Year : 1985 | Volume
: 33 | Issue : 4 | Page : 245--247
Congenital glaucoma with neovascularisation of iris managed by a new silicone drainage implant
TA Alexander, Ravi Thomas
Department of Ophthalmology, Christian Medical College Vellore, India
T A Alexander
Department of Ophtalmoloy, Christian Medical College Vellore
|How to cite this article:|
Alexander T A, Thomas R. Congenital glaucoma with neovascularisation of iris managed by a new silicone drainage implant.Indian J Ophthalmol 1985;33:245-247
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Alexander T A, Thomas R. Congenital glaucoma with neovascularisation of iris managed by a new silicone drainage implant. Indian J Ophthalmol [serial online] 1985 [cited 2021 Jun 21 ];33:245-247
Available from: https://www.ijo.in/text.asp?1985/33/4/245/30801
Congenital glaucomas are usually characterised by photophobia, watering, diffuse haziness of cornea, enlargement of cornea, raised intraocular pressure and cupping of the discs. Vascularization of iris associated with congenital glaucomas have not been reported to the best of our knowledge. Vessels can be seen on the iris in association with conditions like retro-lental fibroplasia, persistent primary hyperplastic vitreous, Sturge.Weber's syndrome and heterochromic iridocyclitis.
In this article we are reporting a case of congenital glaucoma with neovascularization of the iris which was managed by a new type of drainage implant.
A five day old baby boy presented with history of watering from the left eye since birth. The child was born to non consanguineous parents in a hospital and was normal full term. The antenatal and labour history did not reveal anything significant. General examination did not show any abnormality. On examination of the eye the lids and lacrimal systems were normal. The left cornea was large and was diffusely hazy. Under the slit lamp there was frank neovascularization of the right iris. New vessels were present at the pupillary border and irregularly on the surface of the iris extending on to the angle. The digital tension recorded was very high. A detailed examination was carried out under general anaesthesia the next day. The diameter of right cornea was 11.5 mm as compared to 10 mm in the left eye. The intraocular tension recorded by Perkins hand held applanation tonometer was 45 mm Hg. in the right eye and 16 mm Hg. in the left eye. A drop of glycerin was instilled on the cornea and gonioscopy was done with Koeppe's lens and this confirmed the presence of the new vessels in the angle. The new vessels were associated with a very thin fibrous membrane. The fundus did not show any abnormal vessels or any signs of choroidal haemangioma. To rule out an intraocular malignancy an anterior chamber tap was done using a 27 gauge needle. The tapped fluid was found to be xanthochromic. Subsequent investigations carried out were (1) x-ray orbit, skull and optic foramina-all were within normal limits (2) aqueous tap was negative for malignant cells (pap stain).
A fluorescein angioscopy was performed a few days later under general anaesthesia and this also did not reveal the presence of any choroidal haemangioma or any vascular abnormality in the peripheral retina. This was followed by implantation of the newly designed silicone drainage implant to control the intraocular tension. [Figure 1]
A 180° peritomy was done in upper half and the two recti muscles, the superior rectus and the medial rectus muscles were isolated. Black silk sutures were passed under the medial rectus and superior rectus, The 20 implant was sutured to the surface of the sclera with 5-0 Merselene sutures. The sutures tied just enough to hold the implant on the surface of the sclera. A large partial thickness scleral flap 6 mm in breadth was fashioned and this flap extended posteriorly for about 7.8 mm, from the limbus [Figure 2]. A slanting entry was made into the anterior chamber, and the end of the silicone tube was placed about 3 mm into the anterior chamber. The partial thickness flap was sutured back using 8-0 monofilament. The black silk sutures of the muscles were cut and the conjunctiva was brought forward and anchored at the limbus. Subconjunctival Gentamycin was given.
Postoperatively the anterior chamber remained very shallow for 4 days. The rubeosis iridis started showing signs of regression from the first week and totally disappeared in about 2 months' time. We have so far followed the child for 22 months. The tension has always been under control and the corneal diameter stationary. At the site of the introduction of the tube a corneal opacity was seen.
Management of congenital glaucoma itself is difficult and it is more so when associated with neovascularisation. The options we have are modified trabeculectomy, Scheie's procedure, a goniophotocoagulation with trabeculectomy, cyclocryotherapy and drainage implants. Various type of drainage implants have been tried by different workers,. The implant that we used is of a very simple design inexpensive and is well tolerated by the eye. The upper nasal quadrant was chosen as it conceals the drainage implant and the bleb very well. The end of the tube was pushed well into the anterior chamber to prevent closure of the tube by clot or fibrous tissue. Earlier our experience with using implants in neovascular glaucoma showed a successful control of tension in 4 out of 5 cases (to be reported) and hence we chose this as the primary procedure in this case.
The common complications associated with the tube implantations are : a prolonged flat anterior chamber, low intraocular tension, hyphaema, postoperative closure of the tube either at the anterior chamber end or at the conjunctival end and subsequent rise of tension, corneal opacification, injury to the lens, uveitis and extrusion of the implant. In our case the anterior chamber was shallow for 4 days and at the site of the implant a small corneal opacity was present.
The disappearance of the rubeoses after the implantation of the tube is interesting, may be due to a rapid drainage of neovasculogenic factors from the anterior chamber or collapse of the vessel.
Molteno implanted the drainage system in two sittings. Initially the episcleral plate was sutured on sclera and left for 4-6 weeks. As a second stage procedure the tube was implanted into the anterior chamber and along with it antifibrosis therapy was given. In our series of neovascular glaucoma the tension was successfully controlled in majority (80%) of cases and we have not used antifibrosis therapy in any of our cases so far.
The cause of neovascularisation in our case is not clear. It may be due to a subclinical neovasculogenic stimulus from the retina or following hypoxia of the retina in the intrauterine life which subsequently disappeared leaving vessels on iris.
This new drainage implant successfully control tension in neovascular glaucomas. We recommend its trial as a primary procedure in such cases.
|1||Bihson, F.A., and Alexan ler, T.A., 1983, Intractahle Glaucoma, Asia Pacific Academy Scientific Meeting, Hong Kong.|
|2||Molteno, A.C.B., 1977, Brit. 1. Ophthalmol. 61 :120.|
|3||Krupin, T. Pedos S.M. and Bacher F., 1983, Amer J. Ophthalmol, 95 : 773.|