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Neodymium-Yag Laser Therapy to the Anterior Hyaloid in Aphakic Malignant (Ciliovitreal Block) Glaucoma
AMERICAN JOURNAL OF VOLUME 98
OPHTHALMOLOGY®
NUMBER 2
AUGUST, 1984
NEODYMIUM-YAG LASER THERAPY TO THE ANTERIOR HYALOID IN APHAKIC MALIGNANT (CILIOVITREAL BLOCK) GLAUCOMA DAVID L. EPSTEIN, M.D., ROGER F. STEINERT, AND CARMEN A. PULIAFITO, M.D. Boston, Massachusetts
M.D.,
In three aphakic eyes and two eyes with intraocular lens implants (five patients, four women and one man, ranging in age from 65 to 76 years) persistent shallow or flat anterior chamber was observed despite multiple patent laser or surgical iridectomies. In each case direct application of the neodymium-YAG laser (3 to 11 mj) to the anterior hyaloid face resulted in immediate deepening of the anterior chamber. This deepening was sustained in four of the cases. These results confirm previous observations suggesting that the anterior hyaloid can be the locus of abnormality in aphakic malignant (ciliovitreal block) glaucoma. Neodymium-YAG "hyaloidotomy" may be better than penetrating sur gery in such cases. Aphakic malignant (ciliovitreal block) glaucoma can be defined as the occur rence of a persistent shallowed or flat tened anterior chamber despite the pres ence of a patent iridectomy in an aphakic (or pseudophakic) eye in the absence of choroidal detachment or hemorrhage.1"3 The condition has perhaps become more common in recent years because of the use of anterior chamber intraocular lens es in intracapsular cataract surgery. In general, surgical vitrectomy is required Accepted for publication June 7, 1984. From the Glaucoma Consultation Service and the Howe Laboratory of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. This study was supported in part by National Glaucoma Research, a program of the American Health Assistance Foundation (Dr. Epstein). Reprint requests to David L. Epstein, M.D., 243 Charles St., Boston, MA 02114.
to normalize anterior chamber depth and reverse this condition. Our previous lab oratory studies4 confirmed Shaffer's1 clini cal observations suggesting that the locus of abnormality in this condition might involve the anterior hyaloid and it seemed reasonable, therefore, to attempt to disrupt the anterior hyaloid with the neodymium-YAG laser before resorting to surgical vitrectomy for this condition. Our initial experience indicates that such treatment with the neodymium-YAG laser cures this condition simply and ef fectively. CASE REPORTS Case 1—This 73-year-old woman had noted gradu al, progressive decrease in visual acuity in her right eye during a two-year period. Her best corrected visual acuity was R.E.: 20/400 and L.E.: 20/25. Her refraction was R.E.: piano and L.E.: +4.25 —1.50 x 89. Intraocular pressure by applanation tonometry
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was 16 mm Hg bilaterally. Both corneas were clear. The anterior chamber was clear and deep (4.5 comeal thicknesses axially and 0.5 thickness pe ripherally) in each eye. Gonioscopy disclosed that each angle was open to the ciliary body band without abnormality. The right lens demonstrated a dense posterior subcapsular opacity that explained the visu al acuity. Ultrasound disclosed the axial length of the right eye to be 22.4 mm. The patient underwent an uncomplicated intracapsular cataract extraction in the right eye with two peripheral iridectomies and insertion of a 21-diopter 13-mm anterior chamber intraocular lens. On the first postoperative day corneal edema and a shallow anterior chamber were noted. Intraocular pressure by applanation tonometry was 53 mm Hg. Both pe ripheral iridectomies appeared to be patent but there seemed to be vitreous behind them. The right pupil was dilated with tropicamide and phenylephrine but the anterior chamber remained shallow, with the intact hyaloid of the vitreous filling the space be tween the pupillary iris margin and intraocular lens optic (Fig. 1). Three iridectomies were performed with the argon laser but the chamber remained shallow (Fig. 1). After obtaining an informed consent from the patient, we focused the neodymium-YAG laser at a setting of 3 mj on the hyaloid in the pupillary margin. After one application of the neodymium-YAG laser the anterior chamber immedi ately deepened. Additional applications were made through the temporal surgical iridectomy to the anterior hyaloid. After the procedure the anterior chamber was of normal depth and loose vitreous was present in the anterior chamber (Fig. 2). The patient had an uneventful postoperative course. However, gonioscopy demonstrated periph eral anterior synechiae covering five clock hours in the right eye. Visual acuity was correctable to 20/30 in the right eye and has remained stable for 15 months. Intraocular pressure has remained < 2 0 mm Hg without therapy. Case 2—This 74-year-old woman noted a gradual decrease in vision in her left eye. With a correction of R.E.: piano and L.E.: +0.75 - 2 . 