Pars plana vitrectomy combined with hyaloido‐zonula‐iridectomy in treatment of patients with chronic aqueous misdirection: A systematic literature review and case series

Abstract

To evaluate the efficacy of vitrectomy combined with hyaloido-zonulairidectomy from an anterior or a posterior approach in patients with treatmentresistant aqueous misdirection (chronic aqueous misdirection) by systematically reviewing existing literature in combination with presentation of a case series. Methods: A systematic literature review was performed in PubMed, EMBASE and Cochrane Library databases using search terms: malignant glaucoma, ciliary block, ciliolenticular block and aqueous misdirection. A consecutive series of three pseudophakic patients (5 eyes) diagnosed with chronic aqueous misdirection after cataract surgery is presented. Results: A literature search identified 31 articles describing treatment of chronic aqueous misdirection with vitrectomy and a hyaloido-zonula-iridectomy. Studies, where patients were treated with a complete vitrectomy from pars plana in combination with a hyaloido-zonula-iridectomy, reported low relapse rates. Studies describing a surgical approach with vitrectomy performed from the anterior chamber, followed by a hyaloido-zonula-iridectomy, also reported low relapse rates except for one reporting relapse in nearly half of the patients. In our case series, a complete vitrectomy combined with a hyaloido-zonula-iridectomy resolved the chronic aqueous misdirection in all five eyes after one procedure except one eye where the hyaloido-zonula-iridectomy was repeated due to an insufficient opening. Some of the eyes still needed antiglaucomatous treatment due to chronic angle closure. Conclusion:In treatment-resistant malignant glaucoma, vitrectomy combined with a hyaloido-zonula-iridectomy should be considered performed to ensure communication between the anterior chamber and the vitreous cavity. If the condition has been unresolved for a long time, extensive synechiae of the angle may decrease the success rate due to chronic angle closure.

Successful Management of Malignant Glaucoma With Irido-Zonulo-Hyaloidotomy and Complete Pars Plana Vitrectomy

“…In malignant glaucoma, Nd: YAG laser posterior capsulotomy in conjunction with hyaloidotomy aims to disrupt the posterior capsule and anterior hyaloid membrane to allow communication between the drainage angle of the AC and vitreous cavity. However, the relapse rate is as high as 75% [ 3 ]. Another option is the Chandler procedure, which was first described in 1964 and aims to remove the anterior hyaloid face, thus redirecting the posterior segment positive pressure [ 7 ].…”

“…The Pars plana approach to vitrectomy otherwise permits a better field of view, wider access to allow disruption of anterior hyaloid, and has a lower recurrence rate as compared to the anterior approach. This is postulated to be due to satisfactory vitreous base removal through the pars plana approach coupled with the feasibility of total vitrectomy to prevent secondary blockage by the residual vitreous [ 3 ]. Irido-zonulectomy in combination with incomplete PPV, which includes anterior vitrectomy, core vitrectomy, or partial vitrectomy, has observed a higher percentage of relapse during follow-up [ 3 ].…”

“…This is postulated to be due to satisfactory vitreous base removal through the pars plana approach coupled with the feasibility of total vitrectomy to prevent secondary blockage by the residual vitreous [ 3 ]. Irido-zonulectomy in combination with incomplete PPV, which includes anterior vitrectomy, core vitrectomy, or partial vitrectomy, has observed a higher percentage of relapse during follow-up [ 3 ]. Anterior vitrectomy performed via anterior approach with tunnel creation serves the benefit of allowing the anterior segment surgeon to manage refractory malignant glaucoma, especially in the setting short of vitreoretinal expertise.…”

“…Non-surgical options for treating malignant glaucoma, such as medical therapy with IOP-lowering agents, cycloplegics, and Neodymium: Yttrium aluminium garnet (Nd: YAG) laser posterior capsulotomy and hyaloidotomy, are associated with a high relapse rate of 75-100% [2]. Surgical intervention is often necessitated in refractory cases, and the different approaches that have been previously described include conventional vitrectomy without tunnelling, incomplete vitrectomy either through the anterior or pars plana approach with tunnelling, and pars plana vitrectomy (PPV) with tunnelling [2][3][4][5]. We highlight a case with successful treatment of pseudophakic malignant glaucoma with complete PPV with irido-zonulohyaloidotomy and restoration of good visual acuity (VA) with no relapse during the 12-month follow-up.…”

Sekundäre Winkelblockglaukome

“…Konservativ kann neben einer drucksenkenden Therapie versucht werden, dass durch Kombination aus systemischem Acetazolamid zur Reduktion der Kammerwasserproduktion und Atropin-Augentropfen aufgrund der Zykloplegie eine Vertiefung der Vorderkammer erreicht wird. Bei nicht ausreichendem Erfolg kann versucht werden, mittels Nd:YAG-Laser-Iridotomie (mit anteriorer Hyaloidotomie) oder Iridektomie (mit Membranektomie) die vordere Glaskörpergrenzmembran zu eröffnen, wobei hierdurch zusätzlich das Vorliegen eines Pupillarblocks ausgeschlossen wird [18]. Ist dies so nicht möglich, muss eine Vitrektomie mit Eröffnung der vorderen Glaskörper-grenzmembran erfolgen.…”