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ORIGINAL ARTICLE
Year : 2014  |  Volume : 107  |  Issue : 3  |  Page : 142-147

Corneal indentation versus anterior chamber paracentesis as an adjuvant to medical treatment in controlling acute primary angle-closure glaucoma


1 Assistant Professor of Ophthalmology, Ain Shams University, Cairo, Egypt
2 Lecturer of Ophthalmology, Ain Shams University, Cairo, Egypt
3 Head of Cataract and Glaucoma Department, Magrabi Eye Hospitals, Cairo, Egypt

Date of Submission18-Feb-2014
Date of Acceptance30-May-2014
Date of Web Publication30-Dec-2014

Correspondence Address:
Lamia S Elewa
Ophthalmology Department, School of Medicine, Ain Shams University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.148114

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  Abstract 

Purpose
The aim of this study is to evaluate the therapeutic efficiency of the noninvasive corneal indentation (CI) procedure versus anterior chamber paracentesis (ACP) as an adjuvant to classic medical treatment in patients with acute primary angle-closure glaucoma (PACG).
Design
This was a prospective, interventional, comparative study.
Place
Ain-Shams university hospitals and Elmaghrabi eye institutes.
Patients and methods
We included 30 eyes of 30 patients who had an attack of acute PACG and presented to us within the first 24 h. All patients received mannitol infusion (20%, 300 ml) as the first line of treatment. CI using Posner gonioprism was applied in 10 eyes (group I), ACP was performed in 10 eyes (group II), and 10 patients received only medical treatment (group III). The severity of pain, intraocular pressure (IOP), best-corrected visual acuity, corneal edema, and pupil size were assessed at multiple time points. The waiting time for laser peripheral iridotomy (LPI) was recorded. All patients were followed up for a minimum of 6 weeks.
Results
Pain relief was achieved rapidly in group II, where IOP reduction was 31% (IOP was 22 ± 11.5 mmHg) and 64% (IOP was 19 ± 7.6 mmHg) at 30 min and 2 h of follow-up, respectively. The grade of corneal edema in group II was 0.8 ± 1.3 and 0.5 ± 0.5 at 30 min and 2 h, respectively, which was significantly lower compared with both group I and III (P < 0.005). This facilitated early LPI (6 ± 2 h) in group II. However, in terms of IOP and best-corrected visual acuity, all the groups showed the same results at 12 h.
Conclusion
CI is a noninvasive and easy adjuvant method of reducing elevated IOP in the setting of PACG; improves corneal clarity and enables LPI. ACP restores corneal clarity faster and would be the choice for selected patients for whom medical therapy is restricted. Medical therapy alone shows a delay in controlling acute PACG and is rather exhausting for the patient.

Keywords: acute primary closure glaucoma, anterior chamber paracentesis, corneal indentation


How to cite this article:
Elewa LS, Elzankaloni YA, Elkholefy H. Corneal indentation versus anterior chamber paracentesis as an adjuvant to medical treatment in controlling acute primary angle-closure glaucoma. J Egypt Ophthalmol Soc 2014;107:142-7

How to cite this URL:
Elewa LS, Elzankaloni YA, Elkholefy H. Corneal indentation versus anterior chamber paracentesis as an adjuvant to medical treatment in controlling acute primary angle-closure glaucoma. J Egypt Ophthalmol Soc [serial online] 2014 [cited 2017 Aug 21];107:142-7. Available from: http://www.jeos.eg.net/text.asp?2014/107/3/142/148114


  Introduction Top


Acute primary angle-closure glaucoma (PACG) is a challenging ocular emergency. Rapid, controlled decrease in intraocular pressure (IOP) should be aimed at to alleviate the suffering of the patients, prevent further visual complications, and reduce the risk of progression to chronic angle-closure glaucoma [1].

Immediate intravenous administration of mannitol, a hyperosmotic agent, is the standard treatment [2]. However, in some cases, medical treatment alone is insufficient and even exhausting. Alternative treatments should be considered if the patient is at high risk of a reaction to mannitol, such as congestive heart failure, chronic renal insufficiency, or other systemic illness [3].

Immediate anterior chamber paracentesis (ACP) has been suggested recently as an alternative treatment in acute PACG to relieve the symptoms and lower IOP as quickly as possible [4,5]. Corneal indentation (CI) can be performed with posner gonioprism that is readily at hand and also allows for rapid pain relief and IOP reduction [6]. This IOP reduction allows resolution of corneal edema and subsequently definitive treatment using laser peripheral iridotomy (LPI).

