Introduction
Methodology
Article | Suggested name of syndrome | No. of eyes (incidence) | Performed procedure | Risk factors | Time of occurrence during surgery | Presumed pathomechanism | Suggested treatment | Outcome (follow-up period) |
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Kam et al. 2016 [2] | Acute intraoperative rock-hard eye syndrome | Two eyes (2/736 phaco procedures) | Phaco + IOL | N/A | During surgery (not described) | Freeing tenacious cortex, direct irrigation with a straight or a curved cannula of the inferior or superior capsular bag fornix, may contribute to finding materials in the vitreous. When repeated with a single, potentially powerful jet of balanced salt irrigated through a syringe and a cannula, may lead to transgression of the zonular apparatus by the balanced salt solution and small pieces of lens material. | Emergent pars plana needle aspiration of retrolenticular fluid with a 23-gauge needle | Good — AC deepening |
Lau et al. 2014 [3] | Acute intraoperative rock-hard eye syndrome | Six eyes (6/413 phaco procedures) | Phaco + IOL | - Higher levels of AC irrigation - Hyperopia | Not only from the phacoemulsification but also from hydrodissection, hydrodelineation, and irrigation of the posterior capsule and equatorial cortex with a hydrodissection cannula. | Residual cortical fiber irrigation maneuver (when residual cortical fibers are being removed, the narrow stream of balanced salt solution generated by the narrow hydrodissection cannula tip may distort the posterior capsule locally) resulting in localized anterior displacement of the contiguous posterior capsule, creating a subcapsular or vitreal space through which the balanced salt solution may move via the zonular fibers. | Emergent pars plana (3 mm from limbus) needle aspiration of retrolenticular fluid with a 23-gauge needle | Good post-op visual acuity and normal IOP. Complications: - mild vitreous hemorrhage (one eye) - temporal arteritis (one eye 1 month post-op) |
Mackool et al. 1993 [4] | Infusion misdirection syndrome | N/A | Phaco + IOL | - Exfoliation - Dense/brunescent cataract | During surgery, especially at the time of removal of the last nuclear pieces | Aqueous can be directed posteriorly behind an intact lens and cause chamber shallowing: - when fluid passes through an opening in the posterior capsule or the equatorial region (especially likely after can-opener capsulotomy or radial extension of capsulorhexis), permitting direct access to the retrocapsular space - in the presence of an intact capsule (intact rim by capsulorhexis) fluid passes through the region of the zonular fibers. More commonly in association with lax zonular fibers | - Viscoadaptive agent to the AC - Pars plana decompression | N/A |
Olson et al. 1994 [5] | Subcapsular fluid entrapment | Five eyes | Penetrating keratoplasty + ECCE + IOL (two eyes) phaco + IOL (three eyes) | - Open sky I/A - Zonular dialysis | During surgery | - Irrigation anterior to the AC flap - Zonular dehiscence | - Dry aspiration (three eyes) - Pars plana paracentesis (one eye) - Spontaneous central capsule rupture (one eye) | Good — AC deepening Paracentesis unsuccessful in one eye — IOL implanted 2 months post-op |
Dewey 2011 [6] | Intraoperative fluid misdirection | Three eyes | Phaco + IOL | - Coughing - Short axial length - Significantly intumescent lens | During surgery | N/A | - Viscoadaptive agents to the AC and dry aspiration (mild cases) - Sharp needle decompression, or automated vitrectomy handpiece to avoid potential vitreous traction (severe cases) - Benzonatate capsules (Tessalon Perles) for patients with a history of coughing, “sinus drainage,” chronic obstructive pulmonary disease, bronchitis, asthma, sleep apnea, snoring, use of supplemental oxygen, difficulty breathing in the supine position for any reason, and at the preoperative nurse’s suspicion. | Good — AC deepening |
Grzybowski et al. 2014 [7] | Acute / chronic aqueous misdirection syndrome | N/A | Phaco + IOL | N/A | During surgery - toward the end of irrigation/aspiration | Inappropriate “movement of the balanced salt solution via the zonular fibers” triggered by the unconventional use of the residual cortical fiber irrigation maneuver | Pars plana decompression with vitreous cutter | Good — AC deepening |