2 5 x 75, her visual acuity was R. E. : 20/30 and L. E. : counting fingers at 6 feet. Intraocular pressure by applanation tonometry was R.E.: 21 mm Hg and L.E.: 22 mm Hg. Both corneas were clear. The anterior chamber was clear and deep in both eyes. A dense nuclear sclerotic and posterior subcapsuiar cataract was present in the left eye. A 19-diopter anterior chamber intraocular lens was implanted after an uncomplicated intracapsular cata ract extraction with two small peripheral iridecto mies. However, on the first postoperative day the anterior chamber was noted to be shallow, intraocu lar pressure was above 20 mm Hg, and no patent peripheral iridectomy was apparent. A thin area in the wound was identified. Laser iridectomy was attempted but was unsuccessful. However, the chamber deepened after pupillary dilatation. A few weeks later when the dilating eyedrops were
A U G U S T , 1984
Fig. 1 (Epstein, Steinert, and Puliafito). Case 1. The anterior chamber is flat peripherally despite the presence of two patent surgical and three patent laser iridectomies (black arrowheads). The anterior hyaloid fills the space (white arrowhead) between the dilated iris pupillary margin and implant optic.
Fig. 2 (Epstein, Steinert, and Puliafito). Case 1. After neodymium-YAG laser treatment to the ante rior hyaloid, the anterior chamber has dramatically deepened. Loose vitreous is present in the anterior chamber (arrow).
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Fig. 4 (Epstein, Steinert, and Puliafito). Case 2. After neodymium-YAG laser treatment to the ante rior hyaloid through the laser iridectomy, a knuckle of loose vitreous (arrowhead) is present in the ante rior chamber, which is now of normal aphakic depth.
Fig. 3 (Epstein, Steinert, and Puliafito). Case 2. There is a bombé configuration to the iris and the anterior chamber is very shallow peripherally. discontinued the anterior chamber shallowed again. At that time visual acuity in the left eye was 20/50 with an intraocular pressure by applanation tonometry of R.E.: 18 mm Hg and L.E.: 23 mm Hg. The left iris contained a bombé configuration and the chamber was shallow (Fig. 3). Two argon laser iridectomies were performed and appeared to be patent but the chamber did not deepen. The neodymiumYAG laser was then used to perform a laser iridecto my superonasally, but the chamber did not deepen until the neodymium-YAG laser (3 mj) was applied to
the anterior hyaloid behind the iridectomy. The anterior chamber immediately deepened and loose vitreous was observed in the anterior chamber, herniating through the iridectomy (Fig. 4). One hour after treatment the intraocular pressure of the left eye was 23 mm Hg and there was minimal inflammation. One month later the patient's visual acuity was 20/30, intraocular pressure in the left eye was 21 mm Hg, and the anterior chamber was deep. Case 3—This 65-year-old woman with known in terstitial keratitis developed progressive cataract for mation bilaterally. She had open-angle glaucoma but treatment with acetazolamide and timolol kept the intraocular pressure "well-controlled." The anterior chamber was observed to be deep and the angles were open. The patient underwent combined penetrating ker-
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atoplasty and intracapsular cataract extraction in her right eye. The patient's pupil had been widely dilat ed preoperatively and peripheral iridectomy was therefore omitted at the time of surgery. The intraoc ular pressure in the right eye was judged to be "normal" at the time the patient left the hospital (three days postoperatively) on a regimen of timolol, pilocarpine 2%, and acetazolamide. Five days post operatively it was 25 mm Hg and the anterior cham ber depth was normal. However, the next day the patient had acute pain in and around her right eye accompanied by nausea and vomiting, 360-degree angle closure, and a flat chamber axially with the central iris approximately 1 corneal thickness behind the graft. The hyaloid face appeared to be intact and flat approximately 2 mm behind the pupil. There was no vitreous bulge. The intraocular pressure was 60 inm Hg. An argon laser iridectomy was done in the mid-periphery at the 9 o'clock position and