SlideShare a Scribd company logo
1 of 72
Download to read offline
CASE PRESENTATION
Presenter- Dr. Nancy Sehdev
Moderator- Dr. Rita Dhamankar
 Name- S W
 Age- 27 years
 Sex- Female
 Address- Kharghar
Chief complaints
First day-14/12/12
 Diminution of vision in left eye even with glasses
since 2 months.
 Pain in left eye since 2 months
History of presenting illness
 Apparently alright 2 months back when she noticed
diminution of vision in left eye, gradual in onset and
progressive in nature.
 Associated with pain in her left eye, pricking in
nature, present throughout the day.
 Sometimes pain used to increase in the evening.
 No aggravating and relieving factors and radiating to
left brow and forehead area.
 Had shown to another ophthalmologist where she
was diagnosed to have anterior segment dysgenesis
and was prescribed following eye drops- left eye
1. Eyemist forte eye drops( Hydroxypropyl methyl
cellulose 3mg, Dextran 70, Glycerin) sos.
2. Travatan eye drops(Travoprost 0.004%) once at
night.
3. Dortas T eye drops( Dorzolamide hydrochloride 2%,
Timolol Maleate 0.5%) 2 times per day.
 History of using glasses since 7-8 years.
 Her present glasses were 5 months old.
 No ho redness, watering.
 No ho photophobia.
 No ho coloured halos.
 No ho trauma
 No ho similar complaints in the other eye.
• PAST HISTORY
No history of similar complaints in the past.
• FAMILY HISTORY
Nothing significant.
 GENERAL PHYSICAL EXAMINATION-
 Normal
 SYSTEMIC EXAMINATION-
 Normal
Ocular examination
 Head posture- Erect
 Facial symmetry- symmetrical
Visual acuity
SPH CYL AXIS VA
DIST -2.50 -1.50 160 6/12
NEAR - - - N18
Extra ocular movements-All uniocular and binocular
extraocular movements are full and free.
SPH CYL AXIS VA
DIST -2.00 -2.00 20 6/6
NEAR - - - N6
Structure Right eye Left eye
lids Normal Normal
Conjunctiva Normal Mild superficial
conjunctival congestion
Cornea Clear Few iris pigments on
endothelium
Anterior chamber Quiet Irregular in depth, quiet
Anterior segment examination
Anterior segment examination
Iris Normal in colour and
pattern
Loss of pattern,
Iris holes
Pupil Round, regular and
reacting to light
single, eccentric pupil,
round,3mm in size,
sluggishly reactive,
pseudopolycoria
Lens Clear Clear, iris pigments on
anterior lens capsule.
OD Anterior Segment
OS Anterior segment
Intraocular pressure
 On applanation tonometer-
14mm Hg in both eyes
OD Fundus
OS Fundus
Fundus
OD OS
Glow Present Present
Media Clear Clear
Disc Small Small
cup:disc 0.4:1 0.8:1, small inferior notch
Macula Foveal reflex present Foveal reflex present
Background Normal Normal
Gonioscopy(OS) PAS
Provisional diagnosis
 Right eye refractive error
 Left eye Iridocorneal endothelial syndrome
 Investigations-
Perimetry(OD)
 OS- Perimetry
Specular microscopy-
RE WNL
LE shows
polymegathism
with silver beaten
appearance
Definitive diagnosis
 Right eye refractive error
 Left eye Iridocorneal endothelial syndrome
 After the above investigations, patient was advised to
continue same eye drops-left eye
1. Eyemist forte eye drops( Hydroxypropyl methyl
cellulose 3mg, Dextran 70, Glycerin) sos.
2. Travatan eye drops(Travoprost 0.004%) once at
night.
3. Dortas T eye drops( Dorzolamide hydrochloride 2%,
Timolol Maleate 0.5%) 2 times per day.
Patient was given appointment for diurnal variation
test.
Diurnal variation test-24-01-13
Time IOP B.P.
3:oo pm 16 16 120/80
5:00 pm 14 24 110/76
7:00 pm 14 24 108/76
9:00 pm 14 24 108/76
12:00 am 14 24 108/76
3:00 am 14 22 108/78
6:00 am 14 22 100/80
Time IOP B.P.
8:00 am 12 16 110/80
10:00 am 12 16 108/76
12:00 pm 14 16 120/72
3:00 pm 14 16 110/78
Right eye Left eye
Highest IOP 16 24
Lowest IOP 12 16
•Patient was asked to continue same eye drops and review
after 6 weeks.
•Also, Dortas T eye drops were asked to be added a little
later in the day to blunt off the spike.
 Subsequently patient was followed up with intervals
of 2-3 months for IOP evaluation.
 Her IOP was well controlled throughout.
23-08-2013
 Patient came for regular follow-up. She was in first
trimester of pregnancy.
 On examination, BCVA in Right eye was 6/6, N6
Left eye was 6/12, N18
 Anterior and posterior findings were same as before.
 Patient was advised to stop Travoprost eye drops for
first trimester as it could be an abortifacient and
follow up 3 weeks.
 On subsequent follow ups till Feb 2014, her pressures
were under control.
 Then she directly came for follow up on 08-10-14.
 She was using both Dortas T eye drops 2 times daily
and Travatan eye drops once daily in left eye.
 IOP was 10mmHg in right eye and 16 mmHg in left
eye.
Perimetry was repeated
Perimetry- OD
Perimetry OS
Not very reliable with
too many fixation losses
 Patient was asked to continue same treatment and
review every 3 months for IOP evaluation.
 On 27-07-15, patient came for follow up.
 IOP was 14 mmHg in both eyes.
Specular microscopy comparison
Repeat perimetry
Perimetry-OS
GPA Printout
There seems to be a
trend towards
progression on VFI
 On her last followup visit- 14-01-16
 IOP- 12 mmHg in right eye and 14 mmHg in left eye.
Perimetry-OD
Perimetry- OS
Shows a definitive inf nasal
arcuate defect with an early
Siedel’s .
OCT
 There seems to be a progresion happening.
 Hence an AGV counselling was done.
 Till then, advised to continue same eye drops and
review after 1 month.
GLAUCOMA AND CORNEAL
DISORDERS
Disorders of the cornea associated
with glaucoma
• Peters’ anomaly
• Aniridia
• Axenfeld-Rieger syndrome
Developmental
disorders
• Keratouveitis
• Full thickness or endothelial
keratoplasty
• Trauma
Acquired
conditions
 Glaucomas associated with primary disorders of
corneal endothelium
1. Iridocorneal endothelial syndrome (Unilateral)
2. Posterior polymorphous dystrophy (Bilateral)
3. Fuch’s endothelial dystrophy (Bilateral)
Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS.
Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
Glaucoma with secondary corneal
abnormalities
A. Pressure induced
corneal changes
1. Epithelial and stromal
oedema
2. Endothelial changes
3. Haab’s
striae(childhood
glaucoma)
B. Exfoliation induced
corneal endothelial
changes
C. Drug induced changes in the cornea
1. Endothelial decompensation with topical
carbonic anhydrase inhibitors.
2. Toxic effects to cornea epithelium(eg:
benzalkonium chloride, β- blockers, miotics.)
Iridocorneal endothelial syndrome
 Characterised by primary corneal endothelial
abnormality.