Wu et al. 2016 [8] | Malignant glaucoma | Thirty-eight eyes (of 1432 eyes undergoing anti-glaucoma surgical treatment for primary angle closure glaucoma) | - After trabeculectomy (32 eyes — 84.2%) - during trabeculectomy (four eyes — 10.5%) - after combined glaucoma/cataract surgery (two eyes — 5.3%) | During or after surgery | 1) Ciliolenticular block or anterior hyaloid obstruction 2) Slackness of lens zonules 3) Severe postoperative inflammation 4) Non ciliary block. It was observed that those patients who developed malignant glaucoma during surgery all showed a high stress level and poor operative cooperation. We speculated that such status caused constriction of extraocular muscles pressing forward, bringing about the increase of ocular venous pressure. |
Article | Suggested name of syndrome | No. of eyes (incidence) | Performed procedure | Risk factors | Time of occurrence related to time of surgery | Presumed pathomechanism | Suggested treatment | Outcome (follow-up period) |
---|---|---|---|---|---|---|---|---|
Little et al. 1993 [9] | Malignant glaucoma, ciliolenticular block, ciliovitreal block, iridovitreal block, aqueous misdirection or aqueous diversion syndrome | Seven eyes (7/ 12,000 surgeries) | - ECCE + IOL (four eyes) - ECCE + IOL + trabeculectomy (two eyes) - trabeculectomy (one pseudophakic eye) | N/A | 1 week–7 months | Cilio-lenticular block of aqueous flow leading to the misdirection of aqueous posteriorly into or in front of the vitreous gel leading to the characteristic diffuse shallowing of the AC accompanied by a precipitous rise in IOP. | Nd:YAG laser capsulotomy and/or vitreolysis | IOP stabilized in five of seven eyes |
Sharma et al. 2006 [10] | Aqueous misdirection syndrome | Five eyes | - Trabeculectomy (one eye) - Redo-trabeculectomy (one eye) - YAG LPI (one eye) - spontaneous, following branch retinal vein occlusion, NdYAG LPI, trabeculectomy, cyclodiode (one eye) - N/A (though phaco-emulsification of the cataract in the fellow eye had resulted in a severe postoperative aqueous misdirection syndrome) | Hyperopia | 1 day–3 months | Blockage of anterior aqueous flow at the level of the ciliary body combined with an inherent impermeability defect in the anterior hyaloid. Abnormal anatomic relationship between the ciliary body, anterior hyaloid, and lens in hyperopic eyes. A forward displacement of the anterior vitreous with apposition of the anterior hyaloid face against the lens and ciliary body prevents the normal anterior flow of aqueous humor. Subsequent misdirection of aqueous flow posteriorly and its accumulation in the posterior segment, with increasing posterior pressure, results in anterior displacement of the iris–lens diaphragm, axial and peripheral AC flattening, and secondary angle closure | Core vitrectomy - phacoemulsification - vitrectomy with iridozonulohyaloidectomy | IOP stabilization with topical hypotensive agents Complications: - serosanguinal choroidal effusion in one eye (16 months/range 5–32) |
Meng et al. 2014 [11] | Ciliary block glaucoma | Eleven eyes (of nine patients) | - Trabeculectomy with peripheral iridectomy | Primary angle closure glaucoma | 3.9 ± 4.1 (range 1–11) days | Lens disproportion and lens–ciliary body apposition in small eyes and anterior hyaloid changes, with increased hydraulic resistance, are thought to be the major pathophysiological factors. In addition, unfavorable vitreous flow and an expansion of the choroidal volume in small eyes may be involved in malignant glaucoma. These anatomical characteristics lead to aqueous humor misdirection into the vitreous cavity and cause forward movement of the lens–iris diaphragm | AC infusion followed by single port 25-G anterior vitrectomy, phaco + IOL in phakic eyes, posterior capsulectomy with anterior hyaloid face removal until sudden pupil dilatation and deepening of the AC is achieved | Although IOP control was achieved in all eyes after surgery, two eyes required long-term topical antiglaucoma medication (6–18 months) |
