Morphological justifi cation of the pathogenesis of angleclosure glaucoma

Objective. To prove the role of interrelated autoimmune, hemostatic and infl ammatory mechanisms in the pathogenesis of angleclosure glaucoma on the basis of experimental morphological research. Material and methods. The work was performed on 3 denucleated eyes of patients with terminal “creeping” angle-closure glaucoma (ACG) and 2 eyes with terminal ACG during an intractable acute exacerbation. Sagittal sections through the area of Schlemm’s canal, as well as serial cross sections, were examined by the method of paraffi n sections stained with hematoxylin-eosin (HE). To assess the degree of the infl ammatory response in the eye tissues, the density of infl ammatory cells was calculated within the standard eyepiece micrometer grid at a magnifi cation of × 20.Results. The formation of peripheral anterior synechiae between the periphery of the iris and the trabecular meshwork in the iridocorneal angle is the main etiological factor in chronic angle closure. Several mechanisms contribute to the formation of anterior synechiae. First of all, in our opinion, it is autoimmune infl ammation. Edema and hyperemia of the ciliary processes pushes the iris anteriad, collagen fi bers of the trabecular meshwork are damaged; delayed endothelialization of the trabecular plate occurs, and the angle of the anterior chamber narrows and closes as a result. The resistance to the outfl ow of intraocular fl uid increases. Ischemia, due to increased intraocular pressure (IOP), causes the formation of new vessels in the iris, where aggregates of blood cells are observed. The walls of the newly formed vessels are defective, which contributes to hemorrhages. Thus, in addition to autoimmune infl ammation, we observe signs of endothelial dysfunction syndrome associated with infl ammatory processes with ACG.Conclusions. 1. The pathogenesis of chronic angleclosure glaucoma is based on autoimmune processes, as proved by lymphocytoplasmocytic infl ammatory infi ltration with an addition of pigment-containing macrophages and fi broblasts at the junction of the iris with the cornea. 2. The detection of intravascular aggregates is a proof of impaired hemostasis in angle-closure glaucoma. 3. Parietal thrombus formation in the newly formed vessels of the iris, fi brin in the tissues are evidence of chronic endothelial dysfunction in ACG. 4. The capillaries of the ciliary processes surrounded by a fi brin ring indicate an acute vasomotor disorder and the release of plasma containing fi brinogen into the surrounding tissue. This is indirect evidence of emotional and vasomotor instability in patients with this form of glaucoma. 5. Disturbances in the systems of immunity and hemostasis are interrelated processes. 6. Increased iris stiff ness is ACG biomarker and may serve as a further target for therapeutic intervention.

Diagnostic imaging of the ciliary body: Technologies, outcomes, and future perspectives

The ciliary body (CB) is part of the uvea and is a complex, highly specialized structure with multiple functions and significant relationships with nearby structures. Its functions include the aqueous humor (AH) production in the ciliary processes, the regulation of the AH output through the uveoscleral pathway, and accommodation, which depends on the ciliary muscle. Also, the CB is an important determinant of angle width as it forms part of the ciliary sulcus. Until recently, knowledge of the CB was based on histological studies. However, this structure can currently be assessed in vivo using imaging techniques such as ultrasound biomicroscopy (UBM) and optical coherence tomography (OCT). Both techniques have shown good reproducibility of their measurements allowing for quantification of CB dimensions and their localization. In effect, studies have shown a larger CB in myopia and its diminishing size with age. Swept-source OCT devices offer fast, non-invasive high-resolution imaging allowing the identification of multiple structures. UBM requires contact and is uncomfortable for the patient. However, this technique offers deeper imaging and therefore remains the gold standard for assessing the posterior chamber, ciliary processes, or zonula. The clinical utility of CB imaging includes its assessment in different types of glaucoma such as angle-closure, malignant or plateau iris. Diagnostic CB imaging is also invaluable for the assessment of ciliochoroidal detachment when suspected, the position after the implantation of a pre-crystalline or sulcus-sutured lenses, diagnosis or monitoring of cysts or tumors, sclerotomies after retinal surgery, intermediate uveitis, or accommodation.

Evaluation strength of the supporting apparatus of the lens at combination of age-related cataract with involutional changes in connective tissue

AIM: The clinical evaluation of zonules condition in patients with age-related cataracts without weak zonular support signs against the background of connective tissue somatic involutional changes. MATERIALS AND METHODS: The main group consisted of 70 patients (70 eyes) with connective tissue involutional somatic pathology without concomitant eye pathology, eye injuries, and decompensated systemic diseases; the control group included 60 people (60 eyes) with age-related cataracts without connective tissue involutional pathology. Using ocular echography (Aviso S, Quantel Medical, France) with high resolution (50 MHz) sensor, we estimated the ciliary processes to lens equator distance symmetry in 2 main meridians (of 6 and 12 hours). Its equal value in 2 opposite meridians or difference less than 0.3 mm between them was considered as the sign of symmetry; the difference of 0.3 mm and more was a sign of asymmetry. RESULTS: The presence of ciliary processes to lens equator distance asymmetry between the meridians was revealed in 28 eyes in the main group (40%); in 14 of the eyes with asymmetry ranging from 0.4 and more, a 1st degree lens subluxation was revealed intraoperatively. CONCLUSIONS: The presence of ciliary processes to lens equator distance asymmetry indicates subclinical involutional changes in the lens ligament apparatus, which has a prognostic value for choosing a model of an intraocular lens to be implanted.

