|Year : 1985 | Volume
| Issue : 5 | Page : 281-283
Aphakic malignant glaucoma
Ravi Thomas, TA Alexander, Sajan Thomas
Department of Ophthalmology, Christian Medical College, Vellore, India
Department of Ophthalmology, Christian Medical College, Vellore
|How to cite this article:|
Thomas R, Alexander T A, Thomas S. Aphakic malignant glaucoma. Indian J Ophthalmol 1985;33:281-3
Malignant glaucoma is a specific type of glaucoma that occurs most commonly as a complication of surgery for angle closure glaucoma. Aphakic malignant glaucoma is extremely rare, except where it follows lens extraction for the treatment of malignant glaucoma.
We describe our experience in the management of six cases of aphakic malignant glaucoma which occurred following routine cataract extraction.
| Case report|| |
The relevant data of six cases has been described in [Table - 1].
| Discussion|| |
Malignant Glaucoma is a serious complication occurring in 2-4% of eyes undergoing surgery for angle closure glaucoma. The glaucoma may persist after lens extraction but a true aphakic malignant glaucoma occurring after a routine cataract extraction is very rare,. Simmons has described the use of Chandler's procedure in 14 phakic and 12 aphakic cases. It was not clear whether the aphakic cases followed lens extraction for malignant glaucoma or occurred after routine cataract surgery. Meisekothen and Allen have described three cases of pupillary block glaucoma following lens extraction caused by aqueous pooling in the vitreous. Two cases were treated with what is essentially Chandler's procedure and one by incision of the anterior hyaloid. Since retrovitreal pooling of aqueous was present and the anterior chamber did not form with an iridectomy, the cases would be better described as aphakic malignant glaucoma.
Exact figures on the incidence of this condition do not seem to be available. Be that as it may, six cases of aphakic malignant glaucoma represented 0.03;0 of all the cases seen in our base hospital and 0.55% of all surgeries undertaken in one year.
The usual onset of aphakic malignant glaucoma is described at 2-5 days postoperatively. In our cases (as far as we could determine) the onset ranged from the second day to sixth week postoperatively.
More important and relevant to our conditions is the interval between onset of symptoms and the time the patient presented to us for treatment. This varied from two days to fortyfive days. The earliest interval was in the patient who developed aphakic malignant glaucoma while under observation in our camp (case 4). Even patients who were operated up on under hospital conditions (cases 3, 5 and 6) sought medical attention fourteen to fortyfive days following onset of symptoms.
All the patients in whom records were available (cases 3, 4, 5, 6) had hypermature senile cataract of the shrunken type. Also, the surgeon had noted that it was difficult to retain air in anterior chamber at the completion of surgery. Malignant glaucoma in phakic eyes undergoing surgery for angle closure glaucoma is usually a bilateral condition. Sugar' described a case of bilateral aphakic malignant glaucoma. Two of our patients had subsequent lens extraction in the fellow eye with no complications. The cataracts were advanced immature and the surgeon did not face the problem of retaining air in anterior chamber. We wonder whether diversion of aqueous was already occurring and causing this problem. Was the occurrence related to the state of shrunken hypermaturity ? It has been -postulated that an increase in the volume of the vitreous may cause the anterior hyaloid membrane to be pressed against pars plana of the ciliary body, occluding an area of hyaloid that would otherwise be free for forward passage of fluid. This may increase the resistance to forward flow through the vitreous body.
Could a subclinical reaction produced by the hypermature senile cataract cause a similar adhesion of the anterior hyaloid membrane to the pars plana, somehow predisposing these eyes to the development of malignant glaucoma? If such a mechanism can produce an increased vitreous resistance to fluid flow it could certainly help perpetuate the vicious cycle postulated by Quigley. However, the state of the lens may not be significant as a majority of our cataract patients do have a shrunken bypermature senile cataract and do not develop aphakic malignant glaucoma.
In all cases except one (case 3) we were successful with a Chandler's procedure. It is known that anterior chamber outflow resistance may not return to normal if the intraocular pressure is increased and then decreased,,. Clinically iridotrabecular contact can cause irreversible damage to the outflow resistance necessitating filtering surgery. Hence in case 6 due to the long duration of symptoms we combined Chandler's procedure with trabeculectomy. Also our patients are usually not available for regular follow ups and even if a simple procedure reforms the anterior chamber, damage to the trabecular meshwork may not be detected till it is too late. It is interesting that cyclodialysis has been combined with vitreous aspiration for malignant glaucoma in phakic cases.
We are clearly dealing with a situation most Western Ophthalmologists may not be confronted with, and have to design our surgery to suit patients, who will not seek medical help unless absolutely necessary, and even then will postpone it as long as possible. A recent reports described 3 cases of aphakic malignant glaucoma treated with laser to the ciliary process. Two cases were of long duration, and required cyclocryotherapy after the laser treatment. One case had had vitrectomy earlier. Another report described the successful use of the YAG laser in aphakic and pseudopbakic cases. We feel a trabeculectomy combined with Chandler's procedure is more suited for cases where damage to the trabecular meshwork is suspected.
Recently, we had occasion to combine vitrectomy with trabeculectomy in two cases with durations more than 2 weeks. The result has been satisfactory. Where vitrectomy instrumentation is not available, trabeculectomy with Chandler's procedure offers the best chances of success and is probably as effective.
| Summary|| |
Aphakic malignant glaucoma was diagnosed in 0.03% of all patients seen in our series. This complication occurred in 0.43% of cases undergoing lens extraction. The management in those cases as been described
| References|| |
|1.||Chandler, P. A., Simmons, R. J , and Grant, W. M., 1968, Amer J. Ophthalmel. 66: 495. |
|2.||Chandler, P. A., and Grant, W. M : Glaucoma, Henry Kimoton Publishers, London, Secord Ed., 1979, page 181. |
|3.||Richard J. Simmons, John V. Thomas. 1982. Malignant Glaucoma" in The Secondary Glaucomas by Robert Ritch and Bruce Sheilds, C. V. Mosby Co.. |
|4.||Simmons, R. J., : 1972. Malignant Glaucoma. Brit. J. Ophthalmol 56 : 263. |
|5.||Meisekothen, W. E•, Allen, J C., 1968, Amer J, Ophthalmol. 65 : 877. |
|6.||Sugar, S.H., 1972, Arch. Opbthalmol 87: 2041-351. |
|7.||Epstein, D. L., Hashimoto. J. M., Anderson, P. J. and Grant, W. M, 1979, Amer J. Ophthalmol. 88 : 1078. |
|8.||Quigley, H. A, 1980, Amer .J. Ophthalmol, 89 : 879. |
|9.||Ellingsen, B. A., and Grant W.M., 1971, Invest Ophthalmol. 10 :430 |
|10.||Moses, R, A., 1977, Surv. Ophthalmol 22:88 |
|11.||Nath, K., 1906, All India Ophthalmol Soc. 14 : 17. |
|12.||Webber, P. A.. Henry, M. A., Kapetansky, F. M. and Lohman. F. R., 1984, Amer J. Ophthalmol 97 : 82. |
|13.||David L. Epstein.. Roger F. Steinert and Carmen, 1984. Amer J. Ophtbalmol 98: 137. |
[Table - 1]