 Associated with-
1. corneal oedema
2. Anterior chamber angle changes
3. Alterations in iris
4. Glaucoma
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
General features
 Clinically unilateral
 Age- early to middle adulthood
 Sex- females more commonly affected
 Familial cases rare
 No consistent association with any systemic disease
 Most common clinical manifestations-
Abnormalities of iris
Reduced vision
Pain
Major clinical variations
Progressive iris
atrophy
• Iris features
predominate
• Corectopia
• Atrophy and hole
formation
Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS.
Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
Chandler
syndrome
• Corneal
oedema often
at normal IOP
• Iris changes
mild to absent
Cogan –Reese
syndrome
• Nodular,
pigmented
lesions of iris
• Corneal and iris
defects
Specular microscopy
 Fine hammered
silver appearance of
posterior cornea.
 Pleomorphism in size
and shape.
 Dark areas within the
cells.
 Loss of clear hexagonal
margins
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
ICE cells
 These endothelial cells appear dark by specular
microscopy except for light central spot and a light
peripheral zone.
 When clustered as continuous cells, known as ICE
TISSUE.
 Give appearance of negative of a tissue.
Variations of ICE tissue
• Disseminated ICE –
1. ICE cells scattered among large
endothelial cells.
2. elevated IOP
• Total ICE-
1. Whole posterior corneal surface
composed of ICE tissue.
Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if
iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
• Subtotal ICE(+)-
1. clearly defined ICE tissue
2. remaining cells-distinct small cells
3. normal IOP
• Subtotal ICE (-)-
1. ICE tissue
2. larger than normal remaining
endothelial cells.
Anterior chamber angle alterations
 Peripheral anterior synechia, usually extending
to or beyond Schwalbe’s line is common to all
variations of ICE syndrome.
 Histology reveals a cellular membrane consisting of a
single layer of endothelial cells and Descemet’s like
membrane extending down from the peripheral
cornea.
Weber PA, Gibb G. Iridocorneal endothelial syndrome glaucoma
without peripheral anterior synchias. Glaucoma. 1994;6:128.
Membrane theory of Campbell
Campbell DG, Shields MB, Smith TR. The corneal endothelium and the
spectrum of essential iris atrophy. AM J Ophthalmos. 1978;86(3):317-324.
Differential diagnosis
Corneal endothelial disorders
Posterior
polymorphous
dystrophy
Fuch’s
endothelial
dystrophy
Dissolution of the iris
Axenfeld Rieger syndrome
• Congenital
• Bilaterality
• Prominant anteriorly
displaced Schwalbe’s line
• Associated ocular and
systemic abnormalities.
Iridoschisis
 Separation of superficial
layers of iris stroma
 May be associated with
glaucoma
 Typically seen in elderly
Nodular lesions of iris
 Bilateral diffuse iris nodular nevi-
1. Neurofibromatosis
2. Oculodermal melanocytosis
3. Axenfeld syndrome
4. Peter’s anomaly
5. Inflammatory disorders-sarcoidosis
Management Of ICE Syndrome
 In early stages, drugs that reduce aquoeus
production are used.
 Aqueous facilitators are of no use, as the TM is
affected . However other pathways may still be
targeted.
 Prostaglandins may not be advocated, as there is a
school of thought that believes the HSV / Epstein Barr
virus to be an aetiological factor.
 There have been no reported cases of reactivation of
the viral infection.
 When the IOP can no longer be controlled medically,
surgical intervention is indicated.
 Laser trabeculoplasty is not effective for this
disease, as the angle is affected.
 Filtering surgery is reasonably successful, though
late failures have occured because of
endotheliazation of the filtering bleb & the fact
that the surgery is done on relatively young
adults, where fibroblastic proliferation is
common. .
 Glaucoma drainage device surgery, is the surgery
of choice & has proven to be more effective.
Kim DK, Aslanides IM, Schmidt CM Jr, et al. Long term outcome of
aqueous shunt surgery in ten patients with iridocorneal endothelial
syndrome. Ophthalmology. 2000;106(5):1030-1034.
 Corneal oedema may be controlled improved by
lowering the IOP.
 Hypertonic saline solutions can be used.
 Penetrating keratoplasty or DSAEK if there is
marked dysfunction of corneal endothelium and
oedema is not getting cleared.
Alwin PT, Cohen EJ, Rapuano CJ, et al. Penetrating keratoplasty in
iridocorneal endothelial syndrome. Cornea. 2001;20(2):134-140.
Glaucoma
medications-
pregnancy
considerations
Beta-blockers-FDA rating class C
 Drugs like timolol, levobunolol, betaxolol, carteolol-
should be avoided in the first trimester of pregnancy
and discontinued 2-3 days prior to delivery to avoid
beta-blockade in the infant.
 Beta-blockers being concentrated in breast milk,
avoided in mothers who are breastfeeding.
 Timolol - reported to be compatible with lactation
according to the American Academy of Pediatrics.
Michael J. Trad. Some ophthalmic drugs not safe for use in
lactating or pregnant women
Primary Care Optometry News, September 2008
Carbonic anhydrase inhibitors- FDA
rating Class C
 Contraindicated during pregnancy because of
potential teratogenic effects.
 Avoided in mothers who are breastfeeding because of
the potential hepatic and renal effects to the infant.
 However, acetazolamide has been reported to be
compatible with lactation according to the American
Academy of Pediatrics.
Miotics-Class C
 Drugs like pilocarpine, echothiophate, carbachol
appear to be safe during pregnancy.
 The toxicity during lactation is unknown.
 One exception is demecarium, which is toxic and is
contraindicated in pregnancy and mothers who are
breastfeeding.
Prostaglandin analogs-Class C
 Prostaglandins are used systemically for labor
induction and termination, and as such, the topical
use for glaucoma during pregnancy raises natural
concern.
 Therefore, caution should be exercised when
latanoprost is administered in women who are
pregnant or breastfeeding.
Adrenergic agonists- Class C
 Brimonidine has not demonstrated any fetal risk.
Although no studies were conducted in pregnant
patients, it may be used if necessary.
 Whether brimonidine is excreted in human milk is
not known. Therefore, caution should be exercised
since topical brimonidine given to human infants
aged younger than 2 months has been reported to
cause bradycardia, hypertension, hypothermia,
and apnea.
THANK YOU

