Classic malignant glaucoma is a rare complication of incisional surgery for angle-closure glaucoma where the anterior chamber shallows due to forward movement of the iris-lens diaphragm despite increased intraocular pressure. It can occur in eyes with or without glaucoma and may be triggered by laser treatment, miotics, or trabeculectomy. Treatment involves reducing pressure and vitreous volume medically or surgically with vitrectomy. Definitive management is phacoemulsification, intraocular lens implantation, and removal of the posterior capsule during vitrectomy.

2. 1869 Von Graefe
 Malignanat glaucoma =shallowing of the central (axial)
anterior chamber in association with increased intraocular
pressure (IOP) and normal posterior segment anatomy
 Classical
malignant glaucoma is reported to occur in 0.4–
6% cases of incisional surgery for primary angle-closure
glaucoma

3. Classification
 Classic malignant glaucoma
: ①rare Cx of incisional surgery for primary angle closure glaucoma
②partial or total closure of the drainage at the time & axial
hypermetropia is associated with increased risk
 Nonphakic malignant glaucoma
: can occur in eye with or without glaucoma
 Other malignant glaucoma syndromes
: laser Tx, use of miotics , trabeculectomy bleb needling

4. Symptom
 The first symptom is often an improvement in near vision
secondary to a myopic shift in refraction as the lens iris
diaphragm moves forward.
 In most eyes the IOP >21mmHg,
In some eyes the IOP≤ 21mmHg
 Pain ,inflammation ,corneal oedema

5. mechanism(1)
 Multifactorial condition
:Occur in anatomically predisposed eyes
 Alteration in the anatomic relationship of the lens, ciliary
body,anterior hyaloid face,and vitreous→ forward
movement of the iris-lens diaphragm
 Exact mechanism remains unclear

6. mechanism(2-1)
(1) Shaffer & Hoskins
①Posterior diversion of aqueous flow → accumulation of
aqueous behind a posterior vitreous detachment
→forward movement of the iris-lens diaphragm
②valve-like mechanism by which aqueous humour
was“misdirected”posteriorly.
③Cause the posterior diversion of aqueous and
the nature of the unidirectional valve remain unclear.

7. mechanism(2-2)
 The mechanisms leading to the posterior diversion of
aqueous
(1) Ciliolenticular (Ciliovitreal) Block

8. mechanism(2-3)
(2) Anterior Hyaloid Obstruction
 The anterior hyaloid →Ciliolenticular block
 Breaks in the hyaloid near the vitreous base → Posterior
diversion of aqueous

9. mechanism(3)
(2) Chandler
①Laxity of lens zonules coupled with pressure
from the vitreous leads to forward lens
movement.
②the higher the pressure in the posterior segment
→ the more firmly the lens is held forward

10. mechanism(4)
(3) Quigley
① Precipitating event which increases vitreous pressure is
choroidal expansion
② The initial compensatory outflow of aqueous along the
posteroanterior pressure gradient → shallowing of the
anterior chamber

11. mechanism(5)
(4) Final Common pathway
 The transvitreal pressure cannot be equalised by outflow
of aqueous humour.
 The anterior vitreous gel becomes less permeable to the
forward movement of gel.
 Fluid buildup behind the vitreous → vitreous condensation
→ exerts a forward force→ anterior displacement of the
lens-iris diaphragm

13. Treatment(1)
 Medical Therapy
(1) Cycloplegia: tighten the lens zonules & pull the anteriorly
displaced lens backwards
 Use for long periods of time
★ The use of miotics are contraindicated
(2) Intraocular Pressure Reduction: Oral acetazolamide
topical beta-blockers & alpha agonists
(3) Reduction of Vitreous Volume: Osmotic agents
(4) Anti-Inflammatory Medication: Topical steroids (reduce
inflammation )

15. Treatment(2)
 Laser Therapy
(1) Restore a normal aqueous flow pattern by establishing a
direct communication between the vitreous cavity and
anterior chamber
(2) Disruption of Anterior Hyaloid Face:
 Intact hyaloid face -pathogenic factor in malignant glaucoma
 Nd:YAG laser capsulotomy with disruption of the anterior
hyaloid face is often effective

16. Treatment(3)
(3) Laser of Ciliary Processes
 Transscleral cyclodiode laser photocoagulation in
pseudophakic patients → posterior rotation of the ciliary
processes secondary to coagulative shrinkage → eliminate
an abnormal vitreociliary relationship
 An alternative option : direct argon laser treatment of the
ciliary processes through a peripheral iridotomy

18. Treatment(4)
 Surgical Therapy
(1) Increase aqueous flow into the anterior chamber
: vitreous aspiration through an 18-guage needle via an incision
through the pars plana by Chandler→ pars plana vitrectomy
(2) Core vitrectomy surgery
:resolution of malignant glaucoma in 25–50% of the phakic
eyes vs 65–90% in pseudophakic eyes
(3)Cataract extraction+ vitrectomy in phakic eyes →increase
from 25% to 83% if the posterior capsule is removed

19. Treatment(5)
★Definitive management
: Phacoemulsification+Intraocular lens implantation +Removal
of the posterior capsule at time of vitrectomy
 A staged surgical approach:
Debulk the vitreous, soften the eye, and deepen the anterior
chamber by core vitrectomy→ Phacoemulsification
+intraocular lens implantation → Residual vitrectomy &
hyaloidectomy with removal of the retrolental posterior
capsule

20. Treatment(6)
 Management of the Fellow Eye
(1) High risk of this complication occurring in the
fellow eye after a surgical intervention
(2) Prophylactic measures
 Cessation of miotic drops
 Prolonged use of atropine after trabeculectomy
 Avoidance of anterior chamber shallowing in the
postoperative period (using anterior chamber
viscoelastic and tight scleral flap suturing)