mechanisms and treatment of malignant glaucoma explained with flow charts and simple diagrams for academic purpose

1. MALIGNANT GLAUCOMA
SIMPLIFIED
DR . NAYANA V GOWDA
PRIMARY DNB

2. • MALIGNANT( CILIARY BLOCK GLAUCOMA OR AQUEOUS
MISDIRECTION SYNDROME) GLAUCOMA WAS DESCRIBED BY VON
GRAEFE IN 1869 AS A RARE COMPLICATION OF CERTAIN OCULAR
PROCEDURES THAT WAS CHARACTERIZED BY SHALLOWING OF
ANTERIOR CHAMBER AND ELEVATION OF IOP.
• CONDITION IS CALLED MALIGNANT GLAUCOMA BECAUSE OF POOR
RESPONSE TO CONVENTIONAL THERAPY.
MALIGNANT GLAUCOMA

3. CLINICAL FORMS
• CLASSICAL MALIGNANT GLAUCOMA
• MALIGNANT GLAUCOMA IN APHAKIA
• MALIGNANT GLAUCOMA IN PSEUDOPHAKIA
• MIOTIC INDUCED MALIGNANT GLAUCOMA
• MALIGNANT GLAUCOMA ASSOCIATED WITH BLEB NEEDLING
• MALIGNANT GLAUCOMA ASSOCIATED WITH INFECTION AND
INFLAMMATION
• MALIGNANT GLAUCOMA ASSOCIATED WITH OTHER OCULAR DISORDERS

4. THEORIES
Tips of ciliary
processes rotate
forward and press
against The lens
equator ( in phakic
eye) or against the
anterior hyaloid (in
aphakic eye).
Obstruction of
forward flow of
aqueous
Cilio- lenticular (cilio-vitreal)
block

5. ANTERIOR HYALOID OBSTRUCTION-EPSTEIN AND
COLLEAGUES
Breaks in
hyaloid
near
vitreous
base
Possibly
allow
posterior
diversion
of the
aqueous
One way
valve
effect –
fluid
coming
posteriorly
closes the
vitreous
face
against the
ciliary
body
preventing
forward
flow

6. SHAFFER AND HOSKINS – POSTERIOR POOLING OF
AQUEOUS
Posterior diversion of
aqueous flow
Accumulation of aqueous
behind a posterior vitreous
detachment
Secondary forward
movement of iris-lens
diaphragm

7. SLACKNESS OF LENS ZONULES – CHANDLER AND GRANT
Laxity of lens zonules due to
prolonged angle closure or ciliary
muscle spasm
Lens subsequently pushes the
peripheral iris into anterior chamber
Direct lens block angle closure

8. FINAL PATHWAY
Establishment of vicious cycle
whereby the transvitreal
pressure cannot be equalized
by outflow of aqueous humour
Fluid build up behind vitreous
leads to vitreous
condensation which exerts a
forward force
Anterior displacement of the
lens-iris diaphragm
An attack of malignant
glaucoma

9. CLINICAL FEATURES
• SYMPTOMS – PAIN, REDNESS, PHOTOPHOBIA.
• SHALLOWING OF CENTRAL AND PERIPHERAL ANTERIOR CHAMBER WITH
ACCOMPANYING RISE IN IOP , DESPITE PATENT PI.
• RECENT HISTORY OF INTRAOCULAR SURGERY, LASER PROCEDURE OR USE OF
MIOTICS.
• NO CHOROIDAL DETACHMENT OR SUPRACHOROIDAL HAEMORRHAGE , OR IRIS
BOMBE.
• NO REDUCTION OF IOP IN RESPONSE TO CONVENTIONAL ANTIGLAUCOMA

10. DIAGNOSIS OF MALIGNANT GLAUCOMA
• ESSENTIALLY CLINICAL
• ULTRASOUND BIO MICROSCOPY(UBM) – SWELLING
AND ANTERIOR ROTATION OF CILIARY BODY ,
FORWARD ROTATION OF THE IRIS- LENS DIAPHRAGM
, DIRECT ANGLE CLOSURE BY PHYSICAL PUSHING OF
THE IRIS AGAINST THE TRABECULAR MESHWORK.
• AS-OCT – SHALLOW ANTERIOR CHAMBER

