ORIGINAL ARTICLES
PURPOSE: To present clinical cases of spontaneous ciliochoroidal detachment (CD) in non-operated eyes in patients with angle-closure glaucoma and nanophtalm.
METHODS: Two patients with nanophthalm and angleclosure glaucoma were examined. Apart from standard ophthalmological examination all patients underwent ultrasound biomicroscopy of the eye using Paradigm P 40 UBM «Medical Industries, Ins» (USA) and optical coherence tomography of the anterior eye segment using Visante OCT «Carl Zeiss» (Germany).
RESULTS: In the first case, the patient underwent microinvasive non-penetrating deep sclerotomy (MNPDS) with preliminary laser iridectomy and phacoemulsification with intraocular lens implantation. During subsequent observation a ciliochoroidal detachment was detected in the paired non-operated eye. In the second case, the patient without any surgical intervention in anamnesis manifested with CD in both eyes.
CONCLUSION: CD is a complication that accompanies surgical intervention, associated with eye globe decompression, trauma and inflammatory ophthalmopathy. Uveal effusion syndrome is a rare pathology characterized by associated ciliochoroidal and serous retinal detachment.
This phenomenon develops because of the peculiarities of the structure and interrelation of vascular and scleral membranes of the eye.
Scientific literature widely coveres cases of effusion syndrome with nanophthalm and cases of CD after deep sclerectomy in patients with glaucoma.
This paper presents a clinical case of spontaneous CD in non-operated eye with angle-closure glaucoma.
Presented clinical cases demonstrate the need for a continued study of the sclera and choroid interrelation role in the pathogenesis of CD and uveal effusion development in patients with angle-closure glaucoma.
PURPOSE: To analyze the initial treatment for newly diagnosed primary open-angle glaucoma (POAG) I-III stages, to assess its efficacy and the extent of IOP level reduction.
METHODS: The study included 597 patients (1 194 eyes) with newly diagnosed mild to advanced POAG, 186 men (31.1%) and 411 women (68.9%) with mean age of 63.9±1.97 years. Study protocol included the following indicators assessment: age, medical history (comorbidity), disease stage, IOP level — initial, 2 weeks, 1, 3, 6 months and 1 year after the hypotensive treatment onset, hypotensive drug regimen and its changes.
RESULTS: 93.6% of POAG patients had concomitant somatic diseases. Beta-blockers (BB) were used as the firstline drug in mild glaucoma in 75.4% of cases, in moderate glaucoma — in 35.6%. Prostaglandin analogues (PA) monotherapy was prescribed in 17.8% of cases in mild glaucoma, 14.1% in moderate glaucoma and 16.0% — in advanced glaucoma. A PA/BB combination was chosen in 14.1% of moderate glaucoma and 33.7% of advanced glaucoma cases. Fixed combinations of these drugs were used in 14.5% and 13.3% of moderate and advanced glaucoma patients respectively. After 12 months of mild glaucoma 40.4% of patients changed their hypotensive regimen, switching from BB to other drugs, glaucoma progression was observed in 7.7% of cases. Hypotensive regimen correction in moderate glaucoma cases was required in over 50% of patients initially instilling BB and 33.3% оf patients adhering to PA monotherapy. In advanced glaucoma patients monotherapy was ineffective in 100% of cases, BB/PA combination showed sufficient effect in 58.7% of cases and their fixed combination — in 45.8%.
CONCLUSION: BB choice as the first-line therapy is not always justified. Active starting therapy in mild glaucoma cases, timely and adequate regimen correction, combination therapy or fixed combinations allow for providing the optimal IOP level at different stages of the disease.
PURPOSE: To study the morphometric parameters of the optic nerve head and retina in premature infants with congenital glaucoma.
METHODS: Children with congenital glaucoma (21 children) with favorable outcomes of 1-3 stages of retinopathy of prematurity (RP) aged from 6 months to 12 years were examined (group I). The control group consisted of 32 fullterm children with congenital glaucoma (group II). In addition to the standard methods of examination, Heidelberg retinal tomography (HRT) and optical coherence tomography (Spectralis-OCT) of optic nerve head (ONH) and retina were used.
