Shallow chamber after trabeculectomy with high IOP
Shallow chamber after trabeculectomy with low IOP
Ciliary body shutdown
Aqueous misdirection (malignant glaucoma) is a rare condition characterized by elevated intraocular pressure and shallow anterior chamber without pupillary block due to an abnormal relationship between the ciliary process, lens and anterior hyaloid. It most commonly occurs in the early post-operative period but can occur months to years after surgery or in patients with no prior operations. The exact mechanism is still unknown.
Medical Therapy – first-line with resolution in 50 percent of cases
Cycloplegic drugs (atropine)
Topical beta-blocker and alpha agonists
Hyperosmotic agents (glycerol, mannitol)
Miotics are contraindicated
Laser Therapy – second-line treatment
Nd: YAG laser capsulotomy with disruption of anterior hyaloid face
Transscleral cyclodiode laser photocoagulation
Surgical treatment – definitive treatment
Transcorneal needling through iridotomy or posterior sclerotomy
Iridectomy-hyaloido-zonulectomy with anterior vitrectomy (pseudophakic patients)
Core vitrectomy-phacoemulsification-complete vitrectomy with iridectomy-hyaloidotomy-zonulectomy (phakic patients)
Prognosis and Future Directions
Visual prognosis tends to be good if diagnosed and properly treated early in disease course
Fellow eye is at increased risk of developing aqueous misdirection and some advocate for prophylactic vitrectomy prior to intraocular surgery in fellow eye
Current research directed at modifying surgical methods and technique; for example, vitrectomy-phacoemulsification-vitrectomy is a relatively new surgical approach where core vitrectomy is performed prior to phacoemulsification to relieve posterior pressure.
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Malvin D. Anders, MD, Professor of Clinical Ophthalmology, Keck School of Medicine of USC, and Chief of Ophthalmology, LAC+USC Medical Center, firstname.lastname@example.org