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Purpose: To evaluate the safety and efficacy of clear corneal approach irido-zonulo-hyaloido-vitrectomy, which we named \"mini-vitrectomy,\" in the management of pseudophakic aqueous misdirection. Methods: In this retrospective, non-comparative interventional case series, 24 eyes with diagnosis of pseudophakic aqueous misdirection were enrolled. Medical therapy with cycloplegics and laser therapy, including posterior capsulotomy and hyaloidotomy, was not effective in the management of the condition. The eyes underwent mini-vitrectomy, a simple technique in which iridotomy, zonulectomy, hyaloidectomy, and limited anterior vitrectomy were performed via a clear cornea incision. The main outcome measure was reformation of the anterior chamber, which was evaluated at day 1 and months 1, 3, 6, and 12. Results: The mean age of patients was 75.3 ± 11.3 years (range, 47 to 90), and 13 (54.2%) patients were women. Anterior chamber was deep in 22 patients (91.7%) at the last follow-up visit. The mean intraocular pressure (IOP) was 30.31 ± 1.9 mm Hg at presentation on 2.67 ± 1.09 glaucoma medications. IOP decreased significantly to 14.5 ± 4.6 mm Hg at 12-month follow-up. (P = 0.001). The number of glaucoma medications at final visit was 2.2 ± 0.9 (P = 0.21). Conclusion: Mini-vitrectomy is a simple, safe, and effective procedure in the management of pseudophakic aqueous misdirection, and it can be adopted by all ophthalmologists who are involved in glaucoma management and are not comfortable with the pars plana vitrectomy approach.

Purpose: To investigate a potential link between the incidence of malignant glaucoma after cataract surgery and seasonal variations in daylight. Methods: In total, 18,374 uncomplicated cataract surgeries were performed between June 2008 and June 2013 at an ambulatory surgery center in Toronto. Toronto's average monthly daylight over that time period-in hours per day for each month-was determined. The number of malignant glaucoma cases that developed after cataract surgery performed in months with above average daylight was compared to the number of cases that developed after cataract surgery performed in months with below average daylight. Fisher's exact test was used to analyze the relationship between the development of malignant glaucoma and variation in daylight during the month of cataract surgery. Results: Malignant glaucoma developed in 16 eyes. Thirteen cases of malignant glaucoma developed in months with above average daylight and three cases developed in months with below average daylight (P = 0.01). Eyes that developed malignant glaucoma in months with more daylight were slightly longer (21.95 ± 1.23 mm) than those that developed malignant glaucoma in months with less daylight (21.55 ± 0.88 mm). Conclusion: Light-induced choroidal expansion may play a major role in the development of malignant glaucoma following cataract surgery.

Purpose To evaluate the outcomes of postoperative aqueous misdirection and factors predicting failure of interventions. Methods This retrospective study included 49 eyes from 47 patients with aqueous misdirection following glaucoma or cataract surgery. Resolution of aqueous misdirection (AM) was deepening of the central anterior chamber (AC) and intraocular pressure (IOP) ≤ 21 mmHg. The Cox proportional hazards regression model was used to evaluate risk factors for failure of various treatments. Results 10/49 eyes (20%) resolved with conservative management, and 39/49 eyes (80%) needed multiple intervention, of which 95% (37/39) eyes achieved resolution of aqueous misdirection. Pseudophakia predicted the need for multiple interventions with a hazard ratio of 2.391 (1.158–4.935), p  = 0.02). Among the risk factors assessed for resolution of AM, longer axial length (HR: 0.61 (0.414–0.891), p  < 0.01) and eyes with prior glaucoma surgery predicted resolution (HR: 0.142 (0.027–0.741), p  < 0.01) and delayed presentation predicted failure (HR: 1.002 (1.0002–1.0031), p  < 0.02). Conclusion Pseudophakic eyes were more refractory and predicted the need for multiple interventions. Eyes with prior glaucoma surgery and those with longer axial length had achieved resolution faster, and delayed presentation was a risk factor for failure to resolve.

