Iris bombing - causes, treatment. Acute attack of glaucoma

Iris adhesions occur when the iris fuses with synechiae with the cornea (front) or with the lens (back). Adhesions are formed as a result of eye injury, inflammatory diseases (iridocyclitis, uveitis). Synechiae can lead to the development of intraocular hypertension and glaucoma. On ophthalmological examination, it is sometimes possible to visualize synechiae, but it is better to examine them with a slit lamp and ophthalmoscopes.

Anterior adhesions can cause angle-closure glaucoma, as in this case, the iris obstructs the outflow of aqueous humor from the anterior chamber. In this case, intraocular hypertension increases. If on the background of the anterior synechia there is high blood pressure inside the eyeball, cyclodialysis must be performed.

With posterior synechiae, glaucoma can also occur, but the mechanism of pressure increase in this case is different. The iris, growing together with the lens, disrupts the outflow of intraocular moisture from the posterior chamber to the anterior chamber. Such a block leads to an increase in the level of intraocular pressure.

With posterior adhesions, synechiae can be separate or form a continuous tape between the edge of the iris and the lens. In the case of secondary changes, exudate in the pupil region may result in complete clogging of the hole. The pre-lens membrane (circular fusion) causes complete separation of the chambers (anterior and posterior) of the eyeball, resulting in intraocular hypertension. With a sufficient accumulation of aqueous humor in the posterior marque, the iris begins to bulge out into the anterior chamber under pressure, that is, the so-called iris bombardment occurs. With the formation of an annular synechia between the iris and the lens (its anterior capsule), complete clogging of the pupillary opening may occur.

Interestingly, synechiae can form both with a natural lens and after IOL transplantation. The degree of adhesions varies depending on the severity and duration of the inflammatory disease.

At the beginning of the formation of adhesions, various proteolytic enzymes can be effective, which include fibrinolysin, chymotrypsin, lekozyme, trypsin, streptodecase, and collalysin. In this case, it is not so much the proteolytic effect of the drug that is important, but an increase in tissue permeability for nutrient compounds, as well as inhibition of the formation of connective tissue cells in the area of \u200b\u200binflammation.

In the treatment of synechia, lidase is used, which leads to an improvement in the flow properties of hyaluronic acid. In addition, it increases the permeability of tissues for intercellular fluid. As a result, the latter accumulates in a smaller amount in this area.

For enzyme therapy, traditional methods are used (instillation of drops, introduction of the parabulbar area or under the conjunctiva) or physiotherapeutic methods (phonophoresis, electrophoresis). Additionally, local or systemic administration of angioprotectors is used.

Cytoplegic drugs (mydriatics), which include homatropine (the action is similar to atropine), are used for posterior synechia. These funds keep the pupil in a dilated state, as a result of which it is located at some distance from the lens capsule. This prevents coalescence. In the presence of synechia, the introduction of atropine-like drugs leads to a change in the shape of the pupillary opening. It becomes not round. The prognosis of the disease is determined by the degree of opening of the hole under the influence of drugs. In the case of a complete opening, the forecast is favorable, that is, the adhesions are reversible.

For the purpose of anti-inflammatory therapy, corticosteroid drugs are prescribed. With an increase in intraocular pressure, antiglaucoma drugs (fotil, travatan) are added to therapy.

Surgical dissection of adhesions with a scalpel, spatula, scissors is used in more serious cases. In order to prevent the development of glaucoma, such manipulation can be performed as an independent intervention. Sometimes it is part of other operations (cataract treatment, iris plasty, anterior eyeball reconstruction).

In the presence of dense and massive adhesions, it is necessary to use Vannas scissors and iris scissors. They enter the anterior chamber of the eye through a small incision in the limbus, which is worn with a special keratoma. The incision should be in the immediate vicinity of the synechia, but not opposite them. If the vessels pass inside the synechia, that is, it is vascularized, then a hyphema can form during dissection.

If the posterior adhesions are located behind the intact iris, then it is worth dissecting them very carefully so as not to damage the lens capsule.

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Angle-closure glaucoma (Angle-closure glaucoma) accounts for about 20% of cases of primary glaucoma and usually develops over the age of 40. Women get sick more often than men.

