients [19 with diabetes (34 eyes) and 25 without diabetes (40 eyes)] underwent a complete ophthalmic examination. Data collected by masked investigators included CH and CCT using the Ocular Response Analyzer. The mean of 3 measurements was considered for each test. We analyzed the difference between the mean CH in both groups using a general linear model. Partial correlation coefficient between CH and CCT was also calculated. ResultsMean±SD age in diabetic and nondiabetic groups was 67.1±8.7 and 65.9±15.1, respectively (P=0.77). There was no significant difference regarding mean CCT between diabetic (531.7±31.3 μm) and nondiabetic (546.6±37.3 μm) groups (P=0.21). Patients with diabetes presented significantly higher CH values than patients without diabetes (9.1±1.9 mm Hg vs. 7.8±1.7 mm Hg, P=0.04). There was a significant and positive correlation between CH and CCT for all patients (r=0.407, P<0.001). ConclusionsPrimary open-angle glaucoma patients with diabetes have significantly higher CH values than those without diabetes. CH and CCT results were positively correlated. These findings merit further investigation to assess the role of different CH values on glaucoma evaluation and susceptibility.

Non-pupillary block angle-closure mechanisms: a comprehensive analysis of their prevalence and treatment outcomes

PURPOSE To assess the prevalence and treatment outcomes of angle-closure mechanisms other than pupillary block in a population of Brazilian patients. METHODS A retrospective chart review was conducted to evaluate patients who had undergone laser peripheral iridotomy (LPI) due to occludable angles at a single institution between July 2009 and April 2012. An occludable angle was defined as an eye in which the posterior trabecular meshwork was not visible for ≥180° on dark-room gonioscopy. Key exclusion criteria were any form of secondary glaucoma and the presence of >90° of peripheral anterior synechiae. Collected data were age, race, gender, angle-closure mechanism (based on indentation goniocopy and ultrasound biomicroscopy), intraocular pressure (IOP), number of antiglaucoma medications and subsequent management during follow-up. If both eyes were eligible, the right eye was arbitrarily selected for analysis. RESULTS A total of 196 eyes of 196 consecutive patients (mean age 58.3 ± 11.6 years) who underwent LPI were included. In most of the patients [86% (169 patients; 133 women and 36 men]), LPI sucessfully opened the angle. Mean IOP was reduced from 18.3 ± 6.4 mmHg to 15.4 ± 4.5 mmHg after LPI (p<0.01). Among the 27 patients with persistent occludable angles, the most common underlying mechanisms were plateau iris (56%) and lens-induced component (34%). Most of these patients (85%) were treated with argon laser peripheral iridoplasty (ALPI); approximately 90% showed non-occludable angles following the laser procedure (mean IOP reduction of 18.9%), with no significant differences between patients with plateau iris and lens-induced components (p=0.34; mean follow-up of 11.4 ± 3.6 months). CONCLUSION Our findings suggest that, in this population of Brazilian patients, several eyes with angle closure were not completely treated with LPI. In the present large case series involving middle-age patients, plateau iris was the leading cause of persistent angle closure and was effectively treated with ALPI. A detailed eye examination with indentation gonioscopy should always be performed after LPI to rule out persistent angle closure due to non-pupillary block mechanisms.

Pattern of inner retinal layers involvement in pigmented paravenous retinochoroidal atrophy as determined by SD-OCT: case report

Pigmented paravenous retinochoroidal atrophy is an ocular disease characterized by outer retina and choroidal atrophy often with overlying intraretinal bone spicule pigment deposition along the retinal veins. As a rare condition, there is scant information in the literature regarding the pattern of inner retinal layers involvement. We present a case of a 41-year-old white man initially referred for a glaucoma evaluation. Fundoscopy revealed patches of retinochoroidal atrophy and light pigmentation extending from the optic nerve head along the inferior-temporal retinal veins in both eyes. Using different spectral-domain optical coherence tomography (SD-OCT) protocols we identified a significant thinning of the inner retinal layers along the inferior-temporal veins, but with a lucid interval surrounding the optic nerve head. Standard automated perimetry revealed a superior absolute arcuate scotoma sparing the central fixation (good structure-functional correlation). This pattern of inner retinal layers involvement was not previously described. We believe SD-OCT added significantly to the anatomical description of this case. Physicians should consider these new anatomical findings and correlate them with functional status while assessing these patients.

Role of Laser Iridoplasty in the Management of Angle Closure Mechanisms other than Pupillary Block.