ap peared to be patent but no change in the chamber depth was observed. The YAG laser was therefore used to deliver a single application of 11 mj through the argon laser iridectomy. This resulted in an immediate "puff" of loose vitreous through the pupil and instant deepen ing of the central anterior chamber. Within 15 min utes the angle from the 12 to the 6 o'clock positions appeared to be open. The intraocular pressure was 45 mm Hg and treatment with timolol, pilocarpine, and acetazolamide had decreased this to 25 mm Hg .three days later. This case was particularly remarkable because of a nonbulging hyaloid face well behind the pupil associ ated with angle closure. Case 4—This 76-year-old woman had undergone an intracapsular cataract extraction with anterior chamber intraocular lens implantation six months previously. Because the implant's size and position were incorrect, the intraocular lens had been re moved and a second one implanted three months after the first procedure. This second implant was removed, however, three weeks after insertion. The patient was first examined here for corneal edema five months after the initial surgery. Her visual acuity was R.E.: counting fingers at 3 feet and L. E.: 20/60. The intraocular pressure was 17 mm Hg in both eyes. The right eye was mildly injected with difluse bullous keratopathy and iris to corneal apposi tion from the 8 to the 11 o'clock positions and from the 2 to the 4 o'clock positions with a moderately deep anterior chamber centrally, vitreous touch su periorly, and an open angle inferiorly. A superior sector iridectomy was apparent. Fibrin and hemor rhage were visible along the border of the iris sphincter to the vitreous from the 3 to the 6 o'clock positions. In the left eye moderate cataract formation and mild corneal guttata were observed. The left anterior chamber was deep. The right eye was being treated with fluorometholone, timolol 0.5%, and 5% sodium chloride ointment. The patient was next seen one month later when her intraocular pressure was 20 mm Hg in the right eye. At that time peripheral angle closure was pres
A U G U S T , 1984
ent from the 8 to 11 o'clock positions and from the 2 to 5 o'clock positions. The central chamber was shal low. Vitreous bulge and endothelial touch were present centrally. Cyclopentolate and phenylephrine were instilled and reexamination showed broken synechiae at the 4 o'clock position and a deeper anterior chamber with less vitreous bulge. The inferi or angle appeared to be deeper as well. The patient was treated with atropine 1% and dexamethasone. Five days later the patient returned with severe pain in her right eye. Her visual acuity had decreased to hand motions and the intraocular pressure was now 35 mm Hg. The right eye was injected and had increased corneal edema. The anterior chamber was flat in the periphery for 360 degrees and vitreous was in contact with the endothelium across the upper two thirds of the cornea. The pupil appeared widely dilated. The diagnosis of probable aphakic malignant glaucoma was made. The YAG laser was used to make four applications of 6 mj to the hyaloid face. The anterior chamber deepened immediately. Examination the next day disclosed the hyaloid face was broken and that the inferior central chamber had returned to normal aphakic depth. Intraocular pressure was still increased at 37 mm Hg, but treat ment with timolol and acetazolamide had decreased it to 20 mm Hg three days later. Thereafter the anterior chamber depth was stable and the inferior angle remained open. Best visual acuity was 20/400. Two months after the YAG laser procedure a pene trating keratoplasty was performed with anterior vitrectomy. Case 5—This 76-year-old man with advanced open-angle glaucoma in both eyes with only central islands of remaining vision underwent full-thickness filtration surgery in his left eye. Preoperatively visual acuity was R E . : 20/50 and L.E.: 20/60. Intraocular pressure was R. E.: 22 mm H g and L. Ε,: 18 mm Hg. Gonioscopy disclosed wide open angles in each eye with ciliary body band easily visible. The anterior chamber was deep centrally. Total glaucomatous cupping was present in each eye. Laser trabeculoplasty had been without effect. The patient was in good health except for locally recurrent transitional cell carcinoma, grade II, of the bladder for which he was receiving treatment. At the time of filtration surgery (posterior lip sclerectomy with peripheral iridectomy, limbalbased flap) in the left eye, an inadvertent conjunctival buttonhole was observed and repaired with 10-0 nylon. Postoperatively the anterior chamber re mained flat with no apparent wound leak (negative Seidel test) and on the fourth postoperative day the patient underwent a choroidal tap (posterior sclerotomy) and re-formation of the anterior chamber. Much choroidal fluid was evacuated and at the conclusion of this procedure the anterior chamber was noted to be deep with a well-elevated, sustained bleb without leakage. However, postoperatively the chamber to tally flattened again despite placement of a glaucoma scierai shell to tamponade the filtration area and a second choroidal tap was performed, after which the
