Factors Impacting Outcomes and the Time to Recovery From Malignant Glaucoma

A rare case of bilateral malignant glaucoma after cataract surgery with capsular tension ring implantation: a case report

BACKGROUND

Bilateral malignant glaucoma induced by a capsular tension ring associated with ring-shaped cysts of the ciliary body post-cataract surgery is rare. Herein, we present a case to highlight the possibility of capsular tension ring-induced malignant glaucoma.

CASE PRESENTATION

A 59-year-old woman underwent phacoemulsification combined with capsular tension ring implantation for cataracts and zonular fibre laxity in both eyes. Upon admission, annular ciliary masses were detected in both eyes using ultrasound biomicroscopy. Two months post-surgery, the patient experienced vision deterioration, high intraocular pressure, and an axial shallowing anterior chamber in the right eye, and responded poorly to traditional anti-glaucoma medication. Ten days later, similar symptoms appeared in the left eye. Ultrasound biomicroscopy detected contact between the ciliary body and the capsular tension ring. Subsequently, malignant glaucoma was diagnosed. Anterior and posterior capsulotomies performed peripheral to intraocular lens optics using neodymium: YAG laser restored communication and alleviated the symptoms. A one-year follow-up revealed stable intraocular pressure and anterior chamber in both eyes.

CONCLUSIONS

This is the first case report of bilateral malignant glaucoma after cataract surgery induced by capsular tension ring, which is associated with bilateral ring-shaped cysts of the ciliary body. Blockage between the ciliary body and capsular tension ring was confirmed using ultrasound biomicroscopy.

Aqueous misdirection syndrome: clinical outcomes and risk factors for treatment failure

PURPOSE

To evaluate the outcomes of postoperative aqueous misdirection and factors predicting failure of interventions.

METHODS

This retrospective study included 49 eyes from 47 patients with aqueous misdirection following glaucoma or cataract surgery. Resolution of aqueous misdirection (AM) was deepening of the central anterior chamber (AC) and intraocular pressure (IOP) ≤ 21 mmHg. The Cox proportional hazards regression model was used to evaluate risk factors for failure of various treatments.

RESULTS

10/49 eyes (20%) resolved with conservative management, and 39/49 eyes (80%) needed multiple intervention, of which 95% (37/39) eyes achieved resolution of aqueous misdirection. Pseudophakia predicted the need for multiple interventions with a hazard ratio of 2.391 (1.158-4.935), p = 0.02). Among the risk factors assessed for resolution of AM, longer axial length (HR: 0.61 (0.414-0.891), p < 0.01) and eyes with prior glaucoma surgery predicted resolution (HR: 0.142 (0.027-0.741), p < 0.01) and delayed presentation predicted failure (HR: 1.002 (1.0002-1.0031), p < 0.02).

CONCLUSION

Pseudophakic eyes were more refractory and predicted the need for multiple interventions. Eyes with prior glaucoma surgery and those with longer axial length had achieved resolution faster, and delayed presentation was a risk factor for failure to resolve.

Impact of improved minimally invasive anterior vitrectomy on the prognosis of patients with malignant glaucoma

BACKGROUND

The importance of communicating the anterior chamber and vitreous cavity for managing malignant glaucoma (MG) is widely recognized. This study investigated the impact of improved minimally invasive anterior vitrectomy (IAV) on the prognosis of MG.

METHODS

This retrospective interventional study included patients with MG who underwent conventional surgery or improved minimally IAV in Nanchang Aier Eye Hospital between January 2011 and April 2021. For the improved step, a small amount of triamcinolone acetonide was injected into the vicinity of the iris. Then, the residual vitreous body adhering to triamcinolone acetonide was excised. Comparisons were made using repeated measures ANOVA, t-test, and chi-squared test.

RESULTS

Thirty-one eyes from 26 patients were included: 15 eyes from 13 patients in the conventional group and 16 eyes from 13 patients in the IAV group. The 1-week, 1-month, and 3-month intraocular pressure (IOP) and the 3-month mean central anterior chamber depth were comparable between the two groups (all P > 0.05). The conventional group showed one eye with intraoperative vitreous hemorrhage and two eyes with postoperative re-shallowing of the anterior chamber; such events did not occur in the IAV group, and none developed corneal endothelial decompensation, IOL deviation, suprachoroidal hemorrhage, or retinal detachment during treatment and follow-up.

CONCLUSION

Patients with MG who undergo improved minimally IAV might have similar postoperative IOP and central anterior chamber depth compared with conventional surgery but with reduced complications such as intraoperative vitreous hemorrhage and postoperative re-shallowing of the anterior chamber. Improved minimally IAV might be an alternative surgery for MG.

