Eyeworld

EW GLAUCOMA 60 September 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer the lens iris diaphragm in phakic and pseudophakic patients, and of the anterior hyaloid face in apha- kic patients, shallowing of both the central and peripheral anterior chamber, and elevated IOP. Creating an iridotomy is important to rule out pupillary block. If IOP persists despite a patent iridotomy, choroi- dal detachment and suprachoroidal hemorrhage should be excluded clinically or by ultrasound biomi- croscopy (UBM). UBM allows in vivo imaging of the structural details of the anterior ocular segment that are critical in glaucoma. It helps to elucidate the mechanism of elevated IOP in some cases by showing the relationship between the peripheral iris and the trabecular meshwork, as well as assessing the effects of interventions like iridotomy and trabeculectomy, thereby helping to diagnose and manage various pa- thologies related to glaucoma. 1 Myopic case report This case report reviews an incident of refractory malignant glauco- ma after a combination cataract/ phacoemulsification and trabeculec- tomy in a 71-year-old myopic female patient with primary open-angle glaucoma, who developed high IOP and a shallow anterior chamber shortly after surgery. The patient's best corrected visu- al acuity (BCVA) was recorded preop and during the follow-up period. UBM and anterior segment OCT (AS- OCT) were performed for differential diagnosis. All medical and surgical treatments were recorded. Preop the patient's BCVA was 0.4, IOP was 28 mm Hg, and the anterior chamber was deep. On day 1 following the phaco/trabeculec- tomy, visual acuity was counting fingers, IOP was 30 mm Hg, and the anterior chamber was shallow. There were no signs of wound leakage and an absence of choroidal detachment on B-scan. Medical therapy was initiated with mannitol, mydriatics, and topical anti-glaucoma agents, and anterior chamber reformation surgery was planned. The reformation of the anterior chamber was attempted on day 2. After a successful peripheral laser iridotomy on day 3, the anterior chamber remained very shallow and the IOP was 22 mm Hg. A ccording to a case study from Dublin, Ireland, that was presented at the 2016 European Society of Cataract and Refractive Surgeons (ESCRS) Congress, the diagnosis of malignant glaucoma may sometimes fall outside the box, despite a well-known set of defining criteria and clinical associations. Aida Hajjar, MD, St. Vincent's University Hospital, Dublin, Ireland, and previously Burgos University Hospital, Burgos, Spain, who pre- sented the case review at an ESCRS poster session, thinks that physi- cians treating glaucoma patients need to exercise particular vigilance in the diagnosis and treatment of their patients with narrow, closed, and even open angle glaucoma un- dergoing filtration surgery. Red flags Malignant glaucoma is complex and can be difficult to treat. It is characterized by elevated IOP with a shallow or flat anterior chamber and is most frequently associated with glaucoma filtration surgery in patients with narrow-angle or angle- closure glaucoma. It also goes by aqueous misdirection, ciliary block glaucoma, and lens block angle clo- sure, depending on the mechanism or anatomic characteristic identified. The entity refers to a sustained, ongoing process that is difficult to treat, often unresponsive to conven- tional anti-glaucoma strategies, and characteristically progresses to blind- ness, without prompt management. Malignant glaucoma can occur in 2–4% of eyes undergoing surgery for angle-closure glaucoma, most typically shortly after incisional sur- gery, but also in the days and weeks afterward. It has also been noted days or years after procedures like trabeculectomy, cataract extraction, glaucoma drainage implantation, la- ser iridotomy, capsulotomy, intravit- real injection, and other intraocular procedures. Preop risk factors such as hyperopia, chronic angle closure with plateau iris configuration, nanophthalmos, or a history of ma- lignant glaucoma in the fellow eye are red flags that require physicians to evaluate patients extensively. Malignant glaucoma presents difficult diagnostic and treatment challenges. Slit lamp examination reveals anterior displacement of Malignant glaucoma: Beware of non-textbook cases Presentation spotlight Anterior segment OCT on day 2 demonstrating shallow anterior chamber, closed angles, and forward shift of the IOL. Anterior segment slit lamp photo on day 3 showing a patent YAG laser peripheral iridotomy. Source: Aida Hajjar, MD Despite the IOP relief, the patient's vision was still counting fingers on postoperative day 7, with a continued IOP of 22 mm Hg and a very shallow anterior chamber. The surgeon opted for pars plana vit- rectomy (PPV), which did not affect the anterior chamber but dropped the IOP to 20 mm Hg on full med- ical treatment, 1 day after PPV. Dr. Hajjar reported that the patient's BCVA from postoperative days 1–12 was counting fingers, the anterior chamber stayed very shallow despite efforts to establish aqueous flow, and IOP was 20 mm Hg with topical treatment. "Short eyes such as in hyper- metropia and nanophthalmia are considered high risk for the develop- ment of malignant glaucoma. In this report, however, the patient had my- opia and did not fit the usual pheno- type," Dr. Hajjar said. "Malignant glaucoma is a diagnosis of exclusion and requires thorough investigations including repeat UBM and AS-OCT for differential diagnosis" Options and success rates Malignant glaucoma has been noted to occur in phakic and pseudophakic eyes of patients having undergone trabeculectomy, cataract surgery, and combined cataract and glaucoma surgery. 2 A retrospective comparative case series observed a 100% relapse rate after medical therapy, 75% after YAG laser capsulotomy and hyaloi- dotomy, 75% after conventional vitrectomy, and 66% after anterior vitrectomy in combination with iridectomy-zonulectomy. It found complete vitrectomy combined with iridectomy and zonulectomy to be the most successful management for aqueous misdirection syndrome. 3 Pars plana vitrectomy was seen to be

• Blank Page
• Blank Page (1)