Laser Iridotomy in Pupillary Block Angle Closure Glaucoma

 

Mamata M Shetty¹, Tejaswi K ², Sai Prashanthi CV³, Nikitha⁴, A Ramesh Reddy⁵, Sudhir Babu P^6*

 

Abstract               Background: Glaucoma is a chronic Progressive multifactorial optic Neuropathy. Pupillary block is the most common mechanism leading to acute angle closure glaucoma. Nd:YAG Laser Iridotomy has been shown to be an effective primary therapy for early Primary Angle Closure Glaucoma with pupillary block as it eliminates the relative pupillary block Aim: To assess the outcome of Nd : YAG laser Peripheral iridotomy in treatment of pupillary block Angle Closure Glaucoma. Material and Methods: Sixty patients diagnosed with pupillary block Angle closure Glaucoma were prospectively enrolled into the study. Intra ocular pressure changes, Peripheral Anterior Chamber Depth and Gonioscopic changes after Nd:YAG laser peripheral Iridotomy were recorded in all patients, data collected was analysed statistically. Results: Maximum patients were in the age group of 41 – 60 years. All patients diagnosed with Primary Angle Closure Glaucoma were treated with Nd: YAG laser iridotomy with an average 10 MJ of energy. IOP was controlled (≤ 21 mm Hg) in 50 (83.3%) patients at 4^th week of post laser iridotomy follow up. Peripheral anterior chamber depth increased to grade 3 and grade 4 in 80% of patients at 4^th week follow up, PACD remained shallow (Grade 1 and Grade 2) in 12 (20%) patients change in PACD was statistically significant. (p< 0.01). Post laser Iridotomy angles opened in 86.6% of patients at 4^th week follow up. Complications like IOP spikes were seen in 36.6 % of patients, Iris bleeding was seen in 20 % of patients and anterior uveitis in 13.3 % of patients after Iridotomy. 28(93.3 %) cases had patent Iridotomy and 2 (6.6 %) had closed Iridotomy during follow up. Conclusion: Nd :YAG laser peripheral Iridotomy has a profound positive impact on the treatment outcome of pupillary block Primary Angle Closure Glaucoma. Early detection of eyes at risk of Angle closure will increase the probability of success of a laser Iridotomy.

Key Words: Pupillary Block, Angle Closure Glaucoma; Nd:YAG laser, Peripheral Iridotomy ; Intra Ocular Pressure

 

 

INTRODUCTION

Glaucoma is a chronic progressive multifactorial Optic neuropathy caused by a group of ocular conditions which damage the optic nerve with a resultant loss of visual function.¹ 60 million people are with glaucoma worldwide and more than 20 million have Primary Angle Closure Glaucoma, 47 % of the glaucoma worldwide would be in Asia with more than75% being Angle Closure.^2,3 Primary angle closure glaucoma is a condition in which elevation of IOP occurs as a result of obstruction of aqueous outflow by partial or complete closure of the angle by peripheral Iris. Functional pupillary block is the most common cause of Angle closure glaucoma. Clinically angle structures can be visualized by gonioscopic examination. Laser Iridotomy has been shown to be effective primary therapy for early Primary Angle Closure Glaucoma. Keeping these aspects in view, present study aims to study the outcome of Nd :YAG laser Iridotomy in the management of pupillary block Primary Angle Closure Glaucoma and its Post Iridotomy complications.

 

MATERIAL AND METHODS

It was a prospective cross-sectional study which included 60 Primary Angle Closure Glaucoma patients who reported to the Department of Ophthalmology at rural tertiary care hospital in Nalgonda District. Study was conducted during October 2018 to December 2019. All patients diagnosed as Pupillary block Angle Closure Glaucoma were included in the study. Patients with Secondary Angle closure Glaucoma, Neovascular Glaucoma, Eyes with Peripheral Anterior Synechiae, Corneal edema were excluded from the study. Detailed ocular Examination was done in each Patient which included, Visual acuity testing, Slit lamp examination for (Peripheral Anterior Chamber Depth - PACD), Intra Ocular Pressure (IOP) measurement with Applanation Tonometry (average of 3 reading), Gonioscopic examination with 4 Mirror Indirect Goniolens, Indentation Gonioscopy was done to rule out Peripheral anterior Synechiae , Fundus examination was done to assess Optic neuropathy , Automated Perimetry was performed to assess Visual fields defects. All cases with pupillary block angle closure glaucoma were subjected to Nd YAG Laser peripheral iridotomy, number of laser pulses and the total energy used was recorded. Patients were closely followed up for any Post-laser complications and managed accordingly. IOP, Peripheral anterior chamber depth and Gonioscopic angle changes were recorded at one hour after the procedure and during further follow up at first week, second week and fourth week.

 

 RESULTS

Table 1: Age wise distribution of study population (n=60)

 In our study 73.3% of patients were in age group 40 to 60 years of age

 

Gender distribution: In present study total of 60 patients, 44 (64%) patients were Female and16 (36%) were Male, indicating a Female : Male ratio of 2.75 : 1.0 , suggestive of female preponderance.

 

Table 2: Intra Ocular Pressure changes- Pre and Post Laser Iridotomy (n=60)

There was decrease in IOP in all cases who underwent laser peripheral iridotomy as compared to their respective initial IOP levels recorded at the time of presentation. Mean range of drop in IOP was 8-10 mmHg. IOP was controlled (≤ 21 mm Hg) in 50 (83.3%) patients at 4^th week of post laser iridotomy follow up. Drop in IOP was statistically significant (p<0.01). 10 cases had raised IOP even after 4 weeks of follow up which required intervention.

 

Table 3: Peripheral Anterior Chamber Depth (PACD) Changes: Pre and Post Iridotomy (n=60)

Peripheral anterior chamber depth increased to Grade 3 and Grade 4 in 80% of patients at 4^th week follow up. Change in PACD was statistically significant. (p <0.01). PACD remained shallow (Grade 1 and Grade 2) in 12 patients (20%).

 

Table 4 :Gonioscopic changes Pre and Post Nd:YAG Laser ( n=60)

Post laser Iridotomy, gonioscopic Anterior chamber angles opened to grade II and III in 86.6% of patients at 4^th week follow up. Change in angle was statistically significant (P < 0.01). In 8 (13.4%) patients angle remained narrow or closed after 6 weeks, these patients were taken for trabeculectomy for control of IOP.

Energy used: In present study 6 -10 MJ energy was used for iridotomy in 70 % of patients, 11-15 M J energy in 23.3% of patients and (6.6%) patients needed 16 – 20 MJ of energy.

 

Table 5:Complications of Nd -YAG Laser iridotomy (n=60)

Transient IOP spikes were seen in 36.6% of patients, iris bleeding was encountered in 20% of patients and anterior uveitis was seen in 13.3% of patients all the complications were managed as per protocol accordingly.

Patency of Laser Peripheral Iridotomies at 6 weeks (n=60)

In the present study 56 out of 60 (93.3%) patients had patent iridotomy during 4 weeks follow up and in 4 (6.6%) patients iridotomy hole was closed who presented with shallow anterior chamber and narrow angles.

 

Policy for Articles with Open Access
Authors who publish with MedPulse International Journal of Ophthalmology (Print ISSN:2550-7575) (Online ISSN: 2636-4700) agree to the following terms:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.