More Related Content

What's hot

Scleral buckling for rhegmatogenous retinal detachment
Scleral buckling for rhegmatogenous retinal detachmentScleral buckling for rhegmatogenous retinal detachment
Scleral buckling for rhegmatogenous retinal detachmentreboca smith
 
Congenital corneal disorders
Congenital corneal disordersCongenital corneal disorders
Congenital corneal disorderssneha_thaps
 
Diagnosis of pre perimetric glaucoma
Diagnosis of pre perimetric glaucomaDiagnosis of pre perimetric glaucoma
Diagnosis of pre perimetric glaucomaSadhwini Harish
 
Hereditary choroidal diseases
Hereditary choroidal diseases Hereditary choroidal diseases
Hereditary choroidal diseases Shruti Laddha
 
Surgical induced astigmatism
Surgical induced astigmatismSurgical induced astigmatism
Surgical induced astigmatismNamrata Gupta
 
Angle recession glaucoma
Angle recession glaucomaAngle recession glaucoma
Angle recession glaucomaSSSIHMS-PG
 
Minimally invasive glaucoma surgery
Minimally invasive glaucoma surgery Minimally invasive glaucoma surgery
Minimally invasive glaucoma surgery aditisingh77985
 
Fuchs dystrophy and pseudophakic bullous keratopathy
Fuchs dystrophy and pseudophakic bullous keratopathyFuchs dystrophy and pseudophakic bullous keratopathy
Fuchs dystrophy and pseudophakic bullous keratopathyunleng
 
Optic nerve head evaluation in glaucoma
Optic nerve head evaluation in glaucomaOptic nerve head evaluation in glaucoma
Optic nerve head evaluation in glaucomaDr Laltanpuia Chhangte
 
Optical coherence tomography in glaucoma - Dr Shylesh Dabke
Optical coherence tomography in glaucoma - Dr Shylesh DabkeOptical coherence tomography in glaucoma - Dr Shylesh Dabke
Optical coherence tomography in glaucoma - Dr Shylesh DabkeShylesh Dabke
 
Clinical examination of squint
Clinical examination of squintClinical examination of squint
Clinical examination of squintReshma Peter
 
Diabetic retinopathy Trials
Diabetic retinopathy TrialsDiabetic retinopathy Trials
Diabetic retinopathy TrialsKaran Bhatia
 
Corneal topography wavefront analysis
Corneal topography wavefront analysisCorneal topography wavefront analysis
Corneal topography wavefront analysisikramdr01
 
Papilledema - Optic Nerve Head Swelling
Papilledema - Optic Nerve Head Swelling Papilledema - Optic Nerve Head Swelling
Papilledema - Optic Nerve Head Swelling Shreeji Shrestha
 

What's hot (20)

Scleral buckling for rhegmatogenous retinal detachment
Scleral buckling for rhegmatogenous retinal detachmentScleral buckling for rhegmatogenous retinal detachment
Scleral buckling for rhegmatogenous retinal detachment
 
Congenital corneal disorders
Congenital corneal disordersCongenital corneal disorders
Congenital corneal disorders
 
Diagnosis of pre perimetric glaucoma
Diagnosis of pre perimetric glaucomaDiagnosis of pre perimetric glaucoma
Diagnosis of pre perimetric glaucoma
 
Hereditary choroidal diseases
Hereditary choroidal diseases Hereditary choroidal diseases
Hereditary choroidal diseases
 
Corneal dystrophy
Corneal dystrophy Corneal dystrophy
Corneal dystrophy
 
Surgical induced astigmatism
Surgical induced astigmatismSurgical induced astigmatism
Surgical induced astigmatism
 
Angle recession glaucoma
Angle recession glaucomaAngle recession glaucoma
Angle recession glaucoma
 
Role of oct in glaucoma
Role of oct in glaucomaRole of oct in glaucoma
Role of oct in glaucoma
 
Minimally invasive glaucoma surgery
Minimally invasive glaucoma surgery Minimally invasive glaucoma surgery
Minimally invasive glaucoma surgery
 
Fuchs dystrophy and pseudophakic bullous keratopathy
Fuchs dystrophy and pseudophakic bullous keratopathyFuchs dystrophy and pseudophakic bullous keratopathy
Fuchs dystrophy and pseudophakic bullous keratopathy
 
Optic nerve head evaluation in glaucoma
Optic nerve head evaluation in glaucomaOptic nerve head evaluation in glaucoma
Optic nerve head evaluation in glaucoma
 
Optical coherence tomography in glaucoma - Dr Shylesh Dabke
Optical coherence tomography in glaucoma - Dr Shylesh DabkeOptical coherence tomography in glaucoma - Dr Shylesh Dabke
Optical coherence tomography in glaucoma - Dr Shylesh Dabke
 
