University of Iowa Health Care

Ophthalmology and Visual Sciences

gonioscopy.org

Examples of Diagnosis


Angle Recession (Deep): 38 year-old man was struck in this eye two weeks ago with a rock thrown by a lawn mower. His lens was dislocated. His intraocular pressure was normal.

Angle Recession Dark CB Band: 44 year-old man who was involved in a motor vehicle accident as a child. He has mildly elevated IOPs and extensive angle recession in both eyes.

Angle Recession Broken Iris Process: 25 year-old man who has been a boxer for many years. He has had elevated IOP since age 22. His angles are recessed OU.

Pigment Dispersion from Angle Recession: This is a 67 year old male who has elevated intraocular pressures in both eyes, the right greater than the left. At age 13 he had severe blunt trauma to the right eye and had a very slow recovery and then a gradual decline again during his childhood. He had been treated for elevated intraocular pressure for over 20 years at the time these videos were taken. The patient has extensive angle recession and has a secondary pigment dispersion syndrome in the right eye. While his axial eye lengths are symmetrical his anterior chamber depth on the right side is deeper than the left (3.52 mm OD and 2.30 mm OS). This patient has been published: McKinney, J. K. and W. L. Alward (1997). "Unilateral pigment dispersion and glaucoma caused by angle recession." Arch Ophthalmol 115(11): 1478-9. Asymmetric pigmentary glaucoma caused by unilateral angle recession: Ritch, R. and W. L. Alward (1993). "Asymmetric pigmentary glaucoma caused by unilateral angle recession." Am J Ophthalmol 116(6): 765-6. NOTE: This clip is presented both under angle recession and under pigmentary.

Tangential Tear: This 32 year old gentleman was hit above the right eye with a golf ball from approximately 100 yards. He developed a hyphema. Subsequently he had an elevated intraocular pressure treated with beta blockers. On gonioscopy he was found to have extensive angle recession and an unusual tear visible in the ciliary body face.

Angle Recession with Sphincter Tear: Examples of angle recession emphasizing the need to compare the angles in the two eyes.
Courtesy of: Howard Cohn, MD, American Hospital of Paris

Angle Recession with Iridodialysis: This young patient was hit with a BB pellet in a glancing blow that did not penetrate the eye or orbit. He presented with a count fingers vision and an intraocular pressure of 9 mmHg. He has an iridodialysis with angle recession. There is an area at 7 o’clock that looks like a cyclodialysis cleft. This patient’s low pressure resolved spontaneously and his vision returned to normal.

Angle Recession with Pigment Dispersion: 39 year-old man suffered severe head trauma six years before (he was in a motorcycle accident and hit a tree with his face). The right optic nerve is avulsed and the eye has no light perception. The left eye has 20/15 vision with mild ocular hypertension controlled on one medication. Both angles are recessed. The right has a flap tear in the ciliary body face and the left has pigment dispersion syndrome.

Angle Recession with Synechia: This 23 year old man was struck in the right eye with a plastic pellet fired from a C02 rifle. He presented with corneal edema, a 10% hyphema, and a pressure of 4 mmHg. At 6 weeks following the injury this video was taken. At that time his vision was 20/20 and his intraocular pressure 13 mmHg. He has a recession for about 180 degrees and also has areas where the iris is adherent across the recession.

Aniridia: 39 year-old woman with a family history of aniridia in her mother and maternal grandmother. She has had an elevated intraocular pressure OU since her teenage years. The lens in her right eye has partially resorbed spontaneously. Her visual acuity is 20/50 OD and (remarkably) 20/80 OS. Her pressures are normal on 4 medications. She is remarkable for her relatively good vision due to a lack of foveal hypoplasia and her remarkably clear corneas.

Aniridia - Pannus (Slit Lamp Only): This elderly woman has had nystagmus since birth. She has severe corneal pannus due to her aniridia.

Traumatic Aniridia: 83 year-old woman who fell and struck her left eye. She had undergone phacoemulsification cataract surgery five months before. Her IOP was 40 mmHg and an Ahmed seton was placed.
Courtesy of Young H. Kwon, MD, PhD, University of Iowa.

Aniridia (slit lamp only): This 43 year old patient has always been blind in her left eye. The right eye shows a dislocated lens, nystagmus, and pannus.

Response to Atropine: This patient was referred 5 days after trabeculectomy with a shallow anterior chamber and an intraocular pressure of 20 mmHg. She responded to treatment with atropine alone.

Aqueous Misdirection (Slit Lamp Only): Elevated IOP since age 23. Underwent a trabeculectomy at age 24. At 5 months after surgery he had an IOP of 13 mmHg. At 8 months after surgery he noted decreased vision. His IOP was 21 mmHg. A large fluid pocket was seen on echography. His anterior chamber deepened with atropine.

Aqueous Misdirection (1): Presented at age 41 with angle closure. She had had an iridotomy and iridoplasty. Despite maximum medical therapy her IOP was 52 mmHg. Her early postoperative course was uneventful. Four months later she presented with blurred vision and pain. Her IOP was 24 mmHg.

Aqueous Misdirection (2): A 48-year-old man was hit with a bungee cord 23 years previously. He had undergone an anterior chamber wash-out for hyphema and subsequently had corneal transplants in 1980 and 1999. When we saw him in 2001 he had been having pain in this eye for 2.5 years. He was on two glaucoma medications. One can see this anterior chamber is completely flat and in fact his IOL is embedding into his cornea. His pressure was 80 mm of mercury (checked on the sclera).

AR Iris Hypoplasia (slit lamp only): This is a patient with Axenfeld-Rieger Syndrome who was not diagnosed until he was 21 years of age. He has iris stromal hypoplasia without polycoria or corectopia. He does have dental anomalies, redundant periumbilical skin, and hypospadias. This patient has a mutation in the PITX2 gene.

AR Syndrome - Mild: This young woman is the mother of a 1 year-old child referred for evaluation of Axenfeld-Rieger syndrome. This woman has no history of glaucoma and no systemic features of Axenfeld-Rieger syndrome. Her daughter had marked corectopia and polycoria but also did not have glaucoma.

Axenfeld-Rieger Syndrome (1): This young patient has a strong family history of Axenfeld-Rieger syndrome. He has no obvious embryotoxon but does have iris hypoplasia and, on gonioscopy. has multiple iris processes up to the embryotoxon.

Axenfeld-Rieger Syndrome (2): This patient has a family history of Axenfeld-Rieger syndrome (ocular findings only). She has had glaucoma since a very young age and has had two trabeculectomies. She has mild iris hypoplasia and a posterior embryotoxon.

Axenfeld-Rieger Marked (slit lamp only): 4 year-old boy whose father has unilateral ectopic pupil, small teeth, redundant periumbilical skin and glaucoma. This patient has the iris changes seen here and dental and umbilical changes – through age seven he has no glaucoma.

AR Syndrome - Broken Embryotoxon: This 36 year-old man was diagnosed first as having glaucoma in 1978. He has had intermittent care throughout his life and has been lost to follow-up many times. He first presented here with no light perception vision in the right eye and 20/40 vision in the left eye. His intraocular pressures were 26 mmHg OD and 13 mmHg OS. He has systemic features of Axenfeld Rieger Syndrome including microdontia and maxillary hypoplasia.

Axenfeld-Rieger Syndrome (3): Presented at age 8 with elevated intraocular pressure in both eyes. She had pressures as high as 40 mmHg OU. She underwent trabeculectomies OU. She is now 20 years-old and her IOP is now well controlled on no medication.

AR Syndrome - Phenotypic Variability: This 8 year-old girl was born prematurely at 23 weeks of gestation. She had cloudy corneas in the first few weeks of life and IOP’s into the mid 40 range. She was diagnosed with primary congenital glaucoma. She had multiple surgeries for glaucoma. With time her iris took on a more hypoplastic look. She was also noted to be small for her age. Because of this she was tested for mutations in the PITX2 and FOXC1 genes. She was found to have a mutation in the FOXC1 gene that was shared by her mother (who had no glaucoma) and her brother (who had no known glaucoma but did have cardiac valve disease – which can be associated with FOXC1 mutations.

Axenfeld-Rieger Syndrome (4): This 22 year-old woman who has had glaucoma since early childhood. She has had at least seven surgeries by her history and was evaluated during the evaluation of her son who also has developmental glaucoma. She has count fingers vision in the right eye and 20/20 in the left. Her intraocular pressures are 20 mmHg OD and 14 mmHg OS using timolol, dorzolamide, and latanoprost in the right eye. One can see the marked embryotoxon and iris hypoplasia OU and changes in the right eye that are partially from the multiple surgical procedures.

Peripheral Peters Anomaly: This patient was seen at age 16 at the University of Iowa in 1976 with 20/50 vision OD and 20/200 vision OS. He has retinopathy of prematurity, left esotropia, and nystagmus. On slit lamp examination he had this interesting adhesion bilaterally between the cornea and the iris that was called a peripheral Peter’s variant. The video here was taken 32 years later when his vision had decreased to count fingers in the left eye due to his worsening cataract.

Unknown Angle Anomaly: This patient was seen at age 16 at the University of Iowa in 1976 with 20/50 vision OD and 20/200 vision OS. He has retinopathy of prematurity, left esotropia, and nystagmus. On slit lamp examination he had this interesting adhesion bilaterally between the cornea and the iris that was called a peripheral Peter’s variant. The video here was taken 32 years later when his vision had decreased to count fingers in the left eye due to his worsening cataract.

