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 Table of Contents  
Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 302-305

A refractory malignant glaucoma posttrabeculectomy in vitrectomized eye: A case report and review of the literature

1 Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Ophthalmology, Kaohsiung Medical University Hospital; Department of Ophthalmology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Submission25-Jan-2019
Date of Acceptance24-Aug-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Dr. Kwou-Yeung Wu
Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung; Department of Ophthalmology, College of Medicine, Kaohsiung Medical University, Kaohsiung
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjo.tjo_8_19

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The objective of this study is to report a case of refractory malignant glaucoma post trabeculectomy in vitrectomized eye and review of previous literature in PubMed database. A 63-year-old male encountered malignant glaucoma after trabeculectomy in vitrectomized eye. We had tried vitreous tapping with peripheral iridectomy and vitreous tapping with intracameral injection of room air (Chandler procedure). All of previous procedures were in vain. Finally, the yttrium–aluminum–garnet laser membranectomy with zonulectomy was done. The intraocular pressure is within normal range without any topical glaucoma eye drops during 3-year outpatient department regular follow-up. Complete vitrectomy with a patent tunnel from posterior chamber to anterior chamber (iridectomy-zonulectomy) is the effective procedure to manage of malignant-like glaucoma.

Keywords: Iridectomy-zonulectomy, malignant glaucoma, vitrectomy

How to cite this article:
Lai HC, Wu KY, Tseng HY. A refractory malignant glaucoma posttrabeculectomy in vitrectomized eye: A case report and review of the literature. Taiwan J Ophthalmol 2020;10:302-5

How to cite this URL:
Lai HC, Wu KY, Tseng HY. A refractory malignant glaucoma posttrabeculectomy in vitrectomized eye: A case report and review of the literature. Taiwan J Ophthalmol [serial online] 2020 [cited 2021 Nov 27];10:302-5. Available from: https://www.e-tjo.org/text.asp?2020/10/4/302/278384

  Introduction Top

Malignant glaucoma was first described by von Graefe in 1869 as a rare condition characterized by a shallow or flat central and peripheral anterior chamber, elevated intraocular pressure (IOP), and the presence of a patent iridotomy without suprachoroidal fluid.[1] It was also named as ciliary block glaucoma, aqueous misdirection syndrome, or cilio-vitreo-lenticular block syndrome.

The pathophysiology of malignant glaucoma is multifactorial and is still not fully understood. Initially, the ciliary body touches the anterior vitreous surface, which causes posterior drainage of aqueous fluid. Subsequent misdirection of aqueous flow posteriorly causes a pressure gradient between the vitreous cavity and the anterior chamber, which results in anterior herniation of lens-iris diaphragm.[2],[3] Malignant glaucoma is frequently noticed after incisional surgery for primary angle-closure glaucoma. Trabeculectomy is the most commonly mentioned incision surgery to cause malignant glaucoma such as glaucoma tube shunt implantation (Baerveldt implant and Ahmed valve), lens extraction extracapsular cataract extraction (ECCE), laser iridotomy, penetrating keratoplasty, and vitrectomy were all mentioned before.[4],[5],[6],[7],[8],[9],[10]

Several medical, laser based, and surgical treatments for malignant glaucoma have been reported. Treatments such as topical cycloplegic agent to push back the iris-lens diaphragm, aqueous suppressants eye drops and oral carbonic anhydrase inhibitors, and systemic hyperosmotic agents should be considered the first-line therapy. These treatments have been reported to relief 50% of malignant glaucoma condition.[11],[12] Other adjuvant or advanced laser treatment includes neodymium-doped yttrium–aluminum–garnet (YAG) laser capsule hyaloidotomy and transcleral cyclodiode laser. Surgical management may be the last resort, which includes Chandler procedure, vitrectomy, and iridectomy-zonulectomy-hyaloidectomy-vitrectomy.

Because vitrectomy is a surgical treatment of malignant glaucoma, we will present a case of malignant glaucoma posttrabeculectomy in a vitrectomized eye.

  Case Report Top

A 63-year-old male had a medical history of well-controlled diabetic mellitus and hypertension. He had undergone pars plana vitrectomy, endolaser, and gas tamponade in 2010 for left eye rhegmatogenous retinal detachment. He underwent bilateral cataracts surgery sequentially in 2010 and 2011. This time, he was referred to our clinic for refractory IOP control with initial IOP up to 50 mmHg for 1 month. At the first visit, completely closed-angle and shallow anterior chamber depth with 1+ of cell were noticed. Under the impression of secondary angle-closure of uveitic glaucoma hyphema syndrome, we performed a lower laser peripheral iridotomy and kept topical IOP lower agent use.