Oct in glaucoma
Oct in glaucomaOct in glaucoma
Oct in glaucoma
 
Clinical examination of squint
Clinical examination of squintClinical examination of squint
Clinical examination of squint
 
Diabetic retinopathy Trials
Diabetic retinopathy TrialsDiabetic retinopathy Trials
Diabetic retinopathy Trials
 
Lasers in Glaucoma
Lasers in GlaucomaLasers in Glaucoma
Lasers in Glaucoma
 
Retinoschisis
RetinoschisisRetinoschisis
Retinoschisis
 
Corneal topography wavefront analysis
Corneal topography wavefront analysisCorneal topography wavefront analysis
Corneal topography wavefront analysis
 
Papilledema - Optic Nerve Head Swelling
Papilledema - Optic Nerve Head Swelling Papilledema - Optic Nerve Head Swelling
Papilledema - Optic Nerve Head Swelling
 
Piggyback iol
Piggyback iolPiggyback iol
Piggyback iol
 

Viewers also liked

Viewers also liked (20)

Iridocorneal endothelial (ICE) syndrome
Iridocorneal endothelial (ICE) syndrome Iridocorneal endothelial (ICE) syndrome
Iridocorneal endothelial (ICE) syndrome
 
Scleritis a case presentation
Scleritis a case presentationScleritis a case presentation
Scleritis a case presentation
 
Congenital glaucoma
Congenital glaucomaCongenital glaucoma
Congenital glaucoma
 
Juvenile glaucoma: a case study and disease review
Juvenile glaucoma: a case study and disease reviewJuvenile glaucoma: a case study and disease review
Juvenile glaucoma: a case study and disease review
 
Steroid induced glaucoma
Steroid induced glaucomaSteroid induced glaucoma
Steroid induced glaucoma
 
Important trials in Glaucoma
Important trials in GlaucomaImportant trials in Glaucoma
Important trials in Glaucoma
 
Visual pathway
Visual pathway Visual pathway
Visual pathway
 
Ocular pharmacology
Ocular pharmacologyOcular pharmacology
Ocular pharmacology
 
OVD RESULTS IN PHACO
OVD RESULTS IN PHACOOVD RESULTS IN PHACO
OVD RESULTS IN PHACO
 
viscoelasic
viscoelasicviscoelasic
viscoelasic
 
OCULAR VISCO ELASTICS
OCULAR VISCO ELASTICSOCULAR VISCO ELASTICS
OCULAR VISCO ELASTICS
 
Viscoadaptive substances
Viscoadaptive substancesViscoadaptive substances
Viscoadaptive substances
 
CCP
CCPCCP
CCP
 
Pigmentary glaucoma - Dr Shylesh B Dabke
Pigmentary glaucoma - Dr Shylesh B DabkePigmentary glaucoma - Dr Shylesh B Dabke
Pigmentary glaucoma - Dr Shylesh B Dabke
 
2014 nw cmv_rcrrd01
2014 nw cmv_rcrrd012014 nw cmv_rcrrd01
2014 nw cmv_rcrrd01
 
Catarata y distrofias endoteliales Jose Salazar
Catarata y distrofias endoteliales Jose SalazarCatarata y distrofias endoteliales Jose Salazar
Catarata y distrofias endoteliales Jose Salazar
 
Malignant glaucoma
Malignant glaucomaMalignant glaucoma
Malignant glaucoma
 
Limbal stem cell Deficiency; amniotic membrane transplantation
Limbal stem cell Deficiency; amniotic membrane transplantationLimbal stem cell Deficiency; amniotic membrane transplantation
Limbal stem cell Deficiency; amniotic membrane transplantation
 
TASS vs Endophthalmitis
TASS vs EndophthalmitisTASS vs Endophthalmitis
TASS vs Endophthalmitis
 
Uveitic Glaucoma
Uveitic GlaucomaUveitic Glaucoma
Uveitic Glaucoma
 

Similar to Ice syndrome

Case Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyCase Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyDan Mulder
 
Refractive changes in Diabetic Mellitus (Optometry Management)
Refractive changes in Diabetic Mellitus (Optometry Management)Refractive changes in Diabetic Mellitus (Optometry Management)
Refractive changes in Diabetic Mellitus (Optometry Management)Manal AlRomeih
 
Congenital glaucoma -Evaluation
Congenital glaucoma  -EvaluationCongenital glaucoma  -Evaluation
Congenital glaucoma -EvaluationDr.Ankit Ahir
 
Case presentation 2 : Duane's Syndrome
Case presentation 2 : Duane's Syndrome Case presentation 2 : Duane's Syndrome
Case presentation 2 : Duane's Syndrome Anis Suzanna Mohamad
 
Amblyopia: Screening and Management
Amblyopia: Screening and ManagementAmblyopia: Screening and Management
Amblyopia: Screening and ManagementObaidur Rehman
 
Optic neuritis treatment trial
Optic neuritis treatment trialOptic neuritis treatment trial
Optic neuritis treatment trialVinitkumar MJ
 
Unilateral Disc Anomaly: Morning Glory Syndrome
Unilateral Disc Anomaly: Morning Glory SyndromeUnilateral Disc Anomaly: Morning Glory Syndrome
Unilateral Disc Anomaly: Morning Glory SyndromeDr. Jagannath Boramani
 
Clinical case presentation of a rare case
Clinical case presentation of a rare caseClinical case presentation of a rare case
Clinical case presentation of a rare casehimanshu202420
 
Case study: Sixth Nerve Palsy (Optometric Management)
Case study: Sixth Nerve Palsy (Optometric Management)Case study: Sixth Nerve Palsy (Optometric Management)
Case study: Sixth Nerve Palsy (Optometric Management)Noor Munirah Aab
 
Congenital glaucomas
Congenital glaucomasCongenital glaucomas
Congenital glaucomasSSSIHMS-PG
 
traumatic abducent nerve palsy
traumatic abducent nerve palsytraumatic abducent nerve palsy
traumatic abducent nerve palsyDr. Bikram Thapa
 