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chamber was observed to be formed although still somewhat shallow. One month later the patient's visual acuity had decreased to hand movements because of a dense cataract in his left eye. The intraocular pressure was 14 mm Hg but there was no discernible bleb. The anterior chamber was deep with a patent peripheral iridectomy. Gonioscopy showed that the angle was open. However, two months postoperatively, de spite the absence of any bleb, the chamber was totally flat again. Ultrasound demonstrated a choroidal detachment in the left eye. There was no obvious wound leak. The intraocular pressure was 0 mm Hg. A repeat choroidal tap was then performed with the final re-formation of the anterior chamber with sodi um hyaluronate. A cleft was tested for by placing fluorescein in the anterior chamber but no dye appeared in the suprachoroidal fluid. The bleb was well formed without any wound leak at the end of the procedure. However, the anterior chamber flattened again within a few days and the patient underwent a repeat choroidal tap (with evacuation of copious amounts of fluid) combined with intracapsular cata ract extraction from the side. This was uneventful but when the comeal scierai sutures were being tied the chamber suddenly shallowed and the eye firmed. The posterior sclerotomy sites were inspected but no blood or additional fluid was found. Only a red reflex was observed with indirect ophthalmoscopy. A Barkan knife was then used to slash the anterior hyaloid through an air bubble after which the ante rior chamber appeared to deepen. During the next two weeks, however, the anterior chamber gradually flattened again with a fibrotic and seemingly intact hyaloid up to the cornea centrally and iris up to the cornea peripherally. The chamber was totally flat. The intraocular pressure was 11 mm Hg, no bleb was apparent, and ultrasound failed to demonstrate a choroidal detachment. A patent surgical iridectomy was apparent but there appeared to be fibrotic hyaloid immediately behind it. Intense treatment with topical and systemic corticosteroids and dilatation and cycloplegia did not deepen the chamber. The YAG laser was then fo cused just posterior to the anterior hyaloid and applications of 1 to 3 mj were made. The anterior hyaloid was thus disrupted and the anterior chamber immediately deepened nasally to one corneal thick ness over the central iris. The temporal chamber did not deepen. However, the next day the hyaloid appeared to have recondensed and the chamber was shallow again. A small hemorrhage from the iris was apparent. Repeat YAG treatment to the hyaloid in the pupillary area with 3 to 4 mj produced notable deepening of the axial chamber nasally and temporal ly over the iris. During the next week the axial chamber depth remained formed—one quarter to two thirds of a corneal thickness—but peripherally iris remained up to the cornea. One week later the chamber flattened again axially in association with fibrotic recondensation of the hyaloid despite contin ued topical corticosteroid therapy. Subsequently a pars plana vitrectomy and anterior segment recon
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struction were performed with lysis of anterior synechiae. Despite this, the iris remained adherent to the cornea temporally with only a small space (one quarter of a corneal thickness) present between iris and cornea nasally. Intraocular pressure has re mained < 1 5 mm Hg with no visible bleb and visual acuity is only counting fingers. DISCUSSION
