Treatment Outcomes in Malignant Glaucoma

Published:January 31, 2013DOI:https://doi.org/10.1016/j.ophtha.2012.10.024

      Purpose

      To report treatment outcomes in malignant glaucoma.

      Design

      Retrospective case series.

      Participants

      Twenty-eight eyes of 26 patients who were treated for malignant glaucoma between 1991 and 2009.

      Methods

      Malignant glaucoma was diagnosed based on the presence of a shallow or flat central and peripheral anterior chamber in the presence of patent iridotomy, with intraocular pressure (IOP) of 22 mmHg or more after any intraocular surgery. The treatment algorithm included antiglaucoma medications and cycloplegics as first-line methods; the second-line therapy in pseudophakic eyes was laser hyaloidotomy, followed by vitrectomy-hyaloidotomy-iridectomy (VHI) or transscleral cyclophotocoagulation (TSCPC).

      Main Outcome Measures

      Resolution was defined as deepening of the central anterior chamber and IOP of 21 mmHg or less (on 2 successive follow-ups at least 1 week apart) with or without topical antiglaucoma medications in the absence of systemic antiglaucoma medications.

      Results

      At the diagnosis of malignant glaucoma, 5 eyes were phakic and 23 were pseudophakic. The preceding surgeries were trabeculectomy (11 eyes), cataract surgery (10 eyes), and combined cataract and glaucoma surgery (7 eyes). Mean IOP decreased from 34±8.3 mmHg at presentation to 14.3±5.2 mmHg at the last visit ( P<0.001). Resolution of malignant glaucoma was seen in 27 eyes (27/28; 96%), 17 eyes resolved with 1 intervention, and 10 eyes required repeat procedures. Of the 27 eyes whose disease resolved, this result was achieved in 4 eyes with medical treatment, in 7 pseudophakic eyes with laser hyaloidotomy, in 4 eyes with VHI, and in 12 eyes with TSCPC. The median duration of follow-up was 192 days (interquartile range, 35–425 days). There was no difference in the visual acuity at presentation and at the final visit in 14 eyes. Eight eyes gained 2 lines or more and 6 eyes lost 2 lines or more of visual acuity.

      Conclusions

      Malignant glaucoma can be managed successfully by appropriate and timely interventions. Medical treatment was beneficial in phakic eyes, laser hyaloidotomy was beneficial in pseudophakic eyes, and vitrectomy and TSCPC were beneficial in refractory cases. A stepladder approach to treatment was successful (96%) in this series.

      Financial Disclosure(s)

      The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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      References

