Pars plana vitrectomy combined with hyaloido-zonula-iridectomy in treatment of patients with chronic aqueous misdirection: A systematic literature review and case series

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.

Ocular Characteristics of Pseudophakic Eyes with Malignant Glaucoma

INTRODUCTION

The aim of the study was to investigate the clinical characteristics and treatment outcomes of the pseudophakic eyes with malignant glaucoma (MG).

METHODS

This retrospective case-control study enrolled 53 eyes of 47 patients with primary angle-closure glaucoma having cataract surgery history, including 19 patients (25 eyes) diagnosed with MG and 28 patients (28 eyes) without MG as the match. Among patients diagnosed with MG, 14 patients (18 eyes) underwent zonulo-hyaloido-vitrectomy (ZHV) and the other 5 patients (7 eyes) received conservative treatments. The visual acuity, refraction status, intraocular pressure (IOP), extent of peripheral anterior synechia, classes of anti-glaucoma medications, and ultrasound biomicroscopy (UBM) examination were recorded before cataract surgery, at the diagnosis of MG, and 3 months after ZHV or atropine application, respectively.

RESULTS

In the pseudophakic eyes with MG, the IOP cannot be well controlled compared to the matched eyes (27.24 ± 8.72 mm Hg vs. 14.30 ± 2.63 mm Hg, p < 0.001). In addition, there was a difference in the average spherical equivalent refractive error between 2 groups of patients (-2.23 ± 0.84 D in MG vs. -0.12 ± 0.64 D in the matched eyes, p < 0.001). By UBM analysis, the anterior chamber depth (ACD) was shallower in MG than that in the matched eyes (2.34 ± 0.20 mm vs. 3.47 ± 0.29 mm, p < 0.001). The difference between the anterior vault distance of the pseudophakic eyes with MG and that of the matched eyes was also significant (p < 0.001). After treated with ZHV, the IOP was greatly decreased from 27.84 ± 10.14 mm Hg to 15.85 ± 4.41 mm Hg (p < 0.001). The refractive error also changed from -2.11 ± 0.91 D to +0.42 ± 0.99 D (p < 0.001). At the same time, the central ACD was significantly deepened from 2.30 ± 0.39 mm to 3.30 ± 0.31 mm (p < 0.001).

CONCLUSION

Uncontrolled IOP and shallow anterior chamber both centrally and peripherally are the primary clinical characteristics for the pseudophakic eyes with MG. An unexpected refractive error or myopic shift for the eyes with PACG after cataract surgery can be an important hint for diagnosis of MG. The typical UBM image is an anterior displacement of the lens-iris diaphragm and a bow-shaped change of the intraocular lens. It is an effective way to treat pseudophakic MG with the ZHV through a peripheral iridectomy.

[Angle closure-glaucoma]

Angle-closure glaucoma is a less common form of glaucoma in Europe than open-angle glaucoma. Nevertheless, the clinical picture should also be known here since it can lead to severe visual disturbances and even blindness within a short time. It is divided into primary and secondary forms and can be further categorized depending on the presence of a pupillary block. In all cases, therapy is initially based on resolving the cause of the angle-closure and treating any underlying disease that may be present. In addition, intraocular pressure reduction must be achieved. This can be effectuated conservatively or surgically. Depending on the specific subtype of angle-closure, different treatments are promising.

Late-onset Relapse of Aqueous Misdirection after Pars Plana Vitrectomy: Case Report and Literature Review

Aim

We report on an 88-year-old female patient who presented with a relapse in aqueous misdirection 15 years after being treated with pars plana vitrectomy (PPV) with hyaloidotomy-zonulectomy-iridotomy (HZI) for the same cause.

Case description

A 73-year-old pseudophakic woman with a history of pseudoexfoliation underwent a trabeculectomy in the left eye in our institution because of uncontrolled intraocular pressure. Days after trabeculectomy, the patient developed aqueous misdirection and was treated with PPV combined with HZI. In the following years, the patient had regular follow-up appointments in our instruction, and she had normal intraocular pressures in the left eye without any treatment. A total of 15 years after the vitrectomy, the patient developed gradual swallowing in the anterior chamber and increased intraocular pressure. Neodymium (Nd): yttrium aluminum garnet (YAG) laser hyaloidotomy through the iridectomy opening was performed, the anterior chamber was immediately deepened, and the intraocular pressure was reduced to normal limits. The anterior chamber remained deep, and the intraocular pressure remained normal through the 36 months of follow-up.

Conclusion

Relapse of aqueous misdirection may occur many years after vitrectomy, even when HZI is performed. An Nd: YAG- laser hyaloidotomy should be attempted before a second HZI is considered.

Clinical relevance

A close and long-lasting follow-up of patients with aqueous misdirection is warranted, especially if the patients are treated not with complete PPV but by a limited disruption of the anterior hyaloid face along with HIZ.

How to cite this article

Halkiadakis I, Tzimis V, Markopoulos I, et al. Late-onset Relapse of Aqueous Misdirection after Pars Plana Vitrectomy: Case Report and Literature Review. J Curr Glaucoma Pract 2023;17(1):49-51.