Ciliary Body Swelling: This patient presented in narrow angles after an ischemic central retinal vein occlusion. One can see that the iridocorneal angle is quite narrow. This is not from papillary block but from swelling of the ciliary body.

Cyclodialysis Cleft (1): This 43 year-old man was punched in this eye 5 years previously and has had decreased vision since that time. On initial examination he had 20/50 vision with an intraocular pressure of 8 mmHg. Gonioscopy was difficult but it appeared that there might be a cyclodialysis cleft inferiorly. The patient was treated with steroids in the hope of decreasing trabecular outflow. He was also placed on atropine to deepen the angle. On follow-up his intraocular pressure had not improved but the atropine had improved the view of his iridocorneal angle and it was clear that there was a cyclodialysis cleft at twelve o'clock.

Cyclodialysis Cleft (2): This 18 year-old woman was struck by a water balloon in her left eye. She presented with count fingers vision and an intraocular pressure of 4 mmHg. She had a 30% hyphema. After a period of hypotony her intraocular pressure gradually returned to a normal level without intervention. This video was taken five months after her injury and shows a cyclodialysis cleft that has healed on its own.

Cyclodialysis Cleft (3): This patient was struck in the eye with a bungee cord five months prior to this examination. He sustained a hyphema, which resolved. However two months later he had decreased visual acuity with optic nerve edema and retinal folds. On examination he had 20/300 vision in the right eye with an intraocular pressure of 7 mmHg.

Cyclodialysis Cleft (4): This patient was injured with a racquetball in the left eye 37 years before he was evaluated in our clinic. He did not have any examination at the time of injury. In 2012 he was found to have an elevated intraocular pressure with angle recession. On our examination we found the angle to be recessed with a very wide area of a cyclodialysis cleft that has clearly healed on its own.

Iris Cyst: On routine eye examination this 33 year-old woman was found to have a mass in her right iris. This had never been noted before. The patient was asymptomatic. Her visual acuity and intraocular pressures were normal. By echography she has a fluid-filled cyst in her iris.

Epithelial Inclusion Cyst (1): Presented at age 32 with a mass in the left eye. He had a vague history of trauma but was not sure which eye. Vision 20/25, IOP 18 mmHg. Underwent iridocyclectomy. At last follow-up, 3 years after surgery, he had no evidence of epithelium. His visual acuity was 20/15 vision and his IOP was 16 mmHg.

Iris Stromal Cyst: 79yo male presented in 2003 with iris stromal cyst OD. This was noted on a routine eye examination and had not been noted three years before. On echography this lesion is cystic. In four years of follow-up there was no interval change.

PDS from Iris Cysts (1): This 42 year-old woman had elevated intraocular pressures with evidence of pigment dispersion. Rather than having the typical slit-like defects in the pigment epithelium that one would see in pigment dispersion syndrome she had large globular areas of pigment epithelial loss and on ultrasound biomicroscopy was found to have cysts of the iris pigment epithelium pushing the pigment epithelium against the zonules. The patient is seen 6-years later at which time one of the cysts has grown large enough to reach into the pupil. You can see that she has undergone a trabeculectomy for intractably elevated intraocular pressures. The video was taken not long after her trabeculectomy, which explains the blood subconjuctivally inferiorly. This patient was reported in the Archives of Ophthalmology volume 113, pages 1574-1575, 1995.

PDS from Iris Cysts (2): This 47 year-old man presented with bilateral narrow angles. On examination he was found to have large iris cysts of the pigment epithelium. His intraocular pressures were normal in both eyes but there were portions of his iridocorneal angle that were closed and therefore an iridotomy was performed in the left eye. This video shows the patient before and after the iridotomy. This patient also had pigment dispersion caused by abrasion of the pigment epithelium against the lens zonules.

Cyst of the Iris Pigment Epithelium: When this patient was undergoing cataract extraction her surgeon noted a mass that had not been seen before and aborted the case. She has a cyst of the iris pigment epithelium that, on dilated examination, extends into the pupillary space.

Epithelial Inclusion Cyst (2): This 25 year old man was struck in the right eye with a screwdriver 6 years before this video was taken. His visual acuity was light perception. He has had a normal intraocular pressure and as can be seen a dense white cataract as well as a small clear cyst in the anterior chamber. The patient had the lens and epithelial cyst removed with placement of a posterior chamber intraocular lens. When he was last seen, 9 months after his surgery he refracted to 20/20 and had no evidence of recurrence of the cyst, which had been removed intact.

Iris Pigmented Epithelial Cysts: On routine examination this 65 year-old female was found to have an area of fullness in the iris of her right eye. Here she was found to have multiple iris cysts in both eyes.

Cyst of the Iris Pigment Epithelium (2): This 61-year-old man had a large iris pigment epithelial cyst that protruded into his pupil. It was so large that it compromised the inferior 180° of his iridocorneal angle. The cyst was lasered where it was very thin in the pupil and his angle opened markedly.

Epithelial Inclusion Cyst with Debris: This 58-year-old woman had a trabeculectomy in her left eye in March 2011. In December 2011, she was found to have a cyst in her inferior anterior chamber and a year later this had grown so she was referred to see us. The cyst was drained and the contents were consistent with an epithelial inclusion cyst. This is interesting in that one can see cellular debris moving within the cyst in convection currents.

Ectopia Lentis (slit lamp only): This patient was first seen at age 13 with ectopia lentis. The left eye lost vision at age 16 due to a retinal detachment. The right eye developed elevated intraocular pressure at age 34.

Lens in Vitreous: 57 year-old woman with presumed Marfan’ syndrome. Her other eye had ectopia lentis and developed phacolytic glaucoma. This eye has a lens in the vitreous that is well tolerated. She wears aphakic correction.

Ectopia Lentis & Pseudoexfoliation: This woman presented at age 83. She was known to have pseudoexfoliation with poor control of her intraocular pressures in both eyes despite maximum tolerated medical therapy. At the time of presentation she had 20/100 vision OD and 20/250 vision OS. Her intraocular pressures were 27 mmHg OD and 52 mmHg OS. She underwent an intracapsular cataract extraction with trabeculectomy OS and had a good visual and intraocular pressure outcome. Note: This clip is presented both under ectopia lentis and pseudoexfoliation.

Ectopia Lentis et Pupillae (slit lamp only): This 37-year old has woman has ectopia lentis et pupillae. She has undergone pars plana vitrectomy and lensectomy approximately 6 years before this examination. One can see that the pupils are displaced up and out. The lenses were displaced down and in.

Traumatic ectopia lentis (slit lamp only): After blunt trauma, this patient has a subluxed lens. He also has asteroid hyalosis, which makes for an interesting slit lamp picture.

Ectopia Lentis: This patient was struck in the eye with a spring from an garage door.

Exfoliation Syndrome with Ectopic Intraocular Lens (slit lamp only)

Epithelial Downgrowth: This patient was referred for a glaucoma evaluation. She had a history of undergoing an intracapsular cataract extraction in 1979. In November 2004 she had a secondary anterior chamber intraocular lens placed and subsequently developed intractably elevated intraocular pressure. She was seen in this video 8 months after the anterior chamber intraocular lens was placed.

Fibrous Downgrowth: This 45-year-old woman has primary open angle glaucoma and had undergone multiple surgeries in this eye including a trabeculectomy in 2007, which required a revision and then an Ahmed stunt surgery, which also required a revision. She was hypotonus for periods during her postoperative care. She was then seen by another physician who found that her Ahmed Seton tube was impaled into her crystalline lens, which required her to have a shunt revision with a cataract extraction. She later underwent another Ahmed revision and subsequently a Baerveldt Seton with a pars plana vitrectomy and the tube placed in the posterior segment. She was referred to the University of Iowa because of the corneal changes seen in this video.

Exfoliation Syndrome at the Pupillary Margin (slit lamp only): This 74 year-old woman has unilateral exfoliation syndrome with an intraocular pressure to 27 mmHg.

Exfoliation Syndrome with Scrolled Material: This 86 year-old woman has exfoliation syndrome. The material on hr anterior lens capsule has been folded back by the action of her iris.

Exfoliation Syndrome (1): 62 year-old woman with unilateral elevated intraocular pressure (to 38 mmHg).

Frosted Zonules: 58 year-old woman with pseudoexfoliation glaucoma diagnosed at 43 years of age when she presented with an IOP of 64 mmHg in this eye. This eye had undergone a trabeculectomy 14 years before this examination.

Exfoliation Syndrome (2): This excellent clip shows many features of exfoliation syndrome.
Courtesy of Howard Cohn, MD, American Hospital of Paris

Phacodonesis: This 83-year-old man has exfoliation syndrome. He was diagnosed eight years before this video was shot. The pressure was uncontrolled and he ultimately required a trabeculectomy. One can see marked phacodonesis.

Exfoliation Syndrome & Ectopia Lentis: This woman presented at age 83. She was known to have exfoliation syndrome with poor control of her intraocular pressures in both eyes despite maximum tolerated medical therapy. At the time of presentation she had 20/100 vision OD and 20/250 vision OS. Her intraocular pressures were 27 mmHg OD and 52 mmHg OS. She underwent an intracapsular cataract extraction with trabeculectomy OS and had a good visual and intraocular pressure outcome. Note: This clip is presented both under exfoliation syndrome and ectopia lentis.

