Refractive Lens Exchange With A Surprise

To report a case of malignant glaucoma after refractive lens exchange, its treatment and further strategy

A 45-year-old patient with hyperopia and presbyopia underwent an uneventful refractive lens exchange with the implantation of a trifocal intraocular lens (IOL). Two days after the surgery intraocular pressure increased and he became myopic up to -3 diopters. Unfortunately, very soon he was diagnosed with malignant glaucoma. 

The patient was first treated with antiglaucoma medication including the systemic administration of Diamox, cycloplegic agents and corticosteroids. Also, iridotomy was performed. Further, pars plana vitrectomy was perfomed to break the pathological process of aqueous misdirection. Finally, cyclophotocoagulation helped to decrease intraocular pressure and his myopia stabilised at -1,5 diopters. Femtolasik was performed for hyperopia in the other eye because malignant glaucoma would occur in the other eye with high probability as well.

In the end we managed to solve both the intraocular pressure and the refractive issues - patient was slightly myopic in the non-dominant eye, emmetropic in the dominant eye and he was free of glaucoma medication.

Refractive lens exchange is an option of refractive surgery in patients in their presbyopic age and is usually a succesful procedure. However, being an intraocular surgery, it always poses the risk of complications icluding malignant glaucoma. To exclude malignant glaucoma in advance, gonioscopy (or better ultrabiomicroscopy) would need to be performed in all patients, which is impossible. In our case, we present the strategy of treatment and point to some ocular findings that might help to identify patients at risk.