Malignant glaucoma is a rare kind of glaucoma presumably due to a misdirection of aqueous humour within the eye....

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

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

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

28. THANK YOU