Managing A Case Of Acute Secondary Angle Closure Glaucoma In A Pseudophakic Eye With A Posterior Chamber Intraocular Lens

To describe the management of acute secondary angle closure glaucoma (ACG) in a pseudophakic patient and the causes, differentials and differences compared to conventional primary ACG.

Pseudophakic pupillary block glaucoma is common in eyes with anterior chamber intraocular lenses (IOL) but rare in eyes with posterior chamber IOLs due to deepening of the anterior chamber post-cataract surgery. Causes include posterior synechiae in inflammation causing adhesions between the pupillary margin and IOL plane, retained lens material behind the iris and blockage of free vitreous or silicone oil. Primary ACG, on the other hand, usually occurs most frequently from pupil block, where the peripheral iris bows forward and covers the trabecular meshwork.

We present a 52-year-old Chinese diabetic female who presented to the Emergency Department with pseudophakic ACG secondary to seclusio and occlusio pupillae. Her past ocular history included bilateral panretinal photocoagulation, intravitreal injections, cataract surgeries and vitrectomies done for diabetic-related complications. Her risk factors for developing bombé included poorly controlled diabetes, small pupil and multiple intraocular surgeries including previous vitrectomy with gas.

Our patient presented with right eye blurring of vision associated with a periorbital headache for a few months.

Best corrected visual acuity was 6/12 and 6/7.5, intraocular pressures (IOP) 46 and 19 in her right and left eye respectively. A right relative afferent pupillary defect was noted. Examination of her right eye showed stellate, diffuse keratic precipitates with 360 degrees iris bombé and a peripherally shallow anterior chamber. Gonioscopy revealed synechial closure. Her cup disc ratio was 1.0.

Initial management was similar to primary ACG- she was started on antiglaucoma, steroid eyedrops and oral acetazolamide. Laser peripheral iridotomy (LPI) was performed, targeting the area of iris bombé. Her anterior chamber deepened significantly after. 3 days later, her IOP remained high at 30 and LPI was repeated, lowering IOP to 20. However, her angles were still closed with significant peripheral anterior synechiae (PAS) and occlusio pupillae.

In primary ACG, she would be considered for early cataract surgery, but it was not an option as she was pseudophakic. Options included trabeculectomy or glaucoma drainage implants, anterior vitrectomy with surgical iridectomy, surgery to remove intraocular membranes or anterior chamber washout of fibrin.

She was listed for goniosynechiolysis and posterior synechiolysis which successfully opened her angles 360 degrees. Postoperatively, she was continued on antiglaucoma medications which maintained normal IOPs during subsequent reviews.

The management of primary ACG is well understood, but the management of pupil block glaucoma in a pseudophakic patient is different and important as well, with good understanding of the causes and differentials to target the inciting cause appropriately. Goniosynechiolysis and posterior synechiolysis can be effective in relieving synechial closure in pupil block glaucoma, utilizing the native outflow pathway by physically separating PAS from trabecular meshwork and lens respectively. This could possibly spare a patient from more invasive procedures with higher complication rates such as glaucoma filtration surgeries. It also spares the conjunctiva, saving it should such filtration surgeries be required.