Rekas et al. 2015 [12] | Malignant glaucoma | Twenty-two eyes (22/1689 glaucoma surgeries, 2.3% penetrating glaucoma procedures, 0% of non-penetrating procedure) | - Phacoiridencleisis (40.9%) - Phacotrabeculectomy (22.7%) - Iridencleisis (18.2%) - Trabeculectomy (13.6%) - Seton valve implantation (4.6%) | Penetrating glaucoma surgery | Average 61 days (1–840 days) | Aqueous humor accumulates in the area of the vitreous cavity due to ciliary block, and, as a result of this, there is an increase in the vitreous pressure that is transferred to the structures of the anterior segment causing a forward movement of the lens-iris diaphragm | 25-gauge vitrectomy with iridectomy/iris-lens/iridocorneal/iris-capsule adhesions released. Authors suggest quick implementation of surgical treatment. | IOP ≤ 21 mmHg without topical hypotensive agents in 49.0% after 12 months, IOP ≤ 21 mmHg with a maximum of two topical hipotensive agents in 85.7% after 12 months (mean 405 days / range 7–1440 days) |
Premsenthil et al. 2012 [13] | Positive vitreous pressure glaucoma | One eye | LPI | N/A | 1 year | In malignant glaucoma, a vicious cycle of poorer vitreous fluid conductivity and increased transvitreal pressure is established. This results in compression of the vitreous gel, progressive forward displacement of the lens-iris diaphragm and eventual direct closure of the AC angle despite the presence of patent iridotomy | PPV, phacoemulsification, primary posterior capsulotomy, and posterior chamber IOL implantation. | IOP stabilization (6 months) |
Pasaoglu et al. 2012 [14] | Malignant glaucoma | Two eyes | - Trabeculectomy (one pseudophakic eye) - Phaco + IOL, recurrence of malignant glaucoma 9 months after PPV with capsulotomy and peripheral iridectomy (one eye) | N/A | 1 week–1 month | Relationship of the lens, ciliary body, and anterior hyaloid face causing an aqueous misdirection and blockade was suggested in the pathogenesis. The aqueous has been thought to be entrapped inside the vitreous cavity as aqueous pockets resulting in forward movement of the iris-lens diaphragm which causes the secondary angle closure glaucoma. | Patients were treated successfully by using an AC approach consisting of a capsulo-hyaloidectomy and anterior vitrectomy performed through a peripheral iridectomy, creating a permanent passage between the AC and vitreous cavity by eliminating the aqueous misdirection. | IOP stabilization (5 months) |
Zarnowski et al. 2014 [15] | Ten eyes | - Phacotrabeculectomy (four eyes) - Trabeculectomy (three eyes) - phaco + IOL (three eyes) | - History of primary angle closure - Hyperopia | N/A | All of the tissues (iris, lens capsule, zonule, and anterior vitreous) have to be removed to create a permanent passage between the AC and the vitreous cavity. Part of the problem is that, during conventional vitrectomy peripheral vitreous can hardly be completely removed, and that is why relapse rate may be very high. | Anterior hyaloidectomy combined with peripheral iridectomy, zonulectomy, and peripheral capsulectomy | IOP stabilization (12 months/range 6–18.0 months) | |
Shahid et al. 2012 [16] | Direct lens block glaucoma | (0.4–6% of incisional surgery for primary angle-closure glaucoma) | - Incisional surgery for primary angle-closure glaucoma - After cataract extraction - Spontaneously, LPI, trabeculectomy scleral flap suture lysis, cyclophotocoagulation, use of miotics and trabeculectomy bleb needling. Sporadically in association with infection, retinopathy of prematurity, retinal detachment, retinal vein occlusion and trauma. | - Tendency in an individual (as it often occurs in fellow eyes) | Immediate postoperative period to many years after surgery | - Posterior diversion of aqueous flow causes accumulation of aqueous behind a posterior vitreous detachment with secondary forward movement of the iris-lens diaphragm - Laxity of lens zonules coupled with pressure from the vitreous leads to forward lens movement. A vicious circle is set up in that the higher the pressure in the posterior segment, the more firmly the lens is held forward. - Choroidal expansion | Cycloplegics, aqueous suppressants, osmotic agents and steroids. Cataract extraction with IOL implantation, posterior capsulotomy and vitrectomy in phakic eyes. In aphakic/pseudophakic eyes the following procedures were performed: - Nd:YAG laser capsulotomy and disruption of anterior hyaloid face - Transscleral cyclodiode laser - Vitrectomy. | N/A |
