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Bilateral choroidal effusion after selective laser trabeculoplasty
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Bilateral choroidal effusion after selective laser trabeculoplasty夽 F. Hernández Pardines ∗ , J.C. Molina Martín, L. Fernández Montalvo, F. Aguirre Balsalobre Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Selective laser trabeculoplasty (SLT) is an effective treatment to treat open-angle glaucoma
Received 12 July 2016
with a low risk of complications. The case is presented of a 73 year-old woman with uncon-
Accepted 14 October 2016
trolled primary open-angle glaucoma who underwent selective laser trabeculoplasty in both
Available online 13 April 2017
eyes and developed bilateral choroidal effusion. ˜ ˜ S.L.U. All rights © 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Keywords: Open-angle glaucoma Bilateral choroidal effusion Selective laser trabeculoplasty
Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser r e s u m e n Palabras clave:
La trabeculoplastia selectiva láser (TSL) es un medio eficaz para tratar el glaucoma de
Glaucoma de ángulo abierto
ángulo abierto con una baja tasa de complicaciones. Reportamos el caso de una mujer de
Desprendimiento coroideo bilateral
˜ 73 anos con un glaucoma primario de ángulo abierto no controlado que tras someterse a
Trabeculoplastia selectiva láser
una trabeculoplastia selectiva láser en ambos ojos desarrolló un desprendimiento coroideo bilateral. ˜ ˜ S.L.U. Todos © 2016 Sociedad Espanola de Oftalmolog´ıa. Publicado por Elsevier Espana, los derechos reservados.
Introduction Selective laser trabeculoplasty (SLT) is a useful and effective tool for diminishing intraocular pressure (IOP) in adults
with open angle glaucoma, with low complication rates.1 Even though the majority of studies conclude that SLT is a safe technique, numerous side effects have been described including increased IOP, iritis, hyphema, macular edema, foveal burns, corneal edema and refractive error changes.2 The case of a
夽 Please cite this article as: Hernández Pardines F, Molina Martín JC, Fernández Montalvo L, Aguirre Balsalobre F. Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser. Arch Soc Esp Oftalmol. 2017;92:295–298. ∗ Corresponding author. E-mail address: [email protected] (F. Hernández Pardines). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
296
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
Fig. 1 – Peripheral serous detachment, bilateral at 360◦ .
patient with uncontrolled open angle glaucoma with topical anti-hypotensive medication who suffered bilateral serous choroidal detachment (CD) after SLT in both eyes is described. Only Kim and Singh reported a similar case but with unilateral expression.3
Clinic case report Female, 73, who consulted for intraocular pressure checkup. Pathological ocular history included primary open angle ® glaucoma in both eyes (BE) in treatment with Ganfort (bimatoprost/timolol 0.3/5 mg/ml; Allergan, S.A.; Tres Can®
tos, Madrid, Spain) and Alphagan (0.2% brimonidin tartrate; Allergan, S.A.; Tres Cantos, Madrid, Spain). Physical examination showed visual acuity (VA) of 20/20 in BE, IOP with applanation of 24 mmHg in the right eye (RE) and 23 mmHg in the left eye (LE), open angle with Shaffer Grade IV in the 4 quadrants of BE, papilla with 7/10 cup, normal color, moderate neuroretinal ring reduction and nasally rejected vessels, retina applied and macular without alterations. Pachymetry was 530 microns in central cornea BE, macular optical coherence tomography (OCT) without alterations. Considering that IOP was not controlled with medical treatment, it was proposed to treat with SLT in BE. In a single session, 50 shots at 0.7 mJ were made at the 180◦ inferior degrees with a spot size of 50 microns. Subsequently, ® Maxidex (0.1% dexamethasone, Alcon Cusí, S.A., El Masnou, Barcelona, Spain) was prescribed to be taken at 4-hour inter-
(tyndall) 3+ as per the International Group for Standardization of Uveitis Nomenclature (SUN),4 bilateral peripheral serous CD 360◦ (Fig. 1). Duplex ocular echography (mode A/mode B) confirmed the diagnostic of bilateral serous CD (Fig. 2) that showed medium hyper-reflectiveness (Fig. 3) at the level of the detached choroids. ® ® Simbrinza was suspended and Maxidex was prescribed ® at one-hour intervals, and Colicursí Atropina (1% atropine sulfate; Alcon Cusí, S.A., El Masnou, Barcelona, Spain) every 8 h and 60 mg oral prednisone per day. One week later, CD had resolved entirely (Fig. 4) with VA of 20/30 in BE. IOP ®