Malignant (ciliovitreal block) glaucoma in an aphakic eye can be thought of as the total obliteration of the posterior cham ber by the vitreous body which comes forward into apposition with the posterior surface of the iris and ciliary body 5 (Fig. 5). Aqueous humor, secreted by the ciliary body, moves into the vitreous body and must pass across the anterior hyaloid to enter into the anterior cham ber. The anterior hyaloid in affected pa tients may be abnormally "thickened" in texture or inherently less permeable, or there may be a limited hyaloid surface area available for fluid transfer. 4 · 6 In any case, the hyaloid restricts fluid move ment into the anterior chamber and thus aqueous humor is retained diffusely with in the vitreous body, which then acts as a mass to maintain a shallowed anterior chamber. A surgical or laser iridectomy does not reverse this condition because the hyaloid is present directly behind the iris, and there is no posterior chamber space filled with aqueous humor that al lows free communication through the iri dectomy from the ciliary body to the anterior chamber (Fig. 5). To treat this condition the anterior hyaloid must be disrupted 1 and bypassed as a fluid barri er, thus allowing equalization of pressure between the vitreous body and anterior chamber. The neodymium-YAG laser is a simple, effective way to accomplish this disrup tion, for its energy effects do not depend on pigmentation of ocular tissues. Thus it is well suited for "cutting" and disrupting the anterior hyaloid. In Cases 1 and 2 one application of the neodymium-YAG laser
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Fig. 5 (Epstein, Steinert, and Puliafito). Concept of aphakic malignant (ciliovitreal block) glaucoma. The vitreous is apposed to the posterior iris surface and there is no posterior chamber space filled with aqueous humor. Aqueous humor moves into the vitreous (arrows) from the ciliary body and must pass across a limited surface area of anterior hyaloid (arrows) to enter the anterior chamber. The anterior hyaloid can act as a restrictive barrier to such fluid movement.
to the anterior hyaloid resulted in imme diate deepening of the anterior chamber. In both cases we deliberately proceeded in stages to rule out pupillary block 7 as the mechanism for the angle closure by performing initially at least two laser iri-
AUGUST, 1984
dectomies. (In Case 1 there were thus two patent surgical iridectomies and three patent laser iridectomies, and in Case 2 there were three patent laser iridectomies.) This failing, the immediate deepening of the anterior chamber which occurred after application of the neodymium-YAG laser to the anterior hy aloid confirmed the importance of the hyaloid in the pathogenesis of this apha kic malignant glaucoma condition. The rapid reversal of the flat chamber in these cases suggests that such neodymium-YAG "hyaloidotomy" may be the procedure of choice rather than pene trating surgery when argon laser iridectomy fails to deepen the anterior cham ber (and choroidal detachment is not present). In most cases we suspect that this procedure will cure such a condition. However, in Case 5 only temporary deepening of the anterior chamber was achieved and surgical vitrectomy was ul timately required (which unfortunately was also only partially successful in main taining anterior chamber depth). We sus pect that in such a case there was not free communication of fluid within the vitre ous space but rather sequestered spaces in the vitreous because of inflammatory membrane formation that may have held the iris forward. Nevertheless, the tem porary deepening of the condition after neodymium-YAG treatment confirmed again the importance of the hyaloid as a restrictive barrier to fluid flow into the anterior chamber. Similarly, we suspect that abnormali ties in the hyaloid are involved in the pathogenesis of malignant (ciliary block) glaucoma in phakic eyes. 4 However, we have not yet treated such a patient. Be cause of the presence of the lens, zonules, and, frequently, a small pupil, ac cess to the hyaloid in such phakic eyes is often limited. Still, we wonder whether such treatment might not prove similarly efficacious in a patient with a large colo-
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boma of the iris where the hyaloid could be visualized. It is possible that argon laser therapy to the ciliary processes, which has been proposed for both phakic 8,9 and aphakic 10 malignant glauco ma, may actually work by disturbing the adjacent peripheral anterior hyaloid. W h e t h e r or not this is the case, in pa tients with aphakic malignant (ciliovitreal block) glaucoma neodymium-YAG laser treatment directly to the anterior hyaloid represents a major advance in therapy and an effective alternative to surgical intervention. REFERENCES 1. Shaffer, R. N.: The role of vitreous detachment in aphakic and malignant glaucoma. Trans. Am. Acad. Ophthalmol. Otolaryngol. 58:217, 1954. 2. Shaffer, R. N., and Hoskins, H. D., Jr.: Ciliary block (malignant) glaucoma. Trans. Am. Acad. Oph thalmol. Otolaryngol. 85:215, 1978.
