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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 894-896

Management of malignant glaucoma following cataract surgery in a nanophthalmic eye: A case report


Department of Glaucoma, Shanti Saroj Netralay, Miraj, Maharashtra, India

Date of Submission01-Mar-2022
Date of Acceptance21-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Ankita Madhavani
Shanti Saroj Netralay, A N Gaikwad Road, Chandanwadi, Miraj - 416 410, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_555_22

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  Abstract 


Nanophthalmos is a rare eye condition characterized by short axial length (<20 mm), high lens-to-eye volume ratio, thick sclera, angle closure, and high hypermetropia. Cataract surgery in nanophthalmic eyes is associated with a higher rate of complications compared to routine cataract surgery. We discuss a case of a nanophthalmic patient (axial length (AL) of 15.80 mm) who presented with angle closure glaucoma, underwent uneventful cataract surgery with in-the-bag intraocular lens (IOL) implantation. The patient developed postoperative uveal effusion followed by malignant glaucoma that was managed effectively by 25 G capsulo-zonulo-iridectomy with anterior vitrectomy. Timely management resolved the episode.

Keywords: Cataract surgery, malignant glaucoma, nanophthalmos, uveal effusion


How to cite this article:
Bhomaj P, Madhavani A. Management of malignant glaucoma following cataract surgery in a nanophthalmic eye: A case report. Indian J Ophthalmol Case Rep 2022;2:894-6

How to cite this URL:
Bhomaj P, Madhavani A. Management of malignant glaucoma following cataract surgery in a nanophthalmic eye: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:894-6. Available from: https://www.ijoreports.in/text.asp?2022/2/4/894/358176



Nanophthalmos is a developmental disorder of the eye that is characterized by short axial length (AL) of at least 2 SD below the mean for age.[1]

They have abnormal collagen fibrils, thick sclera that contribute to inelasticity, impaired vortex venous drainage, and reduced trans-scleral flow of proteins.[2] These features predispose the eye to angle-closure glaucoma, uveal effusion, malignant glaucoma (aqueous misdirection), and retinal detachment.

Malignant glaucoma, if left untreated, may end in corneal decompensation, optic atrophy, and painful blind eye. Establishing a communication between the anterior and posterior segment by capsulo-zonulo-iridectomy along with anterior-core vitrectomy through anterior or pars plana approach has been described as an effective treatment for its management.


  Case Report Top


A 70-year-old woman presented to our hospital with chief complaint of decreased vision in both eyes for the past 6 months. Clinical examination revealed that the patient had high hypermetropia (+14 D) and had vision of counting fingers at 3 meters in both eyes.

Anterior segment examination revealed small eyes with shallow anterior chambers (2.07 mm OD and 2.23 mm OS), corneal diameter of 11 mm OU and a dense cataractous lens in both eyes. IOP was 17 and 22 mmHg, respectively. Gonioscopy revealed closed angles bilaterally [Figure 1].
Figure 1: Anterior segment showing shallow AC and dense cataract

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Posterior segment details were not visible. Intraocular lens (IOL) Master examination (Carl Zeiss Co., Ltd.) revealed AL of 15.8 and 15.79 mm RE & LE respectively. B-scan ultrasonography showed thickened retino-choroid scleral complex at the posterior pole with measurement of ~2.5 mm. Diagnosis of nanophthalmos with angle closure and cataract was made.

Cataract surgery with custom-made IOL implantation was planned. The patient underwent uneventful left-eye temporal clear corneal phacoemulsification with in-the-bag IOL implantation of + 50 D single-piece Hydrophilic IOL with surgical PI.

On post-op day 8, the patient presented with shallow anterior chamber (AC), raised intraocular pressure (IOP) of 34 mmHg, and uveal effusion as seen on fundus photography. The patient was started on oral steroids, topical prednisolone acetate, and antiglaucoma medications with cycloplegics, and was reviewed after a week. On follow-up, there was further shallowing of the AC and higher IOP with decreased visual acuity. A diagnosis of malignant glaucoma was made and confirmed on ultrasound biomicroscopy (UBM). Twenty-five-gauge pars plana anterior and core vitrectomy along with zonulo-capsulo-iridectomy at 10 o'clock was done. Pars plana approach was chosen as the AC was very shallow. To start with, a standard three-port pars plana core vitrectomy was done using a cut rate of 5000 cpm. This deepened the AC to some extent. Following this, zonular iridectomy was done; the vitrectomy probe was used to indent the iris at 10 o'clock from posterior approach. Communication was established between the anterior and posterior segment, allowing free flow of aqueous between the two chambers.

