OBJECTIVE: To report a case of bilateral ciliochoroidal effusion syndrome associated with sildenafil use.
METHODS: A 41-year-old male presented with a five-day history of bilateral blurred vision, elevated intraocular pressure, and myopic shift. Ultrasound biomicroscopy radial scans showed closed angles and 360 degrees of ciliochoroidal effusion in both eyes. Anterior segment coherence tomography angiography showed bilateral shallow anterior chamber. Further questioning revealed that the patient had taken sildenafil several times just a few days before symptoms appeared. Since then, the patient stopped dosing sildenafil. After treatment of anti-inflammation and shifting the lens-iris diaphragm posteriorly, the patient\'s visual acuity improved and intraocular pressure decreased. Follow-up ultrasound biomicroscopy and anterior segment coherence tomography angiography revealed resolution of ciliochoroidal effusion and increase of anterior chamber depth in both eyes.
CONCLUSIONS: The patient demonstrated a rare case of sildenafil-induced bilateral ciliochoroidal effusion syndrome. This case report shows that sildenafil should be added to the possible causative agents of ciliochoroidal effusion syndrome.

UNASSIGNED: To report the clinical course of an aphakic patient who developed positional secondary angle closure glaucoma following pars plana vitrectomy (PPV) with perfluoropropane (C3F8) gas tamponade.
UNASSIGNED: A 23-year-old male presented due to a two-year history of vision loss in the left eye. Best-corrected visual acuity (BCVA) was 20/200 and intraocular pressure (IOP) was 12 mm Hg OS. Exam revealed iridodonesis and aphakia of both eyes, and a total RRD in the left eye. The patient underwent scleral buckle plus PPV with 15 % C3F8 gas and was instructed to maintain face-down positioning for 5 days. On post-operative day 1, IOP was 32 mm Hg and exam revealed significant diffuse corneal edema, a large epithelial defect, and 85 % C3F8 fill of the vitreous cavity. Patient was started on IOP-lowering drops but continued to have elevated IOP and corneal epithelial sloughing over the next 3 weeks. He was taken for a superficial keratectomy, but when placed supine under the microscope, a large new gas bubble was visualized overlying the pupil in a now shallow anterior chamber (AC) and IOP was 52 mm Hg. The patient was positioned back upright and the gas bubble migrated posteriorly out of the AC with return of IOP to 25 mm Hg. The dynamic nature of his IOP raised concerns for intermittent angle closure by C3F8 induced by supine positioning. Thus, a pars plana aspiration of the C3F8 gas was performed and resulted in normalization of the IOP.
UNASSIGNED: Dynamic, positional secondary angle closure glaucoma can occur after vitrectomy with C3F8 in the setting of aphakia. This is the first report to capture C3F8 gas migration causing intermittent acute angle closure in real-time. Due to its intermittent nature however, the diagnosis may not be initially apparent at the slit lamp. Thus, we suggest this potential complication should be carefully monitored for and discussed when advising post-vitrectomy positioning in aphakic patients.

A 65-year-old male was planned for Deep anterior lamellar keratoplasty (DALK) to improve his visual quality from the underlying spheroidal degeneration along the visual axis. An attempt for a big bubble was futile, hence converted to a manual DALK. On postoperative day 1, he developed secondary angle closure glaucoma due to reverse pupillary block by the host DM. Decompression of the big bubble was done and angle closure was resolved with a good visual outcome at 1-month post-op. We present the first case of secondary angle closure glaucoma due to reverse pupillary block by a big bubble in a rigid cornea. Abbreviations: DALK = Deep anterior lamellar keratoplasty, OD = oculus dexter, OS = oculus sinister, DS = Diopters Sphere, DC = Diopters cylinder, AS-OCT = anterior segment optical coherence tomography, DM = Descemet\'s membrane, IOP - Intraocular pressure, GHJ = Graft-host junction, BSS = Balanced salt solution.

Microspherophakia is a rare developmental lens anomaly with increased anteroposterior and reduced equatorial diameter. It presents with refractive myopia, shallow anterior chamber, and angle closure glaucoma. It is associated with subluxated or dislocated lens, progressive myopia, defective accommodation, and glaucoma. Glaucoma is the most common vision-threatening complication and mostly requires surgical management that includes trabeculectomy, lensectomy, and drainage implant. A staged or combined procedure can be performed. The purpose of this video is to highlight the advantages of combining parsplana vitrectomy (PPV) with parsplana lensectomy (PPL), scleral fixated intraocular lens (SFIOL), and Aurolab aqueous drainage implant (AADI) in a young patient with advanced glaucoma and gross subluxation. Drainage implants are preferred over filtering surgeries in eyes undergoing vitreoretinal procedures due to the risk of bleb fibrosis and hypotony seen in the latter. The combined procedures should be tailored according to the lens status and severity of glaucoma in each patient.
The purpose of this video is to illustrate a combined quadruple procedure (PPL, PPV, SFIOL, and AADI) in microspherophakic patients with unstable glaucoma and video-based skill transfer to a novice surgeon.
This video illustrates quadruple surgery in a microspherophakic patient with secondary angle closure glaucoma. The authors also emphasize the advantages of a combined quadruple procedure over staged procedure or combined PPL with filtering procedure.
Quadruple procedure can be performed in young microspherophakic patients with advanced glaucoma or at risk of progression and losing central vision along with gross subluxation of lens. It eliminates the need for multiple procedures, the risk of hypotony, and bleb-related complications.
https://youtu.be/KdFjb7acXCI.

