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MALIGNANT GLAUCOMA
Dr. Philip Kuruvilla
Aradhana Eye Institute
Trivandrum, Kerala,
INDIA
www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com
HFA: Had FD in BE; worse in
left.
Yag PI done BE
 Angles opened
 IOP remained high
 Latanoprost and betaxalol drops
 Dorzolamide drops were added in Feb 2007
 www.aradhanaeyecare.com
Mr. M. with a combined
mechanism glaucoma
on 3 drops; IOP still 20
 Trabeculectomy RE done on 21 July 2008
 www.aradhanaeyecare.com
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.
 www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com
 Treated with atropine drps QID,Tropicamide
with phenylephrine, tab acetazolamide, pad
and bandage.
 Next day AC was formed.
 www.aradhanaeyecare.com
 When atropine was tapered in 2 weeks AC
became shallow.
 AC Became OK when atropine drops was
given QID
 www.aradhanaeyecare.com
Malignant glaucoma
Feb. 2009: stopped atropine. AC became flat
again.
 Since then he was kept on Atropine at least
once in 3 weeks.
 www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com
 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)
 www.aradhanaeyecare.com
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.
 www.aradhanaeyecare.com
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.
 www.aradhanaeyecare.com
MALIGNANT GLAUCOMA
 Coined byVon Grafe in 1869 to describe
 an aggressive type of glaucoma
 resistant to treatment
 resulted in blindness
 www.aradhanaeyecare.com
Other names
 Ciliary block glaucoma
 Aqueous misdirection
 Direct lens block
 www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com

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.
 www.aradhanaeyecare.com
Malignant Glaucoma
 Vitr face bowing forwards
 Optically clear areas inVitreous
 Angles closed
 www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com
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
www.aradhanaeyecare.com
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
 www.aradhanaeyecare.com
 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)
 www.aradhanaeyecare.com
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)
 www.aradhanaeyecare.com
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.
 www.aradhanaeyecare.com
THANK YOU

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Malignant glaucoma

  • 1. MALIGNANT GLAUCOMA Dr. Philip Kuruvilla Aradhana Eye Institute Trivandrum, Kerala, INDIA www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com
  • 3. HFA: Had FD in BE; worse in left.
  • 4. Yag PI done BE  Angles opened  IOP remained high  Latanoprost and betaxalol drops  Dorzolamide drops were added in Feb 2007  www.aradhanaeyecare.com
  • 5. Mr. M. with a combined mechanism glaucoma on 3 drops; IOP still 20  Trabeculectomy RE done on 21 July 2008  www.aradhanaeyecare.com
  • 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.  www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com
  • 8.  Treated with atropine drps QID,Tropicamide with phenylephrine, tab acetazolamide, pad and bandage.  Next day AC was formed.  www.aradhanaeyecare.com
  • 9.
  • 10.  When atropine was tapered in 2 weeks AC became shallow.  AC Became OK when atropine drops was given QID  www.aradhanaeyecare.com
  • 11. Malignant glaucoma Feb. 2009: stopped atropine. AC became flat again.  Since then he was kept on Atropine at least once in 3 weeks.  www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com
  • 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)  www.aradhanaeyecare.com
  • 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.  www.aradhanaeyecare.com
  • 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.  www.aradhanaeyecare.com
  • 16.
  • 17. MALIGNANT GLAUCOMA  Coined byVon Grafe in 1869 to describe  an aggressive type of glaucoma  resistant to treatment  resulted in blindness  www.aradhanaeyecare.com
  • 18. Other names  Ciliary block glaucoma  Aqueous misdirection  Direct lens block  www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com 
  • 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.  www.aradhanaeyecare.com
  • 21. Malignant Glaucoma  Vitr face bowing forwards  Optically clear areas inVitreous  Angles closed  www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com
  • 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 www.aradhanaeyecare.com
  • 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  www.aradhanaeyecare.com
  • 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)  www.aradhanaeyecare.com
  • 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)  www.aradhanaeyecare.com
  • 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.  www.aradhanaeyecare.com