Malignant glaucoma is a complication that can occur after glaucoma filtration surgery where the anterior chamber becomes shallow despite a patent iridotomy. It is caused by abnormal accumulation of aqueous humor behind the lens and iris, causing the iris-lens diaphragm to move forward. Theories of its cause include posterior diversion of aqueous flow, anterior displacement of the vitreous, or pressure from an expanded choroid pushing the lens forward. Treatment involves cycloplegics to pull the lens back, reducing aqueous production and IOP, and sometimes laser treatment or vitrectomy surgery to disrupt the abnormal fluid buildup.

1. Malignant Glaucoma
Presenter: Dr.Niket Gandhi
Moderator: Dr.Vijay Shetty

2. Introduction
 Albrecht von Graefe in 1869
 It is characterized by normal or increased IOP associated with axial
shallowing of the entire anterior chamber in the presence of a patent
peripheral iridotomy
 After surgery in patients with primary angle closure and primary
angle-closure glaucoma
 Synonyms:
1. Ciliary block glaucoma
2. Aqueous misdirection syndrome
3. Direct lens-block glaucoma

3. Prevalence
 2% to 4% - h/o of acute or chronic angle-closure glaucoma that have
undergone filtration surgery
 1.3 % - glaucoma surgery alone or combined with cataracts
 2.3%- Penetrating surgery
 Women are three times more likely than men

4. Predisposing Factors
 Axial hyperopia
 Nanophthalmos
 Disorders of anatomical proportions in the anterior chamber
 chronic angle closure with plateau iris configuration
 History of malignant glaucoma in the fellow eye.

5. Risk Factors
 Filtration surgeries: Trabeculectomy
 Penetrating Keratoplasty
 Laser treatment :
1. Peripheral laser iridotomy
2. trabeculectomy scleral flap suture lysis
3. cyclophotocoagulation
 use of miotics
 trabeculectomy bleb needling
 Infection
 Retinopathy of prematurity
 Retinal detachment
 retinal vein occlusion
 trauma

6.  Preoperative IOP is not a good indicator
 Unlike in pupillary block angle closure, miotics can
exacerbate malignant glaucoma.

7. Theories
Theories
Shaffer
and
Hoskins
Epstein et
all
Chandler
et all
Quigley et
all

8. Shaffer and Hoskins
 Posterior diversion of aqueous flow causes accumulation of aqueous
behind a posterior vitreous detachment with secondary forward
movement of the iris-lens diaphragm
 Collections of fluid behind the vitreous gel, which also seemed more
dense than normal, and believed that this prevented forward flow of
aqueous
 They postulated a valve-like mechanism by which aqueous humour
was “misdirected” posteriorly.

9. Epstein and colleagues
 Anterior displacement of the vitreous due to posterior diversion of
aqueous
 Associated thickening of the anterior hyaloid, and they were able to
demonstrate an impedance to flow across the intact anterior hyaloid
 The accumulation of aqueous within the posterior segment forces the
ciliary body and the anterior hyaloid face forward, shallowing the
anterior chamber and causing secondary angle closure

10. Chandler et all
 Laxity of lens zonules coupled with pressure from the vitreous leads to
forward lens movement
 A vicious circle is set up in that the higher the pressure in the
posterior segment, the more firmly the lens is held forward

11. Quigley et al.
 Proposed that the precipitating event which increases vitreous
pressure is choroidal expansion
 Initial compensatory outflow of aqueous along the posteroanterior
pressure gradient causes shallowing of the anterior chamber.
 Choroidal expansion has been detected on UBM in eyes with
malignant glaucoma, and choroidal effusion secondary to angio-oedema
has also been reported to result in malignant glaucoma

12. Predisposing Anatomical features
 Incorrect anatomical relationships lead to disruptions in the direction
of aqueous humour flow
 The place of increased resistance may be located at the level of the
iris-lens, ciliary-lens, iris-hyaloid, and ciliary-hyaloid block
 Structures that are particularly related to the development of
malignant glaucoma and its clinical picture:
1. Sclera
2. Lens
3. Choroid
4. Vitreous body

13.  Sclera– a thick sclera may lead to partial stenosis of the vortex veins,
impairing normal venous outflow and causing overfilling of the
choroid
 Lens –Disproportions between its volume and the volume of the
entire eyeball
 Choroid – the choroid has a lobular structure with a tendency for
accumulation of blood and thickening when outflow is impaired.
 Secondary, ciliary body and iris rotate to the front in patients with
malignant glaucoma closing access to the filtration angle from the
back.

