Principles Management Of Malignant Glaucoma Following Trabeculectomy

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PRIMARY ANGLE CLOSURE GLAUCOMA

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Presentation transcript:

Principles Management Of Malignant Glaucoma Following Trabeculectomy Roberta Giannini, Tommaso Mascaro, Annamaria Mauro, Giorgio Salinetti, Luigi Zompatori Ophthalmology, San Giovanni Evangelista Hospital, Rome, Italy Purpose: Malignant glaucoma is diagnosed when there is shallowing of the central (axial) anterior chamber in association with increased intraocular pressure (IOP) and normal posterior segment anatomy. Vitreous block (VB) occurs in a variety of settings, but most frequently after glaucoma filtering surgery. We review the history of this condition and present a stepwise approach to its diagnosis and treatment. We describe 23 gauge vitrectomy in the management of malignant glaucoma/aqueous misdirection syndrome in pseudophakic eyes after glaucoma filtering. Methods: In 2016 at the Ophthalmology department of the S. G.E. Hospital of Tivoli, Rome, four eyes of four patients underwent glaucoma filtering surgery and developed malignant glaucoma. All the eyes were pseudophakic. Medical therapy was unsuccessful in each case. A pars plana 25 gauge vitrectomy was performed in all the eyes. Results: The core vitrectomy surgery led to resolution of malignant glaucoma in 4 of the 4 pseudophakic eyes. In two cases after the removal of vitreous we obtained a drastic reduction of IOP up to the normal values within 24 hours; in two eyes the postoperative IOP was 24 mmHg and 22mmHg without medical therapy. We obtain normal values with only beta-blockers topical therapy. Conclusions: In malignant glaucoma that is refractory to medical and laser therapy, vitrectomy to remove the anterior vitreous is necessary to increase aqueous ﬂow into the anterior chamber. Malignant glaucoma continues to provide a therapeutic challenge, which probably reﬂects our limited understanding of its etiology. It is curious that this condition appears to be extremely rare in Asians, where the prevalence of primary angle-closure glaucoma is common. Whatever the true mechanism, the fact that it is relieved when a direct communication is made between the anterior chamber and vitreous cavity supports the theory that the lens, anterior vitreous, and ciliary processes are intimately involved in the pathogenesis. 1) A. von Graefe, “Beitrage zur pathologie und therapie des glaukoms,” Archives of Ophthalmology, vol. 15, p. 108, 1869. 2) R. N. Shaer and H. D. Hoskins, “Ciliary block (malignant) glaucoma,” Ophthalmology, vol. 85, no. 3, pp. 215–221, 1978. 3) D. I. Weiss and R. N. Shaer, “Ciliary block (malignant) glaucoma,”Transactions of the American Academy of Ophthalmology and Otolaryngology, vol. 76, no. 2, pp. 450–461, 1972. 4) R. Levene, “A new concept of malignant glaucoma,” Archives of Ophthalmology, vol. 87, no. 5, pp. 497–506, 1972. 5) R. J. Simmons, “Malignant glaucoma,”British Journal of Ophthalmology, vol. 56, no. 3, pp. 263–272, 1972. 6) P. A. Chandler, “Malignant glaucoma,” American Journal of Ophthalmology, vol. 34, no. 7, pp. 993–1000, 1951. 7) H.EltzandB.Gloor, “Trabeculectomy in cases of angle closure glaucoma—successes and failures,”Klinische Monats blatter fur Augenheilkunde, vol. 177, no. 5, pp. 556–561, 1980.