Shallow chamber after trabeculectomy with high IOP
Suprachoroidal hemorrhage
Aqueous misdirection
Choroidal effusion
Pupillary block
Shallow chamber after trabeculectomy with low IOP
Bleb leak
Excessive filtration
Choroidal effusion
Retinal detachment
Cyclodialysis
Ciliary body shutdown
Additional Investigations
Figure 1: Gonioscopy by Spaeth classification. Angle completely open in left eye and no angle structures visible in right eye.
Figure 2: B-scan of right eye. Small vitreous opacity consistent with vitreous hemorrhage. No evidence of suprachoroidal hemorrhage, choroidal effusion or retinal detachment.
Figure 3: Ultrasound biomicroscopy (UBM) of right eye. Anterior rotation of lens-iris diaphragm and ciliary body with shallowing of anterior chamber.
Diagnosis
Aqueous misdirection
Pathophysiology
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.
Treatment
Medical Therapy – first-line with resolution in 50 percent of cases
Cycloplegic drugs (atropine)
Topical beta-blocker and alpha agonists
Oral acetazolamide
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.
References
Arya SK, et al. Malignant glaucoma as a complication of Nd:YAG laser posterior capsulotomy. Ophthalmic Surg Lasers Imaging. May-Jun 2004;35(3):248-50.
Bitrian E, Caprioli J. Pars plana anterior vitrectomy, hyaloido-zonulectomy, and iridectomy for aqueous humor misdirection. Am J Ophthalmol. July 2010;150(1)82-7.
Brown RH, et al. Neodymium: YAG Vitreous Surgery for Phakic and Pseudophakic Malignant Glaucoma. Arch Ophthalmol. 1986 Oct;104(10):1464-6.
Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol. 1968 Sep;66(3):495-502.
Chaudhry NA, et al. Pars plana vitrectomy during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes. Am J Ophthalmol. Mar 2000;129(3):387-8.
Dorairaj S, et al. Diagnosis and Management of Malignant Glaucoma. EyeNet Magazine. April 2010:37-39.
Francis BA, Wong RM, Minckler DS. Slit-lamp needle revision for aqueous misdirection after trabeculectomy. J Glaucoma. June 2002;11(3):183-8.
Mastropasqua L, et al. Aqueous misdirection syndrome: A complication of YAG posterior capsulotomy. J Cataract Refract Surg. 20 (1994):563-5.
Ruben S, et al. Malignant glaucoma and its management. British Journal of Ophthalmol. Feb 1997; 81(2):163-7.
Sharma A, et al. Vitrectomy-Phacoemulsification-Vitrectomy for the Management of Aqueous Misdirection Syndrome in Phakic Eyes. Ophthalmology. Nov 2006;113(11):1968-73.
Stumpf TH, et al. Transscleral cyclodiode laser photocoagulation in the treatment of aqueous misdirection syndrome. Ophthalmology. Nov 2008;115(11):2058-61.
Contact
Malvin D. Anders, MD, Professor of Clinical Ophthalmology, Keck School of Medicine of USC, and Chief of Ophthalmology, LAC+USC Medical Center, manders@dhs.lacounty.gov
Due to ongoing developments with COVID-19, we are only able to see patients with urgent eye problems at this time. If you have any questions or concerns, please call us at 323-442-6335.