Malignant Glaucoma Treatment & Management

Updated: May 31, 2016
  • Author: Mauricio E Pons, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

The first line of treatment should be medical. [18] The goal is to decrease aqueous humor production, shrink the vitreous body, and move the iris-lens diaphragm backward. 

Cycloplegic agents, including tropicamide, cyclopentolate, and topical atropine, paralyze the sphincter muscle of the ciliary body, increasing zonular tension with flattening and posterior movement of the lens and deepening the anterior chamber.

Topical phenylephrine is used to tighten the zonules by stimulating the longitudinal muscle of the ciliary body.

Topical beta-blockers, alpha-adrenergic agonists, and topical and oral carbonic anhydrase inhibitors are effective in decreasing aqueous humor production and lowering intraocular pressure, presumably decreasing aqueous misdirection.

Osmotic agents used to decrease vitreous volume include oral glycerol or isosorbide, or intravenous mannitol. Hyperosmotic agents are very effective in lowering intraocular pressure and have an onset of action in minutes reaching its maximum peak at 60 minutes. They should be used with caution due to possible metabolic disorders and intravascular volume overload; they are contraindicated in patients with renal or heart failure.

Medical treatment works in approximately one half of patients. Medical management should be continued unless intraocular pressure is higher than acceptable, given the state of the optic nerve. Also, flat anterior chamber with lens-corneal touch and increased intraocular pressure is an indication to proceed with surgical therapy. Once the condition resolves, medications can be withdrawn gradually. The condition may recur when therapy is decreased. Atropine may be required indefinitely to prevent recurrences.

Bimatoprost, travoprost, tafluprost, and latanoprost are effective new medications for lowering intraocular pressure in patients with glaucoma and ocular hypertension. Prostaglandin analogues reduce intraocular pressure by increasing uveoscleral aqueous outflow; however, their role in the treatment of malignant glaucoma is not clearly defined.

Malignant glaucoma with a low IOP is treated in the same way as malignant glaucoma.

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Surgical Care

Argon laser can be used through a peripheral iridectomy to diminish the volume of ciliary processes and, therefore, ciliolenticular block. In 1980, Herschler reported that transpupillary laser shrinkage of ciliary processes in aphakic patients was successful in reversing the posterior secretion of aqueous humor and restoring anterior chamber depth. [19]

YAG laser can break the anterior hyaloid to allow free movement of fluid from the vitreous cavity to the anterior chamber. Hyaloidotomy is preferably performed in the peripheral hyaloid through a large peripheral iridectomy to avoid lens injury in phakic patients and to prevent lens capsule or retained cortical material to obstruct the fluid path in pseudophakic patients. Clear media is required to perform laser treatment for optimal focusing.

If medical or laser treatment fails or if lens-corneal touch occurs, surgery should be considered.

Pars plana vitrectomy, with or without lensectomy, disrupts the impermeable anterior vitreous face and reduces the vitreous volume. The goal is to create a direct communication between the vitreous cavity and the anterior chamber. In phakic eyes, anterior vitreous is difficult to remove without damaging the lens; therefore, treatment is less likely to succeed.

Pars plana vitrectomy combined with pars plana insertion of an aqueous shunt can lower the intraocular pressure and prevent an increase in vitreous volume, reducing the recurrence of malignant glaucoma. [20]

Byrnes et al reviewed the medical records of 21 patients with pars plana vitrectomy surgery for malignant glaucoma. [21] Vitrectomy was unsuccessful in alleviating glaucoma in 6 eyes, 5 of them were phakic. Zacharia and Abboud reported a case of malignant glaucoma after pars plana vitrectomy in which the hyaloid face was left intact. [22]

Debrouwere et al reported that complete vitrectomy, iridectomy, zonulectomy, and phacoemulsification when appropriate were more successful than other forms of therapy. [23] Sclerectomy combined with phacoemulsification, zonulectomy, hyaloidectomy, and anterior vitrectomy have been used in patients with nanophthalmos and malignant glaucoma. [24]

Because pseudophakic patients often have retained cortex in the peripheral capsule, core vitrectomy, anterior hyaloidectomy, and removal of peripheral cortical elements are necessary to create a fluid path from the posterior segment to the anterior chamber. Lynch et al proposed such a method to surgically treat malignant glaucoma in pseudophakic patients. [25] A pars plana approach is advised. A core vitrectomy and peripheral anterior hyaloidectomy are performed. A small area of lens zonules and capsule is excised. This is accomplished using low suction with a high-cutting frequency. Visualization through a previous iridectomy reduces complications and risk to the lens optic and haptics. When visualization is poor in spite of the presence of a peripheral iridectomy, the probe tip can be used to gently push against the posterior capsule and lens optic. The haptics can be identified because they distort the iris anteriorly.

Zarnowski et al described a new surgical approach consisting of anterior vitrectomy performed through the clear cornea, zonulectomy, peripheral capsulectomy, and iridectomy in patients with pseudophakic malignant glaucoma. [26]

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