was 40 mmHg in the RE, for which reason Simbrinza was resumed. The patient maintained high IOP in BE which could not be controlled with maximum medical treatment, for which reason it was decided to perform non-perforating deep scle® rectomy with Esnoper V2000 scleral implant (Hidroxyethyl
®
vals, and Betoptic (0.5% betaxolol hydrochloride; Alcon Cusí, S.A., El Masnou, Barcelona, Spain) every 12 h during one week, ®
and Simbrinza every 12 h (brimonidin tartrate, brinzolamide 10/2 mg/ml; Alcon Cusí, S.A.; Barcelona, Spain). Twenty-four hours after the SLT, the patient appeared at the Emergency Dept. referring diminished vision in BE. VA was 20/25 in the RE and 20/50 in the LE, IOP with applanation of 6 and 8 mmHg respectively, narrow anterior chamber in BE (1.9 mm), diffuse ciliary hyperemia, cellularity and AC
Fig. 2 – Serous choroidal detachment.
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
297
Metacrilate [HEMA]; AJL Ophthalmic; Álava, Spain); first in the RE and one month later in the LE. At present, IOP is 14 mmHg in the RE and 15 mmHg in the LE, without concomitant medication, and a VA of 20/20 in BE.
Discussion
Fig. 3 – Serous choroidal detachment with medium hyper-reflectiveness.
In theory, SLT produces a thermal call that gives rise to the production of cytokins from the trabecular mesh. These cytokins include interleukin-alpha (IL-1), interleukin-1 beta (IL-1), and tumor necrosis factor alpha (TNF-␣). The result is the recruitment of macrophages that ingest detritus in the extracellular matrix of the trabecular mesh. In addition, lipidic peroxidase increases and free radical scanning is diminished due to superoxide dismutase and gluthathione-S-transferase in the aqueous humor, suggesting a formation of free radicals capable of producing post-surgery inflammation.5 It has been demonstrated that patients that utilize bimatoprost exhibit significantly higher levels of IL-1 and TNF-␣ in their tears.6 In the present case, the patient utilized bimatoprost before SLT, which could have contributed to activate said inflammation pathway. The exact mechanism of CD is unknown. It has been proposed that a sudden IOP drop, together with increased transmural pressure in the vascular choroidal plexus, could be the cause. Even so, it is considered that ocular inflammation plays an important role in the physiopathology of CD as it increases vascular permeability enabling the passage of serum carrying large proteic molecules into the suprachoroidal space.7 The authors report the case of a patient with open angle glaucoma who had bilateral serous CD after SLT in BE. Reviewing the literature, the only finding was a single case of serous CD secondary to SLT published by Kim and Singh.3 In said case, CD was unilateral in a patient with a vitrectomized eye in ® treatment with Cosopt (Merck Sharp & Dohme, S.A., Madrid, Spain) who exhibited inflammatory reaction 2 weeks after treatment. In addition, the energy applied by Kim and Singh
Fig. 4 – Complete resolution of choroidal detachments.
298
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
was nearly twice that applied in the present case (in addition to being applied at 360◦ in contrast with the 180◦ in the reported case). Reviewing the literature, the authors found an article published by Kennedy et al.8 who treated an open angle chronic glaucoma patient with argon laser trabeculoplasty with the following parameters: 270◦ inferior to the angle with 82 shots of 0.2 s, spot diameter of 50 microns and a power of 1.0 Watts. The patient consulted 3 weeks later exhibiting IOP of 2 mmHg in the LE and a vision of 6/36, with significant narrowing of the AC. In the present case, the patient consulted 24 h after SLT upon appearance of symptoms. It is worthy of note that in the present patient SLT was performed bilaterally in the same session. Phillis and Bourke9 reported a case with intermittent ocular hypertension history (OHT) without previous topical treatment and acute vision loss in BE 12 h after undergoing bilateral SCT in inferior 180◦ of BE. Post-SLT OCT showed retina pigment epithelium detachment in the RE and foveal serous detachment in the LE. As conclusion, despite the fact that SLT is a safe technique, it is not completely innocuous. Possible complications derived from SLT include increased IOP, iritis, hyphema, macular edema, corneal haze and refraction changes without forgetting the possible appearance of uni- or bilateral serous CD.
