Eyeworld

70 | EYEWORLD | SEPTEMBER 2023 G UCOMA Contact Aboobakar: inas_aboobakar@meei.harvard.edu Schlenker: matt.schlenker@utoronto.ca Varma: devesh.varma@prismeye.ca Relevant disclosures Aboobakar: None Schlenker: None Varma: None has been on the drop for weeks to months and you can do a trial off it, as the system has been reset, they no longer need the atropine. Dr. Aboobakar's initial management includes cyclo- plegics and aqueous suppressants, and she said hyperosmotic agents can be considered. Dr. Aboobakar said she'll consider either laser or surgical intervention in cases refractory to medical management. "In pseudophakic or aphakic patients, Nd:YAG laser can be applied in the clinic to disrupt the anterior vitreous face and allow aqueous to flow anteriorly. Surgical management with vitrectomy combined with irido-zonulo-hyaloidotomy provides definitive treatment in cases refractory to medical and/or laser therapy," she said. Prevention From Dr. Aboobakar's perspective, the underly- ing disease mechanisms are not yet fully under- stood, and methods for primary prevention of malignant glaucoma are not well studied. "Once an individual has developed malig- nant glaucoma in one eye, prophylactic postop- erative cycloplegia or vitrectomy at the time of cataract surgery in the contralateral eye can be considered, though the effectiveness of these measures has not been investigated with pro- spective studies to date," she said. Dr. Varma said the biggest preventative ef- fort is to avoid a decompression event by main- taining anterior chamber pressurization when you're changing instruments. In a small eye, Dr. Varma continued, you might do a prophylactic vitrectomy to make space, and use oral carbonic anhydrase inhibitors or mannitol ahead of time. "That helps make space, but if you have a big decompression, it doesn't matter if you've made space, you can still induce malignant glaucoma," he said. Dr. Schlenker said in eyes with an axial length less than 20 mm, he will consider doing a prophylactic irido-zonulo-hyaloidotomy when doing cataract surgery. He might also do this if a patient is at higher risk, such as if they had malignant glaucoma in their other eye. Dr. Schlenker emphasized that early recog- nition of malignant glaucoma is important. "The worst case scenario is someone who has subtle malignant glaucoma, their angles are closed, and it gets sat on for years, and they slowly develop scar tissue in their drain- age system. By the time they get sent to me, their drainage system is completely closed off (peripheral anterior synechiae), and their eye pressure is really high," he said. "Retrospective case series suggest that most individuals with malignant glaucoma will go on to need vitrectomy combined with irido-zonu- lo-hyaloidotomy for definitive management," Dr. Aboobakar said. "With prompt diagnosis and treatment, malignant glaucoma can re- solve, though irreversible vision loss may occur depending on the duration and level of IOP elevation." continued from page 69 A case example Dr. Aboobakar described a 78-year-old female with a history of laser peripheral iridotomy for acute angle closure attack in the left eye 15 years ago who underwent uncomplicated cataract surgery in this eye. She was doing well at her postop week 1 visit, with good visual acuity in the operative eye (20/25) and IOP 15 mm Hg. Three days later, however, she presented to the emer- gency room with acute onset headache, eye pain, blurry vision, and nausea/vomiting. The left eye visual acuity was 20/800, IOP was 48 mm Hg, the pupil was mid-dilated, the anterior chamber was diffusely shallow with irido-corneal touch in the periphery, and a patent peripheral iridotomy and pos- terior chamber intraocular lens were noted. B-scan ultrasound did not demonstrate choroidal effusions, suprachoroidal hemor- rhage, or mass lesions. UBM showed anteri- or displacement of the lens-iris diaphragm and anterior rotation of the ciliary body. The patient was started on maximal topical IOP lowering treatment, topical atropine, and oral acetazolamide with improvement in IOP to 28 mm Hg, though 2 days later IOP was again elevated to 45 mm Hg with anterior chamber shallowing. The patient underwent vitrectomy combined with irido- zonulo-hyaloidotomy with improvement in IOP to 11 mm Hg, deepening of the anterior chamber, and resolution of symptoms.

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