Management of Pseudophakic Malignant Glaucoma Using Modified Nd:YAG Laser Treatment Methodology Through Surgical Preset Iridectomy

INTRODUCTION

The use of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser to treat malignant glaucoma (MG) has been described in the literature since the 1980s. However, the technique has been reported to have a short-term effect, with a notable relapse rate. In the present study, we report the efficacy and durability of a modified Nd:YAG laser treatment methodology for treatment of pseudophakic or aphakic MG.

METHODS

Patients with chronic angle-closure glaucoma and deemed at high risk of developing post-operative MG received prophylactic peripheral iridectomy during their conventional operation beginning in 2017. When the diagnosis of pseudophakic or aphakic MG was confirmed, a thorough Nd:YAG laser capsulo/zonulo-hyaloido-vitreolysis (CZHV) was performed through iridectomy, along with standardized pre- and post-laser medications. This retrospective case series includes 14 eyes of 11 patients with MG who had surgical preset iridectomy and modified Nd:YAG laser CZHV between 2017 and 2022. Outcome measures included resolution and recurrence of MG and incidence of treatment complications.

RESULTS

The mean follow-up was 27.1 ± 15.0 months (range, 12-48). Long-term resolution of MG was obtained in all included eyes at the end of the follow-up. Six eyes (42.9%) achieved long-term resolution with a single Nd:YAG laser intervention. Eight eyes (57.1%) achieved long-term resolution following two to three laser interventions, with two eyes (14.3%) experiencing recurrence. There was no complication during the follow-up. At the final visit, a significant reduction (P = 0.0001) in the mean intraocular pressure (IOP) was observed (13.1 ± 2.8 mmHg) compared to presentation (21.4 ± 6.3 mmHg).

CONCLUSION

The modified Nd:YAG laser treatment methodology is a minimally invasive option to manage pseudophakic or aphakic MG with sustained effectiveness. Reduced inflammatory reactions due to prophylactic peripheral iridectomy, rapid diagnosis, and timely treatment initiation have all contributed to the favorable outcomes associated with this modified treatment methodology.

Evaluation of the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy for malignant glaucoma

PURPOSE

To assess the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy (IZH) for fluid misdirection syndrome (FMS) in pseudophakic eyes.

METHODS

This was a retrospective case series study of patients treated with pars plana vitrectomy with IZH for FMS between February 2017 and March 2020. Complete success was defined as central anterior chamber (AC) deepening with an intraocular pressure (IOP) of 21mmHg or less (on 2 consecutive visits at least 1 week apart) without topical or systemic glaucoma medications. Qualified success was defined as central AC deepening with an IOP of 21mmHg or less (on 2 consecutive visits at least 1 week apart) with topical or systemic glaucoma medications.

RESULTS

Twelve eyes of 12 patients with a diagnosis of FMS were included. The mean age of the population was 73.6±15.4 years [39-90] with a majority of women (58.3%). Prior surgeries at the time of FMS diagnosis were trabeculectomy (4 eyes) and non-perforating deep sclerectomy (2 eyes). At presentation, mean IOP was 38.2±9.8mmHg, which decreased to 17.9±7.7mmHg (P<0.0001) at final follow-up (mean follow-up of 4.9±4.3 months). Complete success was achieved in 6 eyes (50%) and qualified success in 10 eyes (83%), with two eyes failing treatment. There was no statistical significant relationship between demographic data and clinical success (P > 0.05).

CONCLUSION

Pars plana vitrectomy combined with IZH appears to be a safe and effective technique for the treatment of FMS in pseudophakic patients.

Exploration on surgery of malignant glaucoma with prolonged absence of the anterior chamber: a retrospective consecutive case series

OBJECTIVE

To evaluate the surgical outcomes of anterior chamber restoration in patients with malignant glaucoma and a prolonged absence of the anterior chamber.

METHODS

Five patients with malignant glaucoma and a long-term absence of the anterior chamber underwent a combination of anterior pars plana vitrectomy (aPPV), phacoemulsification cataract excision, intraocular lens implantation, peripheral iridotomy (PI), goniosynechialysis (GSL) (referred to aPPV + P + I + PI + GSL) at Beijing Tongren Hospital from October 2018 to June 2021. The study compared the changes in their visual acuity, intraocular pressure (IOP) and medication requirements between the pre-surgery period and their most recent follow-up visit.

RESULTS

The five patients did not report any discomfort, such as pain, tearing, swelling, etc., in their affected eyes, and maintained a stable restoration of the anterior chamber. Among the affected eyes, only one eye demonstrated improved vision during the follow-up visit, while the remaining four eyes did not show any significant improvement. One eye underwent transscleral cyclophotocoagulation as an additional procedure, while the other four eyes did not require any further surgical intervention. In all cases, the intraocular pressure (IOP) was successfully controlled below 30 mmHg. Post-surgery, four eyes still required cycloplegia treatment, and three eyes continued to rely on eye drops to manage their IOP.

