Malignant glaucoma: a review of the modern literature

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.

Comparison of Long-Term Effects Following Phacoemulsification Combined with Goniosynechialysis and Trabeculectomy in Patients with Primary Angle-Closure Glaucoma and Cataract

INTRODUCTION

Goniosynechialysis (Phaco-GSL) is a logical therapeutic approach for patients with primary angle-closure glaucoma (PACG) and cataract. The aim of this study was to compare the long-term effectiveness and safety of Phaco-GSL and trabeculectomy (TRB) in the management of PACG with coexisting cataract.

METHODS

A review was conducted on 96 Chinese patients (96 eyes) with PACG and cataract from Peking Union Medical College Hospital (PUMCH). Among them, 56 patients underwent Phaco-GSL, while 40 underwent TRB. Intraocular pressure (IOP), best corrected visual acuity (BCVA), use of supplemental antiglaucoma medical therapy, surgery success rates, and complications for both procedures were assessed.

RESULTS

The average follow-up period was 50.3 ± 18.7 months in the Phaco-GSL group and 61.2 ± 15.1 months in the TRB group. At the final follow-up, IOP decreased from 27.0 ± 11.1 mmHg to 13.5 ± 2.1 mmHg in the Phaco-GSL group and in the TRB group IOP decreased from 27.1 ± 7.7 mmHg to 16.5 ± 5.5 mmHg. The long-term postoperative IOP in the Phaco-GSL group was significantly lower than that in the TRB group. There was a statistically significant reduction in medication usage in both groups, with the TRB group having a higher number of postoperative medications at the final follow-up. The incidence of postoperative complications was significantly higher in the TRB group compared to the Phaco-GSL group.

CONCLUSIONS

Phaco-GSL is the recommended surgical approach for Chinese patients with primary angle-closure glaucoma (PACG) and cataract. Compared to traditional TRB, eyes undergoing Phaco-GSL show a reduced requirement for antiglaucomatous medications, improved management of IOP, decreased risk of complications, and higher long-term cumulative probability of treatment success for patients with PACG.

Efficacy of Micropulse Laser Cyclophotocoagulation Therapy in Primary Angle Closure Glaucoma

PRCIS

In primary angle closure glaucoma (PACG), micropulse cyclophotocoagulation resulted in a significant reduction in intraocular pressure (IOP), and the number of antiglaucoma medications without any sight-threatening complications. However, the IOP lowering efficacy decreased over time.

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of micropulse trans-scleral cyclophotocoagulation (MP-TSCPC) in PACG.

PATIENTS AND METHODS

Thirty-three phakic PACG eyes with patent laser peripheral iridotomy and IOP uncontrolled on maximum tolerable antiglaucoma medications (AGMs), scheduled for trabeculectomy, were given a trial of MP-TSCPC (810 nm laser, 2000 mw power for 180 seconds, 360 degrees). The primary outcome measure was a success at 1 year with IOP ≤18 mm Hg and ≤15 mm Hg with (qualified success) or without (absolute success) AGMs after a single session of MP laser. Secondary outcome measures were changes in pupillary diameter, visual acuity, central macular thickness, and subjective pain perception.

RESULTS

Thirty-two out of 33 PACG patients completed 12 months of follow-up. The mean age of patients was 54.7±8.9 years; male:female ratio was 1:1. The baseline IOP was 25.7±5.3 mm Hg, which reduced to 17.9±4.6 mm Hg at the end of 12 months (P<0.0001). Twenty eyes (62.5%) achieved qualified success, and 1 eye (3.125%) had absolute success at 12 months for IOP ≤18 mm Hg; 6 eyes (18.75%) had qualified success, and 1 eye (3.125%) had absolute success for IOP ≤15 mm Hg at 12 months follow-up. A significant reduction was also observed in the number of AGMs (4.4±0.8 at baseline to 2.9±1.1 at 12 months; P <0.0001). Five eyes (15.6%) received additional treatment-3 eyes (9.4%) requiring a subsequent filtering procedure, and 2 eyes (6.2%) requiring an additional MP-TSCPC session. No significant change in pupillary diameter (P=0.489) or central macular thickness (P=0.938) was noted at 12 months. There was a transient drop of visual acuity >2 lines in 1 patient due to cystoid macular edema, and no major postlaser complications were noted.

CONCLUSIONS

MP-TSCPC can be used as an interim procedure to reduce IOP in PACG eyes and delay the need for invasive surgery. Most patients require continued use of glaucoma medications, and target IOPs achieved are in the high teens.

Malignant Glaucoma After Immediate Primary Phacoemulsification for Acute Primary Angle Closure: A Case Report

Malignant glaucoma is characterized by ciliary block or aqueous misdirection, shallowing of the anterior chamber with elevated intraocular pressure (IOP), resistance to treatment, and rapid progression to blindness. However, the exact pathogenic mechanism is yet to be established. Here, we report a case of malignant glaucoma caused by immediate primary phacoemulsification for acute primary angle closure (APAC). A 90-year-old woman, who had experienced right eye pain and blurred vision one day prior, had a cataract in the same eye without phacodonesis. The right eye IOP was 39 mmHg, preoperative anterior chamber depth was 1.00 mm, and the axial length was 22.31 mm. We diagnosed APAC in the right eye and performed phacoemulsification. On postoperative day one, the IOP decreased to the normal range (15 mmHg), the anterior chamber deepened, and the angle became open. However, one week after phacoemulsification, the anterior chamber and angle became shallower and closer again. We diagnosed the patient with malignant glaucoma, performed hyaloid-zonulo-iridectomy, and administered 1% atropine eye drops postoperatively. As a result, the IOP was limited to a 10 mmHg range with an open angle and deep anterior chamber. Malignant glaucoma can be caused by immediate primary phacoemulsification for APAC.

Low-dose transscleral cyclophotocoagulation with subsequent phacoemulsification in the treatment of prolonged acute primary angle closure

BACKGROUND

To explore the outcomes and mechanisms of intraocular pressure (IOP) control using low-dose transscleral cyclophotocoagulation (LDTSCP) followed by phacoemulsification in patients with prolonged acute primary angle closure (APAC).

METHODS

Patients with prolonged APAC refractory to all other treatment modalities were prospectively recruited, and underwent LDTSCP (10 shots, 2 s duration, 120° treatment with the energy starting at 1500 mW and titrated to the level with audible burst but not exceeding 2000 mW) and anterior chamber paracentesis 1 week prior to phacoemulsification with intraocular lens implantation and viscogoniosynechiolysis. Postoperative IOP, vision, anatomic changes on anterior segment optical coherence tomography and complications were recorded.

