Malignant Glaucoma Clinical Presentation

Updated: Sep 20, 2018
  • Author: Mauricio E Pons, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Presentation

History

Typically, patients with narrow-angle or acute or chronic angle-closure glaucoma, who recently underwent filtration surgery, present shortly after surgery; however, it can develop months later or even in the absence of surgery.

Patients may present with pain and discomfort, increasing redness, blurring, or decreased visual acuity.

Pain may be severe enough to cause nausea and induce vomiting, similar to an attack of acute angle-closure glaucoma.

Precipitating factors are suture lysis, initiation of miotic therapy, or discontinuation of cycloplegics.

Shallowing of the anterior chamber due to wound leak must be ruled out by performing a Seidel test during slit lamp examination.

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Physical

In malignant glaucoma, slit lamp examination reveals anterior displacement of the lens-iris diaphragm in phakic patients and the anterior hyaloid face in aphakic patients, shallowing of the central and peripheral anterior chamber, and elevated intraocular pressure with a patent iridectomy present.

Optically clear spaces can be observed within the vitreous cavity and have been interpreted as pockets of fluid.

With the Goldman lens, a completely closed angle can be observed. Choroidal detachments or suprachoroidal hemorrhage should be ruled out using the goniolens mirrors and indirect ophthalmoscopy. The retina should be evaluated for vascular occlusions, and the vitreous should be evaluated for possible hemorrhages. B-mode ultrasound can be extremely useful if direct visualization is not possible.

Malignant glaucoma is not caused by pupillary block where laser iridotomy can relieve the flow obstruction. In malignant glaucoma, a patent iridectomy must be demonstrated. If not, a new laser iridotomy must be performed.

Ultrasound biomicroscopy has demonstrated anterior rotation of the ciliary body with apposition to the ciliary process in contact with the lens equator and anterior displacement of the ciliary body and lens, causing iridocorneal touch and appositional angle closure in these patients.

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Causes

The exact mechanism that leads to malignant glaucoma is not clearly understood. Movement of aqueous humor from the posterior chamber into the vitreous instead of draining to the anterior chamber may be the cause.

Malignant glaucoma may occur within hours to days or years after surgery. Most commonly, it is seen after trabeculectomy or surgical iridectomy. This condition may be noted after the cessation of cycloplegic drops or the initiation of miotic therapy after surgery for angle-closure glaucoma.

The fellow eye is predisposed strongly to develop malignant glaucoma.

In 1954, Shaffer proposed that misdirection of aqueous humor into the vitreous body or around it was the pathogenic mechanism. [14]

In 1972, Levene suggested that malignant glaucoma results from forward movement of the lens with direct closure of the angle intensified by surgery, and it represents a more severe form of angle-closure glaucoma. [15] The tone of the ciliary body muscle and the tension of the zonules could explain the anterior movement of the lens.

Epstein et al hypothesized that a sustained expansion in total vitreous volume moves available peripheral anterior hyaloid into apposition with the posterior ciliary body increasing the resistance for anterior fluid transfer and causing forward displacement of the lens-iris diaphragm and shallowing of the anterior chamber. [5]

In 1980, Quigley incorporated data from Fatt into this theory and proposed that dehydrated and compressed vitreous with a decreased fluid conductivity establishes a vicious circle of elevated pressure and anterior chamber shallowing. [16, 17]

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