Dislocated IOL - slit lamp only: 82 year-old man with pseudoexfoliation and ocular hypertension. He had undergone phacoemulsification six years before and had gradually declining visual acuity. He regained 20/25 vision after the lens was repositioned.

Corneal Deposits - slit lamp only: In this video one can see pseudoexfoliative material on the corneal endothelium of this 63 year-old gentleman who has unilateral glaucoma with a peak intraocular pressure of 52 mmHg. These deposits look somewhat like keratic precipitates except if one studies them carefully it is possible to see that there is a movement in the aqueous. This means that these are not likely to be KP, which should be firmly adherent to the cornea, but more likely flakes of pseudoexfoliative material that are partially attached to the cornea and partially wafting in the aqueous.

Pseudophacodonesis: This 78 year old woman has a history of exfoliation syndrome in the right eye. She had had a vitrectomy and laser treatment for a retinal tear 11 years prior to this video. Subsequently, 10 years prior to this video, she had cataract extraction with an intraocular lens in the right eye. Her vision was excellent at 20/25 and her intraocular pressure was 18 mmHg. She had marked pseudophacodonesis as seen in this video. A year later the lens dislocated inferiorly and was sutured into place.

Exfoliation Syndrome with Marcelling: This 63 year old man was referred with asymmetric glaucoma. The right eye had a large cup with an intraocular pressure of 36 mmHg while the left eye had a pressure of 20 mmHg and no cup whatsoever. One can see these ridges of light and dark bands that are characteristically seen in exfoliation syndrome. There is also heavy angle pigmentation. The patient was pseudophakic and therefore we were not able to evaluate whether he had typical pseudoexfoliative debris on the anterior lens capsule. The iris changes and angle pigmentation are certainly suggestive of exfoliation syndrome.

Exfoliation Syndrome with a Chunk of Debris in the Angle: This 60-year-old man was found to have elevated intraocular pressures 16 years prior to this video. On examination he is found to have classic exfoliation syndrome. The interesting finding in him is a sheet of pseudoexfoliative debris that has collected as a mass in the inferior angle.

Fragment of Lens in Angle: At age 35 was pounding metal on metal and sustained an intraocular foreign body. He underwent an immediate lensectomy and vitrectomy. Five years later he presented with an intraocular pressure of 60 mmHg. His iris had turned brown. No metal could be detected on X-ray but the ERG was unrecordable. Seven years later (12 years after the injury) he was found to have a brown foreign body in the anterior chamber that was presumed to be retained lens material discolored by iron.

Perfluoro-n-octane in Angle: 58 year-old man who had a retinal detachment surgery 9 years before in which perfluoro-n-octane was used to flatten the retina.

Silicone Oil in the Angle: This 27 year-old male with type 1 diabetes mellitus underwent a pars plana vitrectomy with silicone oil for traction retinal detachment.

Triamcinolone in Angle: 75 year-old man with age-related macular degeneration with a sub-foveal choroidal neovascular membrane. Had intravitreal triamcinolone (Kenalog). Seven days later he was found to have crystals in his anterior segment. There was no history of prior intraocular surgery. Courtesy of Young H. Kwon, MD, PhD, The University of Iowa

Perfluoro-n-octane in the Anterior Chamber: This 26 year-old man has Marfan syndrome and had bilateral pars plana vitrectomy, lensectomy with anterior chamber intraocular lenses. Perfluoro-n-octane (PFO)was used during his vitrectomy and one can see the silicone oil in the anterior chamber at the haptic of the intraocular lens.

Fuchs Heterochromic Iridocyclitis - slit lamp only (1): 42 year-old man presented for cataract evaluation. He was found to have iris atrophy and keratic precipitates and a diagnosis of Fuchs heterochromic iridocyclitis was made.

Fuchs Heterochromic Iridocyclitis - slit lamp only (2): This 39 year-old woman had a ten-year history of iritis in the right eye. She presented on two medications with inadequate intraocular pressure control. On examination she had an intraocular pressure of 40 mmHg with iris atrophy in stellate KP. She had neovascularization of the iris and the iridocorneal angle.

Fuchs Heterochromic Iridocyclitis - Bleeding: 45 year-old male with Fuchs heterochromic iridocyclitis. Developed cataract and was undergoing phacoemulsification. Bleeding from fragile iris vessels occurred. Courtesy of Robert Honkanen, MD. SUNY Stony Brook.

Fuchs-like Uveitis: 61 year-old woman who noted floaters and decreased vision in her left eye for five months. Her IOP was 37 mmHg. She presented with KP and angle neovascularization suggestive of Fuchs' heterochromic iridocyclitis but, on dilated examination had severe sarcoid disease in her fundus. NOTE: This clip is presented both under Fuchs' heterochromic iridocyclitis and under uveitis.

Glaucomatocyclitic Crisis (slit lamp only) - 1: This 44 year old man with noted 4 years prior to this examination blurred vision in his left eye. At that time he was found to have markedly elevated intraocular pressure of 50 mmHg. Intermittently since that time he has had marked spikes in intraocular pressure requiring chronic use of corticosteroids and aqueous suppression.

Glaucomatocyclitic Crisis (slit lamp only) - 2: Presented at 37 years-old with a history of unilateral haloes and foggy vision. His IOP in this eye was 51 mmHg.

Dural Cavernous Fistula (slit lamp only): An 83 year-old woman with a dural-cavernous fistula and markedly engorged episcleral vessels.

Blood in Schlemm's Canal - 1: 72 year-old woman with asymmetric elevated IOP (48 mmHg OD, 25 mmHg OS). Dilated episcleral veins and blood in Schlemm's canal. An underlying etiology was never found.

Blood in Schlemm's Canal - 2: At age 38 this patient developed blurred vision in his left eye and was diagnosed with nonischemic central retinal vein occlusion. On follow-up 3 years later he was found to have engorged vessels in the left eye and blood in Schlemm’s canal. The intraocular pressure in this eye was elevated at 28 mmHg compared to 10 mmHg in the fellow eye. An ultrasound examination of the orbit revealed no reverse blood flow. No etiology for the elevated episcleral venous pressure was ever found.

Hyphema (slit lamp only): This 15 year-old African-American male is had undergone fine needle aspiration for a lesion that was ultimately determined to be an adenoma of the non-pigmented epithelium of the ciliary body (see his pre-hemorrhage clip under the "Tumor" clips). The patient family denied a sickle cell history but later admitted that the patients uncle died from sickle cell disease. The patient bled at the time of surgery and developed a large hyphema requiring anterior chamber washout and trabeculectomy.

Corneal Blood Staining (slit lamp only) - 1: This 18 year-old man has had diabetes mellitus since age 4. He has had severe proliferative diabetic retinopathy and neovascular glaucoma for which he has undergone setons in both eyes. At the time of this video his intraocular pressure was 4 mmHg in this eye that has had no light perception for many months. This eye has had a long-standing hyphema of more than 6 months duration.

Corneal Blood Staining (slit lamp only) - 2: At age 37 this man was poked with a finger in the eye and had a 100% hyphema. During his management he had intraocular pressures as high as 60 mmHg. He was first seen in our clinic 6-months after the injury with an intraocular pressure of 20 mmHg and the corneal blood staining that can be seen clearly in this video. He ultimately required corneal transplantation because after 13 months this staining had not resolved.

Corneal Blood Staining -1: This 11 year-old was struck by a twig in the right eye. He had a partial thickness corneal laceration and a 1.8 mm hyphema with an intraocular pressure of 18 mmHg and 20/250 vision. Four days later he developed the flu with violent vomiting. When he was seen he had light perception vision with a 100% hyphema. He underwent anterior chamber washout with a trabeculectomy. This was repeated with an iridectomy a week later. Ten days after his severe rebleed he was noted to have corneal blood staining. The video follows the course of the resolution of his blood staining over the course of 14 months. He eventually underwent cataract extraction with IOL placement and had 20/25 vision.

Corneal Blood Staining - 2: This clip is an abbreviated version of the preceding clip. It shows the resolution of corneal blood staining over 14 months.

Interstitial Keratitis (slit lamp only): This 69 year old patient has had left esotropia and amblyopia since birth. She has hand motion vision in the left eye. Both eyes have ghost vessels and stromal haze.

Interstitial Keratitis w/ Descemet's Crolls (slit lamp only): This is a patient with long standing interstitial keratitis. Unfortunately the patient is deceased and the chart is not available. She was seen with these rather spectacular scrolls of Descemet’s in the posterior cornea and in the anterior chamber. This finding has been described previously (Scattergood KD, Green WR, and Hirst LW Ophthalmology 90:1518-1523, 1983). In their paper, histopathologic studies of this material demonstrated it to have the appearance of laminated scrolls of Descemet’s membrane-like tissue.

ICE Syndrome - Subtle: This is a 43 year-old with unilateral glaucoma with an intraocular pressure to 15 mmHg and a history of a failed trabeculectomy. A great example of the endothelial changes on slit lamp examination.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Iridocorneal Endothelial: 61 year-old woman with unilateral ICE. Her slit lamp exam shows the hammered silver endothelium characteristic of ICE.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Presumed Early ICE: This is a 62 year-old woman whose physician noticed an iridocorneal adhesion one month prior to this exam. The same physician had followed this patient earlier and had never noticed a similar change. The patient’s intraocular pressure was 16 mmHg in both eyes. The central corneal endothelium was normal in this eye but the diagnosis by both the corneal specialist and glaucoma specialist was that this is probably a very early variant of ICE with abnormalities only in the peripheral cornea.