        • von Graefe A.
        Beitrage zur pathologie und therapie des glaucoms.
        Arch fur Ophthalmol. 1869; 15: 108-252
        • Chandler P.A.
        • Simmons R.J.
        • Grant W.M.
        Malignant glaucoma: medical and surgical treatment.
        Am J Ophthalmol. 1968; 66: 495-502
        • Simmons R.J.
        Malignant glaucoma.
        Br J Ophthalmol. 1972; 56: 263-272
        • Tomey K.F.
        • Traverso C.E.
        The glaucomas in aphakia and pseudophakia.
        Surv Ophthalmol. 1991; 36: 79-112
        • Lippas J.
        Mechanics and treatment of malignant glaucoma and the problem of a flat anterior chamber.
        Am J Ophthalmol. 1964; 57: 620-627
        • Tomey K.F.
        • Senft S.H.
        • Antonios S.R.
        • et al.
        Aqueous misdirection and flat chamber after posterior chamber implants with and without trabeculectomy.
        Arch Ophthalmol. 1987; 105: 770-773
        • Duy T.P.
        • Wollensak J.
        Ciliary block (malignant) glaucoma following posterior chamber lens implantation.
        Ophthalmic Surg. 1987; 18: 741-744
        • Reed J.E.
        • Thomas J.V.
        • Lytle R.A.
        • Simmons R.J.
        Malignant glaucoma induced by an intraocular lens.
        Ophthalmic Surg. 1990; 21: 177-180
        • Rieser J.C.
        • Schwartz B.
        Miotic-induced malignant glaucoma.
        Arch Ophthalmol. 1972; 87: 706-712
        • Cashwell L.F.
        • Martin T.J.
        Malignant glaucoma after laser iridotomy.
        Ophthalmology. 1992; 99: 651-658
        • Mastropasqua L.
        • Ciancaglini M.
        • Carpineto P.
        • et al.
        Aqueous misdirection syndrome: a complication of neodymium:YAG posterior capsulotomy.
        J Cataract Refract Surg. 1994; 20: 563-565
        • Hardten D.R.
        • Brown J.D.
        Malignant glaucoma after Nd:YAG cyclophotocoagulation [letter].
        Am J Ophthalmol. 1991; 111: 245-247
        • Mathur R.
        • Gazzard G.
        • Oen F.
        Malignant glaucoma following needling of a trabeculectomy bleb [letter].
        Eye (Lond). 2002; 16: 667-668
        • Jones B.R.
        Principles in the management of oculomycosis.
        Am J Ophthalmol. 1975; 79: 719-751
        • Lass J.H.
        • Thoft R.A.
        • Bellows A.R.
        • Slansky H.H.
        Exogenous Nocardia asteroides endophthalmitis associated with malignant glaucoma.
        Ann Ophthalmol. 1981; 13: 317-321
        • Weiss I.S.
        • Deiter P.D.
        Malignant glaucoma syndrome following retinal detachment surgery.
        Ann Ophthalmol. 1974; 6: 1099-1104
        • Kushner B.J.
        Ciliary block glaucoma in retinopathy of prematurity.
        Arch Ophthalmol. 1982; 100: 1078-1079
        • Jacoby B.
        • Reed J.W.
        • Cashwell L.F.
        Malignant glaucoma in a patient with Down's syndrome and corneal hydrops.
        Am J Ophthalmol. 1990; 100: 434-435
        • Schwartz A.L.
        • Anderson D.R.
        “Malignant glaucoma” in an eye with no antecedent operation or miotics.
        Arch Ophthalmol. 1975; 93: 379-381
        • Simmons R.J.
        • Belcher C.D.
        • Dallow R.L.
        Primary angle-closure glaucoma.
        in: Tasman W. Jaeger E.A. Duane's Clinical Ophthalmology. Vol 3. Lippincott, Philadelphia1985: 23-31
        • Luntz M.H.
        • Rosenblatt M.
        Malignant glaucoma.
        Surv Ophthalmol. 1987; 32: 73-93
        • Epstein D.L.
        • Steinert R.F.
        • Puliafito C.A.
        Neodymium–YAG laser therapy to the anterior hyaloid in aphakic malignant (ciliovitreal block) glaucoma.
        Am J Ophthalmol. 1984; 98: 137-143
        • Lin S.
        Endoscopic and transscleral cyclophotocoagulation for the treatment of refractory glaucoma.
        J Glaucoma. 2008; 17: 238-247
        • Lynch M.G.
        • Brown R.H.
        • Michels R.G.
        • et al.
        Surgical vitrectomy for pseudophakic malignant glaucoma.
        Am J Ophthalmol. 1986; 102: 149-153
        • Weiss H.
        • Shin D.H.
        • Kollarits C.R.
        Vitrectomy for malignant (ciliary block) glaucomas.
        Int Ophthalmol Clin. 1981; 21: 113-119
        • Byrnes G.A.
        • Leen M.M.
        • Wong T.P.
        • Benson W.E.
        Vitrectomy for ciliary block (malignant) glaucoma.
        Ophthalmology. 1995; 102: 1308-1311
        • Chandler P.A.
        Malignant glaucoma.
        Am J Ophthalmol. 1951; 34: 993-1000
        • Lois N.
        • Wong D.
        • Groenewald C.
        New surgical approach in the management of pseudophakic malignant glaucoma.
        Ophthalmology. 2001; 108: 780-783
        • Sharma S.
        • Sii F.
        • Shah P.
        • Kirkby G.R.
        Vitrectomy–phacoemulsification–vitrectomy for the management of aqueous misdirection syndromes in phakic eyes.
        Ophthalmology. 2006; 113: 1968-1973
        • Azuara-Blanco A.
        • Katz L.J.
        • Gandham S.B.
        • Spaeth G.L.
        Pars plana tube insertion of aqueous shunt with vitrectomy in malignant glaucoma [letter].
        Arch Ophthalmol. 1998; 116: 808-810
        • Debrouwere V.
        • Stalmans P.
        • van Calster J.
        • et al.
        Outcomes of different management options for malignant glaucoma: a retrospective study.
        Graefes Arch Clin Exp Ophthalmol. 2012; 250: 131-141
        • Quigley H.A.
        • Friedman D.S.
        • Congdon N.G.
        Possible mechanisms of primary angle-closure and malignant glaucoma.
        J Glaucoma. 2003; 12: 167-180
        • Mackool R.J.
        • Sirota M.
        Infusion misdirection syndrome [letter].
        J Cataract Refract Surg. 1993; 19: 671-672
        • Epstein D.L.
        • Hashimoto J.M.
        • Anderson P.J.
        • Grant W.M.
        Experimental perfusions through the anterior and vitreous chambers with possible relationships to malignant glaucoma.
        Am J Ophthalmol. 1979; 88: 1078-1086
        • Muqit M.K.
        • Menage M.J.
        Malignant glaucoma after phacoemulsification: treatment with diode laser cyclophotocoagulation.
        J Cataract Refract Surg. 2007; 33: 130-132
        • Carassa R.G.
        • Bettin P.
        • Fiori M.
        • Brancato R.
        Treatment of malignant glaucoma with contact transscleral cyclophotocoagulation.
        Arch Ophthalmol. 1999; 117: 688-690
        • Sengupta R.
        • Austin M.
        • Morgan J.
        Treatment of aqueous misdirection by trans-scleral diode laser photocoagulation [letter].
        Eye (Lond). 2000; 14: 808-810
        • Reed J.E.
        • Thomas J.V.
        • Lytle R.A.
        • Simmons R.J.
        Malignant glaucoma induced by an intraocular lens.
        Ophthalmic Surg. 1990; 21: 177-180