Madgula et al. 2014 [17] | Ten eyes | - Phacotrabeculectomy - Trabeculectomy with mitomycin - Phaco + IOL - ECCE - Phacovitrectomy | N/A | N/A | Various anomalies of the ciliary body, choroid, lens, zonule, and vitreous which may lead to posterior diversion of aqueous humor into the vitreous cavity have been proposed. Anterior rotation of the ciliary body processes can lead to cilio-lenticular touch and ciliary block | Zonulo-hyaloido-vitrectomy (anterior approach) | Malignant glaucoma recurred in four eyes. The reasons are blockage of the channel by vitreous or fibrin. Complications: - macular hole - cystoid macular edema - corneal decompensation (50.2 ± 27.2 months) | |
Lois et al. 2001 [18] | Malignant glaucoma | Five pseudophakic eyes | - Phacotrabeculectomy (three eyes) - Phaco + IOL (one eye) - Trabeculectomy (one eye) | N/A | N/A | Existence of an abnormal anatomic relationship between the ciliary processes, the crystalline lens, or IOL and anterior vitreous face, which leads to misdirection of aqueous fluid into the vitreous cavity | Zonulo-hyaloido-vitrectomy (anterior approach) | Resolution of the malignant glaucoma was achieved in all cases. In one patient with extensive anterior synechiae, bleb failure occurred after the resolution of the malignant glaucoma. This patient was treated successfully with a guarded filtration procedure supplemented with 5-fluorouracil. (1–9 months) |
Varma et al. 2014 [19] | Malignant glaucoma | Twenty eyes | Phaco + IOL | - Female hyperopic patients | 5.8 ± 7.1 weeks | Ciliolenticular block presumably induced by anterior movement of the lens–iris diaphragm, poor vitreous conductivity, and choroidal expansion. | - Medical therapy: cycloplegics and aqueous suppressants - Nd:YAG Iridozonulohyaloidotomy - AC reformation/IOL pushback - Iridozonulohyaloidovitrectomy (pars plana approach) | Symptoms resolved in (IOP control with topical medications): Medical therapy (two eyes) Iridozonulohyaloidotomy (seven eyes) AC reformation–IOL pushback (six eyes) Iridozonulohyaloidovitrectomy (five eyes) |
Dave et al. 2013 [20] | Malignant glaucoma | Twenty-eight eyes | Trabeculectomy (11 eyes) Cataract surgery (ten eyes) Combined cataract and glaucoma surgery (seven eyes). | N/A | N/A | Misdirection of aqueous into or behind the vitreous body that is responsible for an increase in vitreous volume and subsequent obliteration of the anterior and posterior chambers. | 1. Medical management included topical cycloplegics (atropine or cyclopentolate) and topical / oral aqueous suppressants. Intravenous 20% mannitol in a dose of 1 mg/kg was administered at the discretion of the treating physician. 2. Nd:YAG Laser hyaloidotomy in pseudophakic eyes through an existing peripheral iridotomy or beyond the haptic of the IOL. 3. Vitrectomy-hyaloidotomy-iridotomy (pars plana approach) 4. Transscleral cyclophotocoagulation | IOP <21 mmHg with up to two topical medications in: 1) four eyes 2) seven eyes 3) four eyes 4) 11 eyes In two eyes repeated transscleral cyclophotocoagulation was required — in one eye symptoms have not resolved (192 days/ range 35–425 days) |
Stumpf et al. 2008 [21] | Aqueous misdirection syndrome | Five eyes | - Phacoemulsification (one eye) - Phacoemulsification and trabeculectomy (three eyes) - Phacotrabeculectomy (one eye) | - Hyperopia / short axial length (< 22.64 mm) - Narrow iridocorneal angle - Shallow AC | Directly after surgery to 2 years | n/a | Large posterior Nd:YAG laser capsulotomy / LPI was ineffective in deepening the AC. Transscleral cyclophtotocoagulation (9–33 pulses) of 2–2.5 W for 2 s in 1–2 quadrants | All cases responded rapidly, though in one eye required a subsequent second application a year later (15–96 months) |
