Effectiveness of surgical management of malignant glaucoma in phakic eyes

AIM: To assess the effectiveness of core vitrectomy-phacoemulsification-intraocular lens (IOL) implantation-capsulo-hyaloidotomy in treating phakic eye at least 1mo after the onset of malignant glaucoma. METHODS: A retrospective analysis were performed on malignant glaucoma patients treated in Zhongshan Ophthalmic Center between 2016 and 2018. Demographic and clinical data were described. The preoperative and postoperative visual acuity (VA), intraocular pressure (IOP), number of IOP-lowering medications used, and anterior chamber depth (ACD) of the case series were compared by Wilcoxon signed-rank test. RESULTS: Thirteen phakic eyes with long time intervals between onset and surgery were identified in this case series. Core vitrectomy-phacoemulsification-IOL implantation-capsulo-hyaloidotomy reduced the IOP (P=0.046) and the number of IOP-lowering medications used (P=0.004), deepened the ACD (P=0.005). Complete success was achieved in 38.5% of the eyes, and anatomical success was achieved in 100% of the eyes without any recurrence. The only postoperative complication observed is corneal endothelial decompensation. It occurred in two cases. CONCLUSION: Core vitrectomy-phacoemulsification-IOL implantation-capsulo-hyaloidotomy is safe and effective for treatment of long onset phakic malignant glaucoma.

Vitrectomy in Lens and Glaucoma Pathologies

Pars plana vitrectomy (PPV) is currently used as an effective method in many posterior segment pathologies. Although the most common indication is retina and vitreous pathologies, PPV is also preferred in some cases associated with lens and glaucoma. In case the crystalline lens or artificial intraocular lens, which is a product of industrial development, falls into the vitreous, it is essential to remove it mostly with the PPV approach. In some types of secondary glaucoma, especially malignant glaucoma, successful results are obtained in terms of visual prognosis and complications with vitreoretinal surgery techniques.

Associations Between the Choroidal Vascularity Index and Malignant Glaucoma After Trabeculectomy for Primary Angle Closure Glaucoma

Purpose: To compare the choroidal vasculature characteristics by using the choroidal vascularity index (CVI) in eyes with malignant glaucoma (MG), fellow eyes with non-MG, and eyes with uncomplicated primary angle-closure glaucoma (PACG) after trabeculectomy by spectral-domain optical coherence tomography (SD-OCT).Methods: This case–control study included 53 patients diagnosed with MG after trabeculectomy. Eyes with MG (n = 53) and the fellow eyes with non-MG (n = 50) were included. Eyes with PACG without MG after trabeculectomy (n = 60) were also enrolled as controls. The choroidal parameters, including CVI and the subfoveal choroidal thickness (SFCT), were measured by using SD-OCT images.Results: Eyes with MG and the fellow eyes showed a significantly lower CVI than eyes with PACG controls (p < 0.001). After adjusting for age, sex, axial length (AL), and intraocular pressure (IOP), eyes with the greater CVI [odds ratio (OR), 0.44] were significantly related to MG. The area under the receiver operating characteristic curve of the CVI was greater than that of the SFCT in the diagnosis of MG (0.911 vs. 0.840, p = 0.034).Conclusion: Eyes with MG showed a significantly lower macular CVI than eyes with PACG controls. A higher macular CVI was an associated factor of eyes with MG. The CVI serves as a more stable and sensitive indicator for MG than the SFCT in this group of patients with PACG.

Malignant Glaucoma in a Pseudophakic Eye with Slack Lens Zonules

Purpose: To report a case of malignant glaucoma after glaucoma surgery in a pseudophakic eye with slack lens zonules.Case summary: An 83-year-old man presented with high intraocular pressure of the left eye. He underwent cataract surgery in the left eye ten years ago. He was diagnosed with glaucoma two years ago and had used anti-glaucoma medications. The initial examination of the left eye revealed intraocular pressure of 24 mmHg and zonular dehiscence. We performed Ahmed valve implant surgery because medical treatment failed to lower the intraocular pressure. The anterior chamber angle was nearly closed. After the surgery, over-filtration of aqueous fluid was observed. Injecting the balanced salt solution into the anterior chamber demonstrated misdirected flow of aqueous fluid into the vitreous cavity behind the unstable intraocular lens. The eye was diagnosed with malignant glaucoma; therefore, pars plana vitrectomy was performed. After the vitrectomy, the anterior chamber was not deep; therefore, we repositioned the tip of Ahmed valve implant from the anterior chamber to the vitreous cavity. Subsequently, the anterior chamber became deep and intraocular pressure normalized. The patient remained stable two months after the vitrectomy.Conclusions: Malignant glaucoma can occur in pseudophakic eyes with slack lens zonules after glaucoma surgery, due to misdirection of aqueous fluid. This case suggests that the tip of Ahmed valve implant should be located in the vitreous cavity after vitrectomy, to prevent misdirected flow of aqueous fluid.