Etiology. The reasons for the increase in IOP are the closure of the anterior chamber angle, the contact of the peripheral part of the iris with the trabecula. The etiology of primary closed-angle glaucoma is also associated with a large number of factors, including:

1) individual anatomical features;

2) age changes in different structures eyes;

3) the state of the nervous and endocrine systems.

Anatomical predisposition is due to the small size of the eyeball and the anterior chamber, the large size of the lens, and the narrow profile of the anterior chamber angle. Angle-closure glaucoma develops much more often in people with hyperopia, since the anatomical features of the eyes with this type of refraction contribute to its development.

Age-related changes include an increase in lens thickness due to its swelling, as well as destruction and increase in volume. vitreous.

Functional factors, such as dilation of the pupil in the eye with a narrow angle of the anterior chamber, increased production of aqueous humor and increased blood filling of the intraocular vessels, directly determine the closure of the angle of the anterior chamber.

Pathogenesis... With a pupillary block (due to the contact of the posterior surface of the iris with the anterior chamber of the lens in the pupil area), an obstacle arises for the outflow of aqueous humor from the posterior chamber to the anterior chamber through the pupil. This leads to an increase in pressure in rear camera compared to the front. As a result, the thinner peripheral part of the iris bulges anteriorly (bombardment) and comes into contact with the trabecula. The angle of the anterior chamber closes, leading to a significant increase in IOP, and with a circular block of trabecular outflow - to an acute attack of glaucoma.

Classification and clinical picture. There are four main forms of primary closed-angle glaucoma:

1. With pupillary block.

2. With a flat iris.

3. "Creeping".

4.With a vitreous lens unit.

1. Primary angle-closure glaucoma with pupillary block occurs in more than 80% of cases of angle-closure glaucoma. It occurs in middle-aged or older people as an acute or subacute attack, with a further transition to chronic formulas. Risk factors are hyperopia, small size eyes, small anterior chamber, narrow angle of the anterior chamber, large lens, thin peripheral iris, anterior position ciliary body and the root of the iris.

As a result of the contact of the posterior surface of the iris with the anterior lens capsule in the region of the pupil, an obstacle arises for the outflow of aqueous humor from the posterior chamber to the anterior chamber. This leads to an increase in IOP in the posterior chamber as compared to the anterior chamber. Due to the accumulation of aqueous humor and an increase in pressure, the peripheral part of the iris bends anteriorly and overlaps the trabecular zone. The angle of the anterior chamber closes, the IOP rises up to an acute attack.

Most often, the direct cause of an acute attack of glaucoma is: emotional excitement, long and hard work with a tilt of the head, staying in a darkened room, taking a large amount of fluids, hypothermia or taking stimulating medications.

The attack usually develops in the afternoon or evening. The patient begins to notice blurred vision, the appearance of rainbow circles when looking at a light source. The main complaint is pain in the eye, radiating along the trigeminal nerve to the forehead and the rug of the head from the side of the lesion. Of common symptoms characterized by slowing of the pulse, nausea, sometimes vomiting, which is associated with overexcitation of parasympathetic innervation.

Objectively, at first, there is an expansion of the episcleral vessels, and then a stagnant injection develops, in which not only the anterior ciliary arteries expand, but also their branches (Fig. 1). The cornea becomes edematous (due to edema of the epithelium and stroma), less sensitive; the anterior chamber is shallow, the aqueous humor loses its transparency (due to protein effusion). The iris protrudes dome-shapedly, its pattern becomes dull and smoothed; the pupil expands and often takes on an irregular shape, the pupil does not react to light. In the lens, opacities appear in the form of white spots, located mainly in the anterior and middle subcapsular layers.

Corneal edema makes it difficult to see fundus details, but an edematous disc can be seen optic nerve, dilated retinal veins; in some cases, hemorrhages in the optic disc and paracentral areas of the retina.

Figure: 1. Acute attack glaucoma

During this period, IOP reaches its maximum value and rises to 50-60 mm Hg. Art., in a gonioscopic study, the angle of the anterior chamber is closed throughout. Due to the rapid increase in ophthalmotonus and significant compression of the iris root in the corneoscleral zone, segmental circulatory disorders occur in the radial vessels with signs of necrosis and aseptic inflammation.