The aim of this study was to evaluate the therapeutic efficacies of the noninvasive CI procedure versus ACP as an adjuvant to medical treatment in patients with acute PACG taking into account IOP stabilization, corneal condition, timing of LPI, and visual outcomes.


  Patients and methods Top


Thirty patients (30 eyes) with acute PACG who presented to the emergency room or outpatient clinics at Ain-Shams university hospitals and Elmaghrabi eye institutes between March 2013 and October 2013 were included in this study.

Data on age, sex, systemic diseases, current medications, previous attacks, and spectacle correction (hypermetropia) were collected. Observation for severity of pain, nausea, or vomiting was also reported.

Evaluation of IOP was performed using a slit lamp (using Goldmann applanation tonometer; Haag-Streit, USA) or when the patient was sedated in the supine position using a hand-held applanation tonometer (Perkins, Kowa, Japan). Best-corrected visual acuity (BCVA) was assessed using a Snellen chart at 6 m, and assessment of corneal edema severity (grade 0, no corneal edema; grade 1, only mild corneal haze; grade 2, blurred iris details; and grade 3, iris details are only vaguely visible), anterior chamber (AC) depth, iris configuration, and pupil size and shape was performed. Gonioscopy of the other eye of each patient was also performed.

PACG was defined as' acute closure of the AC angle; ranging from iridotrabecular contact to peripheral anterior synechea with anterior segment signs and severe raised IOP in an eye with an anatomically narrow angle'. Our inclusion criteria were as follows:

(a) Attack of acute PACG;

(b) Initial presentation of IOP more than 40 mmHg;

(c) Confirmation of diagnosis by a gonioscopic examination (even if later); and

(d) Onset of symptoms within 24 h.

The exclusion criteria were as follows:

(a) Recurrent attack within the past 6 months,

(b) Use of Mannitol infusion within the past 48 h, and

(c) Previous intraocular surgeries on the same eye.

Procedures

Written informed consent was obtained from each patient. Mild sedation was administered to all the patients. A dose of 300 ml of 20% mannitol (60 gm/bottle; Alcon Pharmaceutical Co. Ltd) was administered by rapid intravenous infusion to all patients. Topical dorzolamide and timolol 0.5% was also administered/12 h to all patients. Placing the patients in a supine position is recommended in all groups as it allows the lens-iris diaphragm to move posteriorly with gravity, which may relieve some of the relative pupillary block.

In group I, using an operation microscope, CI using a Posner gonioprism (Ocular instruments, inc. USA) [Figure 1] was applied to the inferior or the temporal cornea (preserving the upper half) and pressed for 10-15 s; this can be repeated every 15 min up to three times until the pupil shows a decrease in size.

In group II, with the patient in the operative room, 0.5% Alcaine (proparacaine; Alcon Laboratories, Fort Worth, Texas, USA) was administered as a local anesthetic three to four times, and then the lids were disinfected with 5% betadine (povidone-iodine; Purdue Pharma). A sterile 27 G needle was inserted into the AC using the temporal clear-corneal approach; only 0.25 ml of the aqueous humor was drained, while monitoring the pupil [Figure 2]. After ACP, 0.3% topical ciprofloxacin (Alcon Laboratories) was administered immediately and every 10 min for the next 30 min.
Figure 1: Posner gonioprism. (Ocular instruments, inc. USA)

Click here to view
Figure 2: ACP procedure. (a, b) Introduction of the needle cautiously in AC. (c) Drain of 0.25 ml of aqueous. (d) Pupil starts to constrict, indicating broken attack. AC, anterior chamber; ACP, anterior chamber paracentesis

Click here to view


Topical pilocarpine 2% (Alcon Laboratories) was administered to achieve and maintain miosis whenever IOP started to decrease. Monitoring was performed every 30 min for the first 2 h, and then every 2 h for the first 12 h.

Main outcome measures

(1) Pain relief.

(2) Reduction in IOP.

(3) Pupil narrowing (miosis)/indicating broken attack.

(4) Vision improvement/as corneal edema subsides.

(5) Reaching suitable circumstances (time) for LPI.

(6) Repeated doses of systemic mannitol were necessary.

