Latanoprost-induced iris heterochromia and open-angle glaucoma: a clinicopathologic report.

PURPOSE: To report the histopathologic and immunohistochemical findings from the iridectomy specimen of a patient with acquired unilateral iris heterochromia due to latanoprost. PATIENT AND METHODS: A 45-year-old woman with open-angle glaucoma and unilateral iris heterochromia was evaluated for uncontrolled intraocular pressure increase. Subsequently, the patient underwent trabeculectomy with mitomycin C and an iridectomy specimen was obtained for analysis. RESULTS: The histopathologic analysis of the iridectomy specimen did not reveal any nuclear atypia, nuclear crowding, or mitotic figures. Immunohistochemical studies showed that the iris melanocytes were negative for HMB45 and S-100, and weakly positive for Melan A. CONCLUSION: Latanoprost-associated iris color change may exhibit a diffuse, uniform, dark velvet-brown appearance, thereby simulating diffuse iris melanoma. Histopathologic and immunohistochemical analysis confirmed the benign characteristics of the affected iris melanocytes.     

The complex study of the iris in transformed light

Complex investigations of the iris in a transformed light by methods of iridochromoscopy, iridochromophotography, examination in a polarized light, transillumination in red light and fluorescence angiography was conducted in 25 eyes of patients with open-angle glaucoma, 10 eyes of patients with anterior flaccid uveitis and in 23 healthy eyes (a control group). It was found that in patients with open-angle glaucoma and anterior flaccid uveitis trophic and vascular changes in the iris predominated, as compared with control. The most typical for open-angle glaucoma changes in the iris were atrophy of the stroma with predominant involvement of the pupillary zone, exogenic pigmentation of the pupillary and ciliary zones, destruction of the pigment margin of the pupil, thickening of the anterior border layer, pseudoexfoliation of the pupillary margin, defects in the posterior pigment layer, being more extensive in the pupillary zone, as well as disturbances in permeability of the iris in a combination with hypoperfusion and rare bundles of microneovascularization in the area of a lesser arterial circle and the ciliary zone. In case of flaccid uveitis, the most frequent changes were diffuse atrophy of the iris, efflorescence of the pupillary margin, destruction of the pigment rim of the pupil, multiple defects in the posterior pigment layer along its whole length, increased permeability of vessel, microneovascularization of the iris stroma in a form of a thin vascular network.     

Iridoschisis

Iridoschisis is a rare condition in which a localised area of iris stroma is cleaved in two with the anterior atrophic portion disintegrating into fibrils. The most common presentation of iridoschisis is as an age-related iris atrophy in association with glaucoma. The association includes angle-closure glaucoma, angle-recession glaucoma and open-angle glaucoma. A finding of iridoschisis is a warning to the clinician to assess the patient for pre-existing glaucoma and to monitor for glaucomatous changes as it is unclear if iridoschisis is a cause or an effect of raised intraocular pressure (IOP).     

Why is glaucoma associated with exfoliation syndrome?

Exfoliation syndrome (XFS) is an age-related, generalized disorder of the extracellular matrix characterized by production and progressive accumulation of a fibrillar material in tissues throughout the anterior segment and also in connective tissue portions of various visceral organs. Mature exfoliation fibrils are composed of 8-10 nm microfibrils resembling elastic microfibrils. The exact chemical composition of exfoliation material (XFM) remains unknown. It appears to consist of a complex glycoprotein/ proteoglycan structure composed of a protein core surrounded by abundant glycoconjugates. The protein components include both non-collagenous basement membrane components and epitopes of the elastic fiber system, particularly components of elastic microfibrils. Overall, XFS is the most common identifiable cause of glaucoma, accounting for the majority of cases in some countries, and causing both open-angle glaucoma and angle-closure glaucoma. Iridolenticular friction leads to loss of XFM from the anterior lens surface and disruption of the iris pigment epithelium, resulting in pigment deposition in the trabecular meshwork, which also produces XFM locally. The primary cause of chronic pressure elevation appears to be the active involvement of trabecular cells and Schlemm's canal cells in particular, in the generalized pathologic matrix process with subsequent degenerative changes of Schlemm's canal and adjacent tissues. Narrow angles and angle-closure are common in XFS. Pupillary block may be caused by a combination of posterior synechiae, increased iris thickness or rigidity, or anterior lens movement secondary to zonular weakness or dialysis. Enlargement of the lens due to cataract formation and relative pupillary constriction are additional factors.     