A 45-year-old male presented with a slowly progressive, painless swelling in his right eye for the past 6 months. He had undergone an open globe injury repair 10 years back and an eventful cataract surgery 5 years back. The presenting visual acuity in the affected eye was perception of light with inaccurate projection of rays. The intraocular pressure was 44 mm Hg with advanced glaucomatous cupping. The swelling was identified to be a communicating sub-tenon cyst secondary to scleral wound dehiscence from secondary angle closure glaucoma. Wound re-suturing, cyst excision and diode laser cyclophotocoagulation was performed in a single sitting, with explained poor visual prognosis.

UNASSIGNED: To present the case of a 72-year-old female with epithelial downgrowth after femtosecond laser-assisted cataract surgery.
UNASSIGNED: The patient previously underwent YAG vitreolysis after uncomplicated femtosecond laser-assisted cataract surgery and presented 1 year later with epithelial downgrowth causing complete pupillary block and severe angle closure glaucoma. Subsequent management with nd:YAG peripheral iridotomies failed rapidly leading to a confusing presentation with a flat anterior chamber and high intraocular pressure ultimately requiring surgical management.
UNASSIGNED: We describe the occurrence of epithelial downgrowth after femtosecond laser-assisted cataract surgery and illustrate the utility of ultrasound biomicroscopy to differentiate between severe pupillary block and malignant glaucoma.

UNASSIGNED: To report a unique presentation of ciliochoroidal effusion syndrome with central serous-like chorioretinopathy and secondary angle closure following exogenous testosterone use.
UNASSIGNED: A 37 year-old man presented with a two week history of blurred vision, elevated intraocular pressure, and myopic shift in his right eye. Gonioscopy showed angle closure. After YAG iridotomy, ultrasound biomicroscopy (UBM) showed ciliochoroidal effusion and anterior rotation of the ciliary processes. Subsequent color fundus photography, enhanced depth imaging optical coherence tomography (EDI-OCT) and near-infrared reduced-illuminance autofluorescence imaging (NIR-RAFI) showed macular striae, choroidal folds, and increased choroidal thickness without presence of subretinal fluid (SRF) or pigment epithelial detachment (PED). Further questioning revealed the patient was using dermal testosterone gel for six months for treatment of hypogonadism. The patient stopped using the testosterone gel, and his visual acuity and intraocular pressure significantly improved six weeks later. Follow-up UBM showed significant improvement of the ciliochoroidal effusion, and repeat multimodal images demonstrated resolution of the macular striae and choroidal folds, and slightly improved choroidal thickness.
UNASSIGNED: Our patient demonstrates a rare case of ciliochoroidal effusion, central serous-like chorioretinopathy, and secondary angle closure that dramatically improved with cessation of testosterone. We believe that this unique clinical constellation is the first to be reported associated with exogenous testosterone use.

OBJECTIVE: Cotton Wool Spots (CWS) are a commonly described retinal finding in the posterior segment associated with an extensive number of systemic diseases. The appearance of a CWS in the setting of glaucoma has rarely been reported and has not been correlated with pathology to localized loss of the nerve fiber layer previously. In this case report, we augment a previous report of an 18 year old female with a diagnosis of low grade ciliary body melanoma. This patient experienced eventual mechanical angle closure with a CWS appearing in the posterior pole in the setting of acute elevation of intraocular pressure (IOP). This eye underwent enucleation and pathology evaluation.
METHODS: Fundus photography documented a CWS in the posterior segment during a period of acute elevation in IOP. Subsequently the eye was enucleated due to pain from refractory angle closure glaucoma secondary to low grade iris-ciliary body ring melanoma. The specific site of the prior CWS was studied with 1μ Epon retinal step sections stained with a novel AgNO3 solution. Light microscopy demonstrated a retinal nerve fiber layer scar and inner nuclear layer collapse in the prior location of the CWS. Light microscopy and transmission electron microscopy shortly after enucleation had demonstrated temporal quadrant laminar optic nerve (ON) retrograde axonal transport block.
CONCLUSIONS: Although not commonly associated with glaucoma, CWS can present in the setting of acute elevations of IOP and may be associated with loss of nerve fiber layer. This loss of nerve fiber layer can confound the ability to judge glaucoma progression based on nerve fiber layer thickness via optical coherence tomography and changes in disc contours. Patient care may benefit from care provider\'s awareness of this possible phenomenon in the setting of angle closure.

A 19-year-old man noticed blurred vision in his right eye. He had an intraocular pressure of 60 versus 12 mmHg in the fellow eye. He was initially diagnosed with an atypical, advanced pigmentary glaucoma. The intraocular pressure did not respond to maximal medication, deep sclerectomy, goniopuncture, and 2 cyclophotocoagulations. Sixteen months after presentation, malignancy was first suspected, and the eye was enucleated. A ring melanoma of the anterior chamber angle was confirmed by the histopathologic examination. Normal nuclear staining for breast cancer 1 gene (BRCA1)-associated protein 1 suggested that the tumor was likely of disomy 3 type with a favorable prognosis. No local or systemic recurrence has developed within 4 years. A literature review of this rare type of minimal volume diffuse uveal melanoma identified 18 additional patients. The initial diagnosis in 18 of the 19 patients with a ring melanoma of the anterior chamber angle was unilateral glaucoma with a median intraocular pressure of 40 mmHg and an age range of 16-76 years. Liver metastasis developed in 5 of 12 patients older than 45 years. This rare subtype is estimated to account for 0.05%-0.16% of all uveal melanomas.