Heindl et al. 2013 [22] | One eye | Phaco + IOL | N/A | 10 days | Ultrasound biomicroscopy shows anterior rotation of the ciliary body processes suggests a blocking mechanism between ciliary processes, IOL, lens capsule, and anterior vitreous face. | 23-gauge PPV combined with iridectomy and peripheral removal of lens capsule behind the iridectomy site at the 1–2-o’clock position. | Complete resolution (6 months) | |
Prata et al. 2013 [23] | Malignant glaucoma | Thirty-one eyes | - Trabeculectomy with mitomycin (14 eyes) - Phaco + IOL (8 eyes) - Phacotrabeculectomy with mitomycin (three eyes) | - Plateau iris configuration | Median 29 days (range 2–364 days). | Anteriorly rotated ciliary in ultrasound biomicroscopy. A plateau iris configuration, defined as large and/or anteriorly positioned ciliary body abutting the peripheral iris, partial visibility or absence of the ciliary sulcus, an iris root that angulates forward and then centrally, presence of a central flat iris plane, and irido-angle contact was noticed in 85% of eyes | N/A | N/A |
Debrouwere et al. 2012 [24] | Malignant glaucoma | Twenty-four eyes | - Trabeculectomy (11 eyes) - Phaco + IOL (eight eyes) - Phacotrabeculectomy (one eye) - Diode laser cyclodestruction (one eye) - ICCE (one eye) - Iridotomy (one eye) - Nd:YAG LPI (one eye) | - Hyperopia - Chronic angle-closure glaucoma - Shallow AC after surgery | N/A | Anterior rotation of the ciliary body, so the aqueous produced by the ciliary body cannot follow its normal pathway and accumulates behind the iris–lens diaphragm. Subsequent increased pressure in the posterior segment results in an anterior displacement of the iris–lens diaphragm, AC flattening and secondary angle | 1) Medical treatment 2) Nd:YAG laser capsulotomy + hyaloidotomy 3) Vitrectomy 4) Anterior vitrectomy + iridectomy–zonulectomy 5) Full vitrectomy–phaco–iridectomy–zonulectomy | Relapse in: 1) 100% eyes 2) 75% eyes 3) 75% eyes 4) 66% eyes 5) 0% eyes (61 days/range 13–228 days) |
Arya et al. 2004 [25] | Malignant glaucoma | One eye | Nd:YAG laser posterior capsulotomy in pseudophakic eye | - Alteration in the anatomic relationship involving the ciliary body, anterior hyaloid membrane face, and vitreous | Four days | B-scan ultrasonography showed aqueous pockets in the vitreous. Persistent liquefaction of the vitreous leading to shifting of vitreous gel forward and misdirection of aqueous posteriorly. | Nd:YAG LPI, medical treatment followed by PPV with air administration to the AC | Recurrence — 8 days after PPV. Repeated PPV stabilized IOP (6 months) |
Brooks et al. 1989 [26] | Malignant glaucoma | One eye | NdYAG LPI | Five days | Strong tropine-like mydriatics and strong miotics in such patients with very shallow ACs and an unstable lens iris diaphragm. | Panretinal photocoagulation. Medical treatment | Resolution after cancelation of mydriatics | |
Wu et al. 2016 [8] | Malignant glaucoma | Thirty-eight eyes (of 1432 eyes undergoing antiglaucoma surgical treatment for primary angle-closure glaucoma) | - After trabeculectomy (32 eyes — 84.2%) - During trabeculectomy (four eyes — 10.5%) - After combined glaucoma/cataract surgery (two eyes — 5.3%) | During or after surgery | 1) Ciliolenticular block or anterior hyaloid obstruction 2) Slackness of lens zonules 3) Severe postoperative inflammation 4) Non ciliary block. It was observed that those patients who developed malignant glaucoma during surgery all showed a high stress level and poor operative cooperation. We speculated that such status caused constriction of extraocular muscles pressing forward, bringing about the increase of ocular venous pressure. | All patients were initially given medical treatment (four eyes). If medical treatment failed: 1) laser posterior capsulotomy with hyaloidotomy (two pseudophakic eyes) Phakic eyes underwent surgical treatment 2) anterior vitrectomy-reformation of AC was chosen if IOP increased non-progressively, the lens is transparent and the ACdepth is on grade II or shallower according to Spaeth (13 eyes) 3) phaco + IOL with goniosynechialysis and reformation of AC was indicated if progressive IOP increase is associated with the development