Case Report - Hordeolum
Case Report - HordeolumCase Report - Hordeolum
Case Report - Hordeolumpaymaun19
 
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...iosrjce
 
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...Apollo Hospitals
 
endogenous endophthalmitis- case presentation.pptx
endogenous endophthalmitis- case presentation.pptxendogenous endophthalmitis- case presentation.pptx
endogenous endophthalmitis- case presentation.pptxpriyanka singh
 
Neromyelitis Optica Spectrum Disorder.pptx
Neromyelitis Optica Spectrum Disorder.pptxNeromyelitis Optica Spectrum Disorder.pptx
Neromyelitis Optica Spectrum Disorder.pptxmaulida47
 
Congenital AML with ocular menifestation-Case presentation
Congenital AML with ocular menifestation-Case presentation Congenital AML with ocular menifestation-Case presentation
Congenital AML with ocular menifestation-Case presentation Dr. vijay pratap
 

Similar to Ice syndrome (20)

Case Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous RetinopathyCase Report and Clinical Findings of Central Serous Retinopathy
Case Report and Clinical Findings of Central Serous Retinopathy
 
Refractive changes in Diabetic Mellitus (Optometry Management)
Refractive changes in Diabetic Mellitus (Optometry Management)Refractive changes in Diabetic Mellitus (Optometry Management)
Refractive changes in Diabetic Mellitus (Optometry Management)
 
Congenital glaucoma -Evaluation
Congenital glaucoma  -EvaluationCongenital glaucoma  -Evaluation
Congenital glaucoma -Evaluation
 
PACG.pptx
PACG.pptxPACG.pptx
PACG.pptx
 
Case presentation 2 : Duane's Syndrome
Case presentation 2 : Duane's Syndrome Case presentation 2 : Duane's Syndrome
Case presentation 2 : Duane's Syndrome
 
Amblyopia: Screening and Management
Amblyopia: Screening and ManagementAmblyopia: Screening and Management
Amblyopia: Screening and Management
 
Optic neuritis treatment trial
Optic neuritis treatment trialOptic neuritis treatment trial
Optic neuritis treatment trial
 
Unilateral Disc Anomaly: Morning Glory Syndrome
Unilateral Disc Anomaly: Morning Glory SyndromeUnilateral Disc Anomaly: Morning Glory Syndrome
Unilateral Disc Anomaly: Morning Glory Syndrome
 
Clinical case presentation of a rare case
Clinical case presentation of a rare caseClinical case presentation of a rare case
Clinical case presentation of a rare case
 
Case study: Sixth Nerve Palsy (Optometric Management)
Case study: Sixth Nerve Palsy (Optometric Management)Case study: Sixth Nerve Palsy (Optometric Management)
Case study: Sixth Nerve Palsy (Optometric Management)
 
Retinoblastoma
RetinoblastomaRetinoblastoma
Retinoblastoma
 
Congenital glaucomas
Congenital glaucomasCongenital glaucomas
Congenital glaucomas
 
traumatic abducent nerve palsy
traumatic abducent nerve palsytraumatic abducent nerve palsy
traumatic abducent nerve palsy
 
Case Report - Hordeolum
Case Report - HordeolumCase Report - Hordeolum
Case Report - Hordeolum
 
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...
A rare case of systemic lupus erythematosis with severe thrombocytopenia lead...
 
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...
 
endogenous endophthalmitis- case presentation.pptx
endogenous endophthalmitis- case presentation.pptxendogenous endophthalmitis- case presentation.pptx
endogenous endophthalmitis- case presentation.pptx
 
Neromyelitis Optica Spectrum Disorder.pptx
Neromyelitis Optica Spectrum Disorder.pptxNeromyelitis Optica Spectrum Disorder.pptx
Neromyelitis Optica Spectrum Disorder.pptx
 
Congenital AML with ocular menifestation-Case presentation
Congenital AML with ocular menifestation-Case presentation Congenital AML with ocular menifestation-Case presentation
Congenital AML with ocular menifestation-Case presentation
 
Primary angle closure
Primary angle closurePrimary angle closure
Primary angle closure
 

More from Laxmi Eye Institute (20)

Supranuclear pathways and lesions
Supranuclear pathways and lesionsSupranuclear pathways and lesions
Supranuclear pathways and lesions
 
IOL power calculation special situations
IOL power calculation special situations IOL power calculation special situations
IOL power calculation special situations
 
Ocular tb
Ocular tbOcular tb
Ocular tb
 
Causes of low vision in adult
Causes of low vision in adultCauses of low vision in adult
Causes of low vision in adult
 
Macular hole
Macular holeMacular hole
Macular hole
 
Trial set
Trial setTrial set
Trial set
 
ASSESMENT OF VISUAL ACUITY IN CHILDREN
ASSESMENT OF VISUAL ACUITY IN CHILDRENASSESMENT OF VISUAL ACUITY IN CHILDREN
ASSESMENT OF VISUAL ACUITY IN CHILDREN
 
INTRAOCULAR FOREIGN BODY
INTRAOCULAR FOREIGN BODYINTRAOCULAR FOREIGN BODY
INTRAOCULAR FOREIGN BODY
 
VITAMIN A & VISUAL CYCLE
VITAMIN A & VISUAL CYCLEVITAMIN A & VISUAL CYCLE
VITAMIN A & VISUAL CYCLE
 
Central Retinal Vein OcclUsIon (CRUISE) Study - Cruise trial
Central Retinal  Vein OcclUsIon (CRUISE) Study - Cruise trialCentral Retinal  Vein OcclUsIon (CRUISE) Study - Cruise trial
Central Retinal Vein OcclUsIon (CRUISE) Study - Cruise trial
 
Colour vision and its clinical aspects
Colour vision and its clinical aspectsColour vision and its clinical aspects
Colour vision and its clinical aspects
 
Normal tension glaucoma
Normal tension glaucomaNormal tension glaucoma
Normal tension glaucoma
 
Cystoid macular oedema
Cystoid macular oedemaCystoid macular oedema
Cystoid macular oedema
 