RESULTS: According to clinical manifestations of glaucoma, there were no significant differences between the groups. Both children with 1-2 stage of RP and congenital glaucoma and full-term infants with congenital glaucoma revealed the same pronounced morphometric changes in structures of the disk and peripapillary zone of the retina, which were characteristic for the development of glaucomatous optic neuropathy and intensified in the course of glaucoma progression. ONH changes interpretation in RP infants was hampered by traction deformation of the ONH and displacement of the central vessel trunk, especially in patients with stage 3 RP. We have not revealed a clear link between the changes in the optic nerve disk and IOP level.
CONCLUSION: Morphometric parameters measurement and a number of pathognomonic symptoms of optic nerve and peripapillary retina damage in congenital glaucoma in premature infants identified in this paper are necessary for studying the pathogenesis of glaucomatous process in RP, clarifying the diagnosis, determining the disease prognosis, assessing glaucoma progression and developing treatment tactics
PURPOSE: A comparative analysis of long-term results of subcleral implantation of two models of “Glautex” biodegradable drainage device and Ahmed glaucoma valve in patients with refractory post-traumatic glaucoma (RPTG).
METHODS: The article presents an analysis of 2 methods of RPTG drainage surgery results. The author’s operation modification includes trabeculectomy, reverse cyclodialysis and the formation of a deep scleral flap, on which the drainage socket is put on. Patients are divided into 3 groups according to the type of surgical treatment: 1) subscleral implantation of Glautex drainage device in the form of a socket (17 patients); 2) implantation of a similar socket drainage device with a triangular tongue on the one side (10 patients); 3) Ahmed’s valve implantation (26 patients).
Average intraocular pressure (IOP) before the surgery was 33.9±5.47 mm Hg.
RESULTS: The hypotensive effect persisted for 3 months in all cases. Three months after Ahmed’s valve implantation IOP level in 7 patients increased to 34.1±4.65 mm Hg, due to conjunctival-scleral scarring in 4 cases and displacement of the drainage tube into the scleral fistula in 3 cases. One patient developed a conjunctival decubitus ulcer above the tube after 5 months. In other patients (18 eyes) IOP remained normal with the average level of 15.3±2.56 mm Hg. The only complication after Glautex drainage device implantation included a single case of fistula obliteration 1 month after the surgery. IOP level 1 year after surgery was 15.3±2.67 mm Hg in the first group and 14.2±1.78 mm Hg in the second group. Ultrasonic biomicroscopy revealed that slit-like spaces facilitating the drainage formed at the implant site and persisted throughout the follow-up period.
CONCLUSION: Glautex drainage device implantation in patients with RPTG is characterized by a stable hyportensive effect and an absence of severe complications observed after Ahmed glaucoma valve implantation.
OBJECTIVE: To assess the features of regional hemodynamics in patients with primary open-angle (POAG), pseudoexfoliation glaucoma (PEG) (and on the paired eye without glaucoma) and ocular hypertension (OH).
METHODS: According to inclusion and non-inclusion criteria, out of 1370 patients under our observation we picked 290 patients (540 eyes) with POAG, PEG and OH, as well as healthy people for control. At baseline all patients underwent visometry, tonometry, elastotonometry (assessed five times in 3 months, with mean value of all measurements used for the calculations), standard automated perimetry (SAP), optical coherence tomography (OCT) of the macular zone and optic disc, pachymetry (Spectralis OCT, «Heidelberg Engineering», Germany), keratorefractometry, ultrasound dopplerography (USDG) of orbital vessels (Toshiba Aplio XG), with intraocular (IOP) and arterial blood (BP) pressure measurement just before USDG. The analysis of structural and functional differences was presented in the previous publication (Part 1) [1].