or worsening of cataract. Anterior vitrectomy procedure was performed if AC failed to form during the surgery (ten eyes) 4) vitreous aspiration or anterior vitrectomy was performed if patients developed malignant glaucoma during surgery (nine eyes). In refractory relapsed eyes with low visual potential, transscleral cyclophotocoagulation was performed. | Thirty of 38 eyes did not require topical treatment achieving IOP <21 mmHg. With topical hipotensive agents: IOP <21 mmHg in four eyes, IOP ranged 23–26 mmHg in four eyes. Complications: One eye exhibited bleeding at the entry site of vitrectomy into vitreous cavity. Corneal endothelial decompensation occurred to one eye, and another eye showed positive response to medical therapy but allergy to atropine. (27.1 ± 9.1 months) | |
Lazar et al. 1981 [27] | Anterior pupillary block | Two eyes | - Surgical peripheral iridectomy (one eye) - Penetrating keratoplasty (one eye) | 8 h–3 days | The mechanism is caused by adhesions between the iris and hyaloid membrane/lens. Pressure disparity between posterior and AC. leads to backward movement of the lens. Further interference of aqueous flow due to by iridocorneal adhesion. | Aspiration of fluid from the posterior chamber with a 25-gauge needle in the slit lamp — under slit-lamp visualization — through cornea and iris/iridectomy. Medical: 1% atropine, 10% phenylephrine, acetazolamide + hypertonic agents (one patient) | A complete reformation of the AC occurred immediately in one eye or in 30 min in one eye | |
Ozeki et al. 2010 [28] | Ciliovitreal block | One eye | Trabeculectomy with unplanned zonulectomy | Two days | Ciliovitreal block caused by the vitreous herniation through the peripheral iridectomy to the limbal incision with flat bleb and AC | Medical: topical atropine, beta-blocker, oral acetazolamide, and intravenous mannitol. Healon5 injected through a paracentesis | This approach was successful, and the malignant mechanism did not recur over a period of almost 2 weeks, until a more rigid and deep AC was constructed by cataract surgery. | |
Massicotte et al. 1999 [29] | Pseudomalignant glaucoma | Two eyes | Partial vitrectomy with C3F8 tamponade (leaving the anterior hyaloid) in phakic eyes | 1–6 days | Obstruction of aqueous flow, either by residual anterior hyaloid or by fibrin and other inflammatory debris at the level of the ciliary body–zonular apparatus. Anterior rotation of the ciliary processes (arrowhead) and an axially shallow and fibrin-filled AC was found in ultrasound biomicroscopy | 1) Medical 2) Nd:YAG LPI and hyaloidectomy through the zonules was performed and resulted in only transient deepening of the AC 3) Vitreous chamber gas was aspirated, and tissue plasminogen activator 10 mg was given intracamerally 4) Phacoemulsification, air–fluid exchange with removal of C3F8 gas and peripheral iridectomy from a posterior approach through the remaining vitreous, zonules, and iris (one eye) | IOP stabilization and AC reformation (1 year) | |
Francis and Babel 2000 [30] | Malignant glaucoma | One eye | PPV with lensectomy, scleral buckling and vitreous injection of 18% SF6
| Fourteen days | Aqueous misdirection apparently requires an intact hyaloid, perhaps with decreased permeability to aqueous or reduced surface area for fluid transfer. Hydration of the vitreous and increase in vitreous volume, exacerbated by expansile gases, may result in elevated IOP and axial shallowing of the AC, even in the presence of a patent iridectomy. | Surgical peripheral iridectomy without any effect on the AC. PPV with a minor buckle release | AC deepening and IOP normalization | |
Al Bin Ali et al. 2016 [31] | Aqueous misdirection syndrome | Sixty-nine eyes | - Cataract surgery (17 eyes — 25%) - Trabeculectomy (nine eyes — 13%) - Phacotrabeculectomy (43 eyes — 62%) | n/a | The authors believe that removal of the anterior hyaloid face is the key to resolving the symptoms of fluid misdirection syndrome, rather than debulking the vitreous. Though they suggest that a two-port PPV with surgical microscope lighting can be as effective as a 3-port procedure | Two-port PPV or three-port PPV. In pseudophakic eyes, a hyaloido-zonulo-iridectomy and posterior capsultomy was performed | Primary functional success rate of PPV in reducing IOP to <21 mmHg was 81%, with recurrence rate 11%. Intraoperative and postoperative complications included retinal detachment in two eyes and endophthalmitis in one eye (3–156 months) | |