A mysterious myopic surprise

A 73-year-old man with an ocular history of inactive age-related macular degeneration and chronic angle-closure glaucoma (CACG) in both eyes recently underwent femtosecond laser-assisted cataract surgery/phacoemulsification and intraocular lens (IOL) implantation with simultaneous Hydrus microstent (Ivantis, Inc.) implantation in the left eye. Although there was some reported subincisional iris prolapse due to intraoperative floppy iris, the case was otherwise uneventful according to the referring surgeon. Two months postoperatively, he was referred to our office for a myopic surprise of approximately 2.0 diopters (D) in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202202000-00022/figure1/v/2022-01-26T192641Z/r/image-tiff). Of note, he has a distant history of acute ACG and complicated cataract surgery in the right eye with a failed trabeculectomy. He subsequently had laser peripheral iridoplasty to pull the iris away from the angle in the right eye (Figure 2JOURNAL/jcrs/04.03/02158034-202202000-00022/figure2/v/2022-01-26T192641Z/r/image-tiff). His topical intraocular pressure (IOP)-lowering medications at presentation included dorzolamide-timolol 1 drop twice daily in the left eye and 1 drop of timolol in the right eye once daily. His past medical history is significant for hypertension and benign prostatic hyperplasia, and his oral medications include Tamsulosin (Flomax), Irbasartan (Avapro), and Atenolol. On examination, he had an UCDVA of 20/20 in the right eye and 20/80 in the left eye, and a BCDVA of 20/20 in the right eye and 20/25 in the left eye. His manifest refraction was plano in the right eye and 1.50 -0.75 × 90 in the left eye. IOP measured 19 mm Hg in the right eye and 26 mm Hg in the left eye. Pupil examination revealed a nonreactive pupil in the right eye and a round sluggish pupil in the left eye without an obvious relative afferent pupillary defect. Extraocular motility and confrontational visual fields were full in both eyes. On slitlamp examination, pertinent findings included the following: 1+ corneal guttata without edema in both eyes; anterior chambers were shallow but adequate in both eyes with scattered peripheral anterior synechiae in the right eye and a uniformly shallow but adequate chamber in the left eye; there was no cell or flare in either eye. Iris findings included a surgical pupil with a fibrotic pupillary membrane, laser iridoplasty scars with scattered temporal transillumination defects (TIDs) in the right eye, and 2.5 clock hours of TIDs and a patent peripheral iridotomy at 1 o'clock in the left eye; lens examination revealed centered posterior chamber IOLs with open posterior capsules in both eyes and lens pitting in the left eye. Pertinent findings on dilated fundus examination included a cup-to-disc ratio of 0.3 in both eyes with good neuroretinal rims and macular examination revealed medium-sized drusen with pigment clumping in both eyes and no active choroidal neovascular membranes. The remainder of the examination was unremarkable. What is the etiology of this myopic surprise? What diagnostic testing will help confirm the diagnosis and what are the best management options for this patient?

Successful Management of Malignant Glaucoma With Irido-Zonulo-Hyaloidotomy and Complete Pars Plana Vitrectomy

Successful irido-zonulo-hyaloidotomy in combination with complete pars plana vitrectomy in malignant glaucoma may lead to better intraocular pressure (IOP) control and a promising visual outcome. We report a case of an 81-year-old woman who presented with a ten-day history of right eye redness and blurring of vision associated with throbbing pain. An ocular examination revealed right-eye visual acuity (VA) of 6/60. The cornea was oedematous with a shallow anterior chamber (AC) and a grade 0 (Shaffer’s grading) by gonioscopy. The intraocular pressure at presentation was 52 mmHg. The optic disc was pink, with a cup-disc ratio of 0.3. Complete pars plana vitrectomy with irido-zonulo-hyaloidotomy was performed in view of poorly controlled intraocular pressure despite aggressive medical therapies, laser treatment, and the Chandler procedure. Postoperatively, the IOP was maintained at mid-teens without intraocular pressure-lowering agents. The visual acuity improved to 6/9. The early decision for irido-zonulo-hyaloidotomy with complete pars plana vitrectomy leads to resolution of malignant glaucoma with a lower relapse risk.

[Secondary Angle Closure Glaucoma]

Secondary angle closure glaucoma is a very heterogeneous subtype of glaucoma with a variety of possible causes leading to a blockade of the regular aqueous humour flow or outflow. A distinction is made between secondary pupillary block, angle closure with "pulling" or angle closure with "pushing" mechanisms. For each of these three subgroups, there are different causes, which in turn require individual therapy. Treatment of the underlying cause should always take priority whenever possible. Reduction of the intraocular pressure is often a symptomatic therapy with surgical, pressure lowering procedures showing a limited success rate in many forms of secondary angle closure glaucoma. This article intends to provide an overview of the different causes of secondary angle closure, diagnostic approaches and targeted therapies of exemplary causes of each subgroup.From the group of secondary pupillary block, mechanical causes, iris bombé, and intraoperative air or oil input are addressed, from the group of "pulling" causes, angle neovascularization, post-inflammatory angle changes, and iridocorneal endothelial syndrome and for the group of "pushing" mechanisms, gas endotamponade, retroiridal neoplasms and aqueous misdirection syndrome.While secondary angle closure is one of the most challenging glaucoma subgroups for treatment it is crucial to know the different subgroups and their development to choose the right treatment.

Sekundäre Winkelblockglaukome

Bei sekundären Winkelblockglaukomen liegt mindestens eine identifizierbare Ursache für den Winkelblock und die Obstruktion des Kammerwasserabflusses vor. Diese spezielle Unterform des Glaukoms ist eine besonders heterogene Gruppe an Erkrankungen bzw. Ursachen, die sich in ihrer Auswirkung auf den Kammerwasserfluss und in ihrer Behandlung deutlich unterscheiden. Dieser Beitrag gibt eine Übersicht über die verschiedenen Formen des sekundären Winkelblockglaukoms und zeigt die Ansatzpunkte für eine zielgerichtete Therapie auf.