Malignant glaucoma diagnosis and management

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1 : Malignant glaucoma diagnosis and management Dr Diana Melinte Dumitrica SCUMC-Bucharest Romania Email:
2 : 1869 Von Graefe Malignanat glaucoma = clinical shallow anterior chamber associated with raised intraocular pressure in the presence of a patent periferic iridectomy for acute angle closure glaucoma
3 : Definition European Glaucoma Society; II edition Secondary angle closure glaucoma with ‘’posterior’’ pushing mechanism, without pupillary block, caused by the ciliary body and iris rotating forward Other terms: aqueous misdirection glaucoma ciliary block cilio-lenticular block malignant glaucoma posterior aqueous diversion syndrom
4 : Incidence 2-4% of eyes undergoing surgery for angle closure glaucoma; more frequently if the angle in closed before surgery may occur at any time following surgery Causes: after filtrating surgery in phakic angle closure eye: spontanous or at the cessation of cycloplegic treatment after cataract surgery at the begining of the miotic treatment after laser iridotomy laser capsulotomy Nd-Yag cyclophotocoagulation hypermetropia intravitrean triamcinolone central retinal vein occlusion inflammations,trauma
5 : Pathophysiology The exact mechanism remains unclear The misdirection of aqueous posterior towards the vitreous (either into or around) ? ? volume of the vitreous ? anterior pushing of irido-cristalinian diaphragm ? shallow of the anterior chamber + ? IOP Causes: shallow anterior chamber angle closure the increase of the volume of the cilliary body and the inflammation anterior rotation of the cilliary body anterior movement of the irido-cristalinian diaphragm by miotics
6 : Misdirection of the aqueous Posterior towards the vitreous Posterior and around the lens (perilenticular misdirection) Posterior of the iridocapsular diaphragm or IOL (retrocapsular misdirection)
7 : Diagnosis A patien with narrow angle / primary angle closure glaucoma / acute angle closure glaucoma following a filtration surgery ? VA Red eye with pain Malaise like in acut angle closure glaucoma Raised IOP (sometimes can be normal ) Accelerating factors: - the end of the cycloplegic treatment - the begining of the miotic treatment
8 : Slit-lamp examination Negative Seidel test Shallow anterior chamber central and periferic Anterior movement of irido-cristalinian diaphragm or anterior hialoid in phak eyes Patent periferic iridectomy No filtration bleb Clear spaces within the vitreous Positive Seidel test Malignant glaucoma
9 : Malignant glaucoma: cilio-lenticular block Malignant glaucoma: cilio-vitrean block
10 : Positive diagnosis Clinical examination The key = raiser IOP + shallow anterior chamber
11 : Investigationes Ultrasound A scan: axial length Ultrasound B scan: exclude other pathologies Ultrasound biomicroscoscopy
12 : Ultrasound biomicroscopy Confirm the diagnosis by the visualitation of the anterior segment structures: Irido-corneal touch Appositional angle closure Anterior rotation of the ciliary body Apposition to the iris
13 : Differential diagnosis Pupilary block Suprachoroidian hemoragie Choroidal effusion syndrom Pupillary block Malignant glaucoma
14 : Evolution Corneal decompensation by irido-cristalinian touch with endothelium damage Peripheral anterior synechies Posterior synechies Cataract Optic nerve damages by rised IOP Decrees of visual acuity
15 : Treatment Medical treatment – first step (good results in 50% of cases) - Cycloplegia with atropin 1%x 4-6/zi - Mydriasis with phenilephrin 2,5%x 4-6/zi Mechanism of action posterior push of the irido-cristalinian diaphragm cilliary muscles relaxation Long time treatment with atropin is required because of the recurences (sometime for several years) - ß blockers, AIC,a agonists - Hyperosmotics agents: Glicerol (po), Manitol (2g/kgcorp iv) !!! Miotics are contraindicated !!!
16 : Medical treatment Medical treatment has to be tried for 2-4 days with the observation of the evolution If everything is ok – no need of hypotensors Cyloplegia has to be for long periods of time
17 : Laser treatment Laser Argon throught periferic iridectomy - decrease the vlolume of cilliary body Laser Nd Yag – capsulotomy and/or anterior hialoidotomy
18 : Surgery Indication: no succes in medical or laser treatment corneo-cristalinian contact Pars plana vitrectomy ± lensectomy Lensectomy: - corneal oedema - dens cataract - no anterior chamber formation during vitrectomy Pseudophak: vitrectomy + anterior hialoidotomy Aspiration of the fluid from the vitreous with an 20 gauge needle
19 : The prognosis depends of the severity and the anterior situation Malignant glaucoma remains a most difficult clinical problem in terms of diagnosis and management The precise mechanism remains unclear and that why the management is controversial
20 : Bibliography M Yanoff, JS Duker – Ophthalmology (second edition) European Glaucoma Society – Terminology and guidelines for glaucoma (second edition) British Journal of Ophthalmology 1997;81:163-167 ‘’Malignant glaucoma and its management’’ S Ruben, J Tsai, R Hitchings JJ Kanski – Clinical Ophthalmology E-medicine 2007 ‘’Malignant glaucoma’’ Mauricio E Pons Benjamin F Boyd, Maurice Luntz, Samuel Boyd - Innovations in the glaucomas 2002 American Academy of Ophthalmology – Glaucoma (2005)


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