Conflict of interests No conflict of interests was declared by the authors.
references
1. Tang M, Fu Y, Fu MS, Fan Y, Zou HD, Sun XD, et al. The efficacy of low-energy selective laser trabeculoplasty. Ophthalmic Surg Lasers Imaging. 2001;42:59–63. 2. Song J. Complications of selective laser trabeculoplasty: a review. Clin Ophthalmol. 2016;10:137–43. 3. Kim DY, Singh A. Severe iritis and choroidal effusion following selective laser trabeculoplasty. Ophthalmic Surg Lasers Imaging. 2008;39:409–11. 4. Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140:509–16. 5. Guzey M, Vural H, Satici A, Karadede S, Dogan Z. Increase of free oxygen radicals in aquous humor induced by selective Nd:YAG laser trabeculoplasty in the rabbit. Eur J Ophthalmol. 2001;11:47–52. 6. Malvitte L, Montange T, Vejux A, Baudouin C, Bron AM, Creuzot-Garcher C, et al. Measurement of inflammatory cytokines by multitudinous assay in tears of patients with glaucoma topically treated with chronic drugs. Br J Ophthalmol. 2007;91:29–32. 7. Healey PR, Herndon L, Smiddy W. Managemet of suprachoroidal hemorrhage. J Glaucoma. 2007;16:577–9. 8. Kennedy CJ, Roden DM, McAllister IL. Suprachoroidal effusion following argon laser trabeculoplasty. Aust N Z J Ophthalmol. 1996;24:279–82. 9. Phillis CA, Bourke RD. Bilateral subretinal fluid mimicking subretinal neovascularization within 24 hours after selective laser trabeculoplasty. J Glaucoma. 2016;25:e110–4.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Bilateral choroidal effusion after selective laser trabeculoplasty夽 F. Hernández Pardines ∗ , J.C. Molina Martín, L. Fernández Montalvo, F. Aguirre Balsalobre Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Selective laser trabeculoplasty (SLT) is an effective treatment to treat open-angle glaucoma
Received 12 July 2016
with a low risk of complications. The case is presented of a 73 year-old woman with uncon-
Accepted 14 October 2016
trolled primary open-angle glaucoma who underwent selective laser trabeculoplasty in both
Available online 13 April 2017
eyes and developed bilateral choroidal effusion. ˜ ˜ S.L.U. All rights © 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Keywords: Open-angle glaucoma Bilateral choroidal effusion Selective laser trabeculoplasty
Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser r e s u m e n Palabras clave:
La trabeculoplastia selectiva láser (TSL) es un medio eficaz para tratar el glaucoma de
Glaucoma de ángulo abierto
ángulo abierto con una baja tasa de complicaciones. Reportamos el caso de una mujer de
Desprendimiento coroideo bilateral
˜ 73 anos con un glaucoma primario de ángulo abierto no controlado que tras someterse a
Trabeculoplastia selectiva láser
una trabeculoplastia selectiva láser en ambos ojos desarrolló un desprendimiento coroideo bilateral. ˜ ˜ S.L.U. Todos © 2016 Sociedad Espanola de Oftalmolog´ıa. Publicado por Elsevier Espana, los derechos reservados.
Introduction Selective laser trabeculoplasty (SLT) is a useful and effective tool for diminishing intraocular pressure (IOP) in adults
with open angle glaucoma, with low complication rates.1 Even though the majority of studies conclude that SLT is a safe technique, numerous side effects have been described including increased IOP, iritis, hyphema, macular edema, foveal burns, corneal edema and refractive error changes.2 The case of a
夽 Please cite this article as: Hernández Pardines F, Molina Martín JC, Fernández Montalvo L, Aguirre Balsalobre F. Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser. Arch Soc Esp Oftalmol. 2017;92:295–298. ∗ Corresponding author. E-mail address: [email protected] (F. Hernández Pardines). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2016 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
296
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
Fig. 1 – Peripheral serous detachment, bilateral at 360◦ .