RESULTS: The peak systolic (Vmax) 28.0 (22.8; 34.0); 29.2±9.0 cm/sec and end diastolic (Vmin) 5.7 (4.3; 7.7); 6.0±2.6 cm/sec blood flow velocity in the ophthalmic artery (OA) in patients with POAG was lower than in other groups, however, the difference was statistically significant only when compared to PEG groups 30.6 (24.0; 38.2); 31.2±10.1/6.8 (4.2; 8.6); 7.3±5.2 cm/sec and unilateral PEG 27.6 (24.1; 36.7); 30.4±9.3 / 6.0 (4.4; 7.4); 6.7±4.0 cm/sec, while blood flow velocity in OH, norm, PEG and unilateral PEG groups did not differ, when compared between themselves. Central retinal artery (CRA) hemodynamics also allows one to speak of the existence of a hemodynamic compensatory mechanism, a statistically significant increase in Vmax, in the OH group 11.8 (9.5; 14.3); 12.1±3.5 and unilateral PEG 11.8 (8.7; 13.9); 11.7±3.9, and at 10.7 (8.8; 13.0); 11.0±3.2, the Vmax level is comparable to the normal values of 10.0 (8.3; 11.9); 10.5±3.0 (which is probably related to IOP compensation), but differed from unilateral PEG group values at the statistical hypothesis level. Reduction of CRA blood flow velocity in patients with PEG reached 10.9 (9.2; 13.0); 11.4±3.7, in comparison with «PEG-», also differing from the normal values at the statistical hypothesis level. Also it’s important to note a higher level of Vmin in the OH group: 2.4 (1.7; 3.4); 2.7±1.4 and PEG patients 2.4 (1.7; 3.1); 2.7±1.7 compared with the norm 2.15 (1.7; 2.8); 2.3±0.9, Vmin in groups of POAG 2.5 (1.7; 2.9); 2.4±0.9 and PEG also differed at the level of the statistical hypothesis, increasing with PEG. Hemodynamic analysis of choroid parameters detected similar changes in OA with a tendency towards Vmax increase in patients with OH and unilateral PEG. There was no statistically significant difference in hemodynamic parameters of the posterior short ciliary arteries (PSCA).
CONCLUSION: Our study found convincing evidence of the difference in the regional hemodynamics characteristics, depending on the diagnosis, in the OA, CRA, CRV, and the temporal choroid. The increase in velocity characteristics in these vessels is probably a consequence of compensatory defense mechanisms in response to increased intraocular pressure. Velocity indicators decrease shows a disruption in the adaptation mechanisms and can be a predictor of the transition from a «healthy» state to a mild glaucoma, which is especially important for patients with OH and unilateral PEG.
PURPOSE: To evaluate the efficacy of initial hypotensive treatment strategies in patients with different stages of primary open-angle glaucoma in order to predict glaucoma progression or lack thereof.
METHODS: This combined analytical scientific and clinical multicenter study was conducted between January and April 2017. A total of 136 participants (237 eyes) from 30 academic referral centers from 6 (six) countries (Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Uzbekistan) — 52 (38.2%) males and 84 (61.8%) females — were included into the study. Glaucoma anamnesis and all treatment regimens were evaluated retrospectively. The study of treatment regimens included the assessment of the effectiveness of topical medication, laser and surgical treatment. Four (4) successive regimen changes were analyzed, each of them with no less than three (3) months duration.
RESULTS: The research team has established that the quantity of treatment regimens rises with each next regimen change: from 14 regimens at baseline to 30 regimens at the third adjustment. Prostaglandin analogues (PGA) and beta-blockers (BB) monotherapy were used as baseline first-choice therapy in 37.6% and 21.5% of cases respectively (66.2% in total). Fixed or unfixed combinations with PGA and BB were preferred in 16.5% of cases, BB and carbonic anhydrase inhibitors (CAI) combination — in 8.4% of cases.