Clinical case of phakic intraocular lens rotation

Purpose. To analyze causes of the emerged postoperative rotation of the phakic intraocular lens (PIOL) of the IPCLT V2.0 model, to assess the effectiveness of its elimination and the outcomes. Clinical case. Patient A., 42 years old. Clinical diagnosis: High myopia, chorioretinal form, direct corneal astigmatism in both eyes. The combination of thin cornea with limbal vascularization did not allow to perform for him photorefractive surgery. The implantation of PIOL IPCLT V2.0 model was performed according to the method recommended by the manufacturer. On the first day after the operation, the position of the PIOL was correct in both eyes. Indicators of uncorrected visual acuity significantly increased from initial 0.01–0.02 to 0.4–0.5. The best corrected visual acuity also increased, amounting to 0.7–0.9 for the right/left eye, respectively. 1.5 months after the operation, the patient complained of a decrease and the appearance of instability in visual acuity in both eyes. Biomicroscopic examination revealed the PIOL rotation along the plane from a horizontal to a vertical position. Conclusion. At the stage of preoperative examination, special attention should be paid to the presence of circular symmetry of the zonule of Zinn attachment to the ciliary processes and to the lens capsule. Such indirect clinical signs as prolapse of the iris, asymmetry of the distances «ciliary processes – the edge of the lens» may indicate the presence of individual unfavorable anatomical features of the shape of the eye, which with high probability can lead to displacement or rotation of the PIOL IPCLT V2.0 model. Key words: myopia, phakic intraocular lens (PIOL), PIOL IPCLT V2.0 model.

Evaluation of ciliary body by ultrasound bio-microscopy after trans-scleral diode cyclo-photocoagulation in refractory glaucoma

Purpose: To evaluate the morphological changes of the ciliary body after diode laser trans-scleral cyclo-photocoagulation using ultrasound bio-microscopy in refractory glaucoma. Settings: This prospective, interventional, non-comparative, non-randomized, longitudinal study was performed on 40 eyes with refractory glaucoma, during the period between February 2016 and March 2018. Methods: All patients were treated with single session diode laser trans-scleral cyclo-photocoagulation. The intraocular pressure was obtained over a period of 3 months after the operation and morphological changes of the ciliary body were observed using ultrasound bio-microscopy. Results: Trans-scleral cyclo-photocoagulation has achieved a reasonable success in reducing intraocular pressure to less than 22 mm Hg without increasing the number of glaucoma medication. The overall success rate was 40%, as the intraocular pressure decreased from a baseline mean value of 54.70 ± 12.27 to 42.45 ± 9.85 mm Hg 1 week after operation, 33.50 ± 8.00 mm Hg after 1 month, and 25.60 ± 6.62 after 3 months of operation. Ultrasound bio-microscopy detected reduction in the length and width of ciliary processes in addition to the ciliary muscle thickness of the treated quadrants. Intraocular pressure was more correlated to the width of the ciliary processes. Conclusion: Trans-scleral cyclo-photocoagulation is a rapid and effective procedure in treatment of refractory glaucoma with intraocular pressure reduction. Ultrasound bio-microscopy is a promising twin tool for cyclo-destructive procedures to detect ciliary body changes and can be used as a guide for re-treatment procedures.

Management of dislocated nucleus with corneal opacity by combined deep anterior lamellar keratoplasty, pars- plana vitrectomy and phaco-fragmentation

A 32-year-old man presented with bilateral diminution of vision for 10 years. Visual acuity was light perception in both eyes with inaccurate projection in the oculus dextrus(OD) and accurate projection in the in oculus sinister (OS). Intraocular pressure was 6 and 12 mm Hg in the OD and OS, respectively. Slit-lamp examination revealed the presence of leucomatous corneal opacification with microcornea in oculus uterque (OU). Both eyes had a dislocated nucleus in the vitreous cavity on ultrasound B-scan with advanced cupping in the right eye. Ultrasound biomicroscopy revealed ciliary body atrophy in the OD and preserved ciliary processes (two quadrants) in the OS. In view of a partially preserved ciliary body function and a potential for gaining useful vision, we planned surgical intervention in the left eye. Deep anterior lamellar keratoplasty with pars planavitrectomy (PPV) and phacofragmentation of the nucleus was done. Donor lamellar graft was sutured after completion of PPV and nucleus fragmentation. The patient regained useful ambulatory vision postoperatively with clear corneal graft.