CONCLUSION

Despite minimal improvement in vision, surgical intervention successfully restored the anterior chamber in malignant glaucoma patients with a prolonged absence of anterior chamber. This restoration contributed to alleviating subjective complaints of discomfort and delaying eyeball atrophy.

Outcomes of Medical and Surgical Management in Aqueous Misdirection Syndrome

Purpose

To report the outcomes of medical and surgical management in patients diagnosed with aqueous misdirection syndrome (AMS).

Patients and Methods

A retrospective chart review of all cases diagnosed with AMS at a single tertiary care eye center during the period from 2014 to 2021. Outcome measures were anatomical success (deepening of the anterior chamber (AC)), functional success (improvement in visual acuity), and treatment success (control of intraocular pressure (IOP)).

Results

A total of 26 eyes with AMS from 24 patients were included. The patients were followed for a mean duration of 24 ± 18 months. Although some patients initially responded to medical and laser therapy, all but one (3.8%) eventually required surgery during the first 3 months after presentation. The mean duration from presentation until surgery was 45.9 ± 45.8 days (range: 2-119 days). The majority of cases (69.2%) were managed by pars plana vitrectomy. At the last follow-up visit, anatomical success was achieved in 20 (76%) eyes, 15 (57%) eyes had a final visual acuity that was either similar to or better than baseline, and successful control of IOP was achieved in 17 (65%) eyes. Univariate analysis revealed that a history of trabeculectomy as a cause of AMS was a risk factor for treatment failure (OR, 7.8; 95% CI, 1.16-52.35; P, 0.02).

Conclusion

Our findings indicate that medical and laser management of AMS provide temporary control, and almost all patients eventually require surgery within the first 3 months. A history of trabeculectomy was found to be a risk factor for treatment failure.

[Therapy of malignant glaucoma]

Malignant glaucoma is a rare and complex eye disease but the exact cause has not yet been clarified with certainty. Malignant glaucoma can be treated with medication or by means of laser surgery or open incisional surgery. In this article the possible procedures for the treatment of malignant glaucoma (medicinal and surgical) are presented together and justifications for the procedures described are given.

Application of Nd:YAG laser to the anterior vitreous in malignant glaucoma - a systemic review and meta-analysis

PURPOSE

The study aims to review the efficacy, safety, and technique of Nd:YAG laser vitreolysis for the management of malignant glaucoma (MG).

METHODS

We performed a search of electronic databases for all published studies which included technical specifications of Nd:YAG laser application for MG. Individual patient data was extracted and evaluated in a weighted pooled analysis.

RESULTS

Thirty eyes were reported on from seven studies worldwide. Age of affected patients ranged between 37 and 82 years. Nd:YAG vitreolysis was performed either through an iritodomy (66.7%, 18/27 eyes), transpupillary (18.5%, 5/27 eyes), or through both simultaneously (14.8%, 4/27 eyes). Treatment intensity ranged between 1.0 and 11.00 mJ with 75.9% (22/29 eyes) of treatments being 3.0 mJ or lower. Between 1 and 41 pulses per session were applied. Rates of both anatomical and intraocular pressure resolution were examined. Overall, in a pooled analysis, 77% of eyes demonstrated MG resolution with no further treatment required after Nd:YAG vitreolysis (95% CI: 58.1 to 91.4%). A trend for lower need of additional interventions was seen with transpupillary application (11.1% versus 42.1%). No complications were reported.

CONCLUSIONS

Nd:YAG laser vitreolysis is a safe procedure, associated with MG resolution in the majority of reported cases, regardless of treatment intensity. Transpupillary treatment may be associated with lower risk of re-intervention.

Pediatric intraoperative ciliary block

Pediatric patients who undergo intraocular surgery are at risk for many of the same perioperative complications as adults. The same methodical approach to assessing perioperative shallowing of the anterior chamber that presents in the adult population should be followed for children. We present a rare case of intraoperative ciliary block in a 3-year-old boy undergoing a second glaucoma drainage device implantation that was successfully treated with pars plana vitrectomy and hyaloid-zonulo-iridectomy.

[Chronification of malignant glaucoma after cataract surgery]

Das maligne Glaukom mehrere Jahre nach Kataraktoperation stellt eine sehr seltene Spätkomplikation dar. Eine zunehmende Myopisierung kann einen frühen Hinweis auf das Entstehen geben. Eine chirurgische Intervention ist oft unumgänglich. Die Druckeinstellung kann wie in unserem Fall aber auch konservativ gelingen. Es kann daher der Situation angepasst und individuell entschieden werden, wie invasiv die Behandlung erfolgen muss und ob eine Vitrektomie zwingend notwendig ist.