Year : 2002 | Volume
: 50 | Issue : 3 | Page : 220--221
Angle closure glaucoma following pupillary block in an aphakic perfluoropropane gas-filled eye
A Kumar, S Kedar, Vinay K Garodia, Rajinder P Singh
Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India
Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi
We report the case of a 35-year-old aphakic patient who developed an intractable secondary glaucoma due to angle closure after pupillary block following the use of perfluoropropane (C3F8) gas at a nonexpansile concentration of 14%.
|How to cite this article:|
Kumar A, Kedar S, Garodia VK, Singh RP. Angle closure glaucoma following pupillary block in an aphakic perfluoropropane gas-filled eye.Indian J Ophthalmol 2002;50:220-221
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Kumar A, Kedar S, Garodia VK, Singh RP. Angle closure glaucoma following pupillary block in an aphakic perfluoropropane gas-filled eye. Indian J Ophthalmol [serial online] 2002 [cited 2021 Feb 26 ];50:220-221
Available from: https://www.ijo.in/text.asp?2002/50/3/220/14780
A 35-year-old male presented to the vitreoretina services of our centre complaining of sudden decreased vision in the left eye for a week, associated with flashes and floaters. He had undergone cataract surgery (extracapsular cataract extraction) in both eyes 10 years previously, with good recovery of vision with aphakic correction. He had not suffered from any such chronic systemic illness as diabetes mellitus or other metabolic disorders. The best-corrected visual acuity was 6/12 in the right eye and hand movements with accurate projection of rays in the left eye. Ocular examination revealed aphakia with posterior capsular opacification in both eyes. The pupillary reactions were brisk and intraocular pressure (IOP) was normal in both eyes. Gonioscopy revealed open angles in both eyes with no peripheral synechiae. Fundus examination revealed normal optic nerve head with a cup-disc ratio of 0.3 in both eyes. Indirect and direct ophthalmoscopy showed normal retina in the right eye and a fresh bullous rhegmatogenous retinal detachment in the left eye. No retinal break or hole could be detected even with scleral indentation in the left eye; hence a primary vitreoretinal surgery was performed. The surgery consisted of 360° scleral buckling with encirclage, vitrectomy, removal of the opacified posterior capsule, retinotomy, fluid air exchange, internal drainage of the subretinal fluid, and laser delimitation of the retinotomy. At the end of procedure, 50 cc of 14% C3F8 gas was flushed through the vitreous cavity with constant monitoring of IOP.
Postoperatively, a strict prone positioning was advised, and topical antibiotic (0.3% ciprofloxacin q4h), topical corticosteroid (1% prednisolone acetate q 4h), and topical 0.5% timolol q 12h were prescribed. During discharge on the first postoperative day, the retina was attached, anterior chamber was of normal depth and IOP was normal (16-mm Hg) in the operated eye. Follow-up was scheduled for day 3, day 7, and weekly after that. On day 3, the retina was attached and the anterior chamber depth and IOP were normal. The patient returned for follow up on the 14th day, instead of the scheduled 7th day. At this visit, the retina was found settled, with gas filling approximately two-thirds of the vitreous cavity, but IOP was recorded high (40 mm Hg) with flat anterior chamber superiorly with closed angles, and subepithelial corneal oedema (Figure). The patient did not give any history of pain, redness or decrease in vision in the left eye. He was started on maximal anti-glaucoma medications including tablet acetazolamide 500mg q614 and syrup glycerol 30 ml q8h, along with topical 0.5% timolol q12h and 0.2% brimonidine q12h. YAG peripheral iridotomy was performed in the inferonasal area where the anterior chamber was shallow but not flat, but this failed to open the angles and control the IOP. As IOP was not controlled despite maximal medical treatment, a cyclodestructive procedure was performed (transcleral cyclophotocoagulation using diode laser: Nidek Co., Japan; 810nm, 40 spots each, 1750-2000 mw, 0.2 sec duration) in three sittings at intervals of 2 weeks each. This helped to control IOP three weeks after the last sitting, to a level of 20-mm Hg using topical timolol and brimonidine. At subsequent follow-up 12 weeks postoperative, the retina remained settled, with controlled IOP (20 mm Hg on topical medications) and a visual acuity of 6/36.
This case highlights a potential complication of pupillary block glaucoma when long-standing gases like perfluoropropane (C3F8) are used for tamponade. Initially the patient maintained good prone positioning and thus had no problems. However, later in the second week, he did not maintain proper prone positioning, which probably led to pupillary block by the buoyant gas bubble, thus pushing the iris diaphragm anteriorly. The patient did not experience any pain or other symptom of pupillary block glaucoma, and hence did not report to the hospital earlier. He even missed one of his scheduled appointments (7th day) and instead reported on the 14th postoperative day. This delay resulted in a prolonged period of angle-closure and peripheral iridocorneal touch, thus leading to permanent peripheral anterior synechiae and intractable secondary glaucoma, not amenable to either medical management or laser iridotomy, and required a cyclodestructive procedure.
This angle closure due to pupillary block in aphakic eyes, though seen commonly with silicone oil, has not yet been reported following the use of non-expansile concentrations of intravitreal gas. The buoyancy of the C3F8 gas bubble is considerably more than that of silicone oil; hence C3F8 should be equally, if not more, likely to cause pupillary block. This is especially so, if the patient does not maintain a strict prone position till a considerable amount of gas bubble is still present in the vitreous cavity. To prevent such pupillary block by silicone oil, Ando has described an inferior peripheral iridectomy to provide an alternate channel for the aqueous. Similarly, for aphakic eyes undergoing intravitreal gas injection, a similar large 6 o'clock inferior iridotomy may be recommended at the time of primary procedure, especially in a patient who is likely to have poor compliance for post-operative positioning. This may help prevent such potentially devastating complications of intractable glaucoma due to pupillary block by the gas bubble.
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