水通道蛋白-1在小梁切除术之切除组织中的表达

目的观察青光跟患者小梁和虹膜组织与正常跟组织水通道蛋白-1（AQP-1）的表达差异。方法收集开角型和闭角型青光跟小梁切除术时切除的小梁和虹膜组织，免疫组织化学法检测AQP-1的表达，并与正常跟相应组织对照。结果正常眼小梁网组织、Schlemm’s管内皮细胞、周边虹膜组织中上皮和基质组织可见AQP-1呈强阳性着色，开角型青光眼和闭角型青光眼组织标本小梁网AQP-1阳性染色较正常弱；部分急性闭角型青光眼患者周边虹膜组织标本上皮层较基质组织染色明显弱。结论开角型青光眼小梁网AQP-1的表达减少可能与小梁网的发育有关，闭角型青光眼虹膜上皮和小梁网AQP-1的表达减少可能与虹膜萎缩或高眼压有关。     

Ultrasound biomicroscopical study of the irido-corneal angle in dominant juvenile open-angle glaucoma, in POAG, and in normal eyes.

PURPOSE: To compare various parameters of the chamber angle in a pedigree with dominant goniodysgenesis and juvenile open-angle glaucoma linked to chromosome 1q, GLC1A, with those in patients with adult-onset primary open-angle glaucoma, and in normal eyes. METHODS: Ultrasound biomicroscopy was performed on 10 eyes with dominant goniodysgenesis and juvenile open-angle glaucoma, on 12 eyes with adult-onset primary open-angle glaucoma, and 24 normal eyes. Eight parameters were measured. RESULTS: The anterior chamber angle, angle opening distance 500 microm from the scleral spur, trabecular meshwork--iris distance, and trabecular meshwork--iris pigment epithelium distance were statistically significantly higher in the group with juvenile glaucoma. CONCLUSION: The wider chamber angle in dominant juvenile open-angle glaucoma could suggest a more complex anomaly with involvement of cornea and iris in addition to goniodysgenesis. The presence of goniodysgenesis in the dominant juvenile open-angle glaucoma patients could not be detected by ultrasound biomicroscopy, however.     

Gonioscopic differences between primary open-angle glaucoma and normal subjects over 40 years of age.

Gonioscopy was performed on 110 patients with primary open-angle glaucoma over 40 years of age and an equal number of normal sugjects, matched by race and age. The frequency distribution of various angle features differed in the two groups: in the glaucoma group, there were more iris processes at all levels of insertion, a higher insertion of the iris root and more trabecular pigmentation. A congenital angle anomaly is one important factor in the pathogenesis of the elevated pressure.     

Iridocorneal endothelial syndrome with contralateral guttate endothelial dystrophy. A light and electron microscopic study

Both eyes from a 75-year-old woman who had unilateral closed-angle glaucoma, characteristic endothelial specular microscopic findings, and slowly progressive tractional iris abnormalities consistent with essential iris atrophy were obtained postmortem and studied by light, scanning, and transmission electron microscopy. Clinically, the nonglaucomatous right eye had an open-angle, normal iris, and severe endothelial dystrophy with three-plus corneal guttae. In this eye, results of histopathologic examination disclosed marked endothelial degeneration and typical guttate excrescences on Descemet's membrane. In contrast, the endothelium in the fellow eye with the essential iris atrophy variant of the iridocorneal endothelial (ICE) syndrome was strikingly different. The endothelial cells were relatively well preserved and exhibited marked pleomorphism, anisocytosis, and flat, occasionally paired oval nuclei. Binucleate cells also were observed. The endothelial monolayer had secreted a new layer of fibrillar extracellular matrix material on the posterior surface of Descemet's membrane. Extracellular matrix material was found interposed between the iris and cornea in zones of synechial closure, and an endothelial membrane was present on the anterior surface of the iris. These observations support the hypothesis that the iris abnormalities in essential iris atrophy are secondary to endothelial proliferation. The endothelial cells displayed neither tonofilaments nor abundant apical microvilli. The latter observation suggests that increased numbers of endothelial microvilli are not responsible for the characteristic specular microscopic picture seen in the ICE syndrome.     

