Transcript Case Presentation - ASCRS/ASOA 2009

Scheimpflug imaging in a case of
Aqueous Misdirection Syndrome
Michael R. Gagnon, M.D.
Valley EyeCare Center
Clinical Instructor
Stanford University School Of Medicine
Maneesh H. Singh, B.S.
Stanford University School Of Medicine
We have no financial interests in the subject matter.*
Introduction
• Aqueous misdirection syndrome (malignant
glaucoma) is a rare condition. It is characterized by a
shallow axial anterior chamber (AC), a patent
peripheral iridotomy and absence of suprachoroidal
fluid.1
• To our knowledge we describe the first case of
aqueous misdirection syndrome documented with
Scheimpflug imaging (Pentacam HR:Oculus, Wetzlar,
Germany).
Case Report
• An 88-year-old woman with prior history of bilateral
cataract extraction 15 years ago presented to the
emergency department with left eye pain and nausea
and vomiting.
• Visual acuity was 20/25 OD and Count Fingers OS.
Examination of the right eye revealed a deep AC and
an intraocular pressure (IOP) of 18 mmHg. The left
eye had corneal edema, a flat AC with iridocorneal
touch, and an IOP of 66 mmHg.
• Gonioscopy revealed a wide-open angle in the right
eye and 360 degrees of angle closure in the left eye.
The posterior segment examination was normal with
no evidence of choroidals.
Pentacam Scheimpflug image of
anterior segment Right Eye
Red arrow - Intraocular Lens
Green arrows- Iris
Pentacam Scheimpflug image of
anterior segment Left Eye
Red arrow - Intraocular Lens
Green arrows- Iris
Case Report
• Topical medications were started consisting of
Combigan (brimonidine tartrate 0.2%/ timolol maleate
0.5%), brinzolamide 1%, prednisolone acetate1%, as
well as oral acetazolamide 500 mg.
• Two neodymium:yttrium-aluminum-garnet (Nd:YAG)
laser peripheral iridotomies were performed.
• The AC did not deepen but the IOP was controlled at
26 mmHg. The patient was discharged on Combigan
twice daily, brinzolamide 1% twice daily, prednisolone
acetate 1% four times daily, and acetazolamide 500
mg extended-release capsules every twelve hours.
Case Report
• The patient experienced eye pain as well as nausea and
vomiting and presented the following morning. The IOP in the
left eye was 40 mmHg and the AC was still flat despite two
patent peripheral iridotomies.
• The diagnosis of aqueous misdirection was made and a
Nd:YAG laser capsulotomy and hyaloidotomy was performed
and was unsuccessful.
• Cycloplegia was started with topical atropine 1% four times daily
and phenylephrine 2.5 % four times daily.
• The aqueous misdirection resolved with medical therapy after 2
days.The vision in the left eye was Hand Motions and the IOP
was 6 mm Hg. The anterior chamber was deep (2.88 mm) and
cornea was edematous with central pachymetry of 946 microns
Pentacam Scheimpflug image of
anterior segment Left Eye
Red arrow - Intraocular Lens
Green arrows- Iris
Case Report
• The corneal edema slowly resolved over two months
and the vision improved to 20/60 The patient was
diagnosed with cystoid macular edema which
resolved over four months with prednisolone 1% and
bromfenac 0.09% and her vision improved to 20/20.
She has been continued on atropine 1% once daily.
Pentacam Scheimpflug image of anterior segment Left Eye
Discussion
• Aqueous misdirection syndrome is a rare type of secondary
angle-closure glaucoma. It is poorly understood but thought
to occur because of the diversion of aqueous behind the
lens and anterior hyaloid and into the posterior segment
with swelling of the vitreous and anterior rotation of the
ciliary body processes.2
• Medical therapy includes topical mydriasis and cycloplegia,
aqueous suppression, and hyperosmotic agents.3 Surgical
treatments include Nd:Yag laser posterior capsulotomy with
hyaloidotomy,4 argon laser ablation of the ciliary processes,5
transscleral cyclodiode laser photocoagulation,6 and
surgical vitrectomy.7
Conclusion
• This case demonstrates the utility of the
Pentacam Scheimpflug imaging of the
anterior chamber in aqueous
misdirection syndrome .
• The Pentacam can be helpful in making
the diagnosis of aqueous misdirection
syndrome.
References
1. Sharma A, Sii F, Shah P, Kirkby G.R.Vitrectomy-phacoemulsification-vitrectomy for the
management of aqueous misdirection syndromes in phakic eyes. Ophthalmology
2006;113(11):1968-73.
2. Tello C, Chi T, Shepps G, Liebmann J, Ritch R. Ultrasound biomicroscopy in pseudophakic
malignant glaucoma. Ophthalmology 1993;100(9):1330-4.
3. Chandler PA, Grant WM. Mydriatic-cycloplegic treatment in malignant glaucoma. Arch
Ophthalmol 1962;68-353-9.
4. Lockie P. Ciliary-block glaucoma treated by posterior capsulotomy. Aust N Z J Ophthalmol
1987;15:207-9.
5. Herschler J. Laser shrinkage of the ciliary processes: A treatment for malignant (ciliary
block) glaucoma. Ophthalmology 87:1155, 1980.
6. Stumpf TH, Austin M, Bloom PA, McNaught A, et al. Transscleral cyclodiode laser
photocoagulation in the treatment of aqueous misdirection syndrome. Ophthalmology
2008;115:2058-2061.
7. Lynch MG, Brown RH, Michels RG, et al. Surgical vitrectomy for pseudophakic
malignant glaucoma. Am J Ophthal 1986;102:149-53.