Automated perimetry
Automated perimetryAutomated perimetry
Automated perimetry
 
Ectopia lentis
Ectopia lentisEctopia lentis
Ectopia lentis
 
Accommodative esotropia
Accommodative esotropiaAccommodative esotropia
Accommodative esotropia
 
Botox in Ophthalmology
Botox in OphthalmologyBotox in Ophthalmology
Botox in Ophthalmology
 
Dysphotopsia
DysphotopsiaDysphotopsia
Dysphotopsia
 
Chemical burns
Chemical burnsChemical burns
Chemical burns
 
LASIK: COMPLICATIONS AND THEIR MANAGEMENT
LASIK: COMPLICATIONS AND THEIR MANAGEMENTLASIK: COMPLICATIONS AND THEIR MANAGEMENT
LASIK: COMPLICATIONS AND THEIR MANAGEMENT
 

Recently uploaded

Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLyons Health
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadAlex Clapson
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)bishwabandhuniraula
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfhezamzaki1
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal TutorNehaKewat
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024Traumasoft LLC
 
Drug stability and chemical Kinetics UNIT V
Drug stability and chemical Kinetics UNIT VDrug stability and chemical Kinetics UNIT V
Drug stability and chemical Kinetics UNIT VDr Rakesh Kumar Sharma
 
Experience the Power of Chiropractic in Maui
Experience the Power of Chiropractic in MauiExperience the Power of Chiropractic in Maui
Experience the Power of Chiropractic in MauiCentral Maui Chiropractic
 
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGPresentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGKREDASONBANGALORE
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdfDolisha Warbi
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsIris Thiele Isip-Tan
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha KewatNehaKewat
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinicsnetraangadi2
 
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11crzljavier
 
Govt releases guidelines to curb unethical pharma sector practices.pdf
Govt releases guidelines to curb unethical pharma sector practices.pdfGovt releases guidelines to curb unethical pharma sector practices.pdf
Govt releases guidelines to curb unethical pharma sector practices.pdfCompetitionPedia
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareratilalthakkar704
 

Recently uploaded (20)

Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete HealthLiving Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
Living Well Every Day: Lyons Wellness Practice | Nurtures Your Complete Health
 
Empathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion insteadEmpathy Is a Stress Response - Choose Compassion instead
Empathy Is a Stress Response - Choose Compassion instead
 
Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)Basics of Giant Cell Tumor of bone (GCTB)
Basics of Giant Cell Tumor of bone (GCTB)
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdfAnatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
Anatomy Shelf Notevbhhhhhhhhhhhhhhhs.pdf
 
ARTHRITIS.pptx Prepared by monika gopal Tutor
ARTHRITIS.pptx Prepared  by monika gopal TutorARTHRITIS.pptx Prepared  by monika gopal Tutor
ARTHRITIS.pptx Prepared by monika gopal Tutor
 
21 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 202421 NEMT Trends & Statistics to Know in 2024
21 NEMT Trends & Statistics to Know in 2024
 
SCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATIONSCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATION
 
Painting Rats White Angers Them to No End
Painting Rats White Angers Them to No EndPainting Rats White Angers Them to No End
Painting Rats White Angers Them to No End
 
Drug stability and chemical Kinetics UNIT V
Drug stability and chemical Kinetics UNIT VDrug stability and chemical Kinetics UNIT V
Drug stability and chemical Kinetics UNIT V
 
Experience the Power of Chiropractic in Maui
Experience the Power of Chiropractic in MauiExperience the Power of Chiropractic in Maui
Experience the Power of Chiropractic in Maui
 
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGPresentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
 
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
"ANATOMY AND PHYSIOLOGY OF THE SKIN".pdf
 
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, BenefitsArtificial Intelligence in Healthcare: Challenges, Risks, Benefits
Artificial Intelligence in Healthcare: Challenges, Risks, Benefits
 
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
LARYNGEAL CANCER.pptx  Prepared by Neha KewatLARYNGEAL CANCER.pptx  Prepared by Neha Kewat
LARYNGEAL CANCER.pptx Prepared by Neha Kewat
 
The Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdfThe Power of Active listening - Tool in effective communication.pdf
The Power of Active listening - Tool in effective communication.pdf
 
Hematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of HematinicsHematinics and Erythropoietin- Pharmacology of Hematinics
Hematinics and Erythropoietin- Pharmacology of Hematinics
 
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES  11
FINAL PROJECT IN EMPOWERMENT TECHNOLOGIES 11
 
Govt releases guidelines to curb unethical pharma sector practices.pdf
Govt releases guidelines to curb unethical pharma sector practices.pdfGovt releases guidelines to curb unethical pharma sector practices.pdf
Govt releases guidelines to curb unethical pharma sector practices.pdf
 
Assisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCareAssisted Living Care Residency - PapayaCare
Assisted Living Care Residency - PapayaCare
 