Early ICE: This 57 year-old man had been noted to have an elevated intraocular pressure in his right eye only since 2000. In 2006 he was noted to have an intraocular pressure of 34 mmHg in the right eye. On examination he has 20/40 vision in the right eye and 20/20 vision in the left eye. His intraocular pressure on three medications is 12 mmHg OD and 8 mmHg OS. The right eye has corectopia and iris nodules. He has mild corneal edema and the hammered silver appearance to his corneal endothelium. He was diagnosed with Cogan-Reese variant of the iridocorneal endothelial syndrome.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Essential Iris Atrophy - slit lamp only: This 38-year-old woman was diagnosed with glaucoma at age 36. She had been treated with multiple medications and had had an argon laser trabeculoplasty. When she was first seen here she 20/30 vision within an intraocular pressure of 34 mm Hg.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Essential Iris Atrophy - 1: Iridocorneal-endothelium syndrome. This is the essential iris atrophy variant with extensive iris damage and synechial angle closure. This patient also has corneal edema.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Essential Iris Atrophy - 2: At 41 this patient was diagnosed with glaucoma. In 1974 at the age of 42 she saw Frederick Blodi and was found to have areas of iris atrophy with a diagnosis of essential iris atrophy. Her intraocular pressure was 42 mmHg and she underwent a Scheie thermal sclerostomy in 1974 by Dr. Charles Phelps. In 2007 at the time when this video was made she had a functioning trabeculectomy with an intraocular pressure of 8 mmHg on no medications, 33 years after her Scheie procedure.

Iridocorneal Endothelial Cogan-Reese: This patient at the age of 69 awoke with sudden decreased vision in the left eye. She was found to have an intraocular pressure of 57 mmHg and was started on medical therapy with a poor response.

PDS OD, ICE OS: At 35 years old was diagnosed with both pigment dispersion OD and essential iris atrophy OS. Her essential iris atrophy prevented her development of PDS OS.

Iridoschisis: This patient was seen at age 72 for the iris changes seen in this video. He was found to have narrow angles in the right eye and on slit lamp examination the right iris appeared to be split with a forward bowing of the anterior lamellae. The left iris was disintegrated inferiorly. The patient also had marked nuclear sclerotic cataract. His intraocular pressures were normal.

Melanosis Oculi - 1: 42 year-old woman has been noted to have a dark sclera since age 15. She has normal intraocular pressures and optic nerves.

Courtesy of Emily C. Greenlee, M.D., The University of Iowa.

Melanosis Oculi - 2: 23 year-old woman presented with eye pain and headache and was incidentally found to have melanosis oculi with normal intraocular pressure.

AV Malformation: This 37 year old was found to have a prominent iris vessel on his right iris during a routine examination. This vessel was found to be non-leaking on fluorescein angiography. This patient has arterial venous malformation of the iris. A series of 14 cases were published by Shields, et. al., in the Archives of Ophthalmology, Vol. 124, pp. 370-375, 2006. To quote Dr. Shields “Iris AV malformation has characteristic clinical and fluorescein angiographic features. It appears to be a benign stationary condition that has no apparent systemic associations and no local complications.”

My thanks to the referring physicians: Kenneth C. Kubis, MD (CAPT, MC, USN - Department Head, Neuro-ophthalmology) and Andrew Doan, MD, PhD (LCDR, MC, USN - Comprehensive Ophthalmology & Ocular Pathology) Naval Medical Center San Diego.

Angle Closure from SCH: This 78 year-old man awoke with acute pain in the right eye and an intraocular pressure of 61 mmHg. His visual acuity was light perception only. He has a shallow anterior chamber and a mid-dilated pupil with corneal edema. This patient has a posterior chamber intraocular lens and his fellow eye has a very deep angle (D40R). On ultrasound examination he was found to have a very large super choroidal hemorrhage. The patient has pre-existing macular degeneration with a neovascular membrane and is on Coumadin.

Stripped Descemet's: This patient had a trabeculectomy and subsequent revision. The revision was performed two months prior to this video. He complained of decreased visual acuity post-operatively and was referred for evaluation. He has a totally detached Descemet’s membrane. Of note, during his trabeculectomy revision he developed a completely flat anterior chamber that was deepened with viscoelastic.

Kaiser-Fleischer Ring: This 15 year-old boy was referred top the Ophthalmology Department during an evaluation for Wilson’s disease. A Kaiser-Fleischer ring can be seen at the slit lamp but is very obvious on gonioscopy.

Sclerocornea - slit lamp only: We first saw this child at 8-months of age. Before being seen she had already had two penetrating keratoplasties in her left eye. This video was taken at 4½ years of age at which time she had count fingers vision in the right eye and light perception vision in the left.

Coloboma: 69 year-old man with poor vision all his life. Had fluid under his right retina that required repeated draining and laser demarcation. At age 68 he developed elevated intraocular pressure and was begun on medication.

Pupillary Membrane: This 35 year-old Asian woman has excellent vision and normal intraocular pressure. This extensive remnant of her pupillary membrane was an incidental finding. The remainder of her eye examination was normal.

Courtesy of: Howard Cohn, MD, American Hospital of Paris

Air-filled Anterior Segment: 56 year-old woman with recurrent retinal detachments. The first detachment was fixed approximately two months prior to this video. Despite this she had a large inferior retinal detachment and was referred for treatment. She had a repeat scleral buckling procedure performed with an air fluid exchange. When seen later her entire globe was gas-filled with no visible aqueous – even on gonioscopy.

Iris Retraction Syndrome: This 44 year-old male was hit with a shotgun shell on the right eye as a child. He had not had much in the way of medical attention. Three years prior to being seen for this examination he had a decrease in vision in the right eye. On examination his visual acuity in this eye was light perception and his intraocular pressure was 56 mmHg. On ultrasound he has a total retinal detachment with a cyst indicating a long standing detachment. He was started on aqueous suppressants and latanoprost. When he returned his intraocular pressure had dropped to 5 mmHg and his iris was markedly backbowed. The marked backbowing in this iris is characteristic of the very unusual condition called iris retraction syndrome that requires a break in the retina as well as 360 degrees of central posterior synechia. When these patients are treated with aqueous suppressants, the small amount of aqueous that is produced leaves via the break and is absorbed by the retinal pigment epithelium. The iris is pulled backwards. Campbell DG, Iris retraction associated with rhegmatogenous retinal detachment syndrome and hypotony. A new explanation. Arch Ophthalmol. 1984;102(10):1457-63.

Iris Flocculi: This is a healthy 36 year-old man with a history of uveitis and glaucoma in the right eye for which he had a successful trabeculectomy five years earlier. He has iris flocculi in both eyes.

Iris Roll - Trying to Dilate: This 78 year old woman with primary open angle glaucoma has been on chronic cholinergics. Her pupil fails to dilate when given cycloplegic/mydriatic drop due to fibrosis of the sphincter. However the peripheral iris does get thrown into folds by the attempt of dilation.

Congenital Microcoria: This patient was seen at age 48 years with very small pupils. She had been born with pinpoint pupils. The pupils were unresponsive to dilation. She complained of worsening visual acuity. Evaluation was challenging because of her microcoria. After discussion with the patient we proceeded to perform a pupil stretching and sphincterotomy. Subsequently the patient’s lens was removed and her visual acuity in this eye improved from 20/70 to 20/20. Ultimately the fellow eye was also done. Congenital microcoria is rare and often associated with angle abnormalities, as was the case in this patient. By definition the pupil is less than 2 mm in diameter and nonreactive or minimally reactive. The patients may have minimal symptoms other than difficulty negotiating dark environments. Microcoria may be sporadic and, when seen as an inherited disorder, is typically autosomal dominant.

Nanophthalmos - 1: This 71-year old patient presented with narrow angles. Her local physician had attempted cataract extraction but found the anterior chamber too shallow and was unable to complete the surgery. She has a refractive error of +10.5 diopters sphere in both eyes. The patient was found to have axial eye length of 16.92 mm OD and 16.97 mm OS.

Nanophthalmos - 2: This patient was first seen at the University of Iowa in 1980 at the age of 32 with narrow angles in both eyes. He underwent laser iridotomies at that time. In 1986 he developed cystoid macular edema in the left eye that persisted over several years. Standardized echography was performed in 1990 that showed actual eye lengths of 19.3 mm OD and 19.1 mm OS with lens thicknesses of 5.1 mm OD and 5.2 mm OS. He had marked thickening of the retinal choroidal layer. In 1991 he developed spontaneous choroidal effusions in the left eye for which he underwent four quadrant scleral windows. The cystoid macular edema in the left eye left him with chronically decreased vision in that eye. In 2007 he was referred with a nearly completely flat anterior chamber in the left eye. He underwent lensectomy vitrectomy on that eye with subsequent control of his intraocular pressure. Viewed here is the right eye which has 20/20 vision and an intraocular pressure of 15 mmHg but a very shallow anterior chamber and a lens that has grown in thickness from 5.1 mm in 1990 to 5.6 mm in 2008.