patient with uncontrolled open angle glaucoma with topical anti-hypotensive medication who suffered bilateral serous choroidal detachment (CD) after SLT in both eyes is described. Only Kim and Singh reported a similar case but with unilateral expression.3
Clinic case report Female, 73, who consulted for intraocular pressure checkup. Pathological ocular history included primary open angle ® glaucoma in both eyes (BE) in treatment with Ganfort (bimatoprost/timolol 0.3/5 mg/ml; Allergan, S.A.; Tres Can®
tos, Madrid, Spain) and Alphagan (0.2% brimonidin tartrate; Allergan, S.A.; Tres Cantos, Madrid, Spain). Physical examination showed visual acuity (VA) of 20/20 in BE, IOP with applanation of 24 mmHg in the right eye (RE) and 23 mmHg in the left eye (LE), open angle with Shaffer Grade IV in the 4 quadrants of BE, papilla with 7/10 cup, normal color, moderate neuroretinal ring reduction and nasally rejected vessels, retina applied and macular without alterations. Pachymetry was 530 microns in central cornea BE, macular optical coherence tomography (OCT) without alterations. Considering that IOP was not controlled with medical treatment, it was proposed to treat with SLT in BE. In a single session, 50 shots at 0.7 mJ were made at the 180◦ inferior degrees with a spot size of 50 microns. Subsequently, ® Maxidex (0.1% dexamethasone, Alcon Cusí, S.A., El Masnou, Barcelona, Spain) was prescribed to be taken at 4-hour inter-
(tyndall) 3+ as per the International Group for Standardization of Uveitis Nomenclature (SUN),4 bilateral peripheral serous CD 360◦ (Fig. 1). Duplex ocular echography (mode A/mode B) confirmed the diagnostic of bilateral serous CD (Fig. 2) that showed medium hyper-reflectiveness (Fig. 3) at the level of the detached choroids. ® ® Simbrinza was suspended and Maxidex was prescribed ® at one-hour intervals, and Colicursí Atropina (1% atropine sulfate; Alcon Cusí, S.A., El Masnou, Barcelona, Spain) every 8 h and 60 mg oral prednisone per day. One week later, CD had resolved entirely (Fig. 4) with VA of 20/30 in BE. IOP ®
was 40 mmHg in the RE, for which reason Simbrinza was resumed. The patient maintained high IOP in BE which could not be controlled with maximum medical treatment, for which reason it was decided to perform non-perforating deep scle® rectomy with Esnoper V2000 scleral implant (Hidroxyethyl
®
vals, and Betoptic (0.5% betaxolol hydrochloride; Alcon Cusí, S.A., El Masnou, Barcelona, Spain) every 12 h during one week, ®
and Simbrinza every 12 h (brimonidin tartrate, brinzolamide 10/2 mg/ml; Alcon Cusí, S.A.; Barcelona, Spain). Twenty-four hours after the SLT, the patient appeared at the Emergency Dept. referring diminished vision in BE. VA was 20/25 in the RE and 20/50 in the LE, IOP with applanation of 6 and 8 mmHg respectively, narrow anterior chamber in BE (1.9 mm), diffuse ciliary hyperemia, cellularity and AC
Fig. 2 – Serous choroidal detachment.
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
297
Metacrilate [HEMA]; AJL Ophthalmic; Álava, Spain); first in the RE and one month later in the LE. At present, IOP is 14 mmHg in the RE and 15 mmHg in the LE, without concomitant medication, and a VA of 20/20 in BE.
Discussion
Fig. 3 – Serous choroidal detachment with medium hyper-reflectiveness.