Ice syndrome

  • 1. CASE PRESENTATION Presenter- Dr. Nancy Sehdev Moderator- Dr. Rita Dhamankar
  • 2.  Name- S W  Age- 27 years  Sex- Female  Address- Kharghar
  • 3. Chief complaints First day-14/12/12  Diminution of vision in left eye even with glasses since 2 months.  Pain in left eye since 2 months
  • 4. History of presenting illness  Apparently alright 2 months back when she noticed diminution of vision in left eye, gradual in onset and progressive in nature.  Associated with pain in her left eye, pricking in nature, present throughout the day.  Sometimes pain used to increase in the evening.  No aggravating and relieving factors and radiating to left brow and forehead area.
  • 5.  Had shown to another ophthalmologist where she was diagnosed to have anterior segment dysgenesis and was prescribed following eye drops- left eye 1. Eyemist forte eye drops( Hydroxypropyl methyl cellulose 3mg, Dextran 70, Glycerin) sos. 2. Travatan eye drops(Travoprost 0.004%) once at night. 3. Dortas T eye drops( Dorzolamide hydrochloride 2%, Timolol Maleate 0.5%) 2 times per day.
  • 6.  History of using glasses since 7-8 years.  Her present glasses were 5 months old.  No ho redness, watering.  No ho photophobia.  No ho coloured halos.  No ho trauma  No ho similar complaints in the other eye.
  • 7. • PAST HISTORY No history of similar complaints in the past. • FAMILY HISTORY Nothing significant.
  • 8.  GENERAL PHYSICAL EXAMINATION-  Normal  SYSTEMIC EXAMINATION-  Normal
  • 9. Ocular examination  Head posture- Erect  Facial symmetry- symmetrical
  • 10. Visual acuity SPH CYL AXIS VA DIST -2.50 -1.50 160 6/12 NEAR - - - N18 Extra ocular movements-All uniocular and binocular extraocular movements are full and free. SPH CYL AXIS VA DIST -2.00 -2.00 20 6/6 NEAR - - - N6
  • 11. Structure Right eye Left eye lids Normal Normal Conjunctiva Normal Mild superficial conjunctival congestion Cornea Clear Few iris pigments on endothelium Anterior chamber Quiet Irregular in depth, quiet Anterior segment examination
  • 12. Anterior segment examination Iris Normal in colour and pattern Loss of pattern, Iris holes Pupil Round, regular and reacting to light single, eccentric pupil, round,3mm in size, sluggishly reactive, pseudopolycoria Lens Clear Clear, iris pigments on anterior lens capsule.
  • 15. Intraocular pressure  On applanation tonometer- 14mm Hg in both eyes
  • 18. Fundus OD OS Glow Present Present Media Clear Clear Disc Small Small cup:disc 0.4:1 0.8:1, small inferior notch Macula Foveal reflex present Foveal reflex present Background Normal Normal
  • 20. Provisional diagnosis  Right eye refractive error  Left eye Iridocorneal endothelial syndrome
  • 23. Specular microscopy- RE WNL LE shows polymegathism with silver beaten appearance
  • 24. Definitive diagnosis  Right eye refractive error  Left eye Iridocorneal endothelial syndrome
  • 25.  After the above investigations, patient was advised to continue same eye drops-left eye 1. Eyemist forte eye drops( Hydroxypropyl methyl cellulose 3mg, Dextran 70, Glycerin) sos. 2. Travatan eye drops(Travoprost 0.004%) once at night. 3. Dortas T eye drops( Dorzolamide hydrochloride 2%, Timolol Maleate 0.5%) 2 times per day. Patient was given appointment for diurnal variation test.
  • 26. Diurnal variation test-24-01-13 Time IOP B.P. 3:oo pm 16 16 120/80 5:00 pm 14 24 110/76 7:00 pm 14 24 108/76 9:00 pm 14 24 108/76 12:00 am 14 24 108/76 3:00 am 14 22 108/78 6:00 am 14 22 100/80
  • 27. Time IOP B.P. 8:00 am 12 16 110/80 10:00 am 12 16 108/76 12:00 pm 14 16 120/72 3:00 pm 14 16 110/78
  • 28. Right eye Left eye Highest IOP 16 24 Lowest IOP 12 16 •Patient was asked to continue same eye drops and review after 6 weeks. •Also, Dortas T eye drops were asked to be added a little later in the day to blunt off the spike.
  • 29.  Subsequently patient was followed up with intervals of 2-3 months for IOP evaluation.  Her IOP was well controlled throughout.
  • 30. 23-08-2013  Patient came for regular follow-up. She was in first trimester of pregnancy.  On examination, BCVA in Right eye was 6/6, N6 Left eye was 6/12, N18  Anterior and posterior findings were same as before.  Patient was advised to stop Travoprost eye drops for first trimester as it could be an abortifacient and follow up 3 weeks.
  • 31.  On subsequent follow ups till Feb 2014, her pressures were under control.  Then she directly came for follow up on 08-10-14.  She was using both Dortas T eye drops 2 times daily and Travatan eye drops once daily in left eye.  IOP was 10mmHg in right eye and 16 mmHg in left eye.
  • 33. Perimetry OS Not very reliable with too many fixation losses
  • 34.  Patient was asked to continue same treatment and review every 3 months for IOP evaluation.  On 27-07-15, patient came for follow up.  IOP was 14 mmHg in both eyes.
  • 37. GPA Printout There seems to be a trend towards progression on VFI
  • 38.  On her last followup visit- 14-01-16  IOP- 12 mmHg in right eye and 14 mmHg in left eye.
  • 40. Perimetry- OS Shows a definitive inf nasal arcuate defect with an early Siedel’s .
  • 41. OCT
  • 42.  There seems to be a progresion happening.  Hence an AGV counselling was done.  Till then, advised to continue same eye drops and review after 1 month.
  • 44. Disorders of the cornea associated with glaucoma • Peters’ anomaly • Aniridia • Axenfeld-Rieger syndrome Developmental disorders • Keratouveitis • Full thickness or endothelial keratoplasty • Trauma Acquired conditions
  • 45.  Glaucomas associated with primary disorders of corneal endothelium 1. Iridocorneal endothelial syndrome (Unilateral) 2. Posterior polymorphous dystrophy (Bilateral) 3. Fuch’s endothelial dystrophy (Bilateral) Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS. Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
  • 46. Glaucoma with secondary corneal abnormalities A. Pressure induced corneal changes 1. Epithelial and stromal oedema 2. Endothelial changes 3. Haab’s striae(childhood glaucoma) B. Exfoliation induced corneal endothelial changes
  • 47. C. Drug induced changes in the cornea 1. Endothelial decompensation with topical carbonic anhydrase inhibitors. 2. Toxic effects to cornea epithelium(eg: benzalkonium chloride, β- blockers, miotics.)
  • 48. Iridocorneal endothelial syndrome  Characterised by primary corneal endothelial abnormality.  Associated with- 1. corneal oedema 2. Anterior chamber angle changes 3. Alterations in iris 4. Glaucoma Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
