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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 408-410

Resolution of malignant glaucoma following laser capsulo-hyaloidotomy through the optic hole of intraocular lens

1 Academy of Eye Education, LV Prasad Eye Institute, Hyderabad, Telangana, India
2 Academy of Eye Education; VST Centre for Glaucoma Care, L V Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission20-May-2021
Date of Acceptance30-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Rashmi Krishnamurthy
Consultant, VST Centre for Glaucoma Care, L V Prasad Eye Institute V Prasad Marg, Banjara Hills, Hyderabad, Telangana - 500 034
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1324_21

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We report a case of pseudophakic malignant glaucoma who was managed with laser capsulo-hyaloidotomy through the dialing hole of the optic of the nonfoldable intraocular lens (IOL). Our case presented with sudden, painful decreased vision in the left eye since 15 days, 3 years after cataract surgery. There was a uniformly shallow anterior chamber with a high intraocular pressure (IOP) of 52 mm Hg and glaucomatous disc damage. After performing laser capsulo-hyaloidotomy through the optic hole of the IOL, we noticed deepening of the anterior chamber, improvement in vision, and good IOP control on antiglaucoma medication, thus showing complete resolution of aqueous misdirection and obviating the need for surgical management.

Keywords: Dialing hole, laser capsulo-hyaloidotomy, malignant glaucoma, non-foldable IOL, optic hole of intraocular lens

How to cite this article:
Krishnamurthy R, Dikshit S, Burugupally K, Singla S. Resolution of malignant glaucoma following laser capsulo-hyaloidotomy through the optic hole of intraocular lens. Indian J Ophthalmol Case Rep 2022;2:408-10

How to cite this URL:
Krishnamurthy R, Dikshit S, Burugupally K, Singla S. Resolution of malignant glaucoma following laser capsulo-hyaloidotomy through the optic hole of intraocular lens. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:408-10. Available from: https://www.ijoreports.in/text.asp?2022/2/2/408/342880

Malignant glaucoma is a rare but serious complication of intraocular surgery, with maximum incidence following trabeculectomy in angle-closure disease, but can also occur following cataract surgery,[1],[2] laser,[3] or use of miotics.[4] There is aqueous misdirection into the vitreous cavity, shallowing of the anterior chamber (AC), and raised intraocular pressure (IOP), causing sudden painful/painless visual deterioration. The aim of treatment is to create a communication between the anterior chamber and anterior vitreous, thus forming a unicameral chamber. Many studies have described yttrium-aluminum-garnet (YAG) laser capsulo-hyaloidotomy in pseudophakics through the optic-haptic junction, peripheral iridotomy (PI), and beyond the optic of the intraocular lens (IOL) to create a unicameral chamber.[5],[6] We describe a unique case where we successfully treated using laser capsulo-hyaloidotomy through the optic hole of the polymethyl methacrylate (PMMA) IOL, thus obviating the need for surgical intervention.

  Case Report Top

A 66-year-old woman presented with painful diminution of vision in the left eye (LE) for the past 15 days. The patient had an ophthalmic consultation locally 5 days ago where IOP was 56 mm Hg and was started on oral and topical antiglaucoma medication (AGM) with atropine eye drops. There was a history of cataract surgery in LE 3 years back. On examination, the best-corrected vision was 20/60 in the right eye (RE) with −2.00 D sphere and 20/200 in LE with −4.50 D sphere. RE was normal with nuclear cataract. LE showed uniformly shallow AC, synechially closed angles on gonioscopy, irregular fixed pupil, PMMA IOL in the sulcus with residual cortex at 12 o'clock [Figure 1]. IOP was 20 and 52 mm Hg in RE and LE, respectively. LE showed a medium-sized disc with a cup-disc ratio of 0.7 and an inferior rim notch.
Figure 1: Image at presentation showing shallow central (a) and peripheral anterior chamber depth (b)

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Pupillary block was ruled out after performing laser PI at 9 o'clock, which did not help either in AC deepening or IOP reduction. B-scan showed attached retina without any evidence of choroidal detachment/suprachoroidal hemorrhage. After excluding pupillary block, choroidal detachment, and suprachoroidal hemorrhage, diagnosis of LE malignant glaucoma was confirmed.

Decision to perform YAG-laser capsulo-hyaloidotomy through the dialing hole of the IOL was made because the area beyond the optic or optic-haptic junction could not be visualized due to fixed mid-dilated pupil. Cortex at 12 o'clock was loosely hanging close to the optic hole, blocking it partially. Thus, it was lasered initially to have a clear view through the optic hole. Energy of 1–2 mJ (single-burst mode) was used to penetrate the posterior capsule first; then, the same setting was used to focus posteriorly at the anterior vitreous till the sound suggestive of the rupture of anterior hyaloid face was heard. The posterior capsular opening was enlarged with additional 3–4 shots. Immediate, significant deepening of the AC was observed without any vitreous prolapse through the dialing hole. The patient was started on topical steroid drops (prednisolone acetate 1%) four times a day, atropine 1% eye drops thrice a day, AGM (combination of brimonidine tartrate-0.2% and timolol maleate-0.5%) twice a day, and oral acetazolamide 250 mg twice a day.

After 1 week, there was recurrence of malignant glaucoma due to blockage of the hyaloidotomy site (optic hole of IOL) by the vitreous. IOP was 28 mm Hg with shallow AC. Repeat YAG-hyaloidotomy was done through the same site till AC deepening was observed. The patient was continued on the same treatment and reviewed after 2 weeks.

