|Year : 2021 | Volume
| Issue : 2 | Page : 137-139
Successful pars plana vitrectomy with zonulo-hyaloidectomy performed 4 years after the onset of chronic low-grade aqueous misdirection
Waleed K Alsarhani1, Abdullah I Almater2, Marwan A Abouammoh2, Faisal A Almobarak2
1 Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
2 Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||20-Jan-2021|
|Date of Acceptance||10-Aug-2021|
|Date of Web Publication||25-Sep-2021|
Dr. Waleed K Alsarhani
Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario
Source of Support: None, Conflict of Interest: None
| Abstract|| |
In aqueous misdirection, the interval between diagnosis and surgical intervention is inversely proportional to the success of the surgery. Here, we report a successful outcome of pars plana vitrectomy (PPV) with irido-zonulo-hyaloidectomy 4 years after the onset of the disease. A 34-year-old female, known to have primary angle closure glaucoma, underwent trabeculectomy with mitomycin C in the right eye for uncontrolled intraocular pressure (IOP). Six weeks after the surgery, the patient presented with a shallow anterior chamber centrally and peripheral iridocorneal touch along with a patent peripheral iridectomy. Ultrasound biomicroscopy showed a shallow AC centrally with peripheral iridocorneal touch, and the ciliary body was rotated forward confirming the diagnosis of aqueous misdirection. The patient refused surgical management and was managed medically, which was unsuccessful. Four years after the diagnosis, the patient underwent PPV with irido-zonulo-hyaloidectomy because of progressive shallowing of the AC and corneal edema. One month postoperatively, visual acuity improved from 20/200 to 20/60, and the AC maintained appropriate depth. In conclusion, PPV with irido-zonulo-hyaloidectomy may result in a complete resolution of a chronic low-grade form of aqueous misdirection.
Keywords: Aqueous misdirection, ciliary block, malignant glaucoma, pars plana vitrectomy, zonulo-hyaloido-vitrectomy
|How to cite this article:|
Alsarhani WK, Almater AI, Abouammoh MA, Almobarak FA. Successful pars plana vitrectomy with zonulo-hyaloidectomy performed 4 years after the onset of chronic low-grade aqueous misdirection. Middle East Afr J Ophthalmol 2021;28:137-9
|How to cite this URL:|
Alsarhani WK, Almater AI, Abouammoh MA, Almobarak FA. Successful pars plana vitrectomy with zonulo-hyaloidectomy performed 4 years after the onset of chronic low-grade aqueous misdirection. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jan 16];28:137-9. Available from: http://www.meajo.org/text.asp?2021/28/2/137/326664
| Introduction|| |
In aqueous misdirection, the interval between diagnosis and surgical intervention is inversely proportional to the success of surgery. Intervention performed later than 4 weeks was associated with decreased success rate. Indeed, it is recommended to intervene surgically within the 1st week of diagnosis, if medical management fails. Inflammation and synechia formation can result in significant damage to the cornea and affect the outcome. Here, we report a successful outcome of pars plana vitrectomy (PPV) with zonulo-hyaloidectomy 4 years after the onset of the disease.
| Case Report|| |
A 34-year-old female, known case of primary angle closure glaucoma, underwent trabeculectomy with mitomycin C in the right eye for uncontrolled intraocular pressure (IOP). Six weeks after the surgery, the patient presented with pain in the right eye. On examination, IOP was 10 mmHg in the right eye and 19 mmHg in the left eye. The bleb was slightly elevated and cystic with no leak. The anterior chamber (AC) was shallow with peripheral iridocorneal touch. The peripheral iridectomy was patent, and dilated fundus examination was unremarkable. Ultrasound biomicroscopy (UBM) showed a shallow AC centrally with peripheral iridocorneal touch, and the ciliary body was rotated forward. The patient had 0.7 cupping in the right eye and 0.5 cupping in the left eye. Given the UBM finding, IOP, patency of the iridectomy, along with the normal fundus examination, the diagnosis of aqueous misdirection was made, and other causes of shallow AC such as pupillary block and suprachoroidal hemorrhage were ruled out. The patient refused any laser or surgical procedure and was given atropine drops in the right eye and was stable during her follow-ups with no need for further intervention. Six months later, the patient decided to proceed with only a cataract surgery in the affected eye. She underwent an uncomplicated phacoemulsification with synecholysis and posterior chamber intraocular lens (IOL) insertion in the right eye for the cataractous lens changes that occurred secondary to the previous trabeculectomy surgery. Progressive shallowing of the AC continued to develop while on atropine, and the patient agreed to proceed with YAG anterior hyaloidotomy in the right eye 6 months following the cataract surgery. Nevertheless, the AC remained shallow with an IOP ranging 15–20 mmHg on atropine and aqueous suppressants. Moreover, the patient underwent trabeculectomy in the fellow eye for uncontrolled IOP but was started on atropine prior to the surgery, which was uneventful. Two years later, the patient presented to the ophthalmology emergency room with blurred vision. Her visual acuity was 20/200 with an IOP of 18 mmHg in the right eye. The right AC was shallow centrally with peripheral iridocorneal touch [Figure 1]a and [Figure 1]b. There was significant iris atrophy, and the intraocular haptic was visible behind the atrophic iris. In addition, there was posterior synechia with multiple pigments over the IOL surface [Figure 1]b. UBM showed a very shallow AC centrally with peripheral iridocorneal touch, the ciliary body was rotated forward with absent ciliary sulcus [Figure 1]c. She was offered surgical intervention which she refused.
