FEATURE EWAP DECEMBER 2023 25 closure, but she added that it can also be seen in predisposed eyes after cataract surgery, iridotomy, or when starting miotic therapy. How to manage malignant glaucoma If you see the chamber shallowing intraoperatively, the first thing to do is determine the cause. Dr. Schlenker said chamber shallowing that is not the result of malignant glaucoma includes leaky wounds, true fluid misdirection through impaired zonules to the posterior chamber, or a suprachoroidal hemorrhage. If the chamber is shallowing, one must address the underlying cause immediately. Check the wounds, and maintain the anterior chamber as much as possible. If the red reflex is dimmed and the fundus exam reveals evidence of a suprachoroidal hemorrhage, he would suture the wounds, form the anterior chamber, and defer any further surgery. If the problem is truly malignant glaucoma, you must consider doing an irido - zonulo - hyaloidotomy. “You need to create a conduit from the back of the eye to the front of the eye to establish an equilibrium; eliminate this pressure gradient between the front and the back of the eye. I usually do an anterior vitrectomy where I’ll do an anterior approach, unless the chamber is so profoundly shallow where I’d have to do a pars plana approach,” he said. If malignant glaucoma develops postop, Dr. Varma said he’ll most often take the patient back to the OR and use the vitreous cutter, but he added that you could do a YAG laser iridotomy, going through the zonules and the hyaloid. Then you can go in with viscoelastic and push the lens back manually. Dr. Varma published a paper on the management of malignant glaucoma after cataract surgery, describing these techniques, in 2014. 3 Dr. Schlenker said if malignant glaucoma occurs postop, he will start with atropine and likely aqueous suppression. This pulls the lens backward, and in some cases, if the patient has been on the drop for weeks to months and you can do a trial off it, as the system has been reset, they no longer need the atropine. Dr. Aboobakar’s initial management includes cycloplegics and aqueous suppressants, and she said hyperosmotic agents can be considered. Dr. Aboobakar said she’ll consider either laser or surgical intervention in cases refractory to medical management. “In pseudophakic or aphakic patients, Nd:YAG laser can be applied in the clinic to disrupt the anterior vitreous face and allow aqueous to flow anteriorly. Surgical management with vitrectomy combined with irido - zonulo - hyaloidotomy provides definitive treatment in cases refractory to medical and/ or laser therapy,” she said. Prevention From Dr. Aboobakar’s perspective, the underlying disease mechanisms are not yet fully understood, and methods for primary prevention of malignant glaucoma are not well studied. “Once an individual has developed malignant glaucoma in one eye, prophylactic postoperative cycloplegia or vitrectomy at the time of cataract Presbyopia eye drops in development Dr. Aboobakar described a 78-year-old female with a history of laser peripheral iridotomy for acute angle closure attack in the left eye 15 years ago who underwent uncomplicated cataract surgery in this eye. She was doing well at her postop week 1 visit, with good visual acuity in the operative eye (20/25) and IOP 15 mm Hg. Three days later, however, she presented to the emergency room with acute onset headache, eye pain, blurry vision, and nausea/vomiting. The left eye visual acuity was 20/800, IOP was 48 mm Hg, the pupil was mid-dilated, the anterior chamber was diffusely shallow with irido-corneal touch in the periphery, and a patent peripheral iridotomy and posterior chamber intraocular lens were noted. B-scan ultrasound did not demonstrate choroidal effusions, suprachoroidal hemorrhage, or mass lesions. UBM showed anterior displacement of the lens-iris diaphragm and anterior rotation of the ciliary body. The patient was started on maximal topical IOP lowering treatment, topical atropine, and oral acetazolamide with improvement in IOP to 28 mm Hg, though 2 days later IOP was again elevated to 45 mm Hg with anterior chamber shallowing. The patient underwent vitrectomy combined with irido-zonulo- hyaloidotomy with improvement in IOP to 11 mm Hg, deepening of the anterior chamber, and resolution of symptoms. A case example surgery in the contralateral eye can be considered, though the effectiveness of these measures has not been investigated with prospective studies to date,” she said. Dr. Varma said the biggest preventative effort is to avoid a decompression event by maintaining anterior chamber pressurization when you’re changing instruments. In a small eye, Dr. Varma continued, you might do a prophylactic vitrectomy to make space, and use oral carbonic anhydrase inhibitors or mannitol ahead of time. “That helps make space, but if
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