RESULTS

Twenty eyes with prolonged APAC were recruited. Median follow-up was 12 months (range 9-18), at which point the vision in all eyes had improved and IOP was ≤17 mm Hg on no antiglaucoma medications. Following LDTSCP at postoperative day (POD) 1, IOP decreased in all eyes to a median 15 mm Hg (range: 6-28 mm Hg). Post-LDTSCP supraciliary effusion (SCE) occurred in 90% of eyes on POD1 or POD7 and ciliary body defect (CBD) was detected in 30% of eyes and resolved in all cases by postoperative month 1. Lower post-LDTSCP IOP was associated with more number of bursts (r=-0.558, p=0.011) and higher grade of SCE (r=-0.877, p<0.001), but not with total energy (p=0.240). Eyes with CBD (p=0.018) and a higher number of bursts (r=0.657, p=0.002) had higher grade SCE.

CONCLUSIONS

LDTSCP-induced SCE may explain the post-LDTSCP IOP reduction seen in eyes with prolonged APAC. LDTSCP instead of traditional more extensive treatment, was sufficient to provide a relatively safe and effective bridge therapy prior to phacoemulsification.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR1900023567).

Cataract surgery in adult eyes with short axial length

PURPOSE OF REVIEW

Cataract surgery in eyes of patients with short axial length (AL) can be technically challenging and is associated with a high risk of intra- and postoperative complications. Several technical and surgical strategies have been proposed to optimize the visual outcome and decrease the rate of surgical complications and it is important to understand their applications in these cases.

RECENT FINDINGS

Traditional intraocular lens (IOL) measurement formulas in eyes with short AL have reduced reliability. Novel formulas such as the Kane formula provide a better refractive prediction. Surgery can be difficult in short eyes due to the crowdedness of the anterior chamber (AC) and the associated scleral abnormalities increasing the risk of uveal effusion. Surgical techniques such as prophylactic scleral incisions, limited pars plana anterior vitrectomy, and modified hydrodissection, have been shown to facilitate surgery in extremely short eyes and decrease the rate of operative complications. Although cataract surgery improves vision in these cases, short AL and shallow AC have been associated with worse visual outcomes.

SUMMARY

Newer 4 th generation IOL formulas have improved the refractive outcomes of cataract surgery in eyes with short AL. There are multiple evolving surgical strategies for optimizing surgery in these eyes. However, studies on the surgical and visual outcomes of cataract surgery in eyes with short AL are limited by their design and sample size. With further research and continued clinical experiences, we hope to develop evidence-based algorithms for the management of these complex cases.

A case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy

Purpose

To describe a case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy.

Observations

A patient who developed refractory bilateral pseudophakic malignant glaucoma underwent an irido-zonulo-hyaloid-vitrectomy via the anterior chamber in both eyes, one 2-months apart from the other. The procedure involved the use of an 18 Gauge needle to perform a straight vertical irido-zonulo-hyaloidotomy and a 25 Gauge vitreous cutter to complete the vitrectomy. The intraocular pressure was recorded on day 1, day 7, day 14, then monthly until 6 months postoperatively, whereas an ultrasound biomicroscopy of the anterior chamber was performed on day 1 and 6 months after the operation. The malignant glaucoma resolved in both eyes with no intra- nor post-operative complications. At 6 months from the surgeries none of the eyes developed recurrences.

Conclusions

The new variant of irido-zonulo-hyaloid-vitrectomy we propose for the management of refractory pseudophakic malignant glaucoma resulted to be a safe and effective technique.

Management of Malignant Glaucoma

Purpose

To compare the outcomes of various invasive and noninvasive approaches to the treatment of malignant glaucoma.

Methods

Glaucoma-related keywords were looked up in PubMed and Google Scholar, and related articles up to 2022 were used to put together this review article.

Results

Numerous surgical methods and techniques have been introduced in the past few years. This review outlined current knowledge regarding the nonsurgical and surgical management of malignant glaucoma. In this regard, we first briefly outlined the clinical presentation, pathophysiology, and diagnosis of this disorder. Then, the current evidence on the management of malignant glaucoma was reviewed. Finally, we discuss the need for treatment of the other eye and the factors that might affect the outcome of surgical intervention.

Conclusions

Fluid misdirection syndrome, or malignant glaucoma, is a severe disorder that can occur spontaneously due to surgical intervention. The pathophysiology of malignant glaucoma is complicated, and numerous theories exist about the underlying mechanisms that may contribute to the disease. Malignant glaucoma can be treated conservatively using medications, laser therapy, or surgery. Laser treatments and medical treatments have been adequate for the treatment of glaucoma, but the effects have generally been short-lived, and surgical treatment has proved to be the most effective. There have been a variety of surgical methods and techniques introduced. Still, none have been studied in a large proportion of patients as a control case to compare effectiveness, outcomes, and recurrence. Pars plana vitrectomy with irido-zonulo-capsulectomy still seems to have the best results.

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.

Argon Laser Synechiolysis for Irido-Corneal Adhesion

Purpose

To introduce a new method for treating irido-corneal adhesion (ICA) by using argon laser. Case Presentation. A 60-year-old woman with advanced glaucoma who is undergoing trabeculectomy. In follow-up visits, choroidal effusion and iridocorneal adhesion were seen in the examination. The massive choroidal effusion was treated with medical therapy. In further follow-up examination, ICA was repaired with argon laser.

Result

Early laser treatment prior to surgical management is suggested in postoperative synechia.

Conclusion

Early argon laser synechiolysis is a less-invasive procedure which prevents probable surgical complications such as local detachment of Descemet's membrane or bleeding in surgical synechiolysis.

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.

Malignant glaucoma following gonioscopy-assisted transluminal trabeculotomy: a case report

BACKGROUND

To report a case of malignant glaucoma that developed after gonioscopy-assisted transluminal trabeculotomy (GATT).

CASE PRESENTATION

An 85-year-old male pseudophakic patient affected by pseudoexfoliative glaucoma (PEXG), unresponsive to medical glaucoma treatment, underwent uneventful GATT surgery. On the first day after surgery, the eye showed a shallow central and peripheral anterior chamber (AC) with a raised intraocular pressure (IOP) measured at 55 mmHg. Optical coherence tomography and ultrasound biomicroscopy confirmed the diagnosis of malignant glaucoma. Laser iridotomy, posterior capsulotomy and hyaloidotomy were performed, and the patient was treated with atropine sulphate 1%, maximum topical and systemic ocular hypotensive drugs with no improvement in the IOP. Subsequently, the patient underwent pars plana anterior vitrectomy, resulting in deepening of the AC with opening of the iridocorneal angle and decrease of the IOP. No further postoperative complications were recorded, and the IOP remained controlled 12 months after surgery without antiglaucoma medications.

CONCLUSIONS

Despite the minimally invasive profile of GATT, malignant glaucoma may develop after this procedure. Early recognition and prompt treatment are mandatory for preventing permanent visual loss.