11. DIFFERENTIAL DIAGNOSIS
PUPILLARY BLOCK GLAUCOMA
• CLOSURE OF ANTERIOR CHAMBER ANGLE
• LASER PERIPHERAL IRIDOTOMY IS TREATMENT OF
CHOICE
• UNLIKE MALIGNANT GLAUCOMA , ANTERIOR
CHAMBER HAS MODERATE DEPTH IN CENTRE

12. SUPRACHOROIDAL HEMORRHAGE
• INTRAOPERATIVE OR EARLY POST OPERATIVE PERIOD
• IOP NORMAL OR ELEVATED
• AC SHALLOW CENTRAL AND PERIPHERAL
• FUNDUS – BULLOUS LIGHT BROWN CHOROIDAL ELEVATIONS
• NO RELIEF WITH IRIDECTOMY

13. CHOROIDAL EFFUSION
• INTRAOPERATIVE OR EARLY POST OPERATIVE
PERIOD
• IOP LOW
• AC SHALLOW CENTRAL AND PERIPHERAL
• FUNDUS – BULLOUS LIGHT BROWN CHOROIDAL
ELEVATIONS
• NO RELIEF WITH IRIDECTOMY

14. MANAGEMENT
MEDICAL
LASER
PROCEDURES
SURGICAL

15. MEDICAL MANAGEMENT
INITIAL MEDICAL THERAPY IS DIRECTED AT
1. LOWERING IOP WITH AQUEOUS SUPPRESSANTS
2. SHRINKING VITREOUS WITH HYPEROSMOTIC AGENTS
3. ATTEMPTING POSTERIOR DISPLACEMENT OF THE LENS-IRIS
DIAPHRAGM WITH STRONG CYCLOPLEGIC SUCH AS ATROPINE

16. CYCLOPLEGIA:
ATROPINE(1%) EYE DROPS TDS – PARALYSIS OF SPHINCTER MUSCLE OF CILIARY BODY- LEADS
TO INCREASED TENSION IN ZONULES , FLATTENS LENS , MOVES LENS POSTERIORLY – DEEPENS
AC.
PHENYLEPHRINE (2.5%)- TIGHTENS ZONULAR COMPLEX BY CONTRACTION OF LONGITUDINAL
MUSCLE OF CILIARY BODY.
FOR SHRINKAGE OF VITREOUS:
BETA BLOCKERS , ALPHA AGONIST- APRACLONIDINE 1% BD , ORAL ACETAZOLAMIDE250MG
QID, ORAL GLYCEROL 50% , IV MANNITOL 1-2MG/KG

17. LASER TREATMENT
• ARGON LASER PHOTOCOAGULATION OF CILIARY PROCESSES.
• ND: YAG ASSISTED DISRUPTION OF ANTERIOR HYALOID FACE OR
POSTERIOR LENS CAPSULE AND HYALOID FACE.
• LASER PERIPHERAL IRIDOTOMY
• TRANS SCLERAL CYCLOPHOTOCOAGULATION IS LIMITED TO PATIENTS
RESISTANT TO MEDICAL AND SURGICAL THERAPIES WITH NO
POTENTIAL FOR IMPROVEMENT IN VISUAL ACUITY.

18. SURGICAL MANAGEMENT
REFRACTORY TO MEDICAL AND LASER THERAPY , SURGICAL
INTERVENTION TO REMOVE THE VITREOUS TO INCREASE AQUEOUS FLOW
INTO ANTERIOR CHAMBER.
CHANDLER’S PROCEDURE – POSTERIOR SCLEROSTOMY , WITH AN 18G
NEEDLE 1- 1.5 ML FLUID IS ASPIRATED AND AC FORMED WITH AIR
BUBBLE
PSEUDOPHAKIC EYE – PPV + ANTERIOR HYALOIDOTOMY
PHAKIC EYE – PPV WITH OR WITHOUT LENSECTOMY
PHAKIC EYE WITH CATARCTOUS LENS – LIMITED CORE VITRECTOMY ,
PHACOEMULSIFICATION WITH LENS IMPLANTATION , RESIDUAL
VITRECTOMY WITH HYALOIDO-ZONULECTOMY

20. THANK
YOU