Aqueous misdirection syndrome: an interesting case presentation

Abstract

ObjectiveTo report a case of an aqueous misdirection-like presentation in a pseudophakic patient.DesignRetrospective case review.ParticipantAn 84-year-old pseudophakic gentleman presented with bilateral blurred vision 8 years after cataract surgery. A refractive shift with shallow anterior chambers and elevated intraocular pressures were noted. No corneal edema was noted. Although aqueous suppression and topical atropine would relieve the signs and symptoms, the effect was temporary with fluctuating and variable changes in refraction, anterior chamber depth, and intraocular pressure. The presence of patent iridotomies had no effect on the fluctuations. A pars plana vitrectomy and surgical iridectomy were successful in preventing further fluctuations.ConclusionAqueous misdirection is a form of secondary angle closure glaucoma marked by elevated intraocular pressures, myopic shift in refraction, and central shallowing of the anterior chamber. Here, a case of a pseudophakic patient experiencing bilateral and fluctuating signs and symptoms resembling aqueous misdirection is presented. Surgical intervention with a pars plana vitrectomy and iridectomy prevented further fluctuations.

Pupillary block due to reverse implantation of a sulcus intraocular lens

“…8–10 In a case study by Sathish et al, 10 anterior segment UBM helped to diagnose iris bombe as the cause of pseudophakic pupillary block glaucoma 3 years after implantation of a 3-piece IOL in the bag 8 . In our case, while the configuration of the haptic provided a clue as to the etiology of pupillary block, anterior segment UBM confirmed that the IOL was causing anterior bowing of the iris and helped to exclude other causes such as aqueous misdirection syndrome, 11 bilateral ring cysts of the ciliary body, 8 late-onset secondary pigmentary glaucoma, 9 a thick Soemmerring ring, and anterior displacement of the ciliary body. 12 …”

Transient complete visual loss and subsequent cystoid macular edema after intracameral lidocaine injection following uneventful cataract surgery

“…The OCT-based early macular edema in our case may be compatible with this hypothesis. 10 ( Fig. 1 ).…”

Suspected Spontaneous Aqueous Humor Misdirection Syndrome in a Boston Terrier

“…Additional diagnostic tests which should be considered for thorough evaluation of cases of suspected AHMS include streak retinoscopy to evaluate for potential refractive errors subsequent to anterior displacement of the iris-lens diaphragm and vitreous body [6,17,18], high-resolution ocular ultrasonography (HRUS) or ultrasound biomicroscopy (UBM) to better quantify the degree of anterior chamber narrowing and evaluate for posterior segment foci of aqueous humor fluid [6,18,19], and optical coherence tomography (OCT) to further quantify anterior and posterior segment abnormalities [19,20]. These tests were not performed in the presented case; however, they may have provided insight to further support a diagnosis of spontaneous AHMS and should be considered for workup of future cases.…”

“…HRUS or UBM provides higher resolution which is valuable for diagnosing more subtle lesions [21]. As a result, HRUS and UBM are the preferred ultrasonic imaging modalities for AHMS diagnosis in humans [6,[17][18][19] and have been used successfully in the diagnosis of feline AHMS [2].…”

“…Induced aqueous humor misdirection syndrome (AHMS) has been reported in a dog [3] and a llama [4] following phacoemulsification, and in humans following penetrating keratoplasty [5], phacoemulsification [6], and neodymium: YAG laser posterior capsulotomy [7]. However, spontaneous AHMS has not yet been described in dogs.…”