Diagnosis of pupillary block glaucoma after removal of congenital cataracts with intraoperative ultrasound biomicroscopy: a case report

Challenges of Secondary Glaucoma Management Following Congenital Cataract Surgery, Penetrating Keratoplasty and Vitreoretinal Surgery

Glaucoma is one of the world's leading causes of irreversible vision loss. It is often asymptomatic until it reaches an advanced stage, which can have a significant impact on patients' daily lives. This paper describes the case of a 50-year-old female patient who presented with acute onset of ocular pain, photophobia, and loss of visual acuity in her right eye (RE). The patient's medical history includes congenital cataracts, surgical aphakia, nystagmus, strabismus, amblyopia, and secondary glaucoma. Ophthalmological examination showed BCVA RE-hand movement, left eye (LE)-0.08 with an intraocular pressure (IOP) of 30 mmHg in RE and 16 mmHg in LE. Biomicroscopic examination of RE showed corneal graft, epithelial and endothelial edema, endothelial precipitates, corneal neovascularization, aphakia, and Ahmed valve superotemporally. Despite maximal topical and systemic treatment, Ahmed valve, and trabeculectomy, secondary glaucoma in the right eye remained refractory. Reimplantation of an Ahmed valve was performed. This resulted in a favorable outcome with increased visual acuity and controlled intraocular pressure. The combination of aphakia, penetrating keratoplasty, and secondary glaucoma is a challenge for any surgeon. It is important that both the perioperative risks and the possible complications are carefully assessed in each patient, especially if associated pathology is present.

Ultrasound biomicroscopy for the assessment of postoperative complications after congenital cataract surgery

Background

The aim of the present study was to investigate the role of ultrasound biomicroscopy (UBM) in the evaluation of postoperative complications in children with congenital cataracts.

Methods

A retrospective study was conducted between September 2012 and December 2016 at Guangzhou Women and Children's Medical Center. Red reflex test and high-resolution bag/balloon UBM were performed to evaluate postoperative congenital cataracts. The red reflex test results were recorded, and UBM imaging results were recorded and analyzed. Different postoperative complications were classified based on the UBM imaging features, and a second procedure was performed accordingly. The UBM images were compared with the images captured from the intraoperative videos.

Results

In total, we looked at 120 eyes in 96 patients (65 males and 31 females) in the present study. The age of the cohort was 3-76 months. A total of 51 eyes with poor red reflex were included. There were complications in 46 eyes after congenital cataract surgery, as detected by UBM, including posterior capsular opacification (n=29 eyes), pupil block (n=8 eyes), synechia (n=5 eyes), hyphema (n=1 eye), and abnormal intraocular lens (IOL) placement (n=3 eyes). UBM images showed specific features of postoperative complications.

Conclusions

UBM is a valuable tool for the early evaluation of postoperative complications of congenital cataracts, especially for those with media opacities or when pupil dilation is not possible.

A systematic review of ultrasound biomicroscopy use in pediatric ophthalmology

Ultrasound biomicroscopy (UBM) is the only available option for noninvasive, high-resolution imaging of the intricate iridociliary complex, and for anterior segment imaging with corneal haze or opacity. While these unique features render UBM essential for specific types of trauma, congenital anomalies, and anterior segment tumors, UBM imaging has found clinical utility in a broad spectrum of diseases for structural assessments not limited to the anterior intraocular anatomy, but also for eyelid and orbit anatomy. This imaging tool has a very specific niche in the pediatric population where anterior segment disease can be accompanied by corneal opacity or clouding, and anomalies posterior to the iris may be present. Pediatric patients present additional diagnostic challenges. They are often unable to offer detailed histories or fully cooperate with examination, thus amplifying the need for high-resolution imaging. This purpose of this systematic review is to identify and synthesize the body of literature involving use of UBM to describe, evaluate, diagnose, or optimize treatment of pediatric ocular disease. The collated peer-reviewed research details the utility of this imaging modality, clarifies the structures and diseases most relevant for this tool, and describes quantitative and qualitative features of UBM imaging among pediatric subjects. This summary will include information about the specific applications available to enhance clinical care for pediatric eye disease.

Back to the Future: Vitreous Pupillary Block and Glaucoma in a Child After Lensectomy

The authors present a case of poorly controlled glaucoma following lensectomy. An examination under anesthesia revealed iris bombe of the anterior vitreous face. This case helps emphasize the importance of a generous anterior vitrectomy at the time of lensectomy in the pediatric population to avoid secondary glaucoma. [J Pediatr Ophthalmol Strabismus. 2020;57:e48-e50.].

Acute angle closure in an aphakic infant: Case report and review of the literature

Purpose

Aphakic pupillary block glaucoma is a rare complication after congenital cataract surgery. We describe the case of an infant with acute angle closure in an aphakic eye following congenital cataract lensectomy with anterior vitrectomy nine months prior. Potential pathophysiology and therapeutic strategies are discussed.

Observations

A one-year-old male infant presented to our emergency unit with right eye injection and pain. At the age of six weeks he had undergone right eye lensectomy with anterior vitrectomy for congenital cataract and was left aphakic with large anterior and posterior capsulorrhexis. Examination was significant for a shallow anterior chamber centrally and iridocorneal touch of the periphery for 360° with intraocular pressure (IOP) measured at 70 mmHg. The child was diagnosed with aphakic pupillary block leading to an acute angle closure event. He underwent emergent anterior vitrectomy with surgical peripheral iridotomy (PI) performed via pars plana approach. This resulted in immediate deepening of the anterior chamber, with resolution of the pupillary block and iridocorneal touch. Thereafter, his ocular exam was normal.

Conclusions and Importance

This unusual case underscores the importance of vigilance in the postoperative management of children after congenital cataract extraction. Unexpected complications remain a threat despite the initial undertaking of preventative measures.