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.

Effectiveness of surgical management of malignant glaucoma in phakic eyes

AIM

To assess the effectiveness of core vitrectomy-phacoemulsification-intraocular lens (IOL) implantation-capsulo-hyaloidotomy in treating phakic eye at least 1mo after the onset of malignant glaucoma.

METHODS

A retrospective analysis were performed on malignant glaucoma patients treated in Zhongshan Ophthalmic Center between 2016 and 2018. Demographic and clinical data were described. The preoperative and postoperative visual acuity (VA), intraocular pressure (IOP), number of IOP-lowering medications used, and anterior chamber depth (ACD) of the case series were compared by Wilcoxon signed-rank test.

RESULTS

Thirteen phakic eyes with long time intervals between onset and surgery were identified in this case series. Core vitrectomy-phacoemulsification-IOL implantation-capsulo-hyaloidotomy reduced the IOP (P=0.046) and the number of IOP-lowering medications used (P=0.004), deepened the ACD (P=0.005). Complete success was achieved in 38.5% of the eyes, and anatomical success was achieved in 100% of the eyes without any recurrence. The only postoperative complication observed is corneal endothelial decompensation. It occurred in two cases.

CONCLUSION

Core vitrectomy-phacoemulsification-IOL implantation-capsulo-hyaloidotomy is safe and effective for treatment of long onset phakic malignant glaucoma.

Aqueous misdirection syndrome masking as myopic surprise following phacoemulsification surgery

Aqueous misdirection syndrome is a rare but serious condition that can present after routine phacoemulsification surgery. This report examines a case of myopic surprise following an uncomplicated left eye (LE) phacoemulsification surgery. The patient had previous bilateral peripheral iridotomies for narrow anterior chamber angles. Repeat biometry measurement of the pseudophakic LE did not show shallow anterior chamber, and intraocular pressure (IOP) was normal at initial presentation. However, approximately 3 years postoperatively, LE IOP was raised. Surgical management was considered as medical and laser procedures did not stop deterioration. Clinical presentation of aqueous misdirection syndrome may be subtle and can occur weeks to years after routine uncomplicated phacoemulsification surgery. Myopic surprise may be the only initial presenting sign. Patients who are at risk of aqueous misdirection syndrome should be followed up closely after cataract surgery with accurate gonioscopic assessments for early diagnosis and treatment to prevent optic nerve damage.

Cataract Surgery in Short Eyes, Including Nanophthalmos: Visual Outcomes, Complications and Refractive Results

Background

To report the visual outcomes, complications and refractive results of phacoemulsification surgery and intraocular lens implantation in a large series of adult patients with short and nanophthalmic eyes.

Methods

The records of all patients with axial length <21.0 mm undergoing phacoemulsification with intraocular lens implantation at an adult teaching hospital were retrospectively reviewed. The main outcome measures were corrected distance visual acuity and refraction at 90 days after surgery and intra- and postoperative complications occurring during the follow-up period.

Results

A total of 71 eyes of 51 patients (median age 71 years, interquartile range 62–75.5) were included. Surgery resulted in an improvement in corrected distance visual acuity in 53 eyes (74.6%) (95% confidence interval, logMAR 0.11–0.29) and was logMAR 0.30 or better in 47 eyes (66.2%). Worsening of corrected distance visual acuity occurred in 9 eyes (12.7%). Median postoperative refractive error was −0.75 dioptres. SRK/T and Kane formula were more accurate in predicting postoperative refraction than Barrett Universal II and Hoffer Q when based on mean absolute error (P < 0.005). Complications occurred in 18 eyes (25.4%). The most frequent complications were iris prolapse, Descemet’s membrane and/or endothelial trauma, transient severe corneal edema and cystoid macular edema. There was no statistically significant difference in complication rates between senior surgeons and senior trainees (P = 0.66).

Conclusion

Cataract surgery in short and nanophthalmic eyes is challenging with a higher complication rate than routine cataract surgery, but frequently results in good visual outcomes. Postoperative refractive outcomes are more difficult to predict in this cohort.

Clinical efficacy of inferior peripheral irido-capsulo-hyaloidotomy for pseudophakic malignant glaucoma

PURPOSE

The present research aimed to investigate the effects of Inferior peripheral irido-capsulo-hyaloidotomy for the management of pseudophakic malignant glaucoma.

METHOD

Ten pseudophakic eyes with aqueous misdirection were diagnosed between September 2017 and December 2018 (10 eyes of 8 patients), which were included in the prospective consecutive case series study. Seven eyes underwent Inferior laser peripheral irido-capsulo-hyaloidotomy, and three eyes underwent pars plana vitrectomy, zonulo-capsulo-hyaloidectomy, and inferior iridectomy.

RESULTS

Eight eyes (80%) had angle-closure glaucoma. The mean duration of the follow-up was 12.25 ± 3.05 months (ranging from 10-18 months). The patients had a mean age of 69.25 ± 6 years. The IOP at the onset of malignant glaucoma was found to be 33.8 ± 5.5 mmHg, which was reduced to 13.9 ± 2.7 mmHg at the final visit (P value = 0.002). The reduction in the number ± SD of anti-glaucoma medications (3.3 ± 0.48 to 1.4 ± 0.51) and improvement in mean ± SD LogMAR visual acuity (1.2 ± 0.06 to 0.61 ± 0.26) between the onset and final visit were significant (p = 0.004 and P = 0.005, respectively). All the patients responded to Inferior peripheral irido-capsulo-hyaloidotomy (with YAG laser or with the surgical procedure), which led to a significant reduction in intraocular pressure (IOP) and deepening of the anterior chamber.

CONCLUSION

The success rate of peripheral irido-capsulo-hyaloidotomy with laser or surgical procedure in the inferior quadrant was high regarding pseudophakic malignant glaucoma patients. The establishment of a patent inferior communication between the vitreous cavity and the anterior chamber was the main component in the treatment of pseudophakic malignant glaucoma patients.

Aqueous misdirection after Nd:YAG goniopuncture in deep sclerectomy treated with Nd:YAG irido-zonulo-hyaloidotomy

BACKGROUND

To report a case of aqueous misdirection after goniopuncture in deep sclerectomy treated with Nd:YAG laser irido-zonulo-hyaloidotomy.

CASE PRESENTATION

About 72 years old patient with pseudoexfoliation glaucoma who underwent deep sclerectomy, developed aqueous misdirection after Nd:YAG laser goniopuncture. Medical management failed and subsequent peripheral Yag laser iridotomy to expose the zonules coupled with laser zonulo-hyaloidotomy was done and an instant gush of aqueous and vitreous substance prolapse through the iridotomy was noticed. Later, the anterior chamber was deep and the pressure was controlled.