Necrotic melanocytoma of iris with secondary glaucoma

A 23-year-old white man had a pigmented iris tumor that was not enlarging; it produced satellite iris lesions, diffuse pigmentation of the trabecular meshwork, and secondary glaucoma. Although enucleation was initially recommended, we chose to remove only the primary lesion with a sector iridectomy. Histologically, the lesion proved to be a benign melanocytoma that had undergone extensive necrosis. Postoperatively, the satellite lesions, pigmentation in the angle, and glaucoma all resolved.     

The Q-switched ruby laser in glaucoma

A pilot study evaluated the safety and effectiveness of a Q-switched ruby laser in the treatment of both pupillary-block (10 eyes) and open-angle glaucoma (4 eyes). All patients had either poor visual acuity or had previously failed with conventional surgery. We created a patent iridotomy in all eyes, with one pulse in eight. Three of the four eyes with open-angle glaucoma had an intraocular pressure decrease of at least 15 mmHg after angle treatment. The major complication of Q-switched ruby iridotomy was blood and pigment within the anterior chamber obscuring the view of the iris. There were no apparent complications noted with Q-switched ruby angle treatment. The potential advantages, complications, and future uses of Q-switched lasers in glaucoma are discussed.     

Pathological study of cases with secondary open-angle glaucoma due to sarcoidosis

PURPOSE: To investigate the cause of secondary open-angle glaucoma due to sarcoidosis. DESIGN: Observational case series studied by histological methods. METHODS: Seven trabeculectomy specimens from six patients with secondary open-angle glaucoma due to ocular sarcoidosis (trabeculectomy group) and anterior parts of seven autopsy eyes from four patients (autopsy eye group) diagnosed as confirmed sarcoidosis were processed for light and transmission electron microscopy. Pathological changes of outflow routes were investigated. RESULTS: Granulomata were found in three eyes of the trabeculectomy group and in three eyes of the autopsy eye group. Part of the Schlemm canal was occluded and replaced by fibrotic tissue and it became narrow in four eyes of the trabeculectomy group and three eyes of the autopsy eye group. The spaces of the trabecular meshwork appeared wide, even in the area close to granulomata and peripheral anterior synechia of the iris. Infiltration of lymphocytes, monocytes, and macrophages around the Schlemm canal was found in all eyes of the trabeculectomy group and in four eyes of the autopsy eye group. The infiltration of these cells was observed not only in the inner wall, but also in the posterior outer wall of the Schlemm canal and the collector channels. CONCLUSION: "Schlemm canalitis" is proposed from the results of inflammatory cell infiltration around the wall of the canal. The occlusion of the Schlemm canal by granulomata or fibrotic tissue replacement of the canal may play an important role in secondary open-angle glaucoma due to sarcoidosis.     

Travoprost compared with other prostaglandin analogues or timolol in patients with open-angle glaucoma or ocular hypertension: meta-analysis of randomized controlled trials

BACKGROUND: It is still uncertain whether travoprost has comparable or better efficacy compared with other prostaglandin analogues or timolol in patients with open-angle glaucoma or ocular hypertension. The authors performed a meta-analysis of randomized controlled trials to evaluate the incidence of reported side-effects and intraocular pressure (IOP)-lowering effect of travoprost versus other prostaglandin analogues (latanaprost, bimatoprost, unoprostone) or timolol. METHODS: Systematic literature retrieval was conducted in Pubmed, EMBASE, Chinese Bio-medicine Database and Cochrane Controlled Trials Register to identify the potentially relevant randomized controlled trials. The statistical analysis was performed by RevMan 4.1 software that was provided by the Cochrane Collaboration. The outcome measures were the incidence of reported side-effects (hyperaemia, iris pigmentation, eyelash changes) and mean IOP pooled over treatment visits. RESULTS: In total, 12 articles involving 3048 patients with open-angle glaucoma or ocular hypertension were included in this meta-analysis. The combined results showed that travoprost 0.004% was more effective than timolol or travoprost 0.0015% in lowering IOP, but not more effective than bimatoprost or latanoprost. Travoprost 0.004% caused a higher percentage of hyperaemia than timolol, latanoprost, or travoprost 0.0015%. There was an increased incidence of pigmentation with travoprost than timolol. Travoprost 0.004% caused a higher percentage of eyelash changes than timolol, latanoprost, or travoprost 0.0015%. CONCLUSION: According to data available, travoprost is more effective than timolol in lowering IOP in patients with open-angle glaucoma or ocular hypertension. Compared with other prostaglandin analogues, travoprost appears to be equivalent to bimatoprost and latanoprost. Although a limited number of local side-effects were reported, no serious treatment-related side-effects were reported.     