Bitrian and Caprioli 2010 [32] | Aqueous misdirection syndrome | Five eyes | - Phacoemulsification (one eye) - Phacoemulsification, trabeculectomy, laser suture lysis (one eye) - Ahmed implant, phacoemulsification, Ahmed revision (one eye) - Phacoemulsification, Nd:YAG laser capsulotomy (one eye) - Phacoemulsification, Ahmed implant, Nd:YAG laser capsulotomy (one eye) | One day–8 months | The exact pathophysiology is not understood fully, but diverse anomalies of the ciliary body, choroid, lens, zonule, and vitreous have been suggested, causing a posterior diversion of the aqueous humor into the vitreous cavity. An anterior rotation of the ciliary body processes, leading to ciliolenticular touch and ciliary block, has been suggested. | Anterior vitrectomy with hyaloido-zonulectomy, peripheral iridectomy (pseudophakic eyes). The infusion line was placed in the AC to deepen it. | This surgical procedure was successful in resolving the aqueous misdirection in all eyes. An anatomic success has been achieved, in most cases IOP normalized (1–13 months) | |
Tsai et al. 1997 [33] | Malignant glaucoma / ciliary block | Twenty-five eyes | Predominantly trabeculectomy. Also cataract extraction, surgical peripheral iridectomy, Molteno implant | n/a | Anatomical obstruction of aqueous flow at the anterior hyaloid/zonule-lens/ciliary process interface. The authors conclude that surgical vitrectomy in the presence of an intact posterior capsule may preclude the surgical resolution of aqueous misdirection. | Anterior vitrectomy or PPV. Additional concomitant cataract extraction should be performed in phakic eyes, preferably with posterior capsulotomy. | Various outcomes depending on the performed surgical procedure. In eyes with pre-existing cataract, combined lens extraction, primary posterior capsulectomy and surgical vitrectomy should be performed (10 days–65 months) | |
Greenfield et al. 1999 [34] | Aqueous misdirection | Ten eyes | Baerveldt glaucoma drainage device implantation. In one eye, concurrent trabeculectomy. | 1–343 days | Overfiltration associated with the drainage device, which developed within 2 months of the implantation We propose that this syndrome results from a cascade of events, which is initiated by external ligature release. This produces immediate overfiltration and shallowing of the AC, anterior rotation of the lens–iris diaphragm, and posterior diversion of aqueous. | Nd:Yag hyaloidotomy. PPV alone (pseudophakic eyes) or with lensectomy (phakic eye) | Normalization of anterior segment anatomy was achieved with aqueous suppression and cycloplegia in one eye; in four eyes after Nd:YAG capsulotomy; in two eyes after PPV; in one eye after PPV with lensectomy; two eyes after PPV with IOL explantation (1–23 months). | |
Lynch et al. 1986 [35] | Malignant glaucoma, ciliovitreal block | Four eyes | - ECCE + IOL and iridectomy (one eyes) - ECCE + IOL and trabeculectomy (one eye) - ICCE with AC IOL implantation and iridectomy (one eye) | - Small eyes with anatomically narrow AC / short axial length - History of narrow angle glaucoma | 2–7 days | Increased resistance of the anterior vitreous is thought to initiate or perpetuate the posterior flow of aqueous humor. This resistance might occur at the level of the ciliary body, and has been called ciliovitreal block. Pseudophakic eyes, especially after ECCE often contain residual cortical lens material, which incites a cellular and fibrous reaction in the equatorial region of the lens capsule. This may contribute to blockage of the aqueous flow through the lens zonules or between the ciliary processes and capsule. | Nd:YAG hyaloidotomy (one eye — unsuccessful) PPV with excision of the lens capsule and zonules (four eyes) | IOP stabilization with or without topical medications and AC deepening in three of four eyes |
