Malignant Glaucoma After Cataract Surgery In A Patient With Fuchs' Uveitis: A Case Report

To report a case of malignant glaucoma that developed after cataract surgery in a patient with Fuchs' uveitis. Fuchs' uveitis is a chronic intraocular inflammation associated with a progressive decline in visual acuity. The clinical manifestation of the triad of heterochromia, cataract and glaucoma varies considerably. Classically, this is chronic open-angle glaucoma. But patients with Fuchs' uveitis can also develop malignant glaucoma. The currently known risk factors for developing malignant glaucoma are hypermetropia and a narrow iridocorneal angle. A thicker choroid has also been described as a potential anatomical risk factor.

A 49-year-old man, originally from Mauritius, with Fuchs’ uveitis. The patient had been followed in the department for several years by an inflammation specialist. The patient was followed up in a tertiary centre at the Cliniques Universitaires Saint Luc in Brussels.

The patient progressively developed a posterior subcapsular cataract with 20/80 vision. This was a myopic patient with a preoperative open iridocorneal angle. After 1 year without inflammation, cataract surgery was proposed. The operation was performed under local anaesthetic without any complications and led to the insertion of a one-piece hydrophobic C-loop intraocular lens in the capsular bag. The day after the operation, at the 1-day post-operative check-up, the patient complained of intense eye pain. Slit-lamp examination revealed a corneal oedema, a semi-mydriatic pupil, a narrow to virtual anterior chamber with moderate inflammation and the intraocular lens was in the capsular bag. Intraocular pressure was 43 mmHg without treatment. We started local and oral hypotensive treatment, as well as atropine. Anti-inflammatory treatment with corticosteroids was also intensified. Given the absence of response to the treatment initiated and the persistence of a virtual anterior chamber, a trabeculectomy and posterior vitrectomy were performed. The patient responded well to surgical treatment. The anterior chamber depth and intraocular pressure normalised. The vision has reached 20/20. A diagnosis of malignant glaucoma following cataract surgery was therefore made.

Malignant glaucoma remains one of the most challenging complications of ocular surgery and can occur after phacoemulsification in patients with Fuchs’ uveitis without any risk factor. The exact etiology of this condition is not fully understood, several mechanisms have been proposed like posterior misdirection of aqueous humor into or behind the vitreous. The clinical presentation consists of a narrow anterior chamber and normal or elevated intraocular pressure. It is important to be able to differentiate the cause of elevated intraocular pressure in these uveitic patients after cataract surgery, which may be due to significant inflammation or to malignant glaucoma, in order to adapt the therapeutic strategy.