Malignant glaucoma typically presents immediately after angle-closure surgery. However, late-onset malignant glaucoma can occur after various ocular procedures. This report describes the case of an African–American woman in her late 70s who developed malignant glaucoma 7 years after cataract surgery. She initially presented with signs of acute angle-closure glaucoma. Symptoms began a few days earlier with unilateral blurred vision and a dull orbital ache. The patient was initially managed with maximum aqueous humor suppressants. Imaging and ocular examination raised suspicion of malignant glaucoma, and a Soemmering’s ring was noted on examination. Laser peripheral iridotomy was attempted in the operating room; however, definitive treatment involving iridozonulohyaloidectomy with vitrectomy was necessary. Patient intraocular pressure, vision, and examination findings improved following intervention, showing continuous postoperative improvements. This case highlights Soemmering’s ring as a potential precipitant of malignant glaucoma as well as the effectiveness of iridozonulohyaloidectomy as a definitive treatment for pseudophakic malignant glaucoma.

Purpose To investigate the preoperative anterior segment structural features in eyes diagnosed with malignant glaucoma (MG) following primary angle-closure glaucoma (PACG) surgery and to provide a clinical reference for the early detection of the risks of MG. Methods A retrospective case-control study. The study population included two groups: the MG group (17 patients, 21 eyes), consisting of eyes with postoperative MG, and the No-MG group (24 patients, 30 eyes), consisting of eyes with no MG. All patients underwent combined surgery for glaucoma and cataract (phacoemulsification cataract extraction combined with intraocular lens implantation plus goniosynechialysis [PEI+GSL]).The groups were matched for age, gender, and clinical condition. Ultrasound biomicroscopy (UBM) was used to measure anterior segment parameters, including anterior chamber depth (ACD), anterior chamber width (ACW), trabecular-ciliary process distance (TCPD), ciliary-ciliary distance (CCD), iris-zonule distance (IZD), trabecular-ciliary process angle a (TCA[sub.a]), trabecular-ciliary process angle b (TCA[sub.b]), iris-ciliary process distance (ICPD), maximum ciliary body thickness (CBT[sub.max]), ciliary body thickness at a distance of 1000mm (CBT[sub.1000]), and vitreous zonule (VZ). Results ACD, ACW, CCD, TCPD, IZD, ICPD, TCA[sub.a], TCA[sub.b], CBT[sub.max], and CBT[sub.1000] were smaller in MG compared to No-MG eyes (p<0.05). Multifactorial logistic regression analysis identified two significant risk factors for developing MG: narrower TCA[sub.b] (odds ratio [OR]=0.761; 95% confidence interval [CI], 0.600-0.964, p<0.05) and smaller VZ (OR=0.076; 95% CI, 0.007-0.836, p<0.05). Conclusion Eyes with PACG having MG exhibit specific anatomical risk factors, including a more crowded anterior chamber space, greater forward displacement of the ciliary body, and more breaks in the VZ. VZ plays a very important role in the pathogenesis of MG.

Purpose This study aimed to observe the clinical efficacy of endoscopic cyclophotocoagulation (ECP) combined with cataract extraction in the management of malignant glaucoma. Methods A total of 33 patients (34 eyes) who experienced malignant glaucoma following anti-glaucoma surgery at Shaanxi Eye Hospital, Xi'an People's Hospital (Xi'an Fourth Hospital) from January 2020 to January 2022 were selected. They were stratified into two groups: the ECP group (16 cases, 16 eyes) and the control group (15 cases, 16 eyes). The ECP group underwent ECP combined with cataract surgery, while the control group underwent anterior vitrectomy combined with cataract surgery. Various parameters, including visual acuity, intraocular pressure (IOP), anterior chamber depth (ACD), ciliary process thickness (CPT), ciliary process width (CPW), ciliary process area (CPA), iridociliary process contact length (ICPCL), and postoperative complications, were recorded and compared between the two groups. Results There was no significant difference in preoperative basic conditions between the two groups. The patients were followed up for a duration ranging from 6 to 18 months. Both groups exhibited improved visual acuity after surgery, with no significant intergroup differences postoperatively ( P  > 0.05). Postoperative IOP in both groups decreased compared to preoperative levels, with the ECP group demonstrating a statistically significant lower IOP than the control group (t = 2.48, P  < 0.05). ACD after surgery was significantly deeper in both groups compared to preoperative levels, with the ECP group showing a greater ACD than the control group (t = 2.14, P  < 0.05). Postoperative CPT, CPW, CPA, and ICPCL in the ECP group were significantly reduced compared to preoperative values ( P  < 0.05), while no significant differences were observed in the control group before and after surgery. Early postoperative complications in both groups included anterior chamber inflammation, corneal edema, and Descemet membrane folds. In the long term, two eyes in both groups experienced increased IOP, requiring 1–2 types of IOP-lowering drugs to maintain IOP below 21 mmHg. Choroidal detachment occurred in one eye in the control group. No serious complications, such as corneal endothelial decompensation, intraocular hemorrhage, infection, or uncontrolled intraocular pressure, were reported. Conclusions The combination of ECP and cataract extraction proves to be a safe and effective therapeutic approach for managing malignant glaucoma following anti-glaucoma surgery.