Radiation-Induced Neovascularization

Neovascularization of the Angle in Diabetes: 20 year-old with type I diabetes mellitus.

NVI with PAS: Neovascularization of the angle with some open areas and areas that are closed by synechiae.

Courtesy of Howard Cohn, MD, American Hospital of Paris

Neovascularization of the Angle Pre- & Post-Laser: This 57 year-old man with a history of diabetes mellitus was seen with a sudden increase of intraocular pressure to 50 mmHg in his right eye. The patient had been treated for proliferative diabetic retinopathy with panretinal photocoagulation in the past. One will see that he has active neovascularization of the iridocorneal angle. The patient underwent further panretinal photocoagulation that day and one week later. Two weeks after the first video he was seen again with dramatic resolution of the neovascularization.

Courtesy of Young H. Kwon, M.D., Ph.D., University of Iowa.

Neovascularization onto the lens - slit lamp only: 41 year-old man with long-standing poorly controlled diabetes mellitus. He has had pan-retinal photocoagulation in this eye on many occasions. At this examination he had light perception vision.

Courtesy of Young H. Kwon, M.D., Ph.D., University of Iowa.

Neovascularization 360 deg Closed Angle: This 21 year-old man has had diabetes since two years of age. He has severe prolferative diabetic retinopathy for which he has undergone many sessions of panretinal photocoagulation as well as pars plana vitrectomy. He has Neovascular glaucoma for which he has had a Baerveldt seton placed.

Neovascularization of Angle with Peripheral Anterior Synechia: This 63 year-old woman had malignant lymphoma of the left orbit for which she received radiation therapy three years prior to this examination. She developed neovascularization of the angle with almost total closure of the angle except for a few clock hours. She was on four classes of medication and had adequate intraocular pressure control at the time that this video was taken.

Iris and Angle Neovascularization: This 80 year old patient was referred to the Glaucoma Service because of neovascular glaucoma. She had a history of a central retinal artery occlusion and ocular ischemia in her left eye. She developed neovascular glaucoma that was uncontrolled on maximal topical and systemic medications. At the time that she was evaluated her vision of hand motion and her intraocular pressure was 55 mmHg. She has ropy vessels and a membrane that distorted her pupil. Her angle is closed and there is hemorrhage in the inferior angle.

Neovascular Glaucoma: This 52 year-old man has severe juvenile glaucoma. This eye has had multiple pan retinal photocoagulations. He has a blind eye that has has cyclophotocoagulation and retrobulbar chlorpromazine. The angle neovascularization grows up onto the cornea.

Neurofibromatosis: This is a 78-year-old man with neurofibromatosis type 1. He has multiple Lisch nodules. He was diagnosed with open angle glaucoma at age 74.

Courtesy of Young H. Kwon, MD, PhD. The University of Iowa

Indentation Broad PAS: This gentleman is moderately hyperopic patient (+1.00 diopters) who has had longstanding glaucoma. He was taking pilocarpine gel at the time that this video was taken. His intraocular pressure was 32 mmHg. On examination he has narrow angles with scattered peripheral anterior synechia that are seen on indentation. Note: This video is also located in the Pupillary Block and Techniques for Difficult Angles - Indentation Gonioscopy categories.

Low PAS: This is a 60 year-old gentleman with inflammatory glaucoma from congenital toxoplasmosis. This video was taken 30-years after the onset of inflammation. He has low peripheral anterior synechia on gonioscopy.

Indentation Gonioscopy with PAS: This 69 year old man has had open angle glaucoma for 17 years and has undergone Argon Laser Trabeculoplasty. He has a long history of pilocarpine use. At the time of presentation his intraocular pressures were 20 mmHg OD and 32 mmHg OS. Note: This video is also located in the Techniques for Difficult Angles category.

Pupillary Block - Narrow Angles PAS on Indentation: 80 year-old woman was found to have elevated IOP on routine examination at age 54. She was treated as a POAG patient. At age 77 she was found to have narrow angle with low PAS on indentation. She is hyperopic with a spherical equivalent of +3.25 D OU. Note: This video is also located in the Techniques for Difficult Angles category.

Peripheral Anterior Synechia - 1: This patient has autosomal dominant neovascularization, inflammation and vitreoretinopathy (ADNIV). The patient has elevated intraocular pressure after multiple vitrectomies. He is found to have a broad peripheral anterior synechia extending to his extracapsular cataract extraction wound.

Peripheral Anterior Synechia - 2: This 76 year old man has a long history of POAG. He presented to here in 2010 after multiple procedures OU. He has PAS that are probably due to a shallow anterior chamber after surgery.

Phacolytic Glaucoma: This patient presented with one week of pain in the right eye. She had known that she had a cataract in that eye for many years but had never gotten around to having cataract surgery. The left eye had had an intracapsular cataract extraction ten to twenty years previously. At presentation her visual acuity was light perception and her intraocular pressure was 32 mmHg.

Hypermature Lens - slit lamp only: This 94 year old patient has a disciform scar in the right eye. He has had vision reduced to the level of light perception for 8 years at the time this video was taken. The right lens shows a hypermature cataract with loss of cortical substance and wrinkling of the anterior capsule. This is what a lens looks like when most of the cortex is gone. This patient never had a phacolytic reaction.

Phacomorphic Glaucoma: 81 year-old woman with chronic angle closure glaucoma. She had undergone laser iridotomies 15 years previously. Her axial aye length is 20 mm and her lens is 5.1 mm thick.

Narrow Angle from Phacomorphic Glaucoma (slit lamp only): This 50 year old man has retinopathy of prematurity. He developed this dense nuclear sclerotic cataract and was diagnosed with phacomorphic glaucoma. His lens at the time of this video was 6.1 mm in thickness and his anterior chamber centrally was 1.0 mm.

Phacomorphic Glaucoma: This 66-year-old woman had an intraocular pressure to 70 mmHg in her left eye. After undergoing laser iridotomy she was found to have persistently narrow angles. Her eyes were found to be quite short (22 mm) and her lens is very thick (5.3 mm).

Krukenberg Spindle: This middle-age woman has a long standing history of pigment dispersion syndrome in this eye.

Pigment Dispersion Syndrome: Pigment on Iris (slit lamp only) - 56 year old with a five year history of pigment dispersion syndrome. His referring physician had performed laser iridotomies in both eyes.

Pigmentary Glaucoma: This patient was diagnosed at age 32 with pigmentary glaucoma. He has had pressures as high as 42 mmHg in both eyes and has required trabeculectomies in both eyes.

Pigment Dispersion Synd. - Iris Pigment and TIDs: This 31 year-old man was found to have pigment dispersion syndrome on routine examination. His intraocular pressures are 22 mmHg OD and 23 mmHg OS. Patient of Young H. Kwon, M.D., Ph.D. University of Iowa, video by Edward Sung, M.D.

PDS Pre and Post LPI: This nice clip shows many features of pigment dispersion syndrome. It also shows the changes to the iris after iridotomy.

Courtesy of: Howard Cohn, MD, American Hospital of Paris

Pigment Dispersion Syndrome with Marked Back Bowing: This young man is in his 30’s. He has had intraocular pressures as high as 32 mmHg in the right eye and 25 mmHg in the left eye. He has never been on therapy for glaucoma and currently has pressures of 17 mmHg and healthy optic nerves. He has remarkable back bowing.

Pigment Dispersion Syndrome - Iris Backbowing: 33 year-old woman with pigment dispersion syndrome.

Pigmentary Glaucoma Scheie Stripe: This 23 year-old man was diagnosed with pigmentary glaucoma one year previously. At the time of this examination he had intraocular pressures of 49 mmHg in the right eye and 42 mmHg in the left eye despite taking a beta blocker and a prostaglandin analog.

Pigment Dispersion Syndome - Scheie Stripe: 40 year-old man with a five-year history of open angle glaucoma. Was found to have pigment dispersion syndrome with a Krukenberg spindle, transillumination defects, dense angle pigmentation and a Scheie stripe.

Pigmentary Glaucoma Scheie Stripe - slit lamp: This patient was diagnosed with pigment dispersion syndrome when she was 27 years old. One year later she was diagnosed as having pigmentary glaucoma.

Sampaolesi Line Visible on Slit Lamp Exam: This patient with pigmentary glaucoma has a Sampaolesi line that is visible on slit lamp examination. He also has an excellent Scheie stripe.

Pigment Glaucoma (Burned-out): This 75 year-old woman was found to have cup-to-disc asymmetry. Her intraocular pressures were normal at 13 mmHg OD and 11 mmHg OS. She was found to have evidence of pigment dispersion syndrome and it was presumed that the optic nerve head asymmetry was from pigmentary glaucoma when she was younger.

Secondary Pigment Dispersion Syndrome: This 53 year old man had undergone phacoemulsification 9-months prior to this examination. He developed an elevated intraocular pressure that was treated with a beta blocker and a carbonic anhydrase inhibitor. On examination he was found to have 4+ angle pigmentation and transillumination defects were felt to be secondary to an intraocular lens.

Courtesy A. Tim Johnson, M.D., Ph.D. University of Iowa.