|Figure 1: Anterior segment photo showing peripheral iridocorneal touch (a) with a shallow anterior chamber centrally (b). Ultrasound biomiocroscopy showing a uniformly shallow anterior chamber with anteriorly rotated ciliary body (c)|
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Four years after the onset of aqueous misdirection, the patient eventually agreed to undergo PPV with irido-zonulo-hyaloidectomy in the right eye after having progressive peripheral corneal edema. The procedure started with three port 23-gauge core vitrectomy and triamcinolone assisted separation of the posterior hyaloid. Visco-dissection of the areas of synechia was done. The previous iridectomy at 12 o'clock was enlarged, and a new iridectomy was created at 6 o'clock position. Zonulectomy with hyaloidectomy were performed aiming at having a single compartment between the vitreous cavity and the AC. Careful removal of the anterior vitreous was done. The procedure continued until the AC deepened. One month postoperatively, the patient had visual acuity of 20/60, and an IOP of 16 mmHg off antiglaucoma medications. The AC was deep with no posterior synechia [Figure 2]a and [Figure 2]b.
|Figure 2: Postoperative anterior segment photo showing a deep anterior chamber with two large iridectomies located at 6 and 12 o'clock positions (a). Ultrasound biomiocroscopy showing a deep anterior chamber (b)|
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| Discussion|| |
Here, we highlight the importance of considering surgical management in late presentation aqueous misdirection. The exact mechanism resulting in aqueous misdirection is poorly understood. However, the most commonly described theory proposes a posterior diversion of the aqueous into or around the vitreous cavity, hence the term aqueous misdirection, leading to forward movement of lens and ciliary processes in anatomically predisposed eyes.
Medical management with topical cycloplegics and aqueous suppressants is attempted initially. Although medical management was reported to be effective in 50% of the cases, a recent study showed 100% recurrence rate following medical management., Subsequently, the patient underwent Nd:YAG laser capsulohyaloidotomy with no improvement. The overall success rate for laser hyaloidotomy alone was found to be 16% and 25%., Due to incomplete disruption of the anterior hyaloid face, our patient continued to have chronic aqueous misdirection. A possible reason for the patient to continue to have a low-grade form of aqueous misdirection, is that it was a disease triggered by trabeculectomy. Matlach et al. reported that IOP in aqueous misdirection following trabeculectomy is lower than that after other interventions.
Four years after the onset of aqueous misdirection, the patient underwent a successful PPV with irido-zonulo-hyaloidectomy. The goal of management was to empty the vitreous cavity and establish a passage between the anterior and posterior segment, and create a single compartment for easy aqueous flow. The key surgical element was to disrupt the anterior hyaloid face and re-establish the physiological aqueous flow to the AC, there is a report of two cases of aqueous misdirection following core vitrectomy, which highlights the importance of irido-zonulo-hyaloidectomy. Al Bin Ali et al., reported the largest retrospective review of 69 eyes that underwent PPV for malignant glaucoma. In their study, they found that surgical intervention within 4 weeks of presentation was associated with two lines improvement of best-corrected visual acuity and overall functional success. The interval between diagnosis and surgical intervention was inversely proportional to the success of surgery. Our patient underwent PPV with irido-zonulo-hyaloidectomy 4 years after the diagnosis of low-grade aqueous misdirection, with successful anatomical and visual outcome. The pseudophakic status of our patient was an important favorable prognostic factor. Tsai et al. evaluated the success rate of PPV alone in pseudophakic compared with phakic patients, the success rate was reported to be 67% in pseudophakic patient compared to 25% in phakic patients.
In conclusion, PPV with irido-zonulo-hyaloidectomy may result in a complete resolution of chronic low-grade aqueous misdirection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al Bin Ali GY, Al-Mahmood AM, Khandekar R, Abboud EB, Edward DP, Kozak I. Outcomes of pars plana vitrectomy in the management of refractory aqueous misdirection syndrome. Retina 2017;37:1916-22.
Grzybowski A, Kanclerz P. Acute and chronic fluid misdirection syndrome: Pathophysiology and treatment. Graefes Arch Clin Exp Ophthalmol 2018;256:135-54.
Simmons RJ. Malignant glaucoma. Br J Ophthalmol 1972;56:263-72.
Debrouwere V, Stalmans P, Van Calster J, Spileers W, Zeyen T, Stalmans I. Outcomes of different management options for malignant glaucoma: A retrospective study. Graefes Arch Clin Exp Ophthalmol 2012;250:131-41.
Tsai JC, Barton KA, Miller MH, Khaw PT, Hitchings RA. Surgical results in malignant glaucoma refractory to medical or laser therapy. Eye (Lond) 1997;11 (Pt 5):677-81.
Matlach J, Slobodda J, Grehn F, Klink T. Pars plana vitrectomy for malignant glaucoma in nonglaucomatous and in filtered glaucomatous eyes. Clin Ophthalmol 2012;6:1959-66.
Massicotte EC, Schuman JS. A malignant glaucoma-like syndrome following pars plana vitrectomy. Ophthalmology 1999;106:1375-9.
[Figure 1], [Figure 2]