  • 49. General features  Clinically unilateral  Age- early to middle adulthood  Sex- females more commonly affected  Familial cases rare  No consistent association with any systemic disease  Most common clinical manifestations- Abnormalities of iris Reduced vision Pain
  • 50. Major clinical variations Progressive iris atrophy • Iris features predominate • Corectopia • Atrophy and hole formation Allingham RR, Damji KF, Freedman SF et al. Editors. SHEILDS. Textbook of Glaucoma.6th ed. Lippincott Williams & Wilkins: 2012
  • 51. Chandler syndrome • Corneal oedema often at normal IOP • Iris changes mild to absent
  • 52. Cogan –Reese syndrome • Nodular, pigmented lesions of iris • Corneal and iris defects
  • 53. Specular microscopy  Fine hammered silver appearance of posterior cornea.  Pleomorphism in size and shape.  Dark areas within the cells.  Loss of clear hexagonal margins Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
  • 54. ICE cells  These endothelial cells appear dark by specular microscopy except for light central spot and a light peripheral zone.  When clustered as continuous cells, known as ICE TISSUE.  Give appearance of negative of a tissue.
  • 55. Variations of ICE tissue • Disseminated ICE – 1. ICE cells scattered among large endothelial cells. 2. elevated IOP • Total ICE- 1. Whole posterior corneal surface composed of ICE tissue. Hirst LW, Quigley HA, Stark WJ, et al. Specular microscopy if iridocorneal endothelia syndrome. AM J Ophthalmol. 1990;89(1):11-21.
  • 56. • Subtotal ICE(+)- 1. clearly defined ICE tissue 2. remaining cells-distinct small cells 3. normal IOP • Subtotal ICE (-)- 1. ICE tissue 2. larger than normal remaining endothelial cells.
  • 57. Anterior chamber angle alterations  Peripheral anterior synechia, usually extending to or beyond Schwalbe’s line is common to all variations of ICE syndrome.  Histology reveals a cellular membrane consisting of a single layer of endothelial cells and Descemet’s like membrane extending down from the peripheral cornea. Weber PA, Gibb G. Iridocorneal endothelial syndrome glaucoma without peripheral anterior synchias. Glaucoma. 1994;6:128.
  • 58. Membrane theory of Campbell Campbell DG, Shields MB, Smith TR. The corneal endothelium and the spectrum of essential iris atrophy. AM J Ophthalmos. 1978;86(3):317-324.
  • 59. Differential diagnosis Corneal endothelial disorders Posterior polymorphous dystrophy Fuch’s endothelial dystrophy
  • 60. Dissolution of the iris Axenfeld Rieger syndrome • Congenital • Bilaterality • Prominant anteriorly displaced Schwalbe’s line • Associated ocular and systemic abnormalities. Iridoschisis  Separation of superficial layers of iris stroma  May be associated with glaucoma  Typically seen in elderly
  • 61. Nodular lesions of iris  Bilateral diffuse iris nodular nevi- 1. Neurofibromatosis 2. Oculodermal melanocytosis 3. Axenfeld syndrome 4. Peter’s anomaly 5. Inflammatory disorders-sarcoidosis
  • 62. Management Of ICE Syndrome  In early stages, drugs that reduce aquoeus production are used.  Aqueous facilitators are of no use, as the TM is affected . However other pathways may still be targeted.  Prostaglandins may not be advocated, as there is a school of thought that believes the HSV / Epstein Barr virus to be an aetiological factor.  There have been no reported cases of reactivation of the viral infection.
  • 63.  When the IOP can no longer be controlled medically, surgical intervention is indicated.  Laser trabeculoplasty is not effective for this disease, as the angle is affected.
  • 64.  Filtering surgery is reasonably successful, though late failures have occured because of endotheliazation of the filtering bleb & the fact that the surgery is done on relatively young adults, where fibroblastic proliferation is common. .  Glaucoma drainage device surgery, is the surgery of choice & has proven to be more effective. Kim DK, Aslanides IM, Schmidt CM Jr, et al. Long term outcome of aqueous shunt surgery in ten patients with iridocorneal endothelial syndrome. Ophthalmology. 2000;106(5):1030-1034.
  • 65.  Corneal oedema may be controlled improved by lowering the IOP.  Hypertonic saline solutions can be used.  Penetrating keratoplasty or DSAEK if there is marked dysfunction of corneal endothelium and oedema is not getting cleared. Alwin PT, Cohen EJ, Rapuano CJ, et al. Penetrating keratoplasty in iridocorneal endothelial syndrome. Cornea. 2001;20(2):134-140.
  • 67. Beta-blockers-FDA rating class C  Drugs like timolol, levobunolol, betaxolol, carteolol- should be avoided in the first trimester of pregnancy and discontinued 2-3 days prior to delivery to avoid beta-blockade in the infant.  Beta-blockers being concentrated in breast milk, avoided in mothers who are breastfeeding.  Timolol - reported to be compatible with lactation according to the American Academy of Pediatrics. Michael J. Trad. Some ophthalmic drugs not safe for use in lactating or pregnant women Primary Care Optometry News, September 2008
  • 68. Carbonic anhydrase inhibitors- FDA rating Class C  Contraindicated during pregnancy because of potential teratogenic effects.  Avoided in mothers who are breastfeeding because of the potential hepatic and renal effects to the infant.  However, acetazolamide has been reported to be compatible with lactation according to the American Academy of Pediatrics.
  • 69. Miotics-Class C  Drugs like pilocarpine, echothiophate, carbachol appear to be safe during pregnancy.  The toxicity during lactation is unknown.  One exception is demecarium, which is toxic and is contraindicated in pregnancy and mothers who are breastfeeding.
  • 70. Prostaglandin analogs-Class C  Prostaglandins are used systemically for labor induction and termination, and as such, the topical use for glaucoma during pregnancy raises natural concern.  Therefore, caution should be exercised when latanoprost is administered in women who are pregnant or breastfeeding.
  • 71. Adrenergic agonists- Class C  Brimonidine has not demonstrated any fetal risk. Although no studies were conducted in pregnant patients, it may be used if necessary.  Whether brimonidine is excreted in human milk is not known. Therefore, caution should be exercised since topical brimonidine given to human infants aged younger than 2 months has been reported to cause bradycardia, hypertension, hypothermia, and apnea.