|Year : 1965 | Volume
| Issue : 4 | Page : 158-160
Bilateral malignant glaucoma
Department of Ophthalmology, King George's Medical College, Lucknow, India
|Date of Web Publication||25-Feb-2008|
K K Bisaria
Department of Ophthalmology, King George's Medical College, Lucknow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bisaria K K. Bilateral malignant glaucoma. Indian J Ophthalmol 1965;13:158-60
The term malignant glaucoma was originally used by Von Graefe (1869) who described the syndrome as "a new acute glaucomatous process brought about by the surgery, and which is unusual only in the continued failure of the anterior chamber to form". Chandler himself described the condition as "a form of postoperative glaucoma in which after any anterior operation for glaucoma, the anterior chamber remains, or soon becomes flat and the tension rises. It apparently occurs in approximately two percent of the cases and is seen in eyes with a shallow anterior chamber and an elevated tension at the time of operation". This acute crisis of raised tension is associated with forward movement of the iris-lens diaphragm which according to Chandler and Grant (1962) is due to an increased vitreous pressure and to an abnormal slackness of the zonules of the lens. Chandler points out the forward displacement of a relatively large lens as an essential feature. Further characteristics of this condition is the propensity of the other eye to follow an identical course when subjected to an anterior chamber glaucoma operation. Recent literature describes few cases of bilateral malignant glaucoma (Cross 1959, Posner 1961, Lippas 1964, Hoshiwara 1964).
This communication describes another case where simultaneous malignant glaucoma occured after one year of glaucoma surgery with good response in one eye by surgical and in the other by medical treatment.
| Report of Case|| |
A woman aged 68 years first presented herself with complaints of headache and blaring of vision in both the eyes during the last few months. There was history of haloes.
| Examination|| |
The visual acuity in the right eye was 6/12 and left 6/36. The anterior chambers were shallow and pupils were semidilated with minimal reaction to light. The intra ocular pressure was 45 mm. of Hg. in the right and 30 mm. of Hg. in the left eye. The case was diagnosed as chronic congestive glaucoma.
| Treatment|| |
1% pilocarpine nitrate drops with Diamox 250 mgm 1 tablet twice daily was given. After four days the tension recorded in the right eye was 40 mm. of Hg. and left eye 28 mm. of Hg. So surgery was resorted to. In the right eye corneoscleral trepanation and in the left eye Holth's iridencleisis were performed at the same sitting.
Two weeks later, although the intra ocular pressure in both the eyes came to normal, the anterior chambers were slightly shallow. She was advised to continue 1% Pilocarpine Nitrate drops in both the eyes for some time.
The patient thereafter was never seen till a year elapsed when she came with the history of marked diminution of vision with pain in and around the left eye for the last one day and in the right for 3 days.
| Examination|| |
Cornea of both the eyes were steamy and the anterior chambers were non-existent. The filtering bleb of corneoscleral trephining in the right eye showed prolapsed iris which had undergone atrophic changes [Figure - 1]. The left eye showed the iridencleisis pillar to be atrophied and absence of the filtering bleb. There was mild ciliary flush in both the eyes. Both pupils were semi dilated and non-responsive to light. The intraocular pressure was 50 mm. of Hg. in the right and 35 mm. in the left. A diagnosis of bilateral malignant glaucoma was made.
| Treatment|| |
Diamox 250 mgm. 1 Tablet thrice daily with a combined therapy of pilocarpine 1% and Atropine 1% was instituted in the right eye only.
After five days, the anterior chamber reformed slightly in the right but remained collapsed in the left eye. The tension curiously enough was lower in the right eye.
Considering the collapsed anterior chamber with a little higher tension in the left eye, the conventional surgical treatment of lens extraction was performed. After delivery of lens, the nasal free portion of iris was incarcerated in the wound, thus performing a second iridencleisis nasally [Figure - 2].