Pigment Dispersion from Angle Recession: This is a 67 year old male who has elevated intraocular pressures in both eyes, the right greater than the left. At age 13 he had severe blunt trauma to the right eye and had a very slow recovery and then a gradual decline again during his childhood. He had been treated for elevated intraocular pressure for over 20 years at the time these videos were taken. The patient has extensive angle recession and has a secondary pigment dispersion syndrome in the right eye. While his axial eye lengths are symmetrical his anterior chamber depth on the right side is deeper than the left (3.52 mm OD and 2.30 mm OS). This patient has been published: McKinney, J. K. and W. L. Alward (1997). "Unilateral pigment dispersion and glaucoma caused by angle recession." Arch Ophthalmol 115(11): 1478-9. Asymmetric pigmentary glaucoma caused by unilateral angle recession: Ritch, R. and W. L. Alward (1993). "Asymmetric pigmentary glaucoma caused by unilateral angle recession." Am J Ophthalmol 116(6): 765-6.

NOTE: This clip is presented both under pigmentary and under angle recession.

PDS with Striking Krukenberg Spindle: At age 39 this woman was seen for her pigment dispersion syndrome. She has a refractive error of -5.50 diopters and had a best corrected visual acuity of 20/30. Her optic nerve head was normal and her intraocular pressure was in a normal range on three classes of medications. This patient has the densest Krukenberg spindle that I have seen and her dense spindle may account for her 20/30 vision because her lens is perfectly clear.

PDS from Iris Cysts - 1: This 42 year-old woman had elevated intraocular pressures with evidence of pigment dispersion. Rather than having the typical slit-like defects in the pigment epithelium that one would see in pigment dispersion syndrome she had large globular areas of pigment epithelial loss and on ultrasound biomicroscopy was found to have cysts of the iris pigment epithelium pushing the pigment epithelium against the zonules. The patient is seen 6-years later at which time one of the cysts has grown large enough to reach into the pupil. You can see that she has undergone a trabeculectomy for intractably elevated intraocular pressures. The video was taken not long after her trabeculectomy, which explains the blood subconjuctivally inferiorly. This patient was reported in the Archives of Ophthalmology volume 113, pages 1574-1575, 1995.

PDS from Iris Cysts - 2: This 47 year-old man presented with bilateral narrow angles. On examination he was found to have large iris cysts of the pigment epithelium. His intraocular pressures were normal in both eyes but there were portions of his iridocorneal angle that were closed and therefore an iridotomy was performed in the left eye. This video shows the patient before and after the iridotomy. This patient also had pigment dispersion caused by abrasion of the pigment epithelium against the lens zonules.

PDS - Reverse Pigmentation: This patient was being evaluated for normal tension glaucoma at age 59. On examination, he has intraocular pressures of 12 mmHg OD and 14 mmHg OS. He has trans illumination defects of the iris and marked angle pigmentation. Note that his pigmentation is more striking superiorly than inferiorly. Dr. Robert Ritch makes the point that people who are clearing the pigmentation from their angles often have this reverse pigmentation - where there is more pigment above them below. It is not uncommon to see this in patients who are being evaluated for normal tension glaucoma. They probably have had elevated intraocular pressures when they were young adults.

PDS OD, ICE OS: At 35 years old was diagnosed with both pigment dispersion OD and essential iris atrophy OS. Her essential iris atrophy prevented her development of PDS OS.

Pigment Dispersion from Intraocular Lens: This 66-year-old man had vitreous hemorrhage from a vascular occlusive event. He ultimately underwent vitrectomy and at the time also had a lensectomy. A secondary posterior chamber intraocular lens was inserted but became dislocated. Therefore the intraocular lens was sutured to his iris with Prolene sutures. He subsequently developed ocular hypertension and was found to have marked backbowing and pigmented dispersion syndrome. There is no pigment dispersion in the opposite eye.

Pigment Dispersion Syndrome: A 27-year-old Asian man found to have ocular hypertension at age 26 with intraocular pressures of 30 mmHg OD and 26 mmHg OS.

Asymmetric Pigment Dispersion Syndrome: This patient has markedly asymmetric pigment dispersion syndrome. There is no known cause for the asymmetry. He has no history of trauma and his refractive errors (-3.35 D) are symmetric. The left eye has a larger cup and has required trabeculectomy while the right eye has been easy to control.

Plateau Iris Syndrome 1: 76 year-old woman with a history of narrow angles for which she had undergone iridotomies. She has mild hyperopia (+1.25 D OD and +1.00 D OS).

Plateau Iris Syndrome 2: In this video we see the indentation of a mildly hyperopic patient (+1.75 diopters). His iridocorneal angles were not felt to be occludable but in the on indentation one can see the peripheral roll that is characteristic of plateau iris configuration.

Plateau Iris Syndrome 3: This 39 year-old patient is mildly hyperopic (+2 diopters OU). She had developed narrow iridocorneal angles and had undergone a laser iridotomy in both eyes. Following the iridotomy she continued to have narrow angles and plateau iris syndrome was diagnosed.This patient is included both under Techniques for Difficult Angles and Plateau Iris

Retisert Implant: This patient has chronic posterior uveitis for which he has undergone a Retisert implant. He was referred for uncontrollable steroid-induced glaucoma for which he underwent an Ahmed seton.

Post Canaloplasty: This patient had undergone a canaloplasty and has a prolene suture that clearly delineates Schlemm’s canal.

Eroded Haptic: This patient is an 86-year-old man who has had glaucoma for 20 years. This eye had an extracapsular cataract extraction with posterior chamber lens done 23 years before this video was taken. This eroded haptic into the anterior chamber was an incidental finding on gonioscopy and has caused him no difficulties whatsoever.

Iris into Sclerostomy - slit lamp only: This patient has primary open angle glaucoma. At age 50 he underwent a trabeculectomy in his right eye and, 7 months later had a needling performed of the bleb. After the bleb needling he was referred in with the clinical appearance seen here. His iris is peaked and there is pigmented material inside the filtering bleb. Thankfully, his intraocular pressure was 9 mmHg and his visual acuity was 20/25.

Courtesy of Young H. Kwon, M.D., Ph.D., The University of Iowa

Iris over Sclerostomy: This patient had iris to a sclerostomy after trabeculectomy. The video shows the appearance before and after Nd:YAG laser treatment to open the sclerostomy site.

Nonpenetrating Surgery: At age 31 this 35 year old Asian-American woman underwent nonpenetrating glaucoma surgery while visiting Japan. She had a history of normal tension glaucoma. At the time she was seen she was on three classes of medications in each eye with intraocular pressures of 10 mmHg OD and 11 mmHg OS.

Appearance after diode laser CPC: This patient has traumatic aniridia after a fall. Her early post-trauma appearance is shown under “ghost cell.” She had diode laser cyclohotocoagulation for uncontrolled intraocular pressure. Because of her aniridia we can see clearly the effect that the laser has had on the ciliary body.

Bleb Leak (slit lamp only): This patient has undergone trabeculectomy elsewhere. He developed a bleb leak and had undergone a bleb revision. He presented at this time with a brisk leak. His intraocular pressure was 8 mmHg and as eye was well formed. This is a nice example of a positive Seidel test.

Internal Sclerostomy: This 80-year-old patient had a trabeculectomy performed 13 years before. This brief clip shows an open internal sclerostomy.

Appearance After Iridencleisis: In 1959 this patient had an acute attack of angle closure at the age of 19 and underwent an iridencleisis in both eyes. One can see that there is a superior sector iridectomy through which iris is sutured into the full filtering site and can be seen subconjunctivally. On gonioscopy one can see iris into the sclerostomy site.

Inadvertent Filtering Bleb: This patient underwent extracapsular cataract extract in 1983. Since that time he had a chronic low intraocular pressure. When this video was taken 9-years after his surgery his intraocular pressure was 3 and he suffered from fluctuating visual acuity. He underwent repair of his surgical wound with an ultimate intraocular pressure of 14 mmHg.

Suprachoroidal Hemorrhage: This patient had undergone a trabeculectomy and early after surgery had developed a giant suprachoroidal hemorrhage allowing one to see the retina through the pupil.

Pigment after LPI: Inferior angle increased pigmentation after a laser iridotomy.

Courtesy of Howard Cohn, MD, American Hospital of Paris

Trabectome: This is a 64 year-old woman who had a trabectome performed two months prior to this video. This was done elsewhere and did not function. She subsequently underwent laser trabeculoplasty and was referred in with poorly controlled pressures despite the use of latanoprost and timolol. This is a very nice view of the cleft that’s made with a trabectome.

Bleeding after Trabeculectomy - slit lamp only: 85 year-old man who is one day out from a trabeculectomy. He has active bleeding in his anterior segment. This resolved with patching and his ultimate outcome was excellent with a final IOP of 10 mmHg.

Bleeding Trabeculectomy Site: This patient at age 83 presented with hyphema in the left eye. He had undergone a trabeculectomy a decade earlier and had a phacoemulsification about 6-years earlier. One can see bleeding from the trabeculectomy site. Attempts at laser coagulation were unsuccessful but a surgical revision of the bleb resolved this patients intermittent bleeding episodes.

Courtesy of Young H. Kwon, MD, PhD. The University of Iowa

PAS from ALT: This 74-year-old woman was diagnosed with POAG 18 years previously. She had undergone ALT seven years before this video. She was on four medications, including pilocarpine. The video demonstrates multiple PAS, presumably due to laser trabeculoplasty in an eye with a narrow angle.

