[Skip to Content]
[Skip to Content Landing]

Worsening Angle Closure After Successful Laser Peripheral Iridotomy

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A White woman in her 40s was referred to an outside ophthalmologist after developing nausea and a headache following a dilated eye examination. She was found to have narrow angles in both eyes and a laser peripheral iridotomy (LPI) was performed in her left eye. Two weeks later she developed flickering photopsias and a temporal scotoma progressing to a “brown tint” of her vision in her left eye. Her vision had decreased in her left eye and macular and optic nerve edema were noted and she was subsequently referred to us. In our clinic, her visual acuity was 20/20 OD and 20/50 OS, and she had normal intraocular pressure, a shallow anterior chamber but open angle in both eyes, a patent LPI in the left eye, and clear crystalline lenses in both eyes. The rest of her anterior segment was unremarkable. The posterior examination was notable for shifting subretinal fluid with choroidal detachments without retinal breaks, inflammation, or optic nerve edema and leopard spotting, while her right eye was unremarkable (Figure, A). Fluorescein angiography was unrevealing, while optical coherence tomography showed shallow subretinal fluid and an irregular and thickened choroid (Figure, B). Ultrasonography showed an axial length of 20.0 mm, thickened sclera, anteriorly rotated ciliary body, and 360° of ciliochoroidal detachments in both eyes but worse in the left eye. Results of a systemic laboratory evaluation for infectious and noninfectious disorders were unremarkable. Systemic corticosteroids failed to resolve the subretinal fluid and her vision declined.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

A White woman in her 40s was referred to an outside ophthalmologist after developing nausea and a headache following a dilated eye examination. She was found to have narrow angles in both eyes and a laser peripheral iridotomy (LPI) was performed in her left eye. Two weeks later she developed flickering photopsias and a temporal scotoma progressing to a “brown tint” of her vision in her left eye. Her vision had decreased in her left eye and macular and optic nerve edema were noted and she was subsequently referred to us. In our clinic, her visual acuity was 20/20 OD and 20/50 OS, and she had normal intraocular pressure, a shallow anterior chamber but open angle in both eyes, a patent LPI in the left eye, and clear crystalline lenses in both eyes. The rest of her anterior segment was unremarkable. The posterior examination was notable for shifting subretinal fluid with choroidal detachments without retinal breaks, inflammation, or optic nerve edema and leopard spotting, while her right eye was unremarkable (Figure, A). Fluorescein angiography was unrevealing, while optical coherence tomography showed shallow subretinal fluid and an irregular and thickened choroid (Figure, B). Ultrasonography showed an axial length of 20.0 mm, thickened sclera, anteriorly rotated ciliary body, and 360° of ciliochoroidal detachments in both eyes but worse in the left eye. Results of a systemic laboratory evaluation for infectious and noninfectious disorders were unremarkable. Systemic corticosteroids failed to resolve the subretinal fluid and her vision declined.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Christopher D. Conrady, MD, PhD, Department of Ophthalmology, University of Nebraska Medical Center, 3902 Leavenworth St, Omaha, NE 68105 (cconrady@unmc.edu).

Published Online: February 10, 2022. doi:10.1001/jamaophthalmol.2021.4988

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Azuara-Blanco  A , Burr  J , Ramsay  C ,  et al; EAGLE study group.  Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial.   Lancet. 2016;388(10052):1389-1397. doi:10.1016/S0140-6736(16)30956-4PubMedGoogle ScholarCrossref
2.
Wu  W , Dawson  DG , Sugar  A ,  et al.  Cataract surgery in patients with nanophthalmos: results and complications.   J Cataract Refract Surg. 2004;30(3):584-590. doi:10.1016/j.jcrs.2003.07.009PubMedGoogle ScholarCrossref
3.
Rajendrababu  S , Babu  N , Sinha  S ,  et al.  A randomized controlled trial comparing outcomes of cataract surgery in nanophthalmos with and without prophylactic sclerostomy.   Am J Ophthalmol. 2017;183:125-133. doi:10.1016/j.ajo.2017.09.008PubMedGoogle ScholarCrossref
4.
Uyama  M , Takahashi  K , Kozaki  J ,  et al.  Uveal effusion syndrome: clinical features, surgical treatment, histologic examination of the sclera, and pathophysiology.   Ophthalmology. 2000;107(3):441-449. doi:10.1016/S0161-6420(99)00141-4PubMedGoogle ScholarCrossref
5.
Johnson  MW , Gass  JDM .  Surgical management of the idiopathic uveal effusion syndrome.   Ophthalmology. 1990;97(6):778-785. doi:10.1016/S0161-6420(90)32511-3PubMedGoogle ScholarCrossref
6.
Lam  A , Sambursky  RP , Maguire  JI .  Measurement of scleral thickness in uveal effusion syndrome.   Am J Ophthalmol. 2005;140(2):329-331. doi:10.1016/j.ajo.2005.02.014PubMedGoogle ScholarCrossref
7.
Kaden  TR , Freund  KB , Engelbert  M .  Choroidal effusion after laser peripheral iridotomy.   Ophthalmology. 2019;126(9):1262. doi:10.1016/j.ophtha.2019.05.008PubMedGoogle ScholarCrossref
8.
Gentile  RC , Stegman  Z , Liebmann  JM ,  et al.  Risk factors for ciliochoroidal effusion after panretinal photocoagulation.   Ophthalmology. 1996;103(5):827-832. doi:10.1016/S0161-6420(96)30608-8PubMedGoogle ScholarCrossref
9.
Jin  JC , Anderson  DR .  Laser and unsutured sclerotomy in nanophthalmos.   Am J Ophthalmol. 1990;109(5):575-580. doi:10.1016/S0002-9394(14)70689-0PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close