Current Concepts on Aqueous Misdirection

Aqueous misdirection syndrome post silicone oil removal in a vitrectomized eye - a case report

PUROPSE

Aqueous misdirection syndrome (AMS) is an aggressive post-operative glaucoma unresponsive to conventional measures with grave outcomes. In this report, we describe a rare case of AMS following silicon oil removal in a vitrectomized eye.

METHODS

A diabetic patient with tractional retinal detachment underwent pars plana vitrectomy with silicon oil injection. Following retinal reattachment, silicon oil removal was performed at three months. Post oil removal she developed increased intraocular pressure with shallowing of both the peripheral and central anterior chamber suggestive of AMS.

RESULTS

Initial medical management with anti-glaucoma medications and cycloplegics was not beneficial. A pars plana lensectomy with complete anterior hyaloidectomy along with a surgical peripheral iridectomy helped relieve the aqueous misdirection.

CONCLUSION

AMS can rarely occur following vitrectomy and is likely secondary to intact anterior hyaloid. Lensectomy along with zonulo-hyaloido-iridectomy is essential. This report highlights the occurrence of this rare complication and its effective management.

Malignant glaucoma presenting with uncontrolled intraocular pressure and myopic refractive surprise after cataract surgery

We present a seemingly typical case of bilateral angle closure with elevated intraocular pressures. After cataract surgery, there was axial shallowing, escalating intraocular pressure, anterior displacement of the IOL, and myopic shift in the left eye. Irido‐zonulo‐hyaloido‐vitrectomy resolved the angle closure, normalized intraocular pressure, and corrected the myopic shift.

An iris puncture technique for restoration of the anterior chamber in vitrectomy for pediatric vitreoretinopathies

PURPOSE

To present a novel usage of iris puncture-assisted lensectomy with anterior vitrectomy or vitrectomy in pediatric patients with the absence of anterior chamber caused by various advanced vitreoretinopathies complicated with capsule-endothelial, iris-endothelial adhesion, and secondary glaucoma.

DESIGN

Prospective study.

MATERIALS AND METHODS

Forty-one patients were enrolled in this consecutive, prospective study. The iris puncture was performed in all patients using a 20G Vitrectomy Microsurgical Knife, followed by the lensectomy with anterior vitrectomy or vitrectomy. Demographic information, the number of iris puncture times, surgical procedure, intraoperative and postoperative complications, therapy, and prognosis were collected. Patients were followed up for at least 6 months.

RESULTS

A total of 18 female patients and 23 male patients were included, with a mean age of 9.5 ± 7.5 months. The formation of anterior chamber formation was achieved in 28 (68.3%) eyes, with only 1 initial episode of iris puncture, 11 (26.8%) patients required 2 episodes, and 3 episodes of iris puncture, with additional external drainage of subretinal fluid, were needed in the remaining 2 (4.9%) patients. Except for iris incarceration, which occurred in 7 (17%) eyes during operation, there was no iridodialysis or subretinal fluid overflow during operation. At the last visit (mean: 12.16 ± 5.38 months of follow-up), all eyes had a reconstructed anterior chamber with normal depth. No synechiae between the iris and the cornea occurred after surgery. The mean postoperative intraocular pressure was 6.23 ± 1.64 mmHg. A hazy cornea vanished in 31 out of 41 (75.6%) eyes, relieved in 8 out of 41 eyes (19.5%), and 2 out of 41 eyes (4.88%) did not change. In the 25 eyes accepting vitrectomy and lensectomy, 20 out of 25 (80%) achieved different degrees of reattachment.

CONCLUSION

The innovative iris puncture technique is effective, simple, and safe management for the anterior chamber disappearance caused by various advanced pediatric vitreoretinopathies, which helped to lower the intraocular pressure and offers a chance for lensectomy with anterior vitrectomy or vitrectomy.

Three Cases of Intraoperative Acute Fluid Misdirection Syndrome during Cataract Surgery

Purpose: We report the management of three cases of intraoperative acute fluid misdirection syndrome during cataract surgery.Case summary: Cataract surgery was performed in one eye of an 82-year-old woman with pseudoexfoliation syndrome, one eye of an 80-year-old man with end-stage glaucoma, and both eyes of a 72-year-old man with pseudoexfoliation syndrome. In the first two cases, the capsular bag space decreased during cortex aspiration and after removal of the cortex, respectively. After intravenous mannitol and intake of oral acetazolamide, the intraocular lens was successfully inserted in the first two cases on the same day. In the third case, after first removing the nucleus and cortex of the right eye, the capsular bag space decreased and an intraocular lens was carefully inserted. No intraoperative complications were seen during the left eye operation. One month after the operation, the best-corrected visual acuity had improved and the intraocular pressure was within normal limits for all three cases.Conclusions: A relatively shallow chamber, pseudoexfoliation, zonular laxity, and use of high molecular weight ophthalmic viscosurgical devices may cause acute fluid misdirection syndrome during cataract surgery. Pars plana vitrectomy may be required. However, intravenous high osmotic agent treatment should be attempted first, followed by intraocular lens insertion on the same day.