(7) Complications that can follow ACP, such as endophthalmitis, intraocular trauma, choroidal effusion, and choroidal hemorrhage, were also recorded.

Statistical analysis was carried out using (Medcalc statistical software, Ostend, Belgium) to study the differences in age, sex, course of pain severity, time course of BCVA, amount of IOP reduction, time course of corneal edema, pupil size, AC depth, and timing until LPI can be performed.


  Results Top


Thirty patients (12 men and 18 women) 42-78 years of age (mean age: 60.7 years) were included. Group I included 10 patients (four men and six women) 44-69 years of age (mean age: 60.2 years). Group II included 10 patients (three men and seven women) 42-75 years of age (mean age: 58.8 years). Group III included 10 patients (five men and five women) 50-78 years of age (mean age: 61.5 years).

Seven patients (7/30) were diabetic for more than 5 years and 16 patients were hypertensive, all controlled by medical treatment. Two patients with joint replacement were on systemic steroid therapy, whereas four patients were on oral glucosamine therapy.

Previous attacks were reported by eight patients. Five patients had hypermetropic correction more than + 2 D.

Pretreatment

For all 30 patients, the mean BCVA ranged from 6/24 to 2/60, corneal edema grade was 2.16 ± 1.05, and IOP was 51.4 ± 8.24 mmHg (range 45-58 mmHg). In eyes where corneal edema enabled further evaluation (n = 24/30), AC depth ranged from 0.5 to 2 mm and lens opacities ranged from early posterior subcapsular to corticonuclear cataract.

In group I, the mean BCVA ranged from 6/24 to 2/60, corneal edema grade was 2.07 ± 0.89, the mean IOP was 48.5 ± 7.5(46-55) mmHg, and AC depth was 0.5-2 mm.

In group II, the mean BCVA ranged from 6/60 to 3/60, corneal edema grade was 1.8 ± 1.25, the mean IOP was 53 ± 5.5 (50-58) mmHg, and AC depth was 1-2 mm.

In group III, the mean BCVA ranged from 6/60 to 2/60, corneal edema grade was 2.22 ± 1.31, the mean IOP was 51 ± 6.5 (45-56) mmHg, and AC depth was 0.5-2 mm.

There were no significant differences in terms of age, BCVA, grade of corneal edema, IOP, or AC depth between the three groups at initial presentation.

Detailed patient profiles at presentation and pretreatment are summarized in [Table 1].
Table 1 Patient characteristics at presentation among groups


Click here to view


Post-treatment follow-up schedule

At 30 min

IOP
: In group I, IOP reduced to 31 ± 8.9 mmHg (range 24-38; P < 0.05), in group II, IOP was 22 ± 11.5 mmHg (range 15-34), and in group III, IOP was 40 ± 5.5 mmHg (range 33-42). The mean IOP reduction was 17.5 mmHg (36%), 31 mmHg (58%), and 11 mmHg (22%) in groups I, II, and III, respectively.

Pain: Pain relief was reported in five patients in group I and all 10 patients in group II; only four patients in group III reported a decrease in the intensity of pain.

Corneal edema

In group I, corneal edema grade improved slightly to 2.01 ± 0.5 (P < 0.005). In group II, a significant improvement was observed, 0.8 ± 1.3 (P = 0.0005), and in group III, no to slight improvement was observed, 2.09 ± 1.03.

AC depth ranged from 1.5 to 2.5 mm in 11 eyes (n = 11/30) for which corneal edema enabled visualization.

Pupil

Miosis was achieved in five eyes in group I, eight eyes in group II, and two eyes in group III.

At 2 h

IOP
: In group I, IOP was 25 ± 3.5 mmHg (range 22-31), in group II, IOP was 19 ± 7.6 mmHg (range 14-28), and in group III, IOP was 28 ± 6.5 mmHg (range 33-42). The mean IOP reduction was 23 mmHg (48%), 34 mmHg (64%), and 23 mmHg (45%) in groups I, II, and III, respectively.

Pain: All patients reported either pain relief or a decrease in the intensity of pain.

Corneal edema

Corneal edema showed a significant decrease in all three groups: 1.1 ± 0.4 (P < 0.005) in group I, 0.5 ± 0.5 (P < 0.0005) in group II, and 1.09 ± 0.5 (P < 0.005) in group III.

