The use of intravitreal gas for the treatment of ocular hypotony after glaucoma filtration surgery

TREATMENT OF HYPOTONY WITH AN INTRAVITREAL GAS BUBBLE

PURPOSE

To describe a case of successful resolution of severe hypotony and choroidal detachments following nonfiltering glaucoma surgery with an intravitreal injection of C 3 F 8 gas after a poor response to topical steroids and cycloplegia.

METHODS

Retrospective chart review of a case report.

RESULTS

89 year-old male presented with a central retinal vein occlusion, hyphema, vitreous hemorrhage and neovascular glaucoma. After initial intravitreal injection of aflibercept he was treated with pars plana vitrectomy with panretinal photocoagulation and endocyclophotocoagulation to the ciliary body, but he continued to have elevated intraocular pressure. Subsequent external cyclophotocoagulation was performed but severe hypotony with inflammation, choroidal detachments, and corneal edema developed one week later without response to cycloplegic and steroid medications. A therapeutic injection of perfluorpropane (C3F8) gas led to resolution of the hypotony and choroid detachment and long-term maintenance of intraocular pressure.

DISCUSSION/CONCLUSION

An intravitreal gas bubble can be a very useful outpatient procedure to immediately reverse hypotony, resolve choroidal detachment, and decrease associated inflammation. When hypotony does not respond to medical therapy with cycloplegic drops and steroid medications, then an intravitreal gas bubble can rapidly resolve these complications and result in stabilization of intraocular pressure long-term.

Posterior segment complications following glaucoma surgeries

The present review describes the posterior segment complications following surgical management of glaucoma. Although the majority of glaucoma cases are managed medically, still a large number of patients may require surgery. Moreover, with the advent of newer surgical techniques and adjuncts, encountering retinal complications post-surgery is not uncommon. The incidence, signs, management, and prognosis of common complications such as anesthesia-related retinal toxicity, vitreous loss, suprachoroidal hemorrhage, serous choroidal detachment, hypotonic maculopathy, vitreous hemorrhage, retinal detachment and endophthalmitis will be discussed in detail. Awareness of these complications is necessary as their proper and timely management can save vision in an already compromised eye.

Concurrent Phacoemulsification and Encircling for Hypotony Maculopathy after Blunt Trauma

A 37-year-old Japanese man had his right eye hit by a fist. His right eye developed hypotony maculopathy and secondary cataract, and his visual acuity decreased to 20/200 with an intraocular pressure of 4 mmHg. He underwent phacoemulsification and aspiration, implantation of the intraocular lens, and encircling with a silicone tire. His visual acuity improved to 20/20 and stable for more than one year postoperatively. The intraocular pressure in his right eye increased to 12 mmHg, and maculopathy was resolved entirely. It was suggested that an encircling buckle obstructed the uveoscleral outflow through the cyclodialysis and increased intraocular pressure. Concurrent cataract surgery and encircling was sufficient to improve the vision.

Lens Extraction for Management of Coexisting Cataract and Post-filtering Surgery Ocular Hypotony

Purpose:

To evaluate the safety and efficacy of phacoemulsification for management of post-filtering ocular hypotony.

Methods:

This prospective interventional case series study recruited 21 consecutive patients with an established diagnosis of ocular hypotony with or without maculopathy. Clear corneal incision phacoemulsification was done for all patients. Nineteen cases that completed a follow-up of at least 6 months were considered for final analysis.

Results:

Mean baseline intraocular pressure (IOP) was 2.95 ± 1.43 mm Hg, which increased to 8.84 ± 4.67 mm Hg at 6 months (P < 0.001). Hypotony was resolved in 13 cases (68%) at 6 months while 6 cases (32%) showed persistent hypotony at this time point. Postoperative IOP change at all follow-up time points was not correlated with patient age, time interval between filtering surgery and phacoemulsification, baseline IOP, baseline anterior chamber depth and IOP on the first postoperative day. Three cases (16%) showed filtering bleb failure with dramatic IOP rise around the first postoperative month and required glaucoma medication for IOP control. No significant intra- or postoperative complications were noted.

Conclusion:

Cataract surgery alone seems promising in resolving hypotony in patients with post-filtering ocular hypotony, and can be considered as an effective treatment modality before proceeding to more complicated procedures.

Hypotony Maculopathy: Clinical Presentation and Therapeutic Methods

Introduction

Hypotony maculopathy is ocular hypotony complicated by papilledema and/or folding of the retina and choroid in the posterior pole. Our objective was to examine the current literature regarding hypotony maculopathy and treatment methods.

Methods

A systematic review of the English-language literature was conducted by performing a broad search of PubMed from 1972 through 2015 using the keywords hypotony maculopathy and hypotony. Additional articles were identified from bibliographies of relevant articles.

Results

Hypotony maculopathy was infrequent before the introduction of antimetabolite agents in glaucoma-filtering surgery, and the incidence of this entity is now up to 20%. Risk factors for developing hypotony maculopathy include male gender, young age, myopia, and primary filtering surgery. Correctly identifying the etiology of hypotony is essential for successful treatment. Treatment of hypotony maculopathy includes procedures to elevate the intraocular pressure, thus reversing the collapse of the scleral wall and chorioretinal wrinkling.

Conclusion

This review discusses the definition, clinical presentation, pathophysiology, incidence and risk factors, prevention and treatment of hypotony maculopathy.

Hypotony in patients with uveitis: The Multicenter Uveitis Steroid Treatment (MUST) Trial

PURPOSE

To assess the prevalence of hypotony in patients with severe forms of uveitis.

METHODS

The Multicenter Uveitis Steroid Treatment (MUST) Trial, a randomized study, enrolled 255 patients. Patients with hypotony at the baseline visit were identified.

RESULTS

Twenty (8.3%) of 240 patients with sufficient data had hypotony. Hypotony was more common in patients with uveitis ≥5 years duration (odds ratio [OR] = 5.0; p < .01), and in eyes with a history of ocular surgery (vitrectomy vs. none, OR = 3.1; p = .03). Hypotony was less in patients with older age of uveitis onset (>51 years vs. <51 years, OR = 0.1; p = .02), in Caucasian patients (OR = 0.1; p < .01) compared to African American patients. Hypotonous eyes were more likely to have visual impairment (OR = 22.9; p < .01).

CONCLUSIONS

Hypotony is an important complication of uveitis and more commonly affects African-American patients, those with uveitis onset at a younger age, and those with longer disease duration. It is associated with visual impairment.