CONCLUSIONS

Aqueous misdirection can occur after Nd:YAG laser goniopuncture. Nd:YAG laser irido-zonulo-hyaloidotomy can be effective in breaking the attack.

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

PURPOSE

To evaluate the efficacy of vitrectomy combined with hyaloido-zonula-iridectomy from an anterior or a posterior approach in patients with treatment-resistant aqueous misdirection (chronic aqueous misdirection) by systematically reviewing existing literature in combination with presentation of a case series.

METHODS

A systematic literature review was performed in PubMed, EMBASE and Cochrane Library databases using search terms: malignant glaucoma, ciliary block, ciliolenticular block and aqueous misdirection. A consecutive series of three pseudophakic patients (5 eyes) diagnosed with chronic aqueous misdirection after cataract surgery is presented.

RESULTS

A literature search identified 31 articles describing treatment of chronic aqueous misdirection with vitrectomy and a hyaloido-zonula-iridectomy. Studies, where patients were treated with a complete vitrectomy from pars plana in combination with a hyaloido-zonula-iridectomy, reported low relapse rates. Studies describing a surgical approach with vitrectomy performed from the anterior chamber, followed by a hyaloido-zonula-iridectomy, also reported low relapse rates except for one reporting relapse in nearly half of the patients. In our case series, a complete vitrectomy combined with a hyaloido-zonula-iridectomy resolved the chronic aqueous misdirection in all five eyes after one procedure except one eye where the hyaloido-zonula-iridectomy was repeated due to an insufficient opening. Some of the eyes still needed antiglaucomatous treatment due to chronic angle closure.

CONCLUSION

In treatment-resistant malignant glaucoma, vitrectomy combined with a hyaloido-zonula-iridectomy should be considered performed to ensure communication between the anterior chamber and the vitreous cavity. If the condition has been unresolved for a long time, extensive synechiae of the angle may decrease the success rate due to chronic angle closure.

A case of malignant glaucoma following insertion of Preserflo™ MicroShunt

PURPOSE

To describe a case of malignant glaucoma following insertion of a Preserflo™ MicroShunt in a patient with primary open angle glaucoma (POAG).

DESIGN

Case report.

CASE

A 46-year-old Caucasian man with medically uncontrolled POAG developed malignant glaucoma 1 day after an uncomplicated insertion of a mitomycin C (MMC) augmented Preserflo MicroShunt (PMS).

RESULTS

Initial medical treatment with aqueous suppressants and atropine 1% resulted in temporary resolution of the episode, although partial occlusion of the PMS with iris required a Nd:YAG laser iridotomy to open the inlet of the device. However, the malignant glaucoma recurred 6 days later. Temporary resolution was subsequently achieved with an Nd:YAG laser peripheral irido-zonulo-hyaloidotomy in combination with topical atropine, though a subsequent PMS revision was required due to bleb encapsulation. Unfortunately, the revision procedure was followed 2 days later, by a further recurrence of malignant glaucoma which was eventually resolved by left pars plana vitrectomy (PPV) in combination with clear lens extraction (CLE) and surgical irido-zonulo-hyaloidectomy. Subsequently, the eye remained stable, with a deep anterior chamber (AC), a partially functioning bleb, and an intraocular pressure (IOP) of 14 mmHg on one topical IOP-lowering agent, 8 months after the last procedure.

CONCLUSIONS

The management of malignant glaucoma after PMS insertion and its subsequent clinical course is described. Apart from the propensity for a small tube such as the PMS to obstruct with iris when the AC is shallow, management is similar to other scenarios in which malignant glaucoma may develop.

Iris Stromal Cyst in a 6-Month-Old With Rapid Progression to Angle Closure

CASE REPORT

A 6-month-old female presented with an iris cyst in the left eye, first identified at age 4 months. The patient was seen by an ophthalmologist at age 6 months and referred for further management. Our examination 2 weeks later demonstrated a 6 mm diameter iris cyst originating from the anterior surface of the inferior iris, occupying the inferior two thirds of the anterior chamber and obscuring the pupil. Intraocular pressure was normal and the remainder of the anterior chamber was formed. Because of concern for the development of amblyopia, the patient was scheduled for an examination under anesthesia and iris cyst removal 2 days later. In the intervening 2 days, the patient's mother noted worsening photophobia and tearing. At the time of surgery, the intraocular pressure was 51 mm Hg in the left eye. Anterior examination demonstrated interval development of shallowing of the anterior chamber with irido-corneal and cyst-corneal touch. The iris cyst had increased to 8 mm in size and filled the entire pupillary aperture. The iris cyst was excised, and histopathology confirmed the diagnosis of an iris stromal cyst.

CONCLUSIONS

Congenital stromal cysts of the iris can enlarge, threatening amblyopia and secondary glaucoma in children. Although angle closure is a known theoretical complication of iris stromal cysts, actual cases are rare in the literature. This case demonstrates the importance of serial examinations to monitor progression of iris stromal cysts, particularly in young children.

Age- and refraction-related changes in anterior segment anatomical structures measured by swept-source anterior segment OCT

PURPOSE

To assess the effects of age and refractive status on anterior segment anatomical structures, including the ciliary body, using a new swept-source anterior segment optical coherence tomography (AS-OCT) device.

METHODS

This prospective observational study included 63 healthy volunteers (mean age: 44.2 years). Images of the anterior segment were obtained using a new swept-source AS-OCT (ANTERION, Heidelberg Engineering GmbH, Heidelberg, Germany) with tracking and image averaging from the right eye of all participants. Repeatability as well as inter- and intra-observer reliability of biometric measurements were evaluated. The impact of image tracking and averaging on ciliary muscle measurements was tested. Univariate and multivariable statistical models were developed to evaluate the relationship of age and refractive status on anterior segment biometric measurements.

RESULTS

For all test-retest repeatability and inter- and intra-observer reproducibility of swept-source AS-OCT measurements, high intraclass correlation (ICC) was noted (0.88-1.00). The nasal maximum ciliary muscle thickness (CMTMAX) and distance between scleral spur to the thickest point of the ciliary muscle (SSMAX) were larger than those on the temporal side (p<0.001 and p = 0.006, respectively). Nasal and temporal CMTMAX (p = 0.004 and p<0.001, respectively) and lens thickness (p<0.01) increased with age. Nasal and temporal SSMAX decreased with older age and increasing hyperopia (p = 0.01 and p<0.001, respectively). Image averaging resulted in improved ciliary muscle measurements (p = 0.008 to 0.02). Lens vault increased with older age and increased hyperopia (p<0.01). OCT measurements of the angle decreased with older age and increased hyperopia (p<0.001 to 0.03). Aqueous depth decreased with older age and increased hyperopia (p<0.01). Pupil diameter decreased with older age (p<0.01).