Clinically, this is manifested by the formation of posterior synechia along the edge of the pupil, the appearance of goniosynechiae, focal iris atrophy, deformation and displacement of the pupil. The phase of the reverse development of the attack is due to a decrease in the secretion of aqueous humor and equalization of pressure between the anterior and posterior chambers (the diaphragm of the eye is displaced posteriorly, the bombing of the iris decreases, the angle of the anterior chamber opens partially or completely). Goniosynechiae, segmental and diffuse iris atrophy, displacement and deformation of the pupil remain forever. These consequences affect the further course of the glaucoma process and, with repeated attacks, lead to the development of chronic angle-closure glaucoma with a constantly increased IOP.

Differential diagnosis acute attack of glaucoma and acute iridocyclitis is given below.

Table 1

Differential diagnosis of an acute attack of glaucoma and acute iridocyclitis

Subacute glaucoma attack characterized by the same symptoms, but they are much less pronounced due to the fact that the angle of the anterior chamber is not blocked throughout. The pressure in the eye increases to a lesser extent, therefore, after an attack, posterior and goniosinechiae are not formed. Subacute seizures are treated with medications... Subacute and acute attacks can replace each other over time. As a result of the formation of goniosynechiae, blockade of the trabecula and Schlemm's canal, the disease becomes chronic with a persistent increase in the level of IOP.

2. Angle-closure glaucoma with flat iris occurs in 5% of cases of primary angle-closure glaucoma. It occurs between the ages of 30 and 60. The main anatomical predisposing factors include excessive thickness of the peripheral iris, the anterior location of the corona ciliaris in the posterior chamber, the anterior position of the iris root, steep iris profile, and a very narrow angle of the anterior chamber of the coracoid configuration. The course of the disease is at first acute and then chronic. Seizures occur when the pupil is dilated and the anterior chamber angle is directly blocked by the iris root. A violation of the outflow of aqueous humor from the anterior chamber with an increase in pressure in it develops. The iris remains flat and the camera depth does not change.

3. "Creeping" angle-closure glaucoma develops in 7% of patients with angle-closure glaucoma, mainly in women. It proceeds as a chronic disease, but sometimes acute and subacute attacks occur. It is based on the shortening of the anterior chamber angle due to fusion of the root of the iris with the anterior wall of the angle: the base of the iris "crawls" onto the trabecula, forming fixed anterior synechiae. As a result, the outflow of aqueous humor from the anterior chamber is disturbed and IOP increases.

4. Angle-closure glaucoma with vitreocrustatic block diagnosed relatively rarely. It may be of a primary nature, but more often it develops after antiglaucomatous operations in patients with anatomical features of the structure of the eye (small eye size, large lens and massive ciliary body) and with hyperopia. Clinical picture similar to an acute attack of glaucoma. When ultrasound examination reveals a violation of the structure of the anterior chamber and cavity in the vitreous body with an accumulation of aqueous humor.

Diagnostics... For the diagnosis of all forms of angle-closure glaucoma, stress tests are used - dark and positional.

By doing dark sample the patient is placed for 1 hour in a dark room. The test is considered positive if during this period the IOP increases by at least 5 mm Hg. Art. The effect of the dark test is associated with the expansion of the pupil in the dark and the covering of the drainage zone with a section of the contracted iris.

When conducting positional test the patient is placed on the couch face down for 1 hour. Increase in IOP by 6 mm Hg. Art. and more indicates a predisposition to blockade of the anterior chamber angle. The effect of the positional test is explained by the displacement of the lens towards the anterior chamber.

Zhaboedov G.D., Skripnik R.L., Baran T.V.

Iris bombing is a violation of the structure of the anterior chamber of the eyeball. This condition often accompanies uveitis and can lead to irreversible negative consequences. Also, when the iris is bombarded, there is a violation of the outflow of fluid from the posterior chamber into the trabecular network, which is accompanied by intraocular hypertension.

With the secondary closure of the corner of the anterior chamber of the eyeball, the following structural changes occur:

- Adhesions anterior and posterior in the peripheral zone (synechiae);

- Pupillary membranes, accompanied by the formation of the pupillary block and even the displacement of the processes of the ciliary body to the anterior zone.

