Current concepts in the treatment of vitreous block, also known as aqueous misdirection

Kaplowitz, Kevin; Yung, Edward; Flynn, Rachel; Tsai, James C.

doi:10.1016/j.survophthal.2014.12.004

Cited by 41 publications

(41 citation statements)

References 151 publications

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“…Malignant glaucoma (MG), first described by Von Graefe in 1869, is one of the most challenging types of glaucoma because of its resistance to clinical treatment and its enormous potential to consequently cause loss of vision [1]. It is characterized by normal to elevated intraocular pressure (IOP) with a shallow central and peripheral anterior chamber with the absence of suprachoroidal effusion or hemorrhage, despite a patent iridectomy.…”

Section: Introductionmentioning

confidence: 99%

Is Thicker Choroid a Risk Factor for Malignant Glaucoma?

Chen¹,

Guo²,

Xu³

et al. 2018

Ophthalmic Res

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Purpose: The aim of this study was to evaluate the choroidal thickness (CT) and its determinants in primary angle closure glaucoma (PACG) eyes with and without malignant glaucoma (MG). Methods: In this cross-sectional study, we enrolled 25 patients with bilateral primary angle closure (PAC) diseases; 1 eye of each patient was diagnosed with PACG initially and later with MG after trabeculectomy, and the fellow eyes were diagnosed with PACG, PAC, or PAC suspect. Thirty-seven eyes from 37 PACG patients were recruited as controls. CT was measured at different locations (sub-fovea, 1 and 3 mm from the fovea) using spectral-domain optical coherence tomography. Comparisons of CT were made among MG, the fellow eyes, and the controls. The associations between the determinants and MG were analyzed by univariate and multiple logistic regression analysis. Results: Macular CT in the eyes with MG was thicker than that of the controls (p < 0.001) but not the fellow eyes. Thicker foveal CT was associated with an increased risk of MG (odds ratio 1.141). Conclusions: Thicker foveal CT is an anatomic risk factor for MG. The results of our study were consistent with the hypothesis that choroidal expansion may play a significant role for the development of MG.

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Section: Introductionmentioning

confidence: 99%

Is Thicker Choroid a Risk Factor for Malignant Glaucoma?

Chen¹,

Guo²,

Xu³

et al. 2018

Ophthalmic Res

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“…However, eyes before cataract surgery, which later provoked MG, also had a significantly higher IOP than their contralateral eyes. Therefore, we hypothesize that in addition to ocular hypertension (a known risk factor for MG [ 8 ]), a slightly higher IOP compared with the other eye could be a risk factor and should be considered while planning cataract surgery, especially in anatomically predisposed eyes. Whether preoperative lowering of IOP in such eyes could minimize the risk of MG, however, is unclear.…”

Section: Discussionmentioning

confidence: 99%

“…According to the literature, the rate of immediate success with medical treatment is low and recurrence is high if cycloplegics are withdrawn [ 8 ]. It is difficult to discuss laser treatment modalities, such as laser capsulotomy, hyaloidotomy, and cyclophotocoagulation, confidently because the study groups were extremely small [ 8 ]. A study involving >10 cases reported an initial success rate of 67% after Nd:YAG laser hyaloidotomy, which diminished to 46.7% after 3 months [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…Surgical options, described in the most recent review, are vitreous aspiration (we regard this to be a dangerous approach), anterior vitrectomy, and PPV with or without lensectomy. Although initial success is comparable between PPV and anterior vitrectomy, as well as between PPV with and without lensectomy, the recurrence rate always favors PPV with lensectomy [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

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Clinical Characteristics and Outcomes of Malignant Glaucoma after Different Procedures Treated with Pars Plana Vitrectomy: A 10-Year Retrospective Study

2018

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Background and objectives: Despite established common risk factors, malignant glaucoma (MG) remains a rare condition with challenging management. We aimed to analyze differences in risk factors for MG after different surgeries and outcomes after pars plana vitrectomy (PPV). Materials and Methods: This retrospective study included cases of MG treated with PPV between January 2005 and December 2015 in the Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Results: A total of 39 cases were analyzed: 23 (59%) after cataract surgery, 13 (33.3%) after trabeculectomy, and 3 (7.7%) after other interventions. Characteristics among the groups did not differ. Intraocular lens refractive power was significantly higher in the cataract group, in which intraocular pressure (IOP) before MG was significantly greater in the affected eye. Normotension was achieved in 92.3%, and a normal anterior chamber in 75%. Additional measures included eye drops (n = 24), trabeculectomy (n = 5), bleb revision (n = 2), synechiotomy (n = 4), and cyclophotocoagulation (n = 1). The proportion of drop-free patients significantly increased after PPV compared with that before MG development (38.5% versus 15.4%). Complications were observed in 11 cases: choroidal detachments with spontaneous resolution (n = 2); retinal detachment (n = 1); constant mydriasis (n = 1), neovascular glaucoma (n = 1); obstruction of filtrating zone by iris (n = 1) and by blood clot (n = 1); posterior synechia formation causing IOP rise (n = 4 (all resolved after synechiotomy)). The cataract group experienced significantly fewer complications than the trabeculectomy group (17.4% vs. 53.8%, respectively). Conclusions: There were no differences in the risk of MG among the different surgeries. However, higher IOP in the predisposed eye (versus contra-lateral eye) could indicate additional risk of MG after cataract surgery. PPV afforded reliable treatment for MG and the possibility for glaucoma patients to discontinue topical treatment.

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“…Various methods have been described to overcome this positive pressure which include relieving external pressure on the globe, proper positioning of the instruments, dry insertion of phaco needle, capsule protection with a second instrument, injection of a retentive ophthalmic viscoelastic device, use of the AC maintainer, vitreous dehydration with intravenous (IV) mannitol, vitrectomy through the pars-plana using a 25/23G vitrector, and vitreous aspiration with 20/23G needle. [ 2 ] Large-bore needle aspiration can cause vitreous traction and extrusion of vitreous through the site of entry leading to an increased risk of infection and vitreoretinal traction, especially in the setting of underlying increased vitreous pressure. [ 3 ]…”

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confidence: 99%

Pars-plana fluid aspiration for positive vitreous cavity pressure in anterior segment surgeries

Kuriakose

Jasper

Thomas

2018

Indian J Ophthalmol

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Positive vitreous pressure due to misdirection of aqueous or choroidal effusion leads to shallowing of the anterior chamber (AC) before or during anterior segment surgeries. This shallow AC if not addressed makes surgery difficult and increases the risk of surgical complications. Methods to prevent and manage this condition described in literature are not without problems. We describe a minimally invasive technique of passing a 30G needle through the pars-plana to aspirate misdirected fluid from vitreous cavity either as a prophylaxis just before surgery or during it, thereby decreasing positive vitreous pressure. This technique, used in 12 eyes, seems to be effective in patients with angle-closure glaucoma, malignant glaucoma, and per-operative sudden increase in vitreous pressure during surgery. Small-incision surgeries are ideally suited for this procedure. This minimally invasive technique is simple to perform and complications are unlikely to be more than what is seen with intravitreal injections.

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Current concepts in the treatment of vitreous block, also known as aqueous misdirection

Cited by 41 publications

References 151 publications

Is Thicker Choroid a Risk Factor for Malignant Glaucoma?

Is Thicker Choroid a Risk Factor for Malignant Glaucoma?

Clinical Characteristics and Outcomes of Malignant Glaucoma after Different Procedures Treated with Pars Plana Vitrectomy: A 10-Year Retrospective Study

Pars-plana fluid aspiration for positive vitreous cavity pressure in anterior segment surgeries

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