In theory, SLT produces a thermal call that gives rise to the production of cytokins from the trabecular mesh. These cytokins include interleukin-alpha (IL-1), interleukin-1 beta (IL-1), and tumor necrosis factor alpha (TNF-␣). The result is the recruitment of macrophages that ingest detritus in the extracellular matrix of the trabecular mesh. In addition, lipidic peroxidase increases and free radical scanning is diminished due to superoxide dismutase and gluthathione-S-transferase in the aqueous humor, suggesting a formation of free radicals capable of producing post-surgery inflammation.5 It has been demonstrated that patients that utilize bimatoprost exhibit significantly higher levels of IL-1 and TNF-␣ in their tears.6 In the present case, the patient utilized bimatoprost before SLT, which could have contributed to activate said inflammation pathway. The exact mechanism of CD is unknown. It has been proposed that a sudden IOP drop, together with increased transmural pressure in the vascular choroidal plexus, could be the cause. Even so, it is considered that ocular inflammation plays an important role in the physiopathology of CD as it increases vascular permeability enabling the passage of serum carrying large proteic molecules into the suprachoroidal space.7 The authors report the case of a patient with open angle glaucoma who had bilateral serous CD after SLT in BE. Reviewing the literature, the only finding was a single case of serous CD secondary to SLT published by Kim and Singh.3 In said case, CD was unilateral in a patient with a vitrectomized eye in ® treatment with Cosopt (Merck Sharp & Dohme, S.A., Madrid, Spain) who exhibited inflammatory reaction 2 weeks after treatment. In addition, the energy applied by Kim and Singh
Fig. 4 – Complete resolution of choroidal detachments.
298
a r c h s o c e s p o f t a l m o l . 2 0 1 7;9 2(6):295–298
was nearly twice that applied in the present case (in addition to being applied at 360◦ in contrast with the 180◦ in the reported case). Reviewing the literature, the authors found an article published by Kennedy et al.8 who treated an open angle chronic glaucoma patient with argon laser trabeculoplasty with the following parameters: 270◦ inferior to the angle with 82 shots of 0.2 s, spot diameter of 50 microns and a power of 1.0 Watts. The patient consulted 3 weeks later exhibiting IOP of 2 mmHg in the LE and a vision of 6/36, with significant narrowing of the AC. In the present case, the patient consulted 24 h after SLT upon appearance of symptoms. It is worthy of note that in the present patient SLT was performed bilaterally in the same session. Phillis and Bourke9 reported a case with intermittent ocular hypertension history (OHT) without previous topical treatment and acute vision loss in BE 12 h after undergoing bilateral SCT in inferior 180◦ of BE. Post-SLT OCT showed retina pigment epithelium detachment in the RE and foveal serous detachment in the LE. As conclusion, despite the fact that SLT is a safe technique, it is not completely innocuous. Possible complications derived from SLT include increased IOP, iritis, hyphema, macular edema, corneal haze and refraction changes without forgetting the possible appearance of uni- or bilateral serous CD.
Conflict of interests No conflict of interests was declared by the authors.
references
1. Tang M, Fu Y, Fu MS, Fan Y, Zou HD, Sun XD, et al. The efficacy of low-energy selective laser trabeculoplasty. Ophthalmic Surg Lasers Imaging. 2001;42:59–63. 2. Song J. Complications of selective laser trabeculoplasty: a review. Clin Ophthalmol. 2016;10:137–43. 3. Kim DY, Singh A. Severe iritis and choroidal effusion following selective laser trabeculoplasty. Ophthalmic Surg Lasers Imaging. 2008;39:409–11. 4. Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140:509–16. 5. Guzey M, Vural H, Satici A, Karadede S, Dogan Z. Increase of free oxygen radicals in aquous humor induced by selective Nd:YAG laser trabeculoplasty in the rabbit. Eur J Ophthalmol. 2001;11:47–52. 6. Malvitte L, Montange T, Vejux A, Baudouin C, Bron AM, Creuzot-Garcher C, et al. Measurement of inflammatory cytokines by multitudinous assay in tears of patients with glaucoma topically treated with chronic drugs. Br J Ophthalmol. 2007;91:29–32. 7. Healey PR, Herndon L, Smiddy W. Managemet of suprachoroidal hemorrhage. J Glaucoma. 2007;16:577–9. 8. Kennedy CJ, Roden DM, McAllister IL. Suprachoroidal effusion following argon laser trabeculoplasty. Aust N Z J Ophthalmol. 1996;24:279–82. 9. Phillis CA, Bourke RD. Bilateral subretinal fluid mimicking subretinal neovascularization within 24 hours after selective laser trabeculoplasty. J Glaucoma. 2016;25:e110–4.