14.  Vitreous body –optically clear areas within the vitreous body –
reservoirs of aqueous humour trapped in its gel structure
 In aphakic eyes, the anterior surface of the vitreous body may directly
adhere to the ciliary processes
 Highly resistant anterior hyaloid membrane may be observed in
aphakic and pseudophakic eyes

15. Clinical Features
 Myopic shift - Anterior dislocation of the iris-lens diaphragm with secondary
improvement of near vision
 Narrowing or shallowing of the circumferential and central part of the
anterior chamber even if patent iridotomy or iridectomy is present.
 Persistent symptoms - Anterior adhesions due to the long-lasting shallowing
of the anterior chamber
 Increased IOP
 No decrease of IOP in response to conventional antiglaucoma treatment

17. Examination
 Medical history
1. Determination of predisposing factors
2. Symptoms
 Slit lamp examination
1. ACD - axial (central and peripheral) shallowing of the anterior chamber
2. Patency of the iridotomy
3. Seidel test should be performed to exclude filtering bleb leaking after
filtration surgery.
4. Posterior segment : Ruling out choroidal detachment or suprachoroidal
hemorrhage
 Tonometry – usually reveals increased IOP

20. DDx
 Glaucoma with pupillary block
 Closure of anterior chamber angle
 Laser peripheral iridotomy is the treatment of choice
 Unlike malignant glaucoma the anterior chamber usually remains
deeper in the center than on its circumference

21.  Angle closure glaucoma
 Shallowing of the anterior chamber occurs symmetrically
 Sudden increase in IOP
 Microcystic edema of the cornea
 Conjunctival injection

22. Choroidal effusion
 Cause:
1. inflammatory (trauma and intraocular surgery, scleritis, following
cryocoagulation and photocoagulation, chronic uveitis, Vogt-Koyanagi-
Harada disease)
2. Hydrostatic causes (hypotony and wound leak, dural arteriovenous
fistula, abnormally thick sclera in nanophthalmos)
 IOP may be normal but is often reduced in uveal effusion secondary to
inflammatory factors.

23. Abnormal
amounts of
fluid in the
choroid
Thickening of
the choroid
accumulation
of fluid in the
suprachoroid
space

24. Suprachoroidal hemorrhage
 Shallowing of the anterior chamber coexists with increased IOP, sudden pain,
and the presence of a haemorrhagic, non-serous detachment of the choroid in
biomicroscopic and ultrasonographic examination.
 It occurs most often within 1 week after surgery, rarely later
 may be also related to postoperative hypotony

25. Ultrabiomicroscopy (UBM)
 The rotation of the ciliary body to the front and shallowing of the
anterior chamber
 Marked displacement of the structures of the anterior segment
 Peripheral irido-corneal touch
 Forward shift of the lens may be noted

26. Treatment

27. Medical
 Cycloplegia
 Mydriatics (atropine and phenylephrine) should be given immediately in
order to tighten the lens zonules and pull the anteriorly displaced
lens backwards
 In some cases, Atropine is needed upto one year to avoid
recurrence.
 MIOTICS – CONTRAINDICATED promoting zonular relaxation
and encourage forward lens movement.
 Anti-Inflammatory Medication :
 Topical steroids can help to reduce inflammation

28.  Intraocular Pressure Reduction
 Oral acetazolamide and topical beta-blockers and alpha agonists are used
to reduce aqueous production.
 Reduction of Vitreous Volume.
 Osmotic agents (mannitol or glycerol) are used to reduce vitreous
volume, deepen the anterior chamber, and possibly increase vitreous
permeability

29. Laser
 AIM: to restore a normal aqueous flow pattern by establishing a direct
communication between the vitreous cavity and anterior chamber.
 Disruption of Anterior Hyaloid Face

30.  Laser of Ciliary Processes.
 The successful use of transscleral cyclodiode laser photocoagulation in
pseudophakic patients can help eliminate an abnormal vitreociliary
relationship by posterior rotation of the ciliary processes secondary to
coagulative shrinkage
 Often a single session of therapy is sufficient over 1-2 quadrants
 Cyclocryotherapy has been used in the past but no longer has a place
in modern management

31. Surgical
 The purpose of the vitrectomy is again to disrupt the anterior hyaloid
face and release fluid trapped within the vitreous
Anterior vitrectomy via pars
plana approach and/or in
combination with reformation
of the anterior chamber with
air +/- lens extraction
Iridectomy-hyaloido-zonulectomy
+ anterior
vitrectomy ( anteriorly via the
iridectomy or pars plana )
In phakic patients:
phacoemulsification-vitrectomy
(with zonulo-hyaloidectomy-
iridectomy)
In refractory cases:
Complete pars plana
vitrectomy along with lens
+removal of the entire hyaloid
face as well as creation of
vitrectomy tunnel

33. Conclusion
 Malignant glaucoma – Therapeutic challenge
 Patients with h/o MG in fellow and PACG should be closely followed
in after glaucoma filtration surgeries
 Good prognosis with current treatment modalities

34. Thank You