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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 512-514

Hypotonous malignant glaucoma following glaucoma drainage device implantation


Department of Ophthalmology, Government Medical College and Hospital, Chandigarh, India

Date of Submission06-Aug-2020
Date of Acceptance22-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Parul Ichhpujani
Department of Ophthalmology, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2545_20

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  Abstract 


Malignant glaucoma also known as “aqueous misdirection” is a frightening complication post glaucoma surgery. The usual presentation is with high intraocular pressure with flat anterior chamber both centrally and peripherally. The management option includes pharmacotherapy, laser and pars plana vitrectomy(PPV). We describe a case of malignant glaucoma which presented one day after the surgery with low intraocular pressure. The patient was managed by anterior vitrectomy via paracentesis with anterior vitrectomy settings by glaucoma surgeon.

Keywords: Aqueous misdirection, hypotonous malignant glaucoma, anterior vitrectomy, posterior capsulectomy


How to cite this article:
Kumar S, Singla E, Ichhpujani P, Rehman O. Hypotonous malignant glaucoma following glaucoma drainage device implantation. Indian J Ophthalmol Case Rep 2021;1:512-4

How to cite this URL:
Kumar S, Singla E, Ichhpujani P, Rehman O. Hypotonous malignant glaucoma following glaucoma drainage device implantation. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:512-4. Available from: https://www.ijoreports.in/text.asp?2021/1/3/512/319997



Malignant glaucoma is one of the most challenging complications of ocular surgery. Herein we report a case of malignant glaucoma, which presented with low intraocular pressure post glaucoma surgery which was managed by anterior vitrectomy.


  Case Report Top


A 75-year-old, hyperopic, hypertensive woman was referred to our Glaucoma services for elevated intraocular pressure (IOP) (right eye, OD: 35 mm Hg; left eye, OS: 40 mm Hg, without any antiglaucoma medications). Slit-lamp examination revealed bilateral pseudophakia with shallow anterior chamber (AC) despite patent iridotomies and patchy iris atrophy. Neovascularization of iris (NVI) was present at 5–7'o clock hour in OS. The angles were open, grade 3 as per Modified Shaffer's grading with no evidence of angle neovascularization (OU).

Fundus showed normal disc OU with signs of old Central retinal vein occlusion (CRVO) and presence of neovascularization elsewhere (NVE) in both eyes (OU). She was diagnosed with bilateral neovascular glaucoma (NVG) and started on tablet acetazolamide 250 mg thrice a day along with a fixed-dose combination of brimonidine 0.1% and brinzolamide 1% BD OU. Subsequently, eye drop timolol 0.5% was added in the OS to control IOP. In addition, aggressive pan retinal photocoagulation (PRP) was done OU. Intravitreal injection of Ranibizumab was given in OS 1 week after the PRP.

IOP was controlled in OD but remained high in OS (30 mm Hg). Hence, the Aurolab Aqueous Drainage Implant (AADI, Baerveldt type) was implanted in OS in supero-temporal quadrant with tube in AC. The tube was ligated using 6-0 prolene suture, lumen of the tube was occluded with 2-0 prolene suture and Sherwood slits were made in the tube proximal to the site of occlusion. The surgery was uneventful.

On first postoperative day, cornea was edematous with flat AC both centrally and peripherally with hypotony (Unrecordable IOP) [Figure 1]a. The implant was in place with patent tube. Seidel's test was negative. B-scan ultrasonography was performed which showed no signs of choroidal effusion [Figure 1]b. No aqueous pockets were noted within the vitreous cavity.

Suspecting malignant glaucoma with low IOP, pressure patch was applied and patient was started on topical steroids, antibiotic and atropine. On second postoperative day, IOP started re-building but AC remained shallow both peripherally and centrally. On day 3, IOP was 10 mm Hg but with no change in the AC. At this stage ultrasound biomicroscopy (UBM) was done and anterior rotation of ciliary processes was noted thus confirming the diagnosis of malignant glaucoma [Figure 1]c.
Figure 1: (a) Shallow Anterior chamber with edematous cornea with a patent tube; (b) Ultrasonography shows no evidence of uveal effusion; (c) UBM showing anterior rotation of ciliary processes confirming malignant glaucoma

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Our patient did not respond to conservative treatment and anterior Nd: YAG laser hyaloidotomy was not possible due to edematous cornea, hence surgical management with anterior vitrectomy with hyaloidotomy through limbal incisions with primary posterior capsulectomy was planned. A 20-G bi-manual vitrector was used, with a cut rate of 600–800 and low-to-moderate flow [Figure 2]. The procedure went uneventful. Post-operatively, the patient had deep AC [Figure 3]a. UBM repeated 2 days after the surgery showed formation of AC and reversal of anterior rotation of ciliary processes [Figure 3]b. The patient had deep AC, clear cornea, IOP without any medications at discharge and at the last postoperative follow-up at 3 months, IOP was maintained at 12 mm Hg with well-formed AC.
Figure 2: Schematic diagram of surgical procedure (Black arrow: Anterior vitreous; White arrow: Vitrectomy cutter

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Figure 3: (a) Deep AC; (b) Postoperative UBM showing normal position of ciliary processes and formed AC (Arrow)

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  Discussion Top


Malignant glaucoma, also known as the “aqueous misdirection (AM),” refers to a uniform shallowing or flattening of both central and peripheral AC in an eye with normal to elevated IOP in the presence of one or more patent iridotomies. It was first described by von Graefe in 1869.[1] AM is usually seen after incisional surgery, particularly glaucoma surgery in eyes with prior angle closure with a reported incidence of 2%–4%. It can present as early as one day or as late as several years after intraocular surgery.[2] Our case presented on the first postoperative day.