The combination therapy with CAI at the start has achieved the most prominent reduction of intraocular pressure (IOP) (till 33.9%). The first choice monotherapy with BB or PGA led to a more effective IOP reduction compared to fixed or unfixed combinations of these drugs: BB reduced the IOP level by 20.0% from baseline, PGA — by 23.1%, their combination — by 19.2%. We have established an intensive use of combination therapy, starting with the 2nd regimen — 71.3%. The laser and surgical treatment was used as initial treatment in 0.8% and 2.1% respectively and achieved 26.7% and 46.0% prevalence respectively by the a final regimen.
We achieved the most prominent IOP reduction (by 37.1%) in regimens No 3 and No 4 that included trabeculectomy.
CONCLUSION: The results show that the tactics of managing patients with newly diagnosed glaucoma is changing in favor of prescribing first-choice monotherapy medicines — PGA. The choice of therapy tactics for patients with moderate and advanced glaucoma remains irrational: laser and surgical treatment becomes relevant only in regimens No 3 and No 4, 3-4 years after the diagnosis of the disease.
REVIEW OF LITERATURE
Intraocular pressure (IOP) is the main risk factor of glaucoma development and progression. Glaucoma screening is mostly based on performing ocular tonometry — the most frequent procedure in patient examination. Clinical practice uses tonometry values that are closely connected to ocular pressure but may differ significantly in absolute values, which is why normative bases of various tonometry devices differ.
Values obtained with Maklakoff and Goldmann tonometers, non-contact tonometry devices and bidirectional applanation tonometry have a practical importance. Data provided by Maklakoff tonometry establishes a mean tonometry value in healthy population at 20 mm Hg with a standard deviation of 2.5-3.0 mm Hg. Most populationbased studies are conducted with the use of Goldmann tonometer.
Its mean tonometry values vary according to different authors, but most prevalently denominated level is 16 mm Hg with a standard deviation of 2-3 mm Hg. Noncontact tonometers generally show a lower by 2-3 mm Hg IOP level and a higher range of standard deviation (3-5 mm Hg). Corneal compensated IOP values normally have an allocation similar to Goldmann tonometry, which can be explained by specifics of calibration and measurement model development. Its men value in healthy population is 16 mm Hg with a standard deviation of 2.5 mm Hg. It should also be noted that corneal compensated IOP has less variation in value distribution.
Thus a question of normal IOP values and tonometric measurements is much more complex than is considered to be the case in modern ophthalmology. Intraocular pressure examination in the context of population diversity aggravated by iatrogenic factors should be conducted by adequate means implementing personalized approach.
NAMES
Ophthalmoscope introduction to clinical practice by Hermann Helmholtz in 1850 allowed Albrecht von Graefe to make a number of discoveries and scientific proposals concerning ocular fundus pathology. His contribution to ophthalmology included retinal artery embolism description, differentiation between central and diffuse recurrent syphilitic retinitis, optic neuritis description and much more.
Albrecht von Graefe devoted seven years of his scientific work to the study of amblyopia, eye muscles functioning, strabismus and its surgical correction. Later, he described in detail the symptoms of ocular muscle paralysis and clinical manifestations of diphtheria and benign renal conjunctivitis outlined the ways of drug treatment of these diseases. Von Graefe identified eye pressure as the main cause of glaucoma and stated that patients could be saved from glaucoma by means of IOP reduction. When treating a patient with complete coreclisis, A. von Graefe performed an iridectomy and noticed that the eye became softer after the operation.
This prompted the doctor to think about the possibility of using this operation in glaucoma treatment. It is important to note that at the first International Ophthalmological Congress in Brussels in 1857 von Graefe made a report «On the nature and treatment of glaucoma by means of iridectomy.» This operation brought him world fame, saved many glaucoma patients from blindness and is still used in wide ophthalmological practice. In 1859 von Graefe proposed a method of cataract extraction by peripheral linear section, which helped eliminate the divergence of the patch cut edges. For this cut von Graefe invented a special long and narrow scalpel subsequently named after him. Time has shown that von Graefe theories and discoveries still form the foundation of our knowledge in ophthalmology
ISSN 2311-6862 (Online)