Three weeks later, poor IOP control was noted even with additional glaucoma eye drops and oral acetazolamide, he underwent trabeculectomy. Two weeks after trabeculectomy, elevated IOP with Grade 2 flat anterior chamber was noticed [Figure 1]. The B-scan rule out suprachoroidal effusion and ultrasound biomicroscopy (UBM) revealed anterior rotation of ciliary body [Figure 2]. Under the impression of malignant glaucoma, 25G vitreous tapping and inferior peripheral iridectomy (surgical enlargement of previous laser iridotomy) were done under emergency. Then, topical 1% atropine every 8 h and topical steroid were given.
Figure 1: Steamy cornea with Grade 2 flat anterior chamber

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Figure 2: Upper picture revealed flat anterior chamber. Lower picture revealed anterior rotation of the ciliary body

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One week later, recurrent elevated IOP and flat anterior chamber were noticed during regular postoperative follow-up. He underwent an emergent 25G vitreous tapping with intracameral injection of room air (Chandler procedure). After operation, we titrated the 1% atropine to every 6 h. Five days later, the third times elevated IOP up to 40 mmHg was noticed. The slit-lamp examination revealed the flat anterior chamber and fibrin occlusion of the inferior peripheral iridectomy. YAG laser membranectomy was done with power 4.0 mJ, and lens zonular was noticed. Then, we performed zonulectomy with YAG laser power 3.5 mJ, and massive fluid drainage from the vitreous cavity was noted. The anterior chamber became deeper immediately [Figure 3]. There was no recurrent malignant glaucoma episode and IOP within the normal range without any IOP-lowering agent during 3-year outpatient department regular follow-up.
Figure 3: Superior columns revealed flat anterior chamber and fibrin occlusion of inferior peripheral iridectomy. Inferior columns revealed patent peripheral iridectomy and deeper anterior chamber immediately after yttrium–aluminum–garnet laser membranectomy with zonulectomy

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  Discussion Top

The pathophysiology of malignant glaucoma is multifactorial but poorly understood. Chandler et al. found that the laxity of lens zonules coupled with pressure from the vitreous leads to forward lens movement. Shaffer and Hoskins suggested that posterior drainage and accumulation of aqueous, which causes secondary iris-lens diaphragm anterior movement.[13] Some studies revealed fluid accumulation behind vitreous gel and believe that prevented the fluid flow to normal direction,[14],[15] however, which mechanism causes the misdirection of aqueous is still controversial. Chandler found that the laxity of lens zonules coupled with pressure from the vitreous leads to forward lens movement, which may be a predisposing factor to build up the aqueous misdirection cycle.[16] Some studies propose that anterior rotation and swelling of the ciliary body may also be predisposing factors of cilio-vitreous adhesion, which enhances the aqueous misdirection cycle.[17],[18] The swelling of the ciliary body was also noted in our case by UBM. The first and the second time attacks of elevated IOP may cause by inflammatory swelling of the ciliary body. The third time attack of elevated IOP may cause by the block of the peripheral iridectomy.

Vitrectomy has been considered to be efficacious in the treatment of pseudophakic malignant glaucoma. The destruction of the anterior hyaloid membrane seems to block the aqueous misdirection cycle. However, there had been reported that malignant glaucoma on vitrectomized eye, which named as a malignant glaucoma-like syndrome.[19] Several surgical method has been reported to treat malignant glaucoma-like syndrome, such as Chandler procedure, complete vitrectomy, and iridectomy-zonulectomy-hyaloidectomy-vitrectomy.