AM may be seen in phakic, aphakic, or pseudophakic eyes. It has predisposition for Asian eyes, probably due to their short axial length and narrow AC angles. It has been associated with CRVO and in patients aged over 70 years with female predisposition.[3] Our patient was a 75-year-old Indian woman, pseudophakic with history of angle closure thus meeting all the risk factors for malignant glaucoma.

The ill-understood pathophysiology involves the anterior hyaloid, disruption of which is key to resolution.[3] IOP is usually elevated at the time of diagnosis. Many case reports cite hypotonous malignant glaucoma after trabeculectomy[4] but literature is sparse after GDD implantation.[5] Post GDD implantation, the median time for development of malignant glaucoma was 33 days and 7 eyes presented with IOP less than 21 mm Hg.[5] The authors proposed it to be a result of cascade of events following external ligature release, which led to overfiltration, shallowing of AC, rotation of Iris lens diaphragm anteriorly and movement of aqueous posteriorly into vitreous. In our case, hypotony would have resulted due to the Sherwood slits.

The management options include medical therapy, laser and surgery (pars plana vitrectomy). Cases where laser is not possible, as in our case, require vitrectomy. Core vitrectomy may not help to achieve this as recurrence of AM is known after PPV.[6],[7] To overcome this an anterior segment approach in the form of Irido-zonulo-hyaloido-vitrectomy for treatment of pseudophakic AM has been described[8] therefore we also adopted this technique using a 20 G bimanual vitrector for our patient. In addition, 23-G or 25-G vitrector was not used because of associated complications related to small gauge vitrectomy, such as, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.[9] Since our patient was pseudophakic, we were able to successfully perform a posterior capsulectomy followed by anterior vitrectomy through limbal incisions with favorable results.

Our case has certain unique features. Firstly, our patient presented with a low IOP and to the best of our knowledge this is the probably the first reported presentation of low IOP post GDD implantation in malignant glaucoma. The early presentation postsurgery is another highlight of our case. Lastly, instead of using the conventional PPV we went ahead with anterior vitrectomy using the limbal incisions. Prevention of recurrence of malignant glaucoma has been reported using anterior vitrectomy.[10]


  Conclusion Top


To conclude anterior vitrectomy in AM can prevent recurrence and reduce the complications of posterior segment surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
von Graefe A. Ueber die Iridectomie bei Glaucom und über den glaucomatösen Process (On the iridectomy in glaucoma and the glaucomatous process) Graefes Arch Clin Exp Ophthalmol. 1857;3/II:456–555.  Back to cited text no. 1
    
2.
Foreman-Larkin J, Netland PA, Salim S. Clinical management of malignant glaucoma. J Ophthalmol 2015;2015:283707.  Back to cited text no. 2
    
3.
Shen C-J, Chen Y-Y, Sheu S-J. Treatment course of recurrent malignant glaucoma monitoring by ultrasound biomicroscopy: A report of two cases. Kaohsiung J Med Sci 2008;24:608-13.  Back to cited text no. 3
    
4.
Burgansky-Eliash Z, Ishikawa H, Schuman JS. Hypotonous malignant glaucoma: Aqueous misdirection with low intraocular pressure. Ophthalmic Surg Lasers Imaging 2008;39:155-9.  Back to cited text no. 4
    
5.
Greenfield DS, Tello C, Budenz DL, Liebmann JM, Ritch R. Aqueous misdirection after glaucoma drainage device implantation. Ophthalmology 1999;106:1035-40.  Back to cited text no. 5
    
6.
Debrouwere V, Stalmans P, Van Calster J, Spileers W, Zeyen T, Stalmans I. Outcomes of different management options for malignant glaucoma: A retrospective study. Graefes Arch Clin Exp Ophthalmol 2012;250:131-41.  Back to cited text no. 6
    
7.
Shahid H, Salmon JF. Malignant glaucoma: A review of the modern literature. J Ophthalmol 2012;2012:852659.  Back to cited text no. 7
    
8.
Zarnowski T, Wilkos-Kuc A, Tulidowicz-Bielak M, Kalinowska A, Zadrozniak A, Pyszniak E, et al. Efficacy and safety of a new surgical method to treat malignant glaucoma in pseudophakia. Eye (Lond) 2014;28:761-4.  Back to cited text no. 8
    
9.
Thompson JT. Advantages and limitations of small gauge vitrectomy. Surv Ophthalmol 2011;56:162-72.  Back to cited text no. 9
    
10.
Ray VP, Malhotra V. Management of recurrent aqueous misdirection by anterior segment surgeon after failed pars plana posterior vitrectomy. Indian J Ophthalmol 2019;67:1204-6.  Back to cited text no. 10
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