V/A improved to 6/60 and IOP was 16 mmHg (without anti glaucoma medication [AGM]) one week postoperatively. AC had deepened (anterior chamber depth [ACD] 2.87 mm) [Figure 2].
Figure 2: Post core vitrectomy and capsulo-zonulo-iridectomy deep AC (anterior chamber)

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The anterior segment optical coherence tomography (OCT) picture shows opening of the angles after core vitrectomy and capsulo-zonulo-iridectomy, which were crowded previously after cataract surgery [Figure 3] and [Figure 4].
Figure 3: ASOCT showing crowded angles post cataract surgery

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Figure 4: Anterior segment optical coherence tomography (ASOCT) showing relatively opened up angles post core vitrectomy and capsulo zonulo iridotomy

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At one-month follow-up, visual acuity was 6/60 (unaided), with maintained IOP at 14 mmHg without any AGM.


  Discussion Top


Nanophthalmic eye poses a significant management challenge for all ophthalmologists. There is no standard protocol for management of nanophthalmos.

These eyes are known to undergo various complications, such as anterior uveitis, uveal effusion, Descemet's detachment, iris prolapse, corneal decompensation, retinal detachment, cystoid macular edema, choroidal hemorrhage, vitreous hemorrhage, and aqueous misdirection. Various strategies are used to prevent and treat the above complications, such as preoperative steroids, perioperative mannitol injection, peripheral iridectomy, scleral lamellar resections, sclerotomy, and prophylactic, intraoperative irido-zonulo-hyaloido-vitrectomy (IZHV).[3]

Intraoperatively, care can be taken to prevent sudden decompression by using dispersive and cohesive ophthalmic viscosurgical devices (OVDs). Iridectomy should be done along with cataract surgery.

Although modern cataract surgery technique is safer (71.1%), complications still occur in nanophthalmic eyes.[4]

This case presented with angle-closure glaucoma. Cataract removal might eliminate some of the causes of angle-closure glaucoma in these eyes.[4] Hence, cataract surgery was planned.

The most common complication following cataract surgery in a nanophthalmic eye was found to be uveal effusion, which led to aqueous misdirection.

We tried managing the uveal effusion with topical and oral steroids with cycloplegics which were ineffective. On follow-up, the IOP was raised along with further shallowing of the AC. A diagnosis of malignant glaucoma was made and confirmed on UBM. Creating the communication between the anterior segment and the vitreous cavity was needed to resolve the problem.[5] Furthermore, it was decided to surgically intervene and go for 25-G anterior core vitrectomy plus capsulo-zonulo-iridectomy.[6]

There have been reports of combined pars plana anterior vitrectomy plus zonulo-iridectomy being successful for treatment of malignant glaucoma in pseudophakic eye.[7]

Combined technique of phacoemulsification with IZHV has also been described to have the lowest relapse rates in patients with coexisting cataract.[8]

Since one eye of the patient developed this complication, it was very much likely that the other eye of the patient could behave in a similar manner, and hence we planned to do phacoemulsification along with IZHV in the same siting for the other eye of the patient.

Knowing the technical difficulties in performing such operations, each case of nanophthalmos should be thoroughly evaluated and the decision to intervene should only be undertaken once the functional indications for cataract extractions outweigh the risks for the same. A balance should be struck between the degree of surgical difficulty and the long-term risks of intra- and postoperative complications. And one should be ready to effectively manage in case of the abovementioned complications.


  Conclusion Top


Timely & accurate diagnosis of nanophthalmic eyes is very important and to Choose suitable treatment for the patient. We need to do Accurate biometry of such patients. Keep in mind intra & post operative complication during cataract sugery & also Optimal management for the complications if they occur.

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.
Singh H, Wang JC-C, Desjardins DC, Baig K, Gagné S, Ahmed IlK. Refractive outcomes in nanophthalmic eyes after phacoemulsification and implantation of a high-refractive-power foldable intraocular lens. J Cataract Refract Surg 2015;41:2394-402.  Back to cited text no. 1
    
2.
Yamani A, Sugino I, Wanner, M, Zarbin M. Abnormal collagen fibrils in nanophthalmos: A clinical and histologic study. Am J Ophthalmol 1999;127:106-8.  Back to cited text no. 2
    
3.
Jung KI, Yang JW, Lee YC, Kim SY. Cataract surgery in eyes with nanophthalmos and relative anterior microphthalmos. Am J Ophthalmol 2012;153:1161-8.e1.  Back to cited text no. 3
    
4.
Steijns D, Bijlsma WR, Van der Lelij A. Cataract surgery in patients with nanophthalmos. Ophthalmology 2013;120:266-70.  Back to cited text no. 4
    
5.
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. 5
    
6.
Bitrian E, Caprioli J. Pars plana anterior vitrectomy, hyaloido-zonulectomy, and iridectomy for aqueous humor misdirection. Am J Ophthalmol 2010;150:82-7.e1.  Back to cited text no. 6
    
7.
Wang J, Du E, Tang J. The treatment of malignant glaucoma in nanophthalmos: A case report. BMC Ophthalmol 2018;18:54.  Back to cited text no. 7
    
8.
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. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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