CONCLUSIONS

Repeatability and reproducibility of biometric measurements using the ANTERION AS-OCT were excellent. Image averaging improved the accuracy of ciliary muscle measurements. The device produced measurements of biometric parameters that described superficial and deep structures including the ciliary body and full lens thickness from a single image.

Choroidal detachment-induced secondary angle-closure after trabeculectomy in patient with ocular venous congestion: A case report

Purpose

To report a particular circumstance that led to the abnormal complication of choroidal detachment (CD)-induced secondary angle-closure after trabeculectomy with mitomycin C (MMC).

Observations

An 82-year-old Japanese male patient with underlying chronic obstructive pulmonary disease and suspicion of ocular venous congestion in both eyes whom diagnosed as primary open-angle glaucoma with uncontrolled intraocular pressure (IOP) of his left eye then underwent an uneventful trabeculectomy with MMC. After the surgery, his left eye had high IOP with a shallow anterior chamber (A/C) but the bleb was hyperfiltration. The high CD was found by B-scan ultrasonography behind the iris and after conservative treatment, the CD was improved, A/C was deepened, and IOP was lower to 16 mmHg.

Conclusion and Importance

CD-induced secondary angle-closure after trabeculectomy with MMC is a complication to be considered in patients with shallow A/C and high IOP. Fundus examination should be done to rule out this condition before any aggressive treatment as CD can resolve spontaneously with time. Clinicians should be aware of this condition especially in patients with any signs of ocular venous congestion as there have been few reports mentioned about the complication in the patients.

Suspected Spontaneous Aqueous Humor Misdirection Syndrome in a Boston Terrier

An eight-year-old female spayed Boston Terrier presented to the North Carolina Veterinary Hospital with glaucoma in the left eye (OS). Initial ophthalmic examination revealed moderate ocular hypertension, a diffusely and markedly shallow anterior chamber with anteriorly displaced iris and lens, vitreal prolapse, and a normal iridocorneal angle (ICA) morphology. The patient displayed a paradoxical response to topical latanoprost with an increase in intraocular pressure. These examination findings led to a putative diagnosis of spontaneous aqueous humor misdirection syndrome (AHMS). The patient was successfully managed with topical carbonic anhydrase inhibitors (CAIs) and apraclonidine for eight months until progressive ulcerative keratitis necessitated enucleation of the affected globe. Histopathology and high-field magnetic resonance imaging (MRI) of the enucleated globe did not identify an underlying cause for the glaucoma. This case suggests that AHMS should be considered in dogs presenting with a shallow anterior chamber, vitreal prolapse, increased intraocular pressure, and no other causes of glaucoma.

Evaluation of Two Different Anterior Vitrectomies for Fluid Misdirection Syndrome Secondary to Cataract Surgery Combined with Goniosynechialysis

Purpose

To evaluate two different approaches of anterior vitrectomy combined with hyaloidotomy, zonulectomy, and iridectomy (VHZI) for fluid misdirection syndrome (FMS) secondary to phacoemulsification with intraocular lens implantation combined with goniosynechialysis (phaco-IOL-GSL).

Methods

Nine patients with FMS who developed after a phaco-IOL-GSL procedure, were retrospectively studied from May 2015 to February 2018. They were treated with VHZI, in which 5 cases underwent local anterior vitrectomy via anterior chamber approach, and the others underwent comprehensive vitrectomy via pars plana approach. Main outcome measures were pre- and postoperative intraocular pressure (IOP), number of antiglaucoma medications, and relapse rate.

Results

Incidence of FMS secondary to phaco-IOL-GSL was 1.4% (9 in 652 eyes), which was promptly resolved in all affected cases. VHZI via anterior chamber approach resulted in a significant decrease in the mean IOP from 40.2 ± 9.7 mm Hg at presentation to 15.2 ± 4.8 mm Hg postoperatively (P=0.01). The median number of antiglaucoma medications reduced from 3 to 2 (P=0.066). Meanwhile, VHZI via pars plana approach also resulted in the reduction of the mean IOP values from 26.0 ± 5.7 mm Hg at presentation to 15.2 ± 3.3 mm Hg postoperatively (P=0.092). The median number of antiglaucoma medications also reduced from 3.5 to 1.5 (P=0.059). Relapse rate of the treatment through pars plana approach (0%, 0/4) was much lower than that through anterior chamber approach (40%, 2/5), although the difference was not statistically significant (P=0.444).

Conclusions

FMS is a rare but severe complication secondary to phaco-IOL-GSL. Compared to VHZI with local anterior vitrectomy via anterior chamber approach, VHZI with comprehensive anterior vitrectomy via pars plana approach might be a more effective procedure to treat FMS. The study has been registered in Contact ClinicalTrials.gov PRS Identifier: NCT04172857.

Incidence of Intraoperative and Early Postoperative Adverse Events in a Large Cohort of Consecutive Refractive Lens Exchange Procedures

PURPOSE

To evaluate the incidence of adverse events (AEs) in patients who underwent refractive lens exchange.

DESIGN

Retrospective case series.

METHODS

Setting: Private refractive surgery clinics. Patients/Study Population: Patients who underwent refractive lens exchange between July 1, 2014, and June 30, 2016. Intervention/Observation Procedures: All AEs recorded in the electronic medical record were extracted and retrospectively reviewed. The total incidence of AEs and serious AEs was calculated. Loss of 2 or more lines of corrected distance visual acuity (CDVA) was calculated for the entire cohort of patients that attended a minimum of 3 months follow-up.

MAIN OUTCOME MEASURES

AEs.

RESULTS

The total number of patients included was 10,206 (18,689 eyes). A multifocal intraocular lens (IOL) was implanted in 84.3% of eyes; 15.7% of eyes received a monofocal IOL. A total of 1164 AEs were recorded (1112 eyes of 1039 patients, incidence 6.0% of eyes, 1:17 eyes). The most common AE was posterior capsular opacification (PCO; 748 eyes, incidence 4.0%). Of all AEs, 171 events (occurring in 165 eyes of 151 patients, incidence 0.9%, 1:113 eyes) were classified as serious, potentially sight threatening. Loss of 2 or more lines of CDVA was 0.56% when excluding eyes where the loss of CDVA was due to PCO; the majority of these were due to macular causes.

CONCLUSION

The incidence of sight-threatening AEs and significant loss of CDVA in elective refractive lens exchange surgery was low. Other than PCO, postoperative macular issues were the most common cause of vision loss in this cohort.