Tomey et al. 1987 [36] | Malignant glaucoma, ciliary block, aqueous misdirection | four eyes | - ECCE + IOL (one eye) - ECCE + IOL with trabeculectomy (three eyes) | 1–10 days | Postoperative wound leakage may be a causative factor. It seems plausible that the initial forward movement of the iris-lens diaphragm caused by the wound leak (and perhaps also aggravated by the absence of iridectomy in some cases) starts a cycle of aqueous misdirection and subsequent accumulation in the posterior segment. Interestingly, trabeculectomy openings may very well be considered deliberate leaks. | Nd:YAG hyaloidotomy as first step management PPV (two eyes) | In two eyes IOP was stabilized and AC deepening was achieved with Nd:YAG hyaloidotomy. In two eyes, PPV was required; in one eye it was redone with IOL removal (6–18 months) | |
Harbor et al. 1996 [37] | Malignant glaucoma | Twenty-four eyes | - Trabeculectomy (six eyes) - Trabeculectomy with mitomycin (three eyes) - Nd:YAG LPI (four eyes) - Central retinal vein occlusion (one eye) - ECCE + IOL (six eyes) - ECCE + IOL with trabeculectomy (four eye) | 1–120 days | Posterior misdirection of aqueous flow into or behind the vitreous body, with subsequent increase in vitreous volume and obliteration of the anterior and posterior chambers. | Vitrectomy without lensectomy (nine eyes) Vitrectomy with lensectomy (six eyes) Nd:YAG LPI (two eyes) Nd:YAG laser posterior capsulotomy (three eyes) ECCE (one eye) Surgical peripheral iridectomy (one eye) AC reformation (one eye) Argon laser gonioplasty (one eye) | In phakic eyes, the initial PPV was successful in seven of svene eyes that underwent lensectomy, and in five of seven eyes that did not undergo lensectomy. In pseudophakic eyes the initial vitrectomy was successful in 9/10 eyes. Perioperative complications included: - transient serous choroidal detachment in two eyes - transient exudative retinal detachment in one eye - suprachoroidal hemorrhage in one eye (1–89 months) |
Onset of fluid misdirection | Risk factor | Influence on pathophysiology |
---|---|---|
During phacoemulsification with IOL implantation or trabeculectomy | - Higher levels of anterior chamber irrigation [3] | Residual cortical fiber irrigation maneuver (when residual cortical fibers are being removed, the narrow stream of balanced salt solution generated by the narrow hydrodissection cannula tip may distort the posterior capsule locally) resulting in localized anterior displacement of the contiguous posterior capsule, creating a subcapsular or vitreal space through which the balanced salt solution may move via the zonular fibers. |
Increased localized pressure in the eye. Constriction of extraocular muscles pressing forward, bringing about the increase of ocular venous pressure. | ||
Small hyperopic eyes with shallow anterior chamber, leading to a decrease of surgical space. | ||
Posterior capsule flaccidity might result in bulging or billowing forward | ||
- Pseudoexfoliation [4] | Lax zonular fibers might facilitate the fluid passage through the region of the zonular fibers. | |
During penetrating keratoplasty with extracapsular cataract extraction and IOL implantation | - Open sky irrigation/aspiration [5]) | Irrigation under the iris, anteriorly to the anterior capsule |
Following phacoemulsification with IOL implantation, trabeculectomy or phacotrabeculectomy | Abnormal anatomic relationship between the ciliary body, anterior hyaloid, and lens in hyperopic eyes. Anterior movement of the lens–iris diaphragm accompanied with poor vitreous conductivity and choroidal expansion. | |
Increased resistance of the anterior vitreous initiates the posterior flow of aqueous humor. | ||
- Plateau iris configuration [23] | Anterior rotation of the ciliary body, so the aqueous produced by the ciliary body cannot follow its normal pathway and accumulates behind the iris–lens diaphragm. | |
- Shallow anterior chamber after surgery [21] | A forward displacement of the anterior vitreous with apposition of the anterior hyaloid face against the lens and ciliary body prevents the normal anterior flow of aqueous humor. |