After six clays the anterior chamber was found to be deep in the left eye with normal tension. The right eye was kept on continued administration of miotic-mydriatic treatment with satisfactory results.
| Discussion|| |
The reported case presented several features of malignant glaucoma. It is frequently a bilateral condition. The long latent period of one year following glaucoma surgery is rare. Usually the attacks occur in the immediate postoperative period. Chandler and Grant (1962) described a case where malignant glaucoma developed after 38 days of surgery and in one case nine months later while Hoshiwara (1964) reported a case where this condition occured after three years of the initial glaucoma surgery.
The surgical treatment of malignant glaucoma has been employed differently. It consists of lens extraction (Chandler 1951) combined with discision of the anterior vitreous face (Shaffer 1954), posterior sclerotomy combined with air injection into the anterior chamber (Birge 1956), a combination of cyclodialysis, posterior sclerotomy, vitreous evacuation along with introduction of air into the anterior chamber (Cross 1959), retrolental decompression with transplanal drainage (Scott and Smith 1961).
The medical treatment has been more recently advocated. Weiss et al (1963) have reported favourable results in three cases by the use of intravenous hypertonic mannitol. Frezzotti and Gentili (1964) concluded from their series of cases that urea and mydriatic by themselves were unable to relieve this condition but, when used in combination they produced better responses. The mydriatic-cycloplegic treatment has been used by Chandler and Grant (1962). The use of miotics has been questionable but Hoshiwara (1964) instituted both pilocarpine and atropine at the same time in an eye and commented on this regime as "This combination would seem illogical pharmacologically, however, the explanation may be that the action of pilocarpine in increasing the aqueous outflow is a direct action upon the trabecular meshwork, independent of its action upon the sphincter muscle (Becker and Shaffer 1961), whereas the action of atropine is to cause the zonules to become taut allowing the lens iris diaphragm to drop back away from the angle (Chandler and Grant 1962)".
In this condition, although the extraction of a clear lens may be unavoidable in some cases, here lens extraction of the left eye, having incidently immature cataract along with a second iredencleisis was performed more logically. The right eye was treated medcally by the combined instillations of pilocarpine and atropine. The responses in both the cases were satisfactory.
We believe that since most of the patients are conscious of using pilocarpine for the treatment of glaucoma, its use apart from pharmacologic effect as pointed out by Hoshiwara will be beneficial in avoiding an emotional trauma caused by its cessation. The role of emotional factor has been described to be one of the important features in pathomechanism of this condition and hence such prophylactic measures should be considered as the best form of treatment.
| Summary|| |
A case of bilateral malignant glaucoma in a 68 years old woman is reported. The points of interest in this case are (1) its rarity. (2) bilaterality (3) A long interval between its development and glaucoma surgery. (4) Favourable response of one eye to surgical and that of the other to medical management.
| References|| |
Von Graefe, A., (1869) Graefe Arch. Ophthal. 15, 108, as cited by Chandler in 5.
Becker, B., and Shaffer, R. N., (1961) Diagnosis and therapy of glaucomas, P. 215, The C. V. Mosby company St. Louis.
Birge, H. L., (1956) Trans. Amer. Ophthal. Soc. 54, 311.
Chandler, P. A., (1951) Amer. J. Ophthal. 34, 993.
Chandler, P. A. and Grant, M. W., (1962) Arch. Ophthal. 68, 353.
Cross, A. G., (1959) Brit. J. Ophthal. 43, 57.
Frezzotti, R., and Gentili, M. C., (1964) Amer. J. Ophthal. 57, 402.
Hoshiwara, I., (1964) Arch. Ophthal 72, 601.
Lippas, J., (1964) Amer. J. Ophthal. 57, 620.
Posner, A., (1961) Eye Ear Nose Throat Monthly, 40, 203.
Scott, A. S., and Smith, V. H., (1961) Brit. J. Ophthal. 45, 654.
Shaffer, R. N., (1954) Trans. Amer. Acad. Ophthal. otolaryng. 58, 217.
Weiss, D. I., Shaffer, R. N., and Harrington, D. O., (1963) A.M.A. Arch. of Ophthal 69, 154.
[Figure - 1], [Figure - 2]