Eyeworld

90 | EYEWORLD | DECEMBER 2021 G UCOMA by Liz Hillman Editorial Co-Director About the physicians Lindsay Foley, MD Resident Department of Ophthalmology New York University Langone Health New York, New York Amenze Oriaifo, MD Central Texas Eye Center San Marcos, Texas Joseph Panarelli, MD Associate Professor Department of Ophthalmology New York University Langone Health New York, New York References 1. Chandler PA, et al. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol. 1968;66:495–502. 2. Quigley HA. Angle-closure glaucoma—simpler answers to complex mechanisms: LXVI Edward Jackson Memo- rial Lecture. Am J Ophthalmol. 2009;148:657–669. 3. Shahid H, Salmon JF. Malig- nant glaucoma: a review of the modern literature. J Ophthalmol. 2012;2012:852659. 4. Simmons RJ. Malignant glaucoma. Br J Ophthalmol. 1972;56:263–272. 5. Lowe RF. Malignant glaucoma related to primary angle closure glaucoma. Aust J Ophthalmol. 1979;7:11–18. M alignant glaucoma is a rare com- plication, but it's still something surgeons need to be on the lookout for after surgery, especially in the early postoperative period. Amenze Oriaifo, MD, defined malignant glaucoma as "uniform shallowing or flatten- ing of both the central and peripheral anterior chambers in an eye with normal to elevated intraocular pressure despite one or more patent iridotomies." "It's also known as aqueous misdirection, ciliary block glaucoma, and lens block angle closure," she said. Lindsay Foley, MD, and Joseph Panarelli, MD, said in an email to EyeWorld that "malig- nant glaucoma involves an alteration in the normal anatomic relationship among the lens, ciliary body, anterior hyaloid face, and vitreous." "Whether aqueous is actually misdirect- ed into the posterior chamber is still being debated," they said. "However, all proposed mechanisms seem to involve abnormal vitreous fluid flow, resulting in fluid buildup behind the vitreous and creation of a significant posterior to anterior pressure gradient. This gradient drives the vitreous, lens, and iris forward, which further reduces vitreous permeability, creating a vicious cycle resulting in angle closure." 1,2,3 Dr. Oriaifo estimated that this complication occurs in 2% to 4% of eyes undergoing surgery for angle closure glaucoma. Drs. Foley and Panarelli cited published research that estimated prevalence of malignant glaucoma after angle closure surgery between 0.6% and 4%. 1,4,5 Dr. Oriaifo said she's only seen it a handful of times during training and her years in practice. Dr. Oriaifo said that while malignant glaucoma can happen at any time in the postoperative period, most cases occur shortly after the incisional surgery. Drs. Foley and Panarelli noted that it's most commonly associated with trabeculectomy and tube shunts (the latter less commonly), but it has also been reported after cataract surgery, surgical iridectomy, pars plana vitrectomy, diode laser cyclophotocoagulation, bleb needling, and even laser iridotomy. "Trying to get ahead of it by recognizing risk factors early and planning out the surgery accordingly is key," Dr. Oriaifo said. Know the risk factors First and foremost, Drs. Foley and Panarelli said that if a patient developed malignant glaucoma in one eye, they're likely to have it happen in the other. "Therefore, if a patient presents with poor vision in one eye due to complications from surgery, it is critical to get old records before proceeding with surgery in the better eye," they said. Factors that increase the risk of malignant glaucoma occurring, according to Dr. Oriaifo, include hyperopia, chronic angle closure with plateau iris configuration, nanophthalmos, or a history of malignant glaucoma in the fellow eye. She also said women are three times more likely than men to develop malignant glaucoma due to smaller eyes. Drs. Foley and Panarelli offered similar risk factors: history of angle closure with peripheral anterior synechiae, axial hyperopia, small eyes, and female gender. 6,7 Mitigating the risk Drs. Foley and Panarelli said there are a few ways to try to prevent malignant glaucoma. "The simplest and most conservative ap- proach is to immediately start an agent such as 1% atropine sulfate and continue it for several weeks to months after the surgical procedure," they wrote. In eyes with an axial length less than 20 mm, which Drs. Foley and Panarelli said are at especially high risk, they will perform pro- phylactic iridozonulohyaloidectomy from an anterior or posterior approach. They said the patient in this case should be pseudophakic or undergoing concurrent cataract surgery. Dr. Oriaifo said approaches to get ahead of malignant glaucoma, in order of effective- ness, are prophylactic vitrectomy, prophylactic iridozonulohyaloidectomy, anterior vitrectomy, sclerotomies, posterior capsulorhexis, ECP, and goniosynechialysis. Malignant glaucoma occurs— now what? Drs. Foley and Panarelli said that in order to diagnose malignant glaucoma, the patient Get ahead of malignant glaucoma in high-risk eyes COMPLICATED CASES

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