Glaucoma is a condition of the eye when the optic nerve of the eye becomes weak, usually because of a rise in pressure within the eye (Intraocular pressure). Malignant glaucoma is a rare condition when the pressure goes up because of a misdirection of aqueous humour within the eye.....
2. Mr. M., born in 1950
first seen by me in Sep 2006
He came for a change of glasses.
BCVA 6/6 N6 BE (+0.50 D hypermetropia)
Ultrasound Scan: Axial length (not taken at this
point. Checked later ) 22.4 mm : so, axially
shorter than normal.
IOP 30.5 BE; Angles narrow, occludable on
gonioscopy;
Cups : OD 0.7 ; OS 0.9
4. Yag PI done BE
Angles opened
IOP remained high
Latanoprost and betaxalol drops
Dorzolamide drops were added in Feb 2007
5. Mr. M. with a combined
mechanism glaucoma
on 3 drops; IOP still 20
Trabeculectomy RE done on 21 July 2008
6. Trab done 21 July 2008
Immediate postop : AC formed and IOP 9 in
RE by appln. Put on antibiotic-steroid drops.
5 Aug 08: Appln: 20
Releasable apical suture removed – IOP 18--
16
7 Sep 08:VR surgeon saw : posterior segment
stable.
7. Mr. M. who had Trab RE on 21
july 2008:
All well: 6/9 BE; IOP 16 RE without any drops
6 Oct 08 : Dim vision (3/60)
flat AC; uniformly flat all around the AC; IOP
26 appln. PI patent.
Fundus normal
8. Treated with atropine drps QID,Tropicamide
with phenylephrine, tab acetazolamide, pad
and bandage.
Next day AC was formed.
9.
10. When atropine was tapered in 2 weeks AC
became shallow.
AC Became OK when atropine drops was
given QID
11. Malignant glaucoma
Feb. 2009: stopped atropine. AC became flat
again.
Since then he was kept on Atropine at least
once in 3 weeks.
12. AC & IOP were normal with
Atropine
But he was unhappy with:
- inconvenience of dilation
- need for constant supervision
- slow development of cataract
- gradual deterioration of vision ( 6/24 )
b/o cataract
13. April 2012: (BCVA 6/24: IC) temporal MSICS
IOLI was done:
SINCETHENTHERE HAS BEEN NO
RECURRENCE OF SHALLOWING OF AC OR
RISE IN IOP INTHE RE (NO DROPS
WHATSOEVER)
14. The other eye…..
LE: Since the beginning he is on 3
antiglaucoma drugs . He has been reticent for
any surgery for LE
Over the years there has been slight
worsening of fields in BE.
15. A Combined mechanism glaucoma
pt : developed Malignant
Glaucoma 3 mths after Trab.
Medical management was successful as long
he was on atropine.
MSICS IOLI seems to have cured it . 4.5 years
follow up.
16.
17. MALIGNANT GLAUCOMA
Coined byVon Grafe in 1869 to describe
an aggressive type of glaucoma
resistant to treatment
resulted in blindness
19. Malignant Glaucoma
Typically happens after a filtration surgery for
ACG
But it can also happen after
filtration surg for POAG, Pseudo exfoliation
glaucoma
cataract surgery
large optic (7 mm) IOLI
Yag PI, etc
High IOP at the time of surg does not seem to
increase the chances of occurrence
20. Malignant Glaucoma
Uniform shallowing / flattenning of AC
Patent PI
IOP high (initially may be normal)
Onset immediately after the procedure or
months later
May be ppted by cessation of cycloplegics or
starting pilocarpine.
22. Pathophysiology
Not well understood
Abnormal relationship betweenVitr face,
Ciliary body and lens equator
Causes the aqueous to flow intoVitr cavity
Causes forward movement of lens iris
diaphragm and antr hyloid face.
Results in complete closure of angles
23. Medical treatment
Cycloplegics (tighten zonules and pull lens
backwards)
Mydriatics (stimulate the longitudinal fibres
of ciliary muscle and tighten zonules)
Acetazolamide (decreases aq production)
Hyperosmotic agents (decreases vitr volume)
Topical drops to reduce IOP
24. Interventional
NdYag Laser hyloidotomy through an
iridectomy : in pseudophakic cases, beyond
the haptic of IOL
Vitr puncture 4 mm behind the limbus and
aspiration
Vitrectomy with or without lensectomy
PP vitrectomy with an aqueous shunt
25. Argon laser transpupillary (or thru PI )
shrinkage of ciliary processes
Transcleral Cyclophotocoagulation for
refractory cases (Coagulative necrosis and
shrinkage of ciliary processes disrupts the
ciliaryV,face interface)
26. In the case presented
A simple cataract extraction with PC IOLI
seems to have cured Malignant Glaucoma.
4.5 years follow up after cat surg: (total 10 yrs
follow up)
27. Conclusion
In selected cases, Cataract surgery with IOLI
alone could be kept as an option for
treatment for Malignant Glaucoma.
More aggressive procedures can be taken up
if there is no relief.