Intra-Operative Ostial Irido-Zonulo-Hyaloido-Vitrectomy with Primary Posterior Capsulectomy for Prevention of Post-Operative Aqueous Misdirection in Combined Phaco-Trabeculectomy in Primary Angle Closure Glaucoma

Purpose: The aim of this study is to investigate the ability of ostial irido-zonulo-hyaloido-vitrectomy (ostial IZHV) with primary posterior capsulectomy (PPC) in preventing aqueous misdirection (AM) in combined cataract and filtration surgery in a high-risk group of angle closure disease. Materials and Methods: Comparative case series-data collection of consecutive adult subjects (>18 years) with angle closure, undergoing phaco-trabeculectomy, when per-operatively anterior chamber depth (ACD) remained shallow, putting them at high risk for development of AM post-operatively. Study subjects were compared to controls, who also underwent combined surgery in angle closure, but did not have shallow AC per-operatively, in the study period of January 2012 to December 2016. Ostial-IZHV was done through sclerostomy and iridectomy created routinely as part of the filtration procedure. Main outcome measure- post-operative deep ACD and comparison of biometric (optical) parameters between study subjects and controls. Results: Twelve eyes of 11 primary angle closure glaucoma subjects who underwent ostial-IZHV intra-operatively (study subjects) in the study period were included. None of the subjects developed post-operative AM. The median IOP pre-procedure decreased significantly at average follow-up of 18.25 months (SD 14.1) post-procedure (p = .003). There was significant decrease in use of anti-glaucoma medications too (p < .001) post-procedure. When compared to controls, study patients were younger (p = .006); these eyes demonstrated greater quadrantic synaechial angle closure on gonioscopy (p < .001), higher pre-operative intraocular pressure (p = .001) and were also found to be smaller (p = .011), shallower (p < .001) with significantly more lens rise (p = .013). Although lens thickness did not differ (p = .689), it appeared to be relatively anteriorly placed (p = .005) in all those eyes that required ostial-IZHV. Conclusions: Ostial IZHV may be considered in eyes in a sub-group of glaucoma patients with high-risk characteristics for prevention of AM in the post-operative period. The anterior segment surgeon can successfully accomplish ostial-IZHV, effectively reducing dependence on a vitreo-retinal surgeon.

Pseudophakic malignant glaucoma - a case report

Purpose. To report a case of malignant glaucoma in a pseudophakic female patient, with no history of glaucoma, resolved through pars plana anterior vitrectomy. Case presentation. An 80-year-old female patient presented in our Emergency Department after a five-day history of pain in her left eye (LE). In the last day, the patient noticed marked visual loss and ocular pain. Visual acuity was light perception and Goldman tonometry was 80 mmHg in her LE. The biomicroscopy revealed absent peripheral and central anterior chamber (AC) and posterior chamber (PC) pseudophakia. Posterior segment ecography showed no vitreous or choroidal abnormalities. A peripheral laser YAG iridotomy was made and the patient was treated with intravenous 20% mannitol, topical timolol, topical brimonidine, and topical cycloplegics. 12 hours later, despite a patent iridotomy in the LE eye, intraocular pressure (IOP) was 55 mmHg, absent AC with severe corneal edema. The diagnosis of pseudophakic malignant glaucoma was made and laser YAG capsulotomy was performed with no resolution of symptoms and signs. 24 hours later, we performed pars plana anterior vitrectomy. Postoperatively, the AC depth increased and the IOP decreased to 20mmHg. After a week, the patient was discharged with hand movement perception visual acuity in her LE, 20 mmHg IOP, reduced corneal edema, normal depth AC. After a month, the corneal edema resolved, the visual acuity was 2/50, IOP was 20mmHg, and the AC had a normal depth. Conclusion. Malignant glaucoma is a sight threatening condition, reported in pseudophakic eyes. Although, literature describes cases solved by cycloplegics and laser YAG capsulotomy, our patient needed pars plana anterior vitrectomy for the resolution of symptoms and signs.

Spontaneous malignant glaucoma: Case report and review of the literature

Malignant glaucoma usually occurs after anterior segment surgery (typically after glaucoma surgery). The aim of this article is to report a case of spontaneous malignant glaucoma (SpMG), which required phacovitrectomy for resolution and to review the cases of SpMG reported in modern literature. Only nine cases were identified. SpMG has no gender predilection and age at onset seems to be lower (mean age 47 years) than in secondary malignant glaucoma (SeMG). Nearly in half of the reported patients (4 out of 9) the condition had a bilateral presentation. The risk factors that have been identified for SeMG (nanophthalmos, shallow anterior chamber, iris plateau, zonular laxity) are underrepresented in SpMG.

Retina and glaucoma: surgical complications

Background

The close structural and microcirculatory co-relation between anterior and posterior segments of eye make them very vulnerable to complications when one of them is affected surgically. With the advent of anti-fibrotic agents in the management of glaucoma, the rates of vitreoretinal complications have become more frequent.

Main body

Common retinal complications after glaucoma surgeries include choroidal detachment; ocular decompression retinopathy; haemorrhagic choroidal detachment; hypotony maculopathy; malignant glaucoma; vitreous haemorrhage; bleb endophthalmitis; retinal detachment. Similarly, intraocular pressure rise is often noted after scleral buckle; pars plana vitrectomy; intravitreal gas injection; silicone oil injection; intravitreal steroid injection.

Conclusion

The article provides some insight into some of the complications after glaucoma and retina surgeries, including the pathogenetic mechanisms behind each complication and available management options.

Spontaneous onset pseudophakic malignant glaucoma secondary to zonular weakness and cilio-lenticular block

Malignant glaucoma (MG), also known as aqueous misdirection and cilio-vitreo-lenticular block, is an infrequent cause of secondary angle closure glaucoma. Despite conventional treatment, it often has a poor visual outcome. It is recognized clinically by raised intraocular pressure associated with shallowing of the peripheral and central anterior chamber in the presence of a patent peripheral iridotomy/iridectomy. Despite being known to occur after a variety of surgical procedures, it most commonly presents following filtration surgery in hypermetropic eyes with angle closure glaucoma. It can present within a range of postsurgical latencies, ranging from 1 day to many months. We describe a case of pseudophakic MG that was unusual in that it presented spontaneously many years following cataract surgery. We postulate the etiology of our spontaneous onset pseudophakic MG was the anterior subluxation of the large diameter intraocular lens secondary to zonular weakness.

Mini-vitrectomy; a Simple Solution to a Serious Condition

Purpose

To evaluate the safety and efficacy of clear corneal approach irido-zonulo-hyaloido-vitrectomy, which we named "mini-vitrectomy," in the management of pseudophakic aqueous misdirection.