In the case of iridocyclitis, there is a high probability of formation of adhesions in the area of \u200b\u200bthe pupillary edge and the lens. Sometimes there is a complete clogging of the pupillary opening. As a result of these pathological processes, the iris is bombarded. In this case, the latter bends anteriorly, as the intraocular pressure sharply increases due to the organic block. Such situations can occur in both aphakic and phakic eyeballs.

Anterior synechiae of the peripheral zone are formed with the formation of adhesions between the cornea or trabecular meshwork and the iris. In this case, the circulation of intraocular fluid from the posterior chamber to the trabecular zone is disturbed. In some cases, the fluid flow becomes completely blocked. Adhesions in this area are often the result of inflammation in uveitis. However, patients with a narrow angle of the anterior chamber of the eyeball (anatomical feature or the result of iris bombardment) are more prone to the formation of synechia.

With posterior synechiae, adhesions occur between the anterior membrane of the lens (vitreous in the absence of a lens lens) and the posterior part of the iris. In this case, the tendency to form synechiae is determined by the severity of the course of uveitis, its duration and type. In the case of relapses of the disease, the risk of the formation of posterior adhesions increases significantly, due to the fact that the pupil dilates worse due to the previous synechia.

The pupillary block occurs when the circulation of the intraocular fluid is disturbed due to the disturbed current from the posterior chamber to the anterior chamber. This condition occurs during the formation of posterior synechia. With a complete block, we are talking about the defeat of the entire radius of the iris, as a result of which the overflow of intraocular fluid from the posterior chamber to the anterior chamber becomes impossible. The result of this condition is a sharp increase in pressure in the posterior chamber and deflection of the iris anteriorly, or the formation of a bombing of the iris due to an increase in the volume of intraocular fluid. If the inflammatory process does not subside, then the bombardment of the iris leads to a rapid closure of the corner of the eye, since peripheral anterior synechiae are easily formed.

In some cases, with pupillary block against the background of uveitis, there are serious extensive adhesions of the iris with the anterior surface of the lens lens. Then only the peripheral zone of the iris sags under the influence of pressure. In this case, the diagnosis of iris bombing requires a gonioscopy.

Diagnostics

If you suspect iris bombing, several tests should be done:

• Visometry;
• Standard ophthalmic examination;
• Biomicroscopy;
• Tonometry.

In addition to instrumental examination, several analyzes are performed in the laboratory:

• Study of blood glucose levels;
• Determination of immunoglobulins to hepatitis B;
• Determination of the concentration of platelets, hemoglobin, leukocytes;
• Serologic tests for syphilis;
• General urine analysis.

If the patient has any concomitant pathologies, then it is advisable to consult a therapist or a specialized specialist.

Treatment

If the patient has confirmed iris bombardment, then the doctor may apply a conservative or surgery.

As drug therapy can be used:

• Diakarba tablets;
• Drops of adrenaline and atropine, timolol, glucocorticoids
• Solutions of mannitol, hypertonic solution (10%) sodium chloride or glucose (40%).

The purpose of these drugs is to normalize intraocular pressure.

If the doctor decided to conduct surgical intervention, then he can resort to the following methods:

1. Iridectomy (surgical or peripheral) is performed if the transparency of the corneal substance is preserved and inflammation is not very pronounced.
2. Surgical synechiotomy is possible only if there is a lens (artificial or own) in the eyeball.
3. Laser iridectomy and synechiotomy is performed with a pseudophakic eyeball.

In the case of the appointment of laser iridotomy, as a result of the intervention, the communication between the anterior and posterior chambers of the eyeball is restored. Since this operation is aimed solely at eliminating the block of the pupil, it is effective only when the iris-corneal angle is open (at least 25%). During the operation, several rather large holes are made. Further monitoring of the patient is required to ensure the effectiveness of these holes.

Iridectomy surgically perform when laser intervention is impossible.

To assess the effectiveness of the manipulation performed, the patient's performance should be monitored for at least a week. In the absence of any inflammatory phenomena and stabilization of intraocular pressure, the result is considered positive.

It should be noted that there is a risk of damage to the lens during surgery. During a bombing operation, the period of incapacity for work is at least 3-4 weeks. After that, you should be regularly observed by an outpatient doctor.

