Treatment outcomes and efficacy of pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy in malignant glaucoma

Abstract

Aim: To study the treatment outcomes and efficacy of pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy in malignant glaucoma. Method: A retrospective case series study of patients treated for malignant glaucoma between 2005 and 2017. The treatment included medical management as first-line in the form of cycloplegic with anti-glaucoma medications (AGM) or pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy as second-line therapy. The resolution was defined as ‘deepening of central anterior chamber’ with intraocular pressure of ⩽ 21 mm Hg (minimum on two consecutive visits 1 week apart) with or without topical anti-glaucoma medications in the absence (complete success) or presence (qualified success) of systemic medications. Results: Twenty-three eyes of 22 patients were included. At the time of diagnosis of malignant glaucoma preceding surgeries were cataract surgery (13 eyes) and trabeculectomy (4 eyes). One eye each had phacotrabeculectomy, Yag capsulotomy and optical keratoplasty. Eighteen eyes were pseudophakic and two eyes were phakic. At presentation, mean intraocular pressure was 26.25 ± 14.78 mmHg which was decreased to 15.90 ± 8.12 mmHg (p < 0.0001) at final follow-up (median follow-up was 15.50 months). Fifteen (75%) eyes had complete success, 3 (15%) eyes had qualified success and 2 (10%) eyes had treatment failure. Of 15 eyes that had achieved complete success, 3 eyes had undergone medical management and 12 eyes undergone second-line procedure. There was no significant difference in visual acuity or number of anti-glaucoma medication at presentation and final follow-up (p > 0.05). Conclusions: Though malignant glaucoma is highly refractory to treatment, appropriate management in the form of medical or vitrectomy-hyaloidotomy-zonulectomy-iridotomy could achieve 90% success in this series.

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

“…On day 14, after the diagnosis of malignant glaucoma, a 23-gauge complete PPV with irido-zonulo-hyaloidotomy was performed on our patient. Similar procedures were described and the majority of patients observed no or very low recurrence throughout the follow-ups [ 2 , 4 , 5 ]. During the post-operative period, the IOP was maintained at mid-teens without IOP-lowering eye drops.…”

“…Its incidence ranges from 0.6% to 4% in eyes treated surgically for angle-closure glaucoma, with a higher prevalence after penetrating glaucoma surgeries [ 6 ]. Pseudophakia post-cataract surgery has been previously included as one of the possible triggering factors [ 4 , 6 ]. It can be classified into: (i) classic malignant glaucoma, which happens after incisional surgery in patients with primary angle-closure glaucoma; (ii) non-phakic malignant glaucoma, which occurs in patients who have had cataract-removal surgery, which is seen in our case; and (iii) other malignant glaucoma syndromes, which have sporadic occurrence and may be associated with laser, miotic agents, and trabeculectomy bleb needling [ 1 ].…”

“…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.…”

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

“…If both medical and laser treatment fail, pars plana vitrectomy is thought to prevent aqueous humour from accumulating in the vitreous cavity and the hyaloido‐zonula‐iridectomy to ensure the communication between the anterior chamber and the vitreous cavity. A few studies have combined the vitrectomy and HZI with the removal of the lens and implantation of IOL if the patients were phakic (Debrouwere et al 2012; Dervenis, Mikropoulou & Dervenis 2017; Tang, Du & Li 2018; Raj et al 2019). We cannot determine whether vitrectomy with HZI combined with phacoemulsification gives a better result than vitrectomy with HZI alone.…”

“…Two studies did not consider cases treated with additional surgeries as relapses (Al Bin Ali et al 2017; Krėpštė, Žemaitienė & Miliauskas 2018). Studies using anterior, core or partial PPV with HZI had variable relapse rates (Bitrian & Caprioli 2010; Koukkoulli & Rahman 2013; Rękas, Krix‐Jachym & Zarnowski 2015; A Khan 2016; He et al 2016; Balekudaru et al 2017; Rani et al 2018; Tang, Du & Li 2018; Patel 2020; Raj et al 2019). One study based on one eye reported relapse that resolved with slit‐lamp needling (Mardelli & Mardelli 2018).…”