Diagnosis and Management of Lens-induced Glaucoma

Lens-induced glaucoma may occur as either secondary angle-closure or open-angle glaucoma. Dislocation or swelling of the lens can cause papillary block and subsequent angle-closure glaucoma. Leakage of soluble lens proteins from a relatively intact cataractous lens can result in a severe secondary open-angle glaucoma (phacolytic glaucoma). Heavy molecular weight protein, believed to be of lens origin, has now been identified in 12 of 12 anterior chamber, specimens from such patients. This liberated lens protein can directly obstruct the trabecular outflow pathways. After extracapsular cataract surgery or after lens trauma, liberated fragments of lens material may mechanically impair the drainage of aqueous humor through the outflow channels (lens particle glaucoma). The diagnosis and management of these different lens-induced glaucomas are reviewed. With proper recognition; these glaucomas are promptly cured by the surgical removal of the lens (material).     

Advanced juvenile open-angle glaucoma in an 8-year-old Haitian girl.

BACKGROUND: Glaucoma can afflict infants and children in several ways. Conditions such as inflammation or trauma can contribute to elevated intraocular pressure in secondary glaucoma, whereas congenital abnormalities of the trabecular meshwork development can result in infantile glaucoma. Lesser known, however, is juvenile open-angle glaucoma, which afflicts children and young adults in a manner similar to primary open-angle glaucoma, with no identifiable trabecular meshwork abnormalities or other secondary causes. CASE REPORT: An 8-year-old Haitian girl was referred for suspicion of a left optic neuropathy. Examination found markedly elevated intraocular pressure with open angles and advanced glaucomatous neuropathy in each eye without evidence of signs of infantile or secondary glaucoma. Medical therapy was instituted before surgical consultation. Clinical features of patients with juvenile open-angle glaucoma are presented along with a discussion of genetic expression and management of the condition. CONCLUSIONS: Juvenile open-angle glaucoma, although uncommon, can cause significant visual morbidity in children. In that children represent a unique and atypical glaucoma population with special therapeutic needs, all treatment options must be clearly understood.     

The histopathology of pigmentary dispersion syndrome with glaucoma.

Iris tissue and trabecular meshwork, obtained at time of trabeculectomy, was studied using the light and electron microscope in a 54-year-old woman with pigmentary dispersion syndrome with glaucoma. The specific defect was a loss of the outer epithelial cells of the iris with marked thinning of the remaining outer layers so that the two-cell architecture of the iris epithelium was maintained. In addition, the radial muscle layer was increased in both number and size of muscle fiber. It would appear that the pigmentary dispersion syndrome may represent a congenital or developmental abnormality of the iris epithelium, or both, and that the glaucoma which occasionally occurs in conjunction with this syndrome is of the usual open-angle type.     

Iris cyst secondary to latanoprost mimicking iris melanoma

PURPOSE: To report an ocular side effect of topical latanoprost therapy. DESIGN: Single interventional case report. METHODS: A 73-year-old woman on latanoprost for primary open-angle glaucoma developed an iris cyst simulating an iris melanoma. RESULTS: The lesion disappeared over 8 weeks when latanoprost was stopped. CONCLUSIONS: In managing patients with iris-pigmented lesions, the list of medications should be reviewed. If the patient takes latanoprost, a trial off latanoprost is warranted.     

非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼

目的 评价非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼的临床效果。方法 16例(16眼)继发性开角型青光眼,行非穿透小梁手术联合羊膜植入术。术后观察眼压、滤过泡、眼内反应及视力等情况。随访6～24个月。结果 术后1、3、6、12和24个月的眼压(单位:mmHg)分别为:13.52±4.71、16.30±4.11、16.38±4.26、16.54±4.39和17.6±4.58,与术前眼压46.24±9.32相比,差异有非常显著性(P<0.01)。随访期间2眼眼压>21mmHg,其中一眼局部用药可控制,另一眼接受再次手术。75％眼可见显著弥散的滤过泡。无手术并发症发生。术后早期视力不稳定,1个月后有不同程度提高。结论 非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼是一种理想的方法,比经典小梁切除术更优越。     