Methods

In this retrospective, non-comparative interventional case series, 24 eyes with diagnosis of pseudophakic aqueous misdirection were enrolled. Medical therapy with cycloplegics and laser therapy, including posterior capsulotomy and hyaloidotomy, was not effective in the management of the condition. The eyes underwent mini-vitrectomy, a simple technique in which iridotomy, zonulectomy, hyaloidectomy, and limited anterior vitrectomy were performed via a clear cornea incision. The main outcome measure was reformation of the anterior chamber, which was evaluated at day 1 and months 1, 3, 6, and 12.

Results

The mean age of patients was 75.3 ± 11.3 years (range, 47 to 90), and 13 (54.2%) patients were women. Anterior chamber was deep in 22 patients (91.7%) at the last follow-up visit. The mean intraocular pressure (IOP) was 30.31 ± 1.9 mm Hg at presentation on 2.67 ± 1.09 glaucoma medications. IOP decreased significantly to 14.5 ± 4.6 mm Hg at 12-month follow-up. (P = 0.001). The number of glaucoma medications at final visit was 2.2 ± 0.9 (P = 0.21).

Conclusion

Mini-vitrectomy is a simple, safe, and effective procedure in the management of pseudophakic aqueous misdirection, and it can be adopted by all ophthalmologists who are involved in glaucoma management and are not comfortable with the pars plana vitrectomy approach.

Acute and chronic fluid misdirection syndrome: pathophysiology and treatment

Purpose

To summarize our current understanding of the specific pathogenic mechanisms of the fluid misdirection syndrome and possible treatment methods.

Methods

We used the PubMed web platform to find relevant studies using the following keywords: infusion misdirection syndrome, aqueous misdirection syndrome, ciliary block, ciliovitreal block, capsular block, intraoperative fluid misdirection, subcapsular fluid entrapment, acute intraoperative rock-hard eye syndrome, positive vitreous pressure glaucoma, and malignant glaucoma. Other publications were also considered as a potential source of information when referenced in relevant articles.

Results

We collected and analyzed 55 articles dated from 1951 to 2016. Acute intraoperative rock-hard eye syndrome is characterized by a very shallow anterior chamber with the absence of suprachoroidal effusion or hemorrhage and no noticeable pathology of the iris–lens diaphragm. It usually occurs during uneventful phacoemulsification, particularly in hyperopic eyes. The pathophysiology of acute fluid misdirection syndrome is based on inappropriate movement of balanced salt solution via the zonular fibers. This syndrome has also been described as occurring from hours to months, or years, after the initial surgery. The pathophysiology of malignant glaucoma is based on similar mechanisms of cilio-lenticular block of aqueous flow leading to the misdirection of aqueous posteriorly into or besides the vitreous gel. Faced with these situations, vitreous decompression is required, preferably with hyaloido-capsulo-iridectomy. In phakic eyes, concomitant cataract extraction would be desirable.

Conclusions

We believe both of these clinical conditions should be considered as one syndrome. We suggest the term acute fluid misdirection syndrome for the cascade of events during phacoemulsification surgery. Chronic fluid misdirection syndrome better describes the nature of malignant glaucoma.

Refractory aqueous misdirection syndrome: A possible complication of penetrating keratoplasty

CLINICAL CASE

An 85 year-old woman presented with a flat anterior chamber of the left eye, severe ocular hypertension, and a normal ultrasound examination in the day following a penetrating keratoplasty (PK). The clinical status did not respond to maximum medical therapy, laser posterior capsulotomy, anterior hyaloidotomy, and complete 23 G vitrectomy. The patient refused further intervention, and light perception was lost after 6 months of follow-up.

DISCUSSION

This is the first report of refractory aqueous misdirection syndrome following primary PK. Despite maximum medical and surgical management efforts, aqueous misdirection syndrome subsequent to primary PK may have a catastrophic outcome.

Postoperative management of trabeculectomy and glaucoma drainage implant surgery

PURPOSE OF REVIEW

This article describes important aspects of postoperative management after trabeculectomy and glaucoma drainage implant surgery.

RECENT FINDINGS

Postoperative management of glaucoma drainage implant surgery includes stabilization of intraocular pressure, possible ligature release, and management of complications such as corneal edema, and tube/plate exposure. Postoperative management of trabeculectomy includes evaluation of bleb encapsulation, management of hypotony, and assessment of need for adjuvant therapy. Recent advances in surgical techniques, device/tissue availability, and imaging continue to shape the postoperative course.

SUMMARY

Careful preoperative planning and postoperative care may decrease the likelihood of complications in tube surgery or trabeculectomy.

Imipramine protects retinal ganglion cells from oxidative stress through the tyrosine kinase receptor B signaling pathway

Retinal ganglion cell (RGC) degeneration is irreversible in glaucoma and tyrosine kinase receptor B (TrkB)-associated signaling pathways have been implicated in the process. In this study, we attempted to examine whether imipramine, a tricyclic antidepressant, may protect hydrogen peroxide (H₂O₂)-induced RGC degeneration through the activation of the TrkB pathway in RGC-5 cell lines. RGC-5 cell lines were pre-treated with imipramine 30 minutes before exposure to H₂O₂. Western blot assay showed that in H₂O₂ -damaged RGC-5 cells, imipramine activated TrkB pathways through extracellular signal-regulated protein kinase/TrkB phosphorylation. TUNEL staining assay also demonstrated that imipramine ameliorated H₂O₂ -induced apoptosis in RGC-5 cells. Finally, TrkB-IgG intervention was able to reverse the protective effect of imipramine on H₂O₂ -induced RGC-5 apoptosis. Imipramine therefore protects RGCs from oxidative stress-induced apoptosis through the TrkB signaling pathway.

Surgical outcome of cats treated for aqueous humor misdirection syndrome: a case series

OBJECTIVE

To evaluate the clinical outcome of cats treated surgically for aqueous humor misdirection syndrome.

METHODS

A retrospective analysis of cats treated surgically between January 1, 2006, and January 1, 2013, for aqueous humor misdirection syndrome was performed. Signalment, medical therapy, eyes affected, intraocular pressures prior to and after surgery, surgical procedures performed, postoperative complications, and visual status were evaluated.

RESULTS

Seven cats (nine eyes) fit the inclusion criteria. Six of seven cats were female, and five of seven cats were diagnosed with bilateral aqueous humor misdirection syndrome. Three surgical approaches were evaluated as follows: (i) phacoemulsification and posterior capsulotomy, (ii) phacoemulsification, posterior capsulotomy and anterior vitrectomy, and (iii) phacoemulsification, posterior capsulotomy, anterior vitrectomy, and endocyclophotocoagulation. The mean age at diagnosis was 12.9 years. Seven of nine eyes had controlled intraocular pressure (≤25 mmHg) during the first 6 months postoperatively. All cats were visual with controlled intraocular inflammation at 1 year postoperatively; however, one eye had an elevated intraocular pressure. All cats were continued on topical antiglaucoma and anti-inflammatory medications following surgery with the mean number of drops per day decreasing from 3.9 drops/day prior to surgery to 2.2 drops/day postoperatively.