BCVA

BCVA improved by one line or more in the three groups: range 4/60-6/24 in group I, 5/60-6/36 in group II, and 5/60 to 6/60 in group III.

AC depth improved in all groups.

Pupil

Pupil miosis indicating broken attack was reported in 24/30 eyes: eight eyes in group I, 10 eyes in group II, and six eyes in group III.

At 12 h

The mean IOP was 18.5 ± 1.8, 19.5 ± 1.5, and 18 ± 2.3 mm Hg in groups I, II, and III, respectively. The mean reduction was 62, 64, and 65% in groups I, II, and III, respectively. The mean IOP values are shown in Graph 1.



Twenty-seven patients (nine patients in group I, 10 patients in group II, and eight patients in group III) subsequently underwent definitive management with LPI (miosis was achieved by administering 2% pilocarpine (Alcon Laboratories) within 10 min before LPI using an Nd:YAG laser (NIDEK YC-1800, Birmingham optical, UK) (10 patients in group I, eight patients in II, and six patients in III) and in two patients, phaco-trab and one extracapsular cataract extraction were required. Two patients were kept on topical pilocarpine 2% twice and IOP was maintained below 22 mmHg. For all 24 patients who underwent LPI, the mean IOP after LPI was 19 ± 2.5 mmHg. Waiting time till LPI was significantly shorter in groups I and II (mean 6 ± 2 h).

Six-week follow-up

For patients who underwent LPI, IOP was maintained at 17 ± 1.5 mmHg (range 16-20 mmHg) without topical medications. In patients who underwent cataract extraction, IOP was maintained at 22 ± 3.6 mmHg.

Corneal edema resolved and BCVA was restored in all patients.

Analysis of our results indicated that group II showed better IOP control at 30 min and at the 2 h follow-up, where the mean IOP reduction achieved at 30 min was 31% (IOP was 22 ± 11.5) and at 2 h, the reduction achieved was 64% (IOP was 19 ± 7.6). The grade of corneal edema in group II was 0.8 ± 1.3 and 0.5 ± 0.5 at 30 min and at the 2 h follow-up, respectively, which was significantly lower than that of group I or III. This facilitated early LPI (less than 6 h). Waiting time for LPI was shorter in both group I and group II compared with group III. The time course of BCVA was slightly shorter in groups I and II, and this supported the patient's emotional health as well. However, in terms of IOP and BCVA, all the groups showed the same results at the 12 h follow-up (Graph 2).




  Discussion Top


Patients with acute PACG classically present with an angry painful eye, a fixed mid-dilated pupil, an edematous cornea with blurry vision, and an IOP of about 50 mmHg or more. Classic management would involve administration of dehydrating agents by intravenous and topical antiglaucoma medication in an effort to lower IOP, constrict the pupil, and clear up the cornea for LPI. Unfortunately, these measures do not work all the time and the cornea remains cloudy, the pupil remains mid-dilated, and IOP still remains in the range of 30-40 mmHg, which do not represent ideal circumstances to perform LPI [7]. Delayed treatment leads to irreversible damage to the corneal endothelium and the optic nerve, and also increases the risk of progression to chronic angle-closure glaucoma [8].

In 2009, Sarabia [7] reported the effect of controlled ACP on 18 Asian female patients ranging in age from 48 to 67 years, whose mean pretreatment IOP was 71 mmHg and mean pretreatment BCVA was 20/200. The mean postoperative IOP after 10 min was 7.5 mmHg and the mean VA after 5 min was 20/30. The mean IOP after 24 h was 16.5 mmHg. The study emphasized on the earlier achievement of LPI.

Recently, Cheng et al. [9] proved that ACP, when compared with a mannitol infusion, more effectively improves the VA of patients with acute PACG and an initial IOP of below 60 mmHg. This was achieved through rapid stabilization of the anterior segment by immediately reducing IOP, rapidly decreasing corneal edema, and enabling LPI to be performed earlier.

In our study, we used ACP as an adjuvant to mannitol treatment, and only 0.25 ml of the aqueous humor was drained irrespective of the pretreatment IOP; this led to a rapid and safe reduction of IOP, avoiding the complications of rapid decompression such as choroidal hemorrhage. Placing the patient flat in the operative theater with mild sedation can contribute toward the ease of the procedure of ACP and avoid the risk of damage to the iris, lens, or corneal endothelium. Taking into consideration that the effect of ACP alone was transient, medical treatment was recommended. We aim to achieve faster broken attack when we perform LPI and save the patient the long waiting time.