Relevance of the pseudoexfoliation syndrome for the glaucomas

Secondary chronic open-angle glaucoma associated with pseudoexfoliation (PEX) syndrome accounts for approximately 25% of all glaucomas and represents the most common identifiable cause of glaucoma overall. The underlying disorder, PEX syndrome, is a generalized process of the extracellular matrix characterized by production and progressive accumulation of an abnormal extracellular material in many intra- and extraocular tissues. Recent data support the pathogenetic concept of PEX syndrome as a type of elastosis affecting particularly elastic microfibrils. Active involvement of the trabecular meshwork in this characteristic matrix process may lead to glaucoma development in 40-60% of the patients. In addition, PEX syndrome also represents an important risk factor for a broad spectrum of spontaneous or intra- and postoperative ocular complications as well as for systemic cardiovascular diseases. PEX-associated open-angle glaucoma represents a relatively severe and progressive type of glaucoma with a generally poor prognosis due to high intraocular pressure levels and fluctuations in the diurnal pressure curve. The primary cause of chronic pressure elevation appears to be local production of PEX material by trabecular meshwork cells and Schlemm's canal cells with subsequent degenerative changes of Schlemm's canal and juxtacanalicular tissues. Additional pathogenetic factors contributing to pressure increase include pronounced melanin dispersion, increased protein concentrations of the aqueous humor, vascular factors, and connective tissue alterations of the lamina cribrosa. Other types of glaucoma, such as acute open-angle glaucoma, provoked by melanin showers during diagnostic mydriasis, or secondary angle closure glaucoma due to pupillary or ciliary block, are also common in PEX patients. The pathogenetic factors TGF-beta1 and TIMP-1/2 appear to be causally involved in this fibrotic process and thus may represent potential targets for specific, rational therapeutic approaches.     

Melanoma of the iris and pregnancy

Iris melanoma is a malignant melanocytic tumor, making up 1.2%-6.6% of uveal malignant melanomas. The growth of choroidal melanoma during pregnancy is described and a hormonal influence is suggested. We present a case of iris melanoma occurring during pregnancy. A 32-year-old woman, in the 28(th) week of her fifth pregnancy, was referred to the ophthalmologist with a 2-month history of blurred vision and pain in her left eye. The visual symptoms became progressively worse with decreasing vision. Her visual acuity was 20/70 in her left eye, with a temporal, pigmented, prominent iris mass extending into the trabecular meshwork and the corneal endothelium. Elsewhere other pigmented localizations were found in the iris and in the trabecular meshwork. There was secondary glaucoma with intraocular pressure of 36mmHg and C/D=0.9. The right eye was normal. A general physical examination found no pigmented lesions. Chest radiography and hepatic ultrasonography revealed no metastasis. The diagnosis of iris malignant melanoma was made from the diffuse involvement extending into the trabecular meshwork and the advanced secondary glaucoma; an enucleation was performed and histopathological examination confirmed the diagnosis of iris melanoma with involvement of the trabecular meshwork. The patient had no further problems (follow-up of 11 months). From this case report, we discuss the differential diagnosis of iris melanoma and the hormonal influence on its growth.     

LASER TRABECULOTOMY OR TRABECULOPLASTY: EARLY EXPERIENCE WITH A NEW NON-INVASIVE SURGICAL TECHNIQUE FOR GLAUCOMA

A series of 38 laser trabeculoplasty operations in 32 eyes of 29 patients is described. An average fall of 5.32 mmHg intraocular pressure was obtained; if secondary glaucomas were excluded the average fall was 7.39 mmHg. If a fall of 10 mmHg or more is considered a good result then eight eyes obtained a good result, five of these eyes having pseudoexfoliative glaucoma. A fall of 3–9 mmHg was considered a moderate result and 12 eyes obtained this, 11 of them having chronic simple open-angle glaucoma, the other being the only other case of pseudoexfoliative glaucoma in the series. Five eyes with chronic simple open-angle glaucoma and seven eyes with secondary glaucoma all obtained no significant fall. It is stressed that in chronic simple open-angle glaucoma there was often only a small fall or no fall at all, so that it seems unwise to temporise if there is a high uncontrolled pressure in this condition. Great care is also needed in advanced chronic simple open-angle glaucoma because of the occasional occurrence of a high rise of pressure soon after operation. The procedure works well in pseudoexfoliative glaucoma.