CONCLUSIONS

Surgical management for feline aqueous humor misdirection syndrome may be a viable option to maintain a visual and normotensive status in cats that no longer have successful control of intraocular pressure with medical therapy.

Recurrence of aqueous misdirection following pars plana vitrectomy in pseudophakic eyes

We present a retrospective interventional case series of four patients with pseudophakic eye who developed recurrent aqueous misdirection following pars plana vitrectomy (PPV) for malignant glaucoma (MG). The patients were treated with neodymium: YAG (Yttrium Aluminum Garnet) laser hyaloidotomy/membranotomy through the patent peripheral iridectomy. The main outcome measure was resolution of MG. The intervention resulted in resolution of MG in all four cases. The cause for recurrence was an inflammatory membrane covering the hyaloidotomy opening in three eyes and the haptic of intraocular lens blocking the hyaloidotomy opening in one eye. Recurrence of aqueous misdirection even after vitrectomy may be related to obstruction of aqueous flow through the communication created, either by intraocular lens or fibrin. Treatment of this condition involves restoring aqueous flow to the anterior chamber from the anterior vitreous by treating the cause, and most often the YAG laser hyaloidotomy/membranotomy is successful in relieving the condition.

Aqueous misdirection syndrome: an interesting case presentation

Objective

To report a case of an aqueous misdirection-like presentation in a pseudophakic patient.

Design

Retrospective case review.

Participant

An 84-year-old pseudophakic gentleman presented with bilateral blurred vision 8 years after cataract surgery. A refractive shift with shallow anterior chambers and elevated intraocular pressures were noted. No corneal edema was noted. Although aqueous suppression and topical atropine would relieve the signs and symptoms, the effect was temporary with fluctuating and variable changes in refraction, anterior chamber depth, and intraocular pressure. The presence of patent iridotomies had no effect on the fluctuations. A pars plana vitrectomy and surgical iridectomy were successful in preventing further fluctuations.

Conclusion

Aqueous misdirection is a form of secondary angle closure glaucoma marked by elevated intraocular pressures, myopic shift in refraction, and central shallowing of the anterior chamber. Here, a case of a pseudophakic patient experiencing bilateral and fluctuating signs and symptoms resembling aqueous misdirection is presented. Surgical intervention with a pars plana vitrectomy and iridectomy prevented further fluctuations.

25-Gauge pars plana vitrectomy for ciliary block (malignant) glaucoma

To evaluate the efficacy of 25-ga pars plana vitrectomy (PPV) and 25-ga PPV combined with phacoemulsification surgery for managing ciliary block (malignant) glaucoma. The medical records of 11 eyes, in nine consecutive patients with malignant glaucoma were retrospectively reviewed to determine the efficacy of 25-ga PPV for alleviating this disease. All phakic eyes underwent phacoemulsification surgery during vitrectomy. Control of intraocular pressure (IOP), pre- and postoperative best-corrected visual acuity (BCVA), and development of intra- and postoperative complications were evaluated during follow-up. Malignant glaucoma was promptly resolved, and recurrence was not observed during a mean follow-up period of 12.7 ± 3.2 (range 6-18) months. The mean IOP decreased from 35.9 ± 2.9 mmHg, preoperatively, to 16.0 ± 1.4 mmHg, measured at last visit (P = 0.013). Although IOP control was achieved in all eyes after surgery, two eyes required long-term topical antiglaucoma medication. The mean logarithm of the minimum angle of resolution BCVA improved from +0.69 ± 0.11, preoperatively, to +0.29 ± 0.07, postoperatively (P = 0.027). No severe intraoperative complications were observed. Postoperative complications mostly occurred during the first week after surgery, including transient corneal edema and Descemet's membrane folds in three eyes, fibrotic exudation in 2, local iris posterior synechia in 1, and transient hypotony in 1, which were resolved spontaneously or with medication. The 25-ga PPV procedure seems to be safe and effective for treating malignant glaucoma. Combined vitrectomy with phacoemulsification surgery and a staged surgical approach may improve the success rate.

Spontaneous simultaneous bilateral malignant glaucoma of a patient with no antecedent history of medical or surgical eye diseases

PURPOSE

Malignant glaucoma, or aqueous misdirection syndrome, is a condition characterized by sudden intraocular pressure (IOP) elevation, and it is usually unilateral and induced by ocular surgical intervention or by medical therapy. Here, we report a case of simultaneous bilateral malignant glaucoma in a young patient with no history of any ocular diseases.

CASE REPORT

A case of a 24-year-old female with no apparent previous history of ocular medical or surgical conditions was referred to our hospital because of recent bilateral IOP elevation associated with a severe drop in vision and shallow anterior chamber with no posterior segment anomalies detected by ocular ultrasound in both eyes. Yttrium aluminum garnet (YAG) laser iridotomy dropped the IOP only temporarily and the patient received topical atropine treatment with combined trabeculectomy and anterior vitrectomy.

RESULTS

In this case, the patient had a typical presentation of bilateral malignant glaucoma and her IOP dropped only temporarily following laser iridotomy to rise again shortly thereafter. Also, deepening of the anterior chamber and IOP decrease after topical atropine was very supportive of the diagnosis of malignant glaucoma. Successful management with trabeculectomy and limited vitrectomy also affirmed the diagnosis of malignant glaucoma.

CONCLUSION

This is a very rare case of bilateral malignant glaucoma in a young adult without any prior eye conditions; only one similar case has been reported in the literature. We propose our own theory regarding this simultaneous occurrence of the pathology based on previously published studies about the presence of communication between the two eyes along the cerebrospinal fluid pathways.

Efficacy and safety of a new surgical method to treat malignant glaucoma in pseudophakia

PURPOSE

To assess the efficacy and safety of a relatively new surgical method in pseudophakic malignant glaucoma patients.

METHODS

This study is a retrospective, non-comparative, interventional case series. Ten eyes of nine pseudophakic malignant glaucoma patients with mean age of 63.3 years were analysed. All 10 eyes underwent a novel surgical technique, an anterior chamber capsulo-hyaloidectomy and anterior vitrectomy through the peripheral iridectomy. Main outcome measures were: reformation of the anterior chamber, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and complications.

RESULTS

All 10 eyes with pseudophakic malignant glaucoma were treated successfully by using a new surgical technique. All cases had a relief of aqueous misdirection with anterior chamber deepening during and after the surgery and post-operative intraocular pressure (IOP) normalization. No relapses have been observed so far. There were no complications during surgery and in the post-operative period.

CONCLUSION

The presented surgical technique seems to be safe and effective in all cases of malignant glaucoma in pseudophakia.