Tittle Page： The ocular biometry characteristics of young patients with primary angle-closure glaucoma

Backgroud: Although Primary angle-closure glaucoma (PACG) mainly occurs in elderly people, diagnosis of PACG in young patients is not uncommon . However, there is no article specialized on the ocular anatomical characteristics in these patients.Methods: In this retrospective, comparative study, patients diagnosed with PACG and recieved ultrasound biomicroscopy (UBM) examination in our department were included. Patients were divided into two groups: a young group comprised of patients aged ≤45 years of age and an old group comprised of patients＞45 years of age. A-scan ultrasonography and ultrasound biomicroscopy (UBM ) were used to measure ocular biometric parameters of patients in the two groups including axial length (AL), lens thickness (LT), central anterior chamber depth (ACD), anterior chamber width (ACW), angle opening distance 500 (AOD500), anterior angle closure 500 (ACA500), iris thickness 1000 mm from the iris root (IT1000), iris thickness 500 mm from the iris root (IT500), trabecular-ciliary process angle (TCPA), trabecular-ciliary process distance (TCPD), scleral– ciliary process angle (SCPA), lens vault (LV), and pupil diameter (PD). Plateau iris (PI) and base iris insertion were determined from UBM images, and the prevalence of PI and base iris insertion were compared between the two groups. The incidence of postoperative malignant glaucoma (MG) was also determined in both groups and ocular anatomical predictors for the development of malignant glaucoma were evaluated in young PACG patients.Results: 115 patients were included into young group and 144 patients were included into old group. The eyes of patients in the young group had shorter TCPD, shorter AL, narrower TCPA and narrower SCPA compared to the eyes of patients in the old group. There were no significant differences in ACD, LT, AL, LV, AOD 500, ACA500, IT500, IT1000, PD or ACW between the two groups. The prevalence of PI was 25.0% in older patients and 66.1% in younger patients (P < 0.001). Significantly more young patients had base iris insertion compared to old patients (P < 0.001). 87 patients in young group and 79 patients in old group underwent trabeculectomy in our department. Among these patients, 21 young patients and 4 old patients developed MG after trabeculectomy (P < 0.001). Conclusions: AL was shorter, the ciliary body was positioned more anteriorly, prevalence of PI was higher, and incidence of postoperative MG was higher in younger PACG patients compared to older PACG patients. Our results suggest that shorter AL, shorter TCPD and narrower TCPA may be predictors for development of malignant glaucoma in young PACG patients after trabeculectomy.

Combined phacoemulsification and iStent inject implantation in Asian eyes

Purpose: To evaluate the safety and efficacy of the iStent inject device combined with phacoemulsification in Asian eyes with primary open angle glaucoma. Methods: A retrospective study of combined phacoemulsification and iStent inject surgeries performed in a single institution from July 2017 to August 2019 on patients with co-existing cataracts and primary open angle glaucoma (POAG). Outcome measures included best-corrected visual acuity, intraocular pressure (IOP), number of glaucoma eyedrop medications, and surgical complications. Results: A total of 95 eyes were included. Majority of subjects were male (59, 62.1%) and Chinese (83, 87.4%). Mean age was 74.7 ± 8.7 years. Pre-operatively, mean IOP was 16.2 ± 4.3 mmHg and number of medications was 1.9 ± 0.9. Significant post-operative reduction in mean IOP was observed at all timepoints – post-operative month (POM)1: 3.0 ± 5.6 mmHg reduction ( n = 95, p < 0.05); POM3: 1.6 ± 3.8 mmHg ( n = 66, p < 0.05); POM6: 1.8 ± 4.7 mmHg ( n = 55, p < 0.05); POM12: 1.3 ± 4.2 mmHg ( n = 48) ( p < 0.05). The number of glaucoma medications was also reduced from a mean of 1.9 ± 0.8 to 0.6 ± 1.0 at POM12 ( p < 0.05). Intraoperatively, one case of malignant glaucoma occurred. Post operatively, implant obstruction by iris was observed in two eyes post-operatively requiring iridoplasty. One case of cystoid macular edema and one case of drop in visual acuity due to glaucoma progression was/were also observed. Conclusion: Asian eyes undergoing combined phacoemulsification and iStent inject surgery demonstrate a significant and sustained reduction in both IOP and number of glaucoma medications. Overall, there is a good safety profile for iStent inject.