Background Malignant glaucoma (MG) is associated with a narrow angle or pseudoexfoliation (PEX)-induced laxity of the zonule. We describe a patient with massive posterior capsule opacification (PCO), i.e. Elschnig’s Pearls (EP) and Soemmering’s ring (SR) causing aqueous misdirection syndrome. Case presentation A 78 - year-old female was referred with rapidly progressive left ocular pain, redness, blurred vision of 20/100, and intraocular pressure (IOP) of 60 mmHg. She had undergone cataract surgery 5 years prior without complications, with a preoperative diagnosis of moderate capsular PEX syndrome. She was first treated by intravenous 250 mg acetazolamide along with maximal pressure-lowering drops, 1% pilocarpine and a patent laser iridotomy. Despite adding 500 cc of 10% mannitol, IOP remained high for 3 days. A shallow anterior chamber with angle closure, myopic shift and filling of the posterior chamber by massive PCO led us to conclude an aqueous misdirection syndrome. We promptly switched 1% pilocarpine to 1% atropine and performed a laser iridotomy enlargement with a posterior capsulotomy and anterior hyaloidotomy. This rapidly controlled the condition with posterior displacement of the intraocular lens (IOL) and fading of the high-IOP associated symptoms. Conclusions Identifying malignant glaucoma could be challenging in the absence of immediate surgical circumstances. To our knowledge, this is the second description of PCO associated with MG. In this case, PCO was thought to narrow the iridocorneal angle and to cause a relative pupillary blockage, subsequently triggering aqueous humor misdirection to the vitreous and forward displacement of the iris-IOL diaphragm in the context of moderate PEX-induced zonular laxity.

Background X-linked retinoschisis (XLRS), due to mutations in the RS1 gene, is a common genetically determined form of macular degeneration. This report describes an unusual case of angle-closure glaucoma (ACG) with XLRS and discusses the treatment. Case presentation A 39-year-old Chinese man with an X chromosome-recessive inherited c.489G > A variant in the RS1 gene was diagnosed as XLRS and ACG, presenting with cystic macular lesions, shallow anterior chamber depth (ACD), and angle-closure with uncontrolled intraocular pressure (IOP). Malignant glaucoma occurred following trabeculectomy combining phacoemulsification with intraocular lens (IOL) implantation and goniosynechialysis. Subsequent anterior vitrectomy and irido-zonulo-hyaloid-vitrectomy (IZHV) effectively lowered IOP and deepened ACD, but the cystic cavity became larger. Conclusions There is a potential risk of malignant glaucoma in ACG patients with XLRS after filtering surgery. Although anterior vitrectomy can effectively resolve aqueous misdirection, the macular retinoschisis may get worse. Awareness of this risk may aid in surgical planning and postoperative management in these patients.

Malignant glaucoma is one of the most challenging conditions in ophthalmology. The exact etiology of this complication is not fully understood, and its management is usually challenging. This brief report discusses current treatment strategies for this relatively uncommon form of secondary glaucoma.

To describe the management and clinical course of 12 cases of pseudophakic aqueous misdirection syndrome (AMS). Twelve eyes of 12 Patients diagnosed with pseudophakic AMS between 2021 and 2022 were included. Best-corrected visual acuity, refraction, intraocular pressure (IOP), anti-glaucomatous medication, spectral domain ocular coherence tomography (SD-OCT) and postoperative complications were evaluated. The mean time of AMS onset was 888 days (SD ± 1210, range: 1–2920) after cataract surgery. Treatment with IOP-lowering medication alone was non-sufficient in all followed cases. Laser iridotomy (LIT) was performed in 4 eyes and led to resolution of AMS in 3 eyes. Nine eyes were treated surgically with 23-gauge pars plana vitrectomy and irido-zonulectomy. The most common postsurgical complication was cystoid macular edema (CME), occurring in 30% of cases. AMS is a rare but serious complication after cataract surgery, which can occur many years later. While LIT can be tried as first line treatment, pars plana vitrectomy with irido-zonulectomy is often required to ultimately control IOP in these eyes. A common complication after vitrectomy is CME.