ABSTRACT Purpose: To investigate the treatment outcomes of argon laser peripheral iridoplasty (ALPI) in angle closure mechanisms other than pupillary block. Methods: We conducted a comprehensive chart review to evaluate consecutive patients who underwent ALPI due to unsuccessful laser iridotomy (whenever the angles remained occludable) between July 2009 and April-2012. An occludable angle was defined as the posterior trabecular meshwork not visible for ≤180° without indentation on dark room gonioscopy. Eyes with previous incisional surgery or more than 90° of peripheral anterior synechiae were excluded. Main data collected were age, presence of glaucoma, pre- and postlaser intraocular pressure (IOP), angle-status, and underlying angle closure mechanism. Main outcomes were post ALPI angle widening on gonioscopy and magnitude of IOP reduction. Results: A total of 41 eyes (27 patients) with persistent occlu-dable angles were initially included in the analysis, comprising approximately 14% of the 196 patients (321 eyes) that had under gone laser iridotomy during the predefined period. Among these cases, most common angle closure mechanisms were plateauiris (56%) and lens-induced component (34%). Patients with plateau iris were mostly women and younger than those with lens-induced component (p ≤ 0.03). A total of 35 eyes (23 patients) underwent ALPI (63% had glaucoma). Mean IOP was significantly reduced from 18. 2 ± 4.7 to 14.6 ± 3.8 (p < 0.01), with no significant difference between patients with plateau iris and lens-induced components (p = 0.22). Over 91% of these eyes showed nonoccludable angles following ALPI (follow-up of 11.8 ± 3.3 months). Conclusion: In this series of middle-aged patients with occlu-dable angles, despite a patent iridotomy, ALPI was a useful procedure independent of the underlying mechanism, leading to angle widening and moderate IOP reduction in most cases. How to cite this article: Prado VG, Dorairaj S, Biteli LG, Sousa AKS, Moreno PAM, Lopes FS, Prata TS. Role of Laser Iridoplasty in the Management of Angle Closure Mechanisms other than Pupillary Block. J Curr Glaucoma Pract 2014;8(2):82-84.

Angle Closure Associated With a Cobblestone Iris Configuration: Clinical and Imaging Description

Purpose:The purpose of the study was to report a patient with primary angle closure associated with a different nonpupillary block mechanism in which an abnormally thick peripheral iris assumes a cross-sectional shape resembling a cobblestone. Methods:This is a case report focussing on clinical and imaging description. Results:Slit-lamp biomicroscopy revealed patent laser peripheral iridotomies OU. The anterior chamber was relatively deep in the center but 360 degrees narrow at the periphery, associated with an abnormally elevated iris contour OU. On dark-room gonioscopy, the angles were occludable with few areas of peripheral anterior synechiae. Anterior segment-adapted spectral domain-optical coherence tomography revealed an unusual iris profile. Despite a flat contour and normal thickness until the mid-periphery, the iris assumed a rectangular cross-sectional shape (resembling a cobblestone) with an abnormal increase in its thickness in the periphery (360 degrees OU). Ultrasound biomicroscopy imaging showed a normal ciliary sulcus and ciliary body configuration, revealing no cysts at 360 degrees. Definitive relief of appositional angle closure was achieved with laser peripheral iridoplasty OU. Conclusions:This unusual anatomic condition of the peripheral iris, which has different characteristics when compared with ordinary cases of thick peripheral iris roll, may lead to angle closure and intraocular pressure elevation despite a patent iridotomy. Clinicians should be aware of this anatomic condition whenever dealing with cases of angle closure.

Eyes with Suspicious Appearance of the Optic Disc and Normal Intraocular Pressure: Using Clinical and Epidemiological Characteristics to Differentiate Those with and without Glaucoma.

Among all glaucoma suspects, eyes with optic nerve head features suspicious or suggestive of early glaucoma are probably those that offer the greatest challenge for clinicians. In contrast with the robust longitudinal data published on ocular hypertension, there is no specific management guideline for these patients. Therefore, evaluating eyes with suspicious optic disc appearance and normal intraocular pressure (IOP), we sought to investigate potential differences in clinical and epidemiological characteristics to differentiate those with normal-tension glaucoma (NTG) from those with presumed large physiological optic disc cups (pLPC). In this observational case-control study, we consecutively enrolled individuals with pLPC and NTG. All eyes had vertical cup-to-disc ratio (VCDR)≥0.6 and untreated IOP<21 mmHg. Glaucomatous eyes had reproducible visual field defects. Eyes with pLPC required normal visual fields and ≥30 months of follow-up with no evidence of glaucomatous neuropathy. Clinical and epidemiological parameters were compared between groups. Eighty-four individuals with pLPC and 40 NTG patients were included. Regarding our main results, NTG patients were significantly older and with a higher prevalence of Japanese descendants (p<0.01). Not only did pLPC eyes have smaller mean VCDR, but also larger optic discs (p≤0.04). There were no significant differences for gender, central corneal thickness, and spherical equivalent (p≥0.38). Significant odds ratios (OR) were found for race (OR = 2.42; for Japanese ancestry), age (OR = 1.05), VCDR (OR = 5.03), and disc size (OR = 0.04; p≤0.04). In conclusion, in patients with suspicious optic disc and normal IOP, those with older age, Japanese ancestry, smaller optic discs, and larger VCDR are more likely to have NTG, and therefore, deserve deeper investigation and closer monitoring.