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3. Simmons, R. J. : Malignant glaucoma. In Chan dler, P. A., and Grant, W. M. (eds.): Glaucoma. Philadelphia, Lea & Febiger, 1979, pp. 172-182. 4. Epstein, D. L., Hashimoto, J. M., Anderson, P. J., and Grant, W. M.: Experimental perfusions through the anterior and vitreous chambers with possible relationships to malignant glaucoma. Am. J. Ophthalmol. 88:1078, 1979. 5. Epstein, D. L.: Malignant glaucoma. In Jakobiec, F., and Sigelman, J. (eds.): Advanced Tech niques in Ocular Surgery. Philadelphia, W. B. Saunders. In press. 6. Grant, W. M.: Experimental aqueous perfu sion in enucleated human eyes. Arch. Ophthalmol. 69:783, 1963. 7. Van Buskirk, E. M.: Pupillary block after intra ocular lens implantation. Am. J. Ophthalmol. 95:55, 1983. 8. Herschler, J.: Laser shrinkage of the ciliary processes. Ophthalmology 87:1155, 1980. 9. Simmons, R. J., in discussion, Herschler, J.: Laser shrinkage of ciliary processes. A treatment for malignant (ciliary block) glaucoma. Ophthalmology 87:1158, 1980. 10. Weber, P. A., Henry, M. A., Kapetansky, F. M., and Lohman, L. F.: Argon laser treatment of the ciliary processes in aphakic glaucoma with flat anterior chamber. Am. J. Ophthalmol. 97:82, 1984.
OPHTHALMOLOGY®
NUMBER 2
AUGUST, 1984
NEODYMIUM-YAG LASER THERAPY TO THE ANTERIOR HYALOID IN APHAKIC MALIGNANT (CILIOVITREAL BLOCK) GLAUCOMA DAVID L. EPSTEIN, M.D., ROGER F. STEINERT, AND CARMEN A. PULIAFITO, M.D. Boston, Massachusetts
M.D.,
In three aphakic eyes and two eyes with intraocular lens implants (five patients, four women and one man, ranging in age from 65 to 76 years) persistent shallow or flat anterior chamber was observed despite multiple patent laser or surgical iridectomies. In each case direct application of the neodymium-YAG laser (3 to 11 mj) to the anterior hyaloid face resulted in immediate deepening of the anterior chamber. This deepening was sustained in four of the cases. These results confirm previous observations suggesting that the anterior hyaloid can be the locus of abnormality in aphakic malignant (ciliovitreal block) glaucoma. Neodymium-YAG "hyaloidotomy" may be better than penetrating sur gery in such cases. Aphakic malignant (ciliovitreal block) glaucoma can be defined as the occur rence of a persistent shallowed or flat tened anterior chamber despite the pres ence of a patent iridectomy in an aphakic (or pseudophakic) eye in the absence of choroidal detachment or hemorrhage.1"3 The condition has perhaps become more common in recent years because of the use of anterior chamber intraocular lens es in intracapsular cataract surgery. In general, surgical vitrectomy is required Accepted for publication June 7, 1984. From the Glaucoma Consultation Service and the Howe Laboratory of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. This study was supported in part by National Glaucoma Research, a program of the American Health Assistance Foundation (Dr. Epstein). Reprint requests to David L. Epstein, M.D., 243 Charles St., Boston, MA 02114.
to normalize anterior chamber depth and reverse this condition. Our previous lab oratory studies4 confirmed Shaffer's1 clini cal observations suggesting that the locus of abnormality in this condition might involve the anterior hyaloid and it seemed reasonable, therefore, to attempt to disrupt the anterior hyaloid with the neodymium-YAG laser before resorting to surgical vitrectomy for this condition. Our initial experience indicates that such treatment with the neodymium-YAG laser cures this condition simply and ef fectively. CASE REPORTS Case 1—This 73-year-old woman had noted gradu al, progressive decrease in visual acuity in her right eye during a two-year period. Her best corrected visual