In the experience of our case, complete vitrectomy with a patent tunnel from vitreous cavity to anterior chamber (iridectomy-zonulectomy) is the efficacious procedure to manage malignant-like glaucoma [Figure 4]a. In completely vitrectomized eyes, the posterior drainage aqueous still pushes the IOL and iris diaphragm anteriorly [Figure 4]b. In only tunnel (iridectomy-zonulectomy) without completely vitrectomized eyes, the residual vitreous may block the tunnel with residual posterior aqueous drainage cycle, which may cause recurrent malignant glaucoma-like syndrome [Figure 4]c and [Figure 4]d. There were similar finds in Debrouwere et al. study.[20]
Figure 4: (a) A patent tunnel from posterior chamber to anterior chamber (iridectomy-zonulectomy) with complete vitrectomy. (b) Only complete vitrectomy. (c) Patent iridectomy-zonulectomy with anterior vitrectomy. (d) Patent iridectomy-zonulectomy with incomplete vitrectomy

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  Conclusion Top

Our case demonstrated a recurrence of malignant glaucoma in vitrectomized eye. In summary of our opinion, complete vitrectomy with a patent tunnel from the posterior chamber to anterior chamber (iridectomy-zonulectomy) is the effective procedure to manage malignant-like glaucoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.

  References Top

Von Graefe A. Contributions to the pathology and therapy of the glaucoma. Arch Ophthalmol 1869;15:108-252.  Back to cited text no. 1
Lippas J. Mechanics and the treatment of malignant glaucoma and the problem of a flat anterior chamber. Am J Ophthalmol 1964;57:620-7.  Back to cited text no. 2
Weiss DI, Shaffer RN, Harrington DO. Treatment of malignant glaucoma with intravenous mannitol infusion. Medical reformation of the anterior chamber by means of an osmotic agent: A preliminary report. Arch Ophthalmol 1963;69:154-8.  Back to cited text no. 3
Harbour JW, Rubsamen PE, Palmberg P. Pars plana vitrectomy in the management of phakic and pseudophakic malignant glaucoma. Arch Ophthalmol 1996;114:1073-8.  Back to cited text no. 4
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.  Back to cited text no. 5
Byrnes GA, Leen MM, Wong TP, Benson WE. Vitrectomy for ciliary block (malignant) glaucoma. Ophthalmology 1995;102:1308-11.  Back to cited text no. 6
Sharma A, Sii F, Shah P, Kirkby GR. Vitrectomy-phacoemulsification-vitrectomy for the management of aqueous misdirection syndromes in phakic eyes. Ophthalmology 2006;113:1968-73.  Back to cited text no. 7
Jacoby B, Reed JW, Cashwell LF. Malignant glaucoma in a patient with Down's syndrome and corneal hydrops. Am J Ophthalmol 1990;110:434-5.  Back to cited text no. 8
Nguyen QH, Budenz DL, Parrish RK 2nd. Complications of Baerveldt glaucoma drainage implants. Arch Ophthalmol 1998;116:571-5.  Back to cited text no. 9
Martínez-de-la-Casa JM, García-Feijoó J, Castillo A, Polo V, Larrosa JM, Pablo L, et al. Malignant glaucoma following combined Ahmed valve implant and phacoemulsification surgery for chronic angle-closure glaucoma. Arch Soc Esp Oftalmol 2005;80:667-70.  Back to cited text no. 10
Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol 1968;66:495-502.  Back to cited text no. 11
Simmons RJ. Malignant glaucoma. Br J Ophthalmol 1972;56:263-72.  Back to cited text no. 12
Shaffer RN, Hoskins HD. The role of vitreous detachment in aphakic and malignant glaucoma. Trans Am Acad Ophthalmol Otolaryngol 1954;58:217-28.  Back to cited text no. 13
Shaffer RN, Hoskins HD Jr. Ciliary block (malignant) glaucoma. Ophthalmology 1978;85:215-21.  Back to cited text no. 14
Buschmann W, Linnert D. Echography of the vitreous body in case of aphakia and malignant aphakic glaucoma (author's transl). Klin Monbl Augenheilkd 1976;168:453-61.  Back to cited text no. 15
Chandler PA. Malignant glaucoma. Am J Ophthalmol 1951;34:993-1000.  Back to cited text no. 16
Epstein DL, Hashimoto JM, Anderson PJ, Grant WM. Experimental perfusions through the anterior and vitreous chambers with possible relationships to malignant glaucoma. Am J Ophthalmol 1979;88:1078-86.  Back to cited text no. 17
Heindl LM, Koch KR, Cursiefen C, Konen W. Optical coherence tomography and ultrasound biomicroscopy in the management of pseudophakic malignant glaucoma. Graefes Arch Clin Exp Ophthalmol 2013;251:2261-3.  Back to cited text no. 18
Hosoda Y, Akagi T, Yoshimura N. Two cases of malignant glaucoma unresolved by pars plana vitrectomy. Clin Ophthalmol 2014;8:677-9.  Back to cited text no. 19
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.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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