At this visit, LE showed deep AC and IOP of 12 mm Hg without any recurrence. Oral acetazolamide was stopped and the patient was continued on topical AGM and cycloplegics. After 1 month, there was complete resolution of malignant glaucoma with 20/80 vision, deep AC, patent optic hole [Figure 2], and an IOP of 18 mm Hg. At the last visit after 4 months, the best-corrected vision had improved to 20/80 with -2D sphere as there was a decrease in myopia due to the backward shift of the IOL-iris-ciliary body complex. There was deep AC with an IOP of 19 mm Hg with two AGM and atropine eye drops.
Figure 2: Image showing deepening of the anterior chamber (a - centrally, b - peripherally) after laser capsulo-hyaloidotomy through the optic hole in direct illumination (a and c-yellow arrow) and retro-illumination (d - yellow circle)

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  Discussion Top

Aqueous misdirection involves uniform shallowing of the anterior chamber with normal to raised intraocular pressure in the presence of patent iridotomy.[7] Various pathogenetic mechanisms proposed include abnormal vitreo-ciliary relationship, anterior rotation of ciliary processes, and forward movement of the iris-lens diaphragm.[8],[9] Aim of the treatment is to create communication between the anterior chamber and anterior vitreous. Medical management includes cycloplegics for posterior displacement of the lens-iris diaphragm, aqueous suppressants to control IOP, laser iridotomy to rule out pupillary block, laser capsulo-hyaloidotomy in pseudophakics, and surgical management including pars-plana vitrectomy and irido-zonulo-hyaloido-vitrectomy (IZHV).[9]

Frequently described YAG-capsulo-hyaloidotomy sites are the optic-haptic junction, beyond the IOL optic, and through the iridotomy.[6] The central optic area is not preferred for capsulo-hyaloidotomy as the optic itself blocks the free movement of the aqueous. Little et al.[10] successfully treated seven cases of malignant glaucoma in pseudophakic eyes with laser capsulotomy peripheral to the lens optic. This may cause subsequent blockage of posterior aqueous flow by the juxtaposed optic.

For YAG hyaloidotomy through iridotomy, large PI is required which may be very painful, with increased risk of hyphema. In patients who have been atropinised prior, performing iridotomy is impossible due to the thick mid-dilated iris. We searched the literature extensively and found only one report on laser done through the optic hole of IOL by Risco et al. in 1989.[5] As the only accessible area of the capsule in their case was that visualized through the positioning holes, the authors attempted only capsulotomy through the dialing hole and were successfully able to treat it. The success was possibly a result of an accidental hyaloidotomy along with capsulotomy and was possibly not intentional. We speculate that capsulotomy alone will not create a unicameral chamber and capsulo-hyaloidotomy should be done, as in our case.

Advantages of YAG-capsulohyaloidotomy through the optic hole are as follows: it is painless; has an easily accessible site; both capsulotomy and hyaloidotomy can be performed in the same sitting; it is a sufficiently large-sized opening for doing laser hyaloidotomy even by a beginner without any learning curve; and no risk of bleeding unlike through iridotomy site.

  Conclusion Top

To conclude, our case emphasizes the importance of this rare technique of laser capsulo-hyaloidotomy through the optic hole of IOL, with minimal risk of recurrence due to vitreous blockage. This route is painless and can result in resolution of malignant glaucoma in some eyes. Knowledge of various possible sites for laser hyaloidotomy is important before planning surgery in these patients.

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

Hyderabad Eye Research Foundation (HERF).

Conflicts of interest

There are no conflicts of interest.

  References Top

Varma DK, Belovay GW, Tam DY, Ahmed IIK. Malignant glaucoma after cataract surgery. J Cataract Refract Surg 2014;40:1843-9.  Back to cited text no. 1
Muqit MM, Menage MJ. Malignant glaucoma after phacoemulsification: Treatment with diode laser cyclophotocoagulation. J Cataract Refract Surg 2007;33:130-2.  Back to cited text no. 2
Brooks AM, Harper CA, Gillies WE. Occurrence of malignant glaucoma after laser iridotomy. Br J Ophthalmol 1989;73:617-20.  Back to cited text no. 3
Merritt JC. Malignant glaucoma induced by miotics postoperatively in open-angle glaucoma. Arch Ophthalmol 1977;95:1988-9.  Back to cited text no. 4
Risco JM, Tomey KF, Perkins TW. Laser capsulotomy through intraocular lens positioning holes in anterior aqueous misdirection. Case report. Arch Ophthalmol 1989;107:1569.  Back to cited text no. 5
Dave P, Senthil S, Rao HL, Garudadri CS. Treatment outcomes in malignant glaucoma. Ophthalmology 2013;120:984-90.  Back to cited text no. 6
Levene R. A new concept of malignant glaucoma. Arch Ophthalmol 1972;87:497-506.  Back to cited text no. 7
Simmons RJ. Malignant glaucoma. Br J Ophthalmol 1972;56:263-72.  Back to cited text no. 8
Shahid H, Salmon JF. Malignant glaucoma: A review of the modern literature. J Ophthalmol 2012;2012:852659.  Back to cited text no. 9
Little BC, Hitchings RA. Pseudophakic malignant glaucoma: Nd: YAG capsulotomy as a primary treatment. Eye (Lond) 1993;7:102-4.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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