If you have been diagnosed with such a serious disease as iris bombardment, then you should definitely contact an experienced specialist who knows what to do. Below is a list of organizations in which each person can receive proper diagnosis and complex treatment when bombing the iris.

The best eye clinics in Moscow

Below are the TOP-3 ophthalmological clinics in Moscow, where you can get diagnostics and treatment of iris bombing.

All eye clinics in Moscow \u003e\u003e\u003e

Bombage is a pathological position of the iris, a protrusion towards the anterior chamber of the eye, which arises as a consequence of diseases and anatomical predisposition.

Main reasons

Obaglaza.ru presents the main reasons for the development of pathology:

Iridocyclitis

Inflammation of the iris or ciliary body (iridocyclitis) increases the risk of fusion or complete overgrowth of the edge of the pupil with the lens. As a result of pathological changes, the pressure inside the eye and the formation of a pupillary block increase. Specialists of the site "obaglaza.ru" draw your attention to the fact that this physiological disorder can occur both on phakic (with a lens) and aphakic (in the absence of a lens) eyes.

Synechia

The anterior peripheral fusion of the anterior iris with the trabecular meshwork or the cornea of \u200b\u200bthe eye prevents the outflow of intraocular fluid or completely blocks it. Such processes can occur as a result of uveitis or anatomical predisposition, with a narrow angle of the anterior chamber of the eyes.

Posterior - manifests itself when the posterior iris fuses with the lens or vitreous body. Оbaglaza.ru, specifies that the iris can form synechiae both with the present and with artificial lens... The development of physiological pathologies after suffering uveitis depends on the severity, duration and extent of inflammation.

Pupillary block

A process by which the flow of fluid between the chambers of the eye through the pupil is obstructed or blocked. When adhesions form on a part of the pupil or its membrane, a block is called partial if there is a complete block along the radius of the entire pupil. The term full pupillary block "obaglaza.ru" refers to the process of fusion of the entire pupil along the perimeter and the complete cessation of fluid circulation.

As a result, the pressure within the chambers increases, leading to strong bending of the iris towards the anterior chamber or bombardment of the iris.

Occasionally, when uveitis occurs with the pupillary block, fusion of the iris with a large lens is formed, then the iris bends only along the periphery. Diagnostics in this case is possible only with the help of a gonioscope.

Methods for diagnosing iris bombing

The main methods for diagnosing the bombardment of the iris from the eye.py:

1. Examination by a specialist - ophthalmologist;
2. Consultation of a therapist (in the presence of chronic diseases).
3. Visometry - determination of visual acuity;
4. Biomicroscopy - a thorough examination of all structures of the eye using a slit lamp;
5. Tonometry is the measurement of intraocular pressure.

A prerequisite for establishing the correct diagnosis and determining the cause of the disease is a number of clinical tests:

• general blood count (main indicators - hemoglobin, platelets, leukocytes) and urine;
• glucometry (determination of sugar level);
• testing for syphilis (serological analysis);
• the presence of antibodies to hepatitis B.

Iris Bombardment Treatments

Conservative

If there is a wide range of products in each pharmacy chain medical supplies to lower and stabilize intraocular pressure, "obaglaza.ru" recommends for use:

• "Diacarb" in the form of tablets;
• "Mannitol" intravenous administration (40% glucose solution with 10% sodium chloride solution);
• for effective local treatment of eye drops - adrenaline with atropine, glucocorticosteroid drugs, thymol.

Surgical

• iridectomy - the formation of a small hole in the iris, to stabilize intraocular pressure, is performed with minor inflammation of the eyeball;
• iridectomy with a laser, can be performed on pseudophakic eyes (with an artificial lens);
• synechiotomy - dissection of the fusion, performed on phakic eyes.

Choosing a medical institution

For high-quality examination, diagnosis and effective treatment of iris bombing, "obaglaza.ru" advises to select eye clinic with good specialists who will take care of your health, not their profits. It is very important to choose medical institution, which will help, not deliberately delay the healing process. This can not only bring serious material costs, but also further development inflammatory processes and worsening the problem.

If you have been diagnosed with iris bombardment, "eyebrowning" recommends the following clinics, where you can undergo a thorough examination and treatment.