Plateau Iris Syndrome

1. Hyperopia

2. Older age

3. Female

4. Asian decent

5. Short axial length

6. Thick/anterior positioned lens

7. Thick/anterior inserted lens

What are the 7 risk factors for Primary Angle Closure (PAC)?

dim; pupil is in mid-dilated to dilated pupil size

To get a good assessment of a narrow angle or angle closure, you want to perform gonio in a (dim/moderate/bright) setting. Why is it important to perform gonio in this setting?

Plateau Iris

Large or anterior placement of ciliary body/processes; pushes peripheral iris forward even though iris is anatomically inserted correctly

True

True/False: Pupillary block can co-exist with plateau iris.

The patient’s plateau iris may co-exist with pupillary block.

If a patient who has plateau iris undergoes an LPI and shows decent improvement, what may this indicate in regards to the patient’s angles?

Indentation Gonioscopy; UBM

What is one examination technique that can be used to tell if the iris has a plateau configuration? What form of imaging may be helpful in better analyzing this?

Sine Wave - hump at ciliary body, hump at anterior lens

What do we call the shape of the Plateau Iris?

Using a narrow beam, apply gentle pressure with gonio lens. You will see the iris indents, but near the angle, it is still narrow.

How is indentation gonio performed to prove a patient has plateau iris?

The ciliary body is physically in the way.

When performing indentation gonioscopy, why doesn’t the angle indent and stays narrow in patients with plateau iris?

False - normal anterior chamber depth centrally with crowded angle

True/False: Patients with plateau iris configuration have a narrow anterior chamber.

Plateau Iris Syndrome

Patient with a patent PI but an angle that is still closed or IOP is still elevated

Argon Laser Iridoplasty

Procedure where laser causes contraction of peripheral iris, mainly the pigmented epithelium of anterior iris; can possibly help with PAS

Argon Laser Iridoplasty

What laser procedure is performed to pull iris stroma away from angle structures, deepening the angle recess?

Abraham Iridotomy Lens

What lens is used for Argon Laser Iridoplasty?

500 microns; 0.5 seconds; 240 mW

What spot size is used for an Argon Laser Iridoplasty? Duration? Starting power?

False

True/False: You should be able to see bubbles or pigment release when performing Argon Laser Iridoplasty.

Lighter

(Darker/Lighter) irides need more power for an Argon Laser Iridoplasty to work.

True

True/False: A patient should be able to feel an Argon Laser Iridoplasty.

1. Alphagan

2. Pilocarpine

What 2 drops should be used prior to Argon Laser Iridoplasty?

Peripheral iris

For Argon Laser Iridoplasty, what part of the iris should you aim for?

20-25 spots; 2 spot sizes

How many spots are often shot at a patient’s iris during Argon Laser Iridoplasty? How many spot sizes should be between each spot?

iris Cyst

What do we call a “Plateau Iris Imposter"?

Pupillary Block

The top image is Pre-LPI. The bottom image is post-LPI. With the difference noted between the 2 images, what type of angle configuration do we expect to be the issue in this angle closure patient?

OCT

What form of imaging can be done to check the patency of a PI?

Pigment Dispersion Syndrome

Deposition of pigment on lens, zones, TM, and endothelium; pigment likely released from zonules rubbing on posterior iris

Pigment released from zonules clogs the TM

What is the MOA of Pigment Dispersion Syndrome in causing increased IOP?

Pigment Dispersion Glaucoma (PDG)

If increased IOP from pigment dispersion syndrome starts to cause optic nerve perfusion issues and changes, what does the patient have?

posterior

In pigment dispersion syndrome, the iris may insert more (anterior/posterior).

posterior to anterior

Normal aqueous flow goes from (posterior to anterior/anterior to posterior).

Aqueous moves from posterior to anterior chamber. Pigment blocks the TM, causing pressure to increase anteriorly. This pushes the iris backwards, causing the zonules to against the lens.

Why does Pigment Dispersion Syndrome have the possibility of causing reverse pupillary block?

Equalizes pressure between anterior & posterior chamber

What does an iridotomy do in relation to the pressure within the eye?

Reduces the concavity of the iris

How does an iridotomy affect the shape of the iris?

Cyclophotocoagulation

Laser ablation of the ciliary body; can be done with endoscope or transscleral

During cataract surgery

When is a cyclophotocoagulation often performed?

Endoscopic Cyclophotocoagulation

What procedure is shown in the image (be specfic)?

Transscleral Cyclophotocoagulation

What procedure is shown in the image?

True

True/False: Transscleral Cyclophotocoagulation uses multi-pulse or continuous wave lasers.

Severe Glaucoma

What is cyclophotocoagulation performed for?

1. Hyphema

2. CME

3. Hypotony/phthisis

4. Sympathetic Ophthalmia

What are the 4 main complications of cyclophotocoagulation?

Vitreolysis

Using a YAG laser to break up vitreous floaters

YAG laser

What type of laser is being used for vitreolysis?

3 mm

How many mm are you supposed to stay away from the retina and lens during a vitreolysis procedure?

Paracentesis

Quickly lowering IOP when highly elevated via needle or incision

paracentesis

What quick procedure can help clear the cornea in angle closure situations?

1. Proparacaine

2. Betadine

What 2 medications should be used prior to paracentesis via incision or needle aspiration?

26-30 gauge needle (no plunger)

What gauge needle is used for paracentesis?

parallel; temporal

For paracentesis, you should insert the needle (perpendicular/parallel) to the iris near the (nasal/temporal) limbus.

0.5 mL

How much aqueous should you remove during a paracentesis?

True

True/False: It is normal to see the iris move or the pupil constrict during a paracentesis.

1. Hemorrhage

2. Iris or lens damage

3. Decompression retinopathy

4. Choroidal Effusion

5. Endophthalmitis

What are the 5 main concerns of paracentesis?