Peripheral Ant Synechiae from Trabeculoplasty: 76 year-old woman diagnosed with primary open angle glaucoma at age 68. She had argon laser trabeculoplasty performed two years before this examination. The patient is hyperopic (+2.50 D OD and +4.00 D OS).

Bleeding from Cataract Incision: 80 year-old woman who had undergone an ECCE 10 years before awoke with blurred vision.

Corneal Decomp Due to Tube Shunt: This patient has end-stage glaucoma. He had a Molteno seton performed when he was phakic and a subsequent Baerveldt seton when he was pseudophakic. He subsequently developed corneal decompensation His inferior tube is in good position behind the trabecular meshwork but the superior tube comes through the peripheral corneal and probably lead to the sectoral corneal decompensation.

UGH Syndrome: This 88 year-old woman had a cataract extraction in the right eye 21 years prior to this exam. She had an iris clip intraocular lens placed and was doing well until the day before presenting when she had sudden loss of vision in the right eye. She had an intraocular pressure of 8 mmHg with corneal guttata and Descemet’s folds. She had pigmented vitreous cells.

UGH Syndrome - slit lamp only: This patient had extracapsular cataract extraction cataract extraction with intraocular lens performed in 1995. He developed chronic iritis at a sputtering hyphema from a lens rubbing on his iris vessels. He ultimately required intraocular lens exchange.

Pseudophakic Pupillary Block: After cataract surgery this patient developed chronic inflammation that was diagnosed as P.acnes endophthalmitis for which he underwent lens exchange with a limited anterior vitrectomy and intravitreal antibiotics. One week later he was found to have an elevated intraocular pressure and evidence of iris bombé with the iris ballooning around his anterior chamber intraocular lens. After laser iridotomy this entirely resolved and his pressure returned to normal.

Posterior Polymorphous Corneal Dystrophy: This patient at age 42 was diagnosed with glaucoma. At age 60 she was found to have narrow angles and underwent laser iridotomies. Two years later one of her physicians performed laser trabeculoplasty on her (ill advised). When we first saw her she had extensive angle closure with corneal endothelial changes including vesicles. She was diagnosed as having posterior polymorphous corneal dystrophy.

Posterior Polymorphous Corneal Dystrophy (Slit Lamp Only): A 44-year-old woman diagnosed with posterior polymorphous corneal dystrophy as a child. She is from a large family of individuals with PPMD.

Primary Congenital Glaucoma - 1: This 18 year-old man was first seen at age 4 months with unilateral buphthalmos and Haab striae. He had near total cupping in his left eye. The patient underwent a trabeculotomy at age 4 months. The video is at age 18. At this time he had an intraocular pressure on no medications of 14 mmHg and healthy optic nerve (C/D 0.25 vs. 0.1 OD).

Primary Congenital Glaucoma - 2: This is an operating room view through a Swan Jacobs lens (direct goniolens) into the angle of a baby with primary congenital glaucoma.

Narrow Angles - Slit lamp only: This is a 51 year-old woman who presented with narrow angles diagnosed by her local ophthalmologist. She has no other known eye pathology. Her Van Herrick test shows extremely narrow angles with areas of apposition. Interestingly, this patient is myopic (-3.50 diopters). Primary pupillary block angle closure is quite uncommon in patients with myopia. This clip is filed under both Examples: Pupillary Block and Techniques for Difficult Angles: Van Herrick.

Narrow Angle, Pupillary Block: This 60 year-old man has a strong family history of glaucoma. He was referred because his local optometrist found his iridocorneal angles to be narrow. He has mild hyperopia with a spherical equivalent of +0.75 OD and +1.25 OS. His intraocular pressures are normal at 12 mmHg OD and 15 mmHg OS. His optic nerve heads are completely normal.

Narrow Angles w/ Indentation Gonio and Corneal Wedge: This 54 year-old woman was referred for narrow angles. She is mildly hyperopic (one diopter).

Pupillary Block - Narrow Angles PAS on Indentation: 80 year-old woman was found to have elevated IOP on routine examination at age 54. She was treated as a POAG patient. At age 77 she was found to have narrow angle with low PAS on indentation. She is hyperopic with a spherical equivalent of +3.25 D OU.

Glaukomflecken - slit lamp only: This 41 year-old man had undergone a trabeculectomy with mitomycin C and had chronic post-operative hypotony. He was symptomatic from the hypotony with macular striae. For this reason a blood patch was performed on the left eye and at the same time the anterior chamber was filled with viscoelastic. After this procedure the patient had an intraocular pressure that went as high as 60 mmHg. Over the next several hours he was given maximum medical therapy and had fluid released from his paracentesis intermittently. Despite this it took almost 6-hours to make the patient comfortable and to attain a steady, normal intraocular pressure. The following week the patient was found to have glaukomflecken. With time as can be seen in the video this dissipated. Note: While these glaukomflecken are not from primary pupillary block angle closure this seems to be the most appropriate place to file this video.

Indentation Broad PAS: This gentleman is moderately hyperopic patient (+1.00 diopters) who has had longstanding glaucoma. He was taking pilocarpine gel at the time that this video was taken. His intraocular pressure was 32 mmHg. On examination he has narrow angles with scattered peripheral anterior synechia that are seen on indentation. Note: This video is also located in the Techniques for Difficult Angles - Indentation Gonioscopy and Peripheral Anterior Synechiae categories.

Pupillary Block: This patient underwent a laser iridotomy and this video shows the very narrow angle before the iridotomy and the deeper angle post iridotomy using the Van Herick technique.

Pupillary Block - Indentation Gonioscopy showing PAS: This is a 64 year-old man who is moderately hyperopic (+1.50 diopter spheres). He was found by his optometrist that morning to have intraocular pressures of 36 mmHg OD and 37 mmHg OS. He was treated with laser iridotomies in both eyes but ultimately required medical therapy because his pressures continued to be elevated.

Sequelae from Acute Angle Closure Attack - slit lamp only: This patient had a bilateral attack of acute angle closure glaucoma with intraocular pressures of 58 mmHg OD and 63 mmHg OS. She is a hyperopic patient and was on no medications that might have induced bilateral angle closure. She had laser iridotomies and now has sequelae of an angle closure attack.

Spherophakia: This young woman at age 26 developed acute angle closure glaucoma in the right eye. She is highly myopic (-11 diopters). She underwent laser iridotomy in both eyes and ultimately required a trabeculectomy the right eye. Her axial eye lengths were 22.21 mm OD and 21.77 mm OS.

Sturge Weber limbal Vessels - slit lamp only: This 39 year-old male has had a prominent port wine stain since birth. He developed secondary glaucoma from which this eye has lost all vision. On examination he has no light perception in the left eye with an intraocular pressure of 38 mmHg and a total optic nerve head cup.

Vossius Ring - slit lamp only: This is a 15 year-old male who was hit in the eye with a football kicked from about 8 feet away. He presented with a hyphema and a visual acuity of hand motion. This video was taken 6 days after the injury and shows Vossius ring.

Iridodialysis - Huge - slit lamp only: 47 year-old struck by rock in OD. Presented with CF vision and an IOP of 27 mmHg. His lens was dislocated. His IOP remained elevated despite maximum medical therapy and he underwent a pars plana vitrectomy, lensectomy and McCannel sutures x 6. The second video is nine years later. The IOP was 12 mmHg on three medications and the visual acuity with a contact lens was 20/20-3.

Metallic FB in CB: 50 years before this video was shot this 70-year old patient was grinding high quality steel and felt something strike his left eye. He was not examined at that point and had been doing well for many years. He developed glaucoma in both eyes, which was more difficult to control in this left eye. Suddenly, 50 years after his injury he developed a peaked pupil. He was found to have metal in his ciliary body.

Iridodialysis - Slit lamp only: This patient was in a car that struck a deer. The left eye had count fingers visual acuity in the large iridodialysis seen here. The pressure was 4 mmHg and the lens was dislocated into the vitreous. The patient underwent a pars plana vitrectomy and McCannel sutures (times four). Ultimately an aniridic style intraocular lens was placed but the patient’s vision never improved over 20/400 due to retinal pathology.

Probable Iris Nevus: This patient had always noted “speckles” of brown pigmentation on her blue iris. Her ophthalmologist noticed that one of the nodules on the right iris appeared raised and referred her for evaluation and ultrasound.

Iris Nevus vs. Small Iris Melanoma: This patient presented in 1999 at the age of 27 years old. At that time she said that she had always had a freckle in her right eye that her parents noted when she was a child. This lesion has been followed at the time of this video for 11 years with no change. It is either a thick iris nevus or a melanoma. On echography the lesion is 0.8 mm thick.

Nevus with Ectropion: 30 yo mass present for 10 years. He has noted a recent change in size. An iridocyclectomy was performed. Pathologic examination demonstrated a spindle cell nevus.

Intrastromal Amelanotic Iris Nevus: This 53 year-old white male went to his optometrist complaining of decreased visual acuity in the right eye and was found to have a hyphema and an elevated intraocular pressure to 32 mmHg. When we saw him he had an amelanotic mass as seen here. His visual acuity was equal and normal in both eyes and his intraocular pressures were 16 mmHg OD and 17 mmHg OS. On echography this lesion was 1.9 mm thick and appeared to extend deep into the angle but not into the ciliary body. The lesion was vascular. It was recommended to this patient that he consider excision of this lesion but he refused any surgical management. 26 months later he returned because the lesion was bleeding intermittently. The lesion was resected and was found to be an intrastromal amelanotic iris nevus. Eight weeks after his surgery he had 20/25 vision and an intraocular pressure of 14 mmHg.