Boey et al. [10] commented on ACP as follows: 'this remains as an approach for patients for whom medical therapy is either unavailable or unsuitable, or for those that are approaching their maximal dosages for certain systemic medications and still have unresolved acute PACG'.

Thus, CI is a safe, noninvasive technique, but not on its own; will go hand in hand with medical treatment until again a broken attack, and LPI. We performed CI for 10 patients with PACG; meanwhile, mannitol was also administered. At 30 min, pain relief and slight improvement in corneal edema were observed in five patients, and miosis occurred in five patients, indicating broken attack in 50% of patients within 30 min.

In 2009, Masselos et al. [6] reported on the effect of CI on six patients with ACG; IOP was significantly reduced (P < 0.05), and three of four patients with severe acute pain reported early resolution of pain after CI. The average reduction in IOP was 20.9 mmHg. Three patients treated acutely with CI without any medical agents showed a mean IOP reduction of 21 mmHg (range, 20-23) after CI alone.

On analysis of our results, it was found that ACP (group II) led to better IOP control at 30 min and at the 2-h follow-up; the mean IOP reduction was 31 and 64% at 30 min and at 2 h, respectively. Also, corneal edema improved significantly faster in group II 0.8 ± 1.3 and 0.5 ± 0.5 at 30 min and 2 h. This facilitated early LPI (6-24 h). The time course of BCVA was slightly shorter in groups I and II, and this supported the patient's emotional health as well. However, in terms of IOP and BCVA, all the groups showed the same results at the 24 h follow-up.


  Conclusion Top


CI is a noninvasive and easy adjuvant method of reducing elevated IOP in the setting of PACG; it improves corneal clarity and enables LPI. ACP restores corneal clarity faster and would be the choice for selected patients for whom medical therapy is restricted. Medical therapy alone shows a delay in controlling acute PACG and is rather exhausting for the patient.


  Acknowledgements Top


 
  References Top

1.
Ang LP, Aung T, Chua WH, Yip LW, Chew PT. Visual field loss from primary angle-closure glaucoma: a comparative study of symptomatic and asymptomatic disease. Ophthalmology 2004; 111 :1636-1640.  Back to cited text no. 1
    
2.
Fricke TR, Mantzioros N, Vingrys AJ. Management of patients with narrow angles and acute angle-closure glaucoma. Clin Exp Optom 1998; 81 :255-266.  Back to cited text no. 2
    
3.
Pérez-Pérez AJ, Pazos B, Sobrado J, Gonzalez L, Gándara A. Acute renal failure following massive mannitol infusion. Am J Nephrol 2002; 22 :573-575.  Back to cited text no. 3
    
4.
Lam DS, Chua JK, Tham CC, Lai JS. Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle-closure glaucoma: a pilot study. Ophthalmology 2002; 109 :64-70.  Back to cited text no. 4
    
5.
Arnavielle S, Creuzot-Garcher C, Bron AM. Anterior chamber paracentesis in patients with acute elevation of intraocular pressure. Graefes Arch Clin Exp Ophthalmol 2007; 245 :345-350.  Back to cited text no. 5
    
6.
Masselos K, Bank A, Francis IC, Stapleton F. Corneal indentation in the early management of acute angle closure. Ophthalmology 2009; 116 : 25-29.  Back to cited text no. 6
    
7.
Sarabia MTS. Controlled anterior chamber paracentesis effective for acute angle-closure glaucoma. Ocular Surgery News Asia Pacific 2009; 4 :26-30.  Back to cited text no. 7
    
8.
Tham CC, Kwong YY, Lai JS, Lam DS. Effect of a previous acute angle closure attack on the corneal endothelial cell density in chronic angle closure glaucoma patients. J Glaucoma 2006; 15 :482-485.  Back to cited text no. 8
    
9.
Cheng CF, Tsai CL, Lee OKS. Anterior chamber paracentesis facilitates laser peripheral iridotomy and restores vision in mild to moderate acute primary angle closure glaucoma. J Exp Clin Med 2012; 4 :52-57.  Back to cited text no. 9
    
10.
Boey PY, Singhal S, Perera SA, Aung T. Conventional and emerging treatments in the management of acute primary angle closure. Clin Ophthalmol 2012;6:417-424.  Back to cited text no. 10
    


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