Simultaneous Bilateral “Malignant Glaucoma” Attack in a Patient with no Antecedent Eye Surgery or Miotics

Simultaneous bilateral aqueous misdirection following certolizumab therapy for rheumatoid arthritis

Aqueous misdirection syndrome is a rare, incompletely understood, sight-threatening eye condition that is difficult to diagnose and treat. We present a case of simultaneous bilateral aqueous misdirection following the administration of certolizumab in a 41-year-old women with rheumatoid arthritis and no known risk factors. To our knowledge, aqueous misdirection has not previously been associated with the use of tumour necrosis factor-alpha inhibitors.

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.

Current concepts in the treatment of vitreous block, also known as aqueous misdirection

Vitreous block (VB), a rare secondary angle-closure caused by anterior rotation of the ciliary body, occurs in a variety of settings, but most frequently after glaucoma filtering surgery. The etiology remains unclear, but choroidal expansion and anterior vitreous abnormalities have been proposed. In the past, treatment of VB has yielded high rates of failure and recurrence. Advancements in surgical techniques, however, have led to improved visual outcomes. We review the history of this condition and present a stepwise approach to its diagnosis and treatment using modern imaging modalities and surgical techniques.

Spontaneous malignant glaucoma in a patient with patent peripheral iridotomy

Background

To report a case of spontaneous malignant glaucoma in an Asian female. To propose the term “positive vitreous pressure glaucoma” to reflect the pathophysiology, treatment and prognosis of the condition.

Case presentation

A 56-year old Chinese female was diagnosed of primary angle closure glaucoma and had bilateral laser peripheral iridotomy one year ago. She presented with spontaneous onset of malignant glaucoma involving the left eye. The condition was treated successfully; the final best corrected visual acuity was 0.67 (decimal notation).

Conclusion

This case highlights that acute angle closure attack can occur in an eye with patent peripheral iridotomy. Early recognition and treatment is essential for good visual prognosis.

Management algorithms for primary angle closure disease

In contrast to primary open angle glaucoma, preventive interventions in primary angle closure disease (PACD) can sometimes be definitive. Data from randomized, controlled trials - and where this is not available - principles grounded in known biology, biological plausibility, logic, preferred practice and personal experience have been synthesized to develop explicit clinical algorithms for management of the spectrum of PACD. The mainstay of first-line intervention is usually a laser iridotomy: a commonly necessary but sometimes insufficient manoeuvre in PACD. The crucial stepwise considerations after iridotomy are: whether the angle is open or closed; whether the IOP can be medically controlled; the extent of PAS, and the presence of visually significant cataract. Indication for subsequent interventions--which may include iridoplasty, cataract surgery, trabeculectomy or phacotrabeulectomy--are herein based on an arbitrary threshold (180 degrees) for angle opening and extent of PAS following initial treatment.

Malignant glaucoma: a review of the modern literature

Malignant glaucoma is a rare form of glaucoma that typically follows surgery in patients with primary angle closure and primary angle-closure glaucoma. In this paper, the clinical features, classification, pathogenesis, and principles of management are discussed. Despite a high prevalence of primary angle closure glaucoma in South-East Asia, the vast majority of cases of malignant glaucoma are reported in White populations. This may reflect differing mechanisms of angle closure in White and Asian patients, which somehow reduces the likelihood of an aberrant relationship developing between the lens, ciliary body, anterior hyaloid, and vitreous structures within the eye. Although the exact underlying pathogenic mechanism remains unclear, the prognosis is good with modern medical, laser, and surgical treatment modalities.

Bilateral acute angle closure glaucoma as a presentation of isolated microspherophakia in an adult: case report

Background

Bilateral simultaneous angle closure glaucoma is a rare entity. To our knowledge this is the first reported case of bilateral acute angle-closure glaucoma secondary to isolated microspherophakia in an adult.

Case presentation

A 45-year-old woman presented with bilateral acute angle closure glaucoma, with a patent iridotomy in one eye. Prolonged miotic use prior to presentation had worsened the pupillary block. The diagnosis was not initially suspected, and the patient was subjected to pars-plana lensectomy and anterior vitrectomy for a presumed ciliary block glaucoma. The small spherical lens was detected intraoperatively, and spherophakia was diagnosed in retrospect. She had no systemic features of any of the known conditions associated with spherophakia. Pars-plana lensectomy both eyes controlled the intraocular pressure successfully.

Conclusion

This case demonstrates the importance of considering the diagnosis of isolated microspherophakia in any case of bilateral acute angle closure glaucoma. Lensectomy appears to be an effective first-line strategy for managing these patients.

Lesser anterior chamber dimensions in women may be a predisposing factor for malignant glaucoma

Malignant glaucoma is a potentially devastating complication of intraocular surgery that may also occur spontaneously. In this condition the aqueous is diverted into the vitreous, so the Iris lens diaphragm is moved forward. This causes shall owing of the anterior chamber and increasing of intraocular pressure. By reviewing 103 patients with malignant glaucoma, the disease was more prevalent in women that men (70% vs 30%). Anterior chamber dimensions in the women is 4% lesser than the men. Therefore, it is hypothesized that these may be due to more anterior position of the lens which not only causes lesser dimension of the anterior chamber but also more cilio-lenticular block and further aqueous diversion into the vitreous cavity, in the women.