Iris Nevus Versus Melanoma: 73 year-old man who has had this lesion on his left iris for over 50 years. There has never been any documented growth.

Iris Melanoma: First seen at age 27 with a mass in the right eye that was first noted by the patient eight years ago. She was followed with standardized echography and clinical evaluation and after seven years was shown to have progressive growth. A fine needle aspiration biopsy showed a melanoma with spindle and epitheliod cells and so she underwent an iridocyclectomy. The margins of the wound were free of tumor and she has been followed for 14 years without recurrence. In the 13th post-operative year she developed a cataract that was removed with placement of a lens with an artificial iris.

Atypical Nevus: 19-year-old white female with a history of a stable iris nevus in her right eye since age 2 years. Significant family history: both father and grandfather died of cutaneous melanoma. This iris lesion was stable until July 2002 when it started to enlarge. This baseline video was obtained. In 2007 the lesion was clearly larger. VA 20/20 IOP = 14 mm Hg bilaterally. She underwent enucleation. Pathologic diagnosis: “Atypical iris nevus, most consistent with borderline spindle cell nevus type. Lesion extends into trabecular meshwork. Satellite lesions are present in the angle.”

Ring Melanoma - 1: 71 year-old man referred for an IOP of 44 mmHg in his left eye. He had 20/30 vision. His ultrasound was compatible with ciliary body melanoma.”

Heterochromia Ring: 49 year-old referred for trabeculectomy with the diagnosis of pigmentary glaucoma. He had a history of elevated IOP in the right eye for 4 years. He had had pressures as high as 47 mmHg. At present he was on four medications and had undergone a trabeculoplasty. On examination he had an IOP of 38 mmHg and total cupping of the optic nerve with a 5-degree visual field. The patient underwent enucleation, which confirmed the diagnosis of diffuse melanoma.”

Recurrent Iris Melanoma: This 40 year-old female first presented in 1991 with a pigmented iris mass lesion OD. She underwent an iridectomy with excisional biopsy of the pigmented iris mass in 1992. She was doing well a year later and then was lost to follow-up for 11 years when she returned with recurrences on her iris. She underwent enucleation.”

Ademona of the Ciliary Body Non-Pigmented Epithelium: This thirteen year-old male first noted a spot on the iris seven moths before this evaluation. A fine needle aspiration biopsy revealed was most consistent with a congenital iris cyst of epithelial origin. Five years later the lesion had grown substantially and an iridocyclectomy was performed. The mass was found to be an adenoma of the non-pigmented epithelium of the ciliary body.”

Melanocytoma: Seen in 1996 at age 36 with a spot on his right eye for 1 - 2 years. Fine needle aspiration biopsy revealed melanocytoma. Followed 11 years without significant change.”

Metastatic Breast Carcinoma: Six years after a diagnosis of breast cancer this patient noted a lesion in her eye that led her to consult her ophthalmologist. The mass seen here was found to be highly reflective and vascular on a standard echography. A chest x-ray revealed a lung lesion that was felt to be a metastatic breast tumor. The patient was started on Tamoxifen and was followed closer to her home.”

Ciliary Body Melanoma - 1: 14 year-old noted to have a mass OS. Echo was highly reflective. The fine-needle aspiration biopsy positive for melanoma. Enucleated, diagnosis spindle cell melanoma.

Ciliary Body Melanoma - 2: This 36 year-old man has a history of superficial skin melanoma on his right forearm that was removed at age 21. A few months prior to this video he developed a red eye and was found to have cell and flare and was started on steroids. Two months later on follow-up this mass was noted. He had a decreasing visual acuity with myopic shift. On exam his visual acuity was 20/125 but refracted to 20/25 with -2.25 diopters of sphere. His intraocular pressure was normal at 13 mmHg. On ultrasound this lesion is 10 mm thick. The patient underwent metastatic workup and was found to have lesions in his brain, spleen and liver. He was treated with chemotherapy and radiation.

Iris Melanoma - Huge: This patient was seen in 1985 at age 66 with a pigmented flat iris lesion on his left eye. He was not seen again until 23 years later at age 89 when this mass had grown to the size seen here. His intraocular pressure had required three medications to keep it in a normal range. On ultrasound the mass extended 3 mm above the iris plane. Interestingly his referring physician had done a phacoemulsification three years earlier and, on ultrasound, the haptic of the IOL appeared to be engulfed in tumor. The patient refused enucleation and had radiation plaque therapy performed.

Ring Melanoma - 2: This 86-year-old woman was found to have more prominent pigmentation of her left iris than previously. Her IOP climbed into the 20s and she was begun on glaucoma medications. Recently she had developed anemia and had colonoscopy during which time a suspicious lesion was identified. This lesion looks like an iris / ring melanoma.

Ciliary Body Melanoma - 3: The iris lesion in this 79 year old patient developed rather suddenly. He had been followed in the same practice for 35 years and three years before this video had undergone cataract extraction with no mention of an iris abnormality. We see a large mass that has broken through the iris and a really nice example of the value infrared video transillumination to see the extent of this lesion posteriorly. This patient was returned to his home state for enucleation and an oncology evaluation.

Ciliary Body Melanoma - 4: This 47 year old woman first noted a dark spot on her iris approximately 5 months before this video was taken. She seemed to have a large dark mass that pushes against her cornea and appears to push the iris out of the way rather than sit on top of the iris. On ultrasound this mass is quite large extending well posteriorly to the iris. The patient returned to her home state for oncology workup.

Iris and Ciliary Body Melanoma: A 57 year old woman noted a light spot on her iris 10 months before being seen at our institution. Her local optometrist had never seen this over the 3 years that the patient had been followed by him. The patient was healthy and had no history of other tumors. One can see a thick angle lesion on slit-lamp examination and gonioscopy. On echography the lesion appeared to be confined to the iris and anterior ciliary body however, in surgery the mass was larger than anticipated. The histopathology was that of a malignant melanoma with epitheloid cells extending to the clinically- uninvolved ciliary body. The patient was advised to consider enucleation and preceded with this.

Adenomatous Tumor of the Ciliary Body: This 35 year old woman was first noted to have an iris lesion on the left side 3 to 4 months prior to presentation. She was in excellent health and has no history suggestive of another malignancy. On ultrasound the lesion measured 3.8 mm in height and one-third of the lesion was behind the ciliary body. A fine needle aspiration biopsy was performed that was not consistent with melanoma but contained eosinophils and macrophages suggesting a granulomatous process. A biopsy was attempted but the tumor was quite friable. Ultimately the entire mass was removed with iridocyclectomy. The pathology was suggestive of either a benign adenoma of the nonpigmented ciliary body epithelium or a metastatic lesion. The patient was evaluated for other primary tumors and none were found.

Amelanotic Iris Lesion: 22 year-old female found to have this lesion on routine examination. Over four years of follow-up it had not changed.

Masquerade Syndrome (slit lamp only): This 60-year-old patient was diagnosed with glaucoma 12 years prior to being seen. He had a history of chronic uveitis in the right eye. In 2012 he was diagnosed with sarcoid based on a positive lung biopsy. In July 2012 he was seen in our glaucoma clinic with an intraocular pressure of 40 mmHg, 360° of peripheral anterior synechia and a cataract. He underwent cataract extraction with intraocular lens and Ahmed seton. Twelve weeks after his surgery he had a hypopyon with an atypical appearance. A tap and inject was performed and no growth was found. Parallel to this he developed epididymitis which worsened on oral steroids. He was also losing weight on oral steroids. A paracentesis demonstrated a high grade B-cell lymphoma and a PET scan showed lymphoma in the retroperitoneal abdominal wall and testes. He had a right orchiectomy which was positive for B-cell lymphoma.

Ciliary Body Ademona: This patient was discovered to have a mass on routine examination. It is noted that the mass is very closely intertwined with the haptic of her intraocular lens. A fine needle aspiration biopsy was performed that demonstrated a probable adenoma of the non-pigmented ciliary epithelium.

Chronic Uveitis w/ Cholesterol Crystals: 49 year-old woman with twenty-year history of granulomatous uveitis OD. Full work-up negative for an underlying etiology. She developed diffuse crystals in anterior chamber and angle. This was presumed to be due to her elevated serum cholesterol (366) and triglyceride (450) in the face of a compromised blood-aqueous barrier.

Fuchs-like Uveitis: 61 year-old woman who noted floaters and decreased vision in her left eye for five months. Her IOP was 37 mmHg. She presented with KP and angle neovascularization suggestive of Fuchs heterochromic iridocyclitis but, on dilated examination had severe sarcoid disease in her fundus. NOTE: This clip is presented both under uveitis and under Fuchs' heterochromic iridocyclitis.

Inflammatory PAS: Progressive peripheral anterior synechiae in a patient with chronic inflammation.

Courtesy of Howard Cohn, MD, American Hospital of Paris

Uveitis Keratic Precipitates (slit lamp only): This 30 year-old man was seen three days after new onset of anterior uveitis. He was begun on prednisolone every two hours and anti-viral therapy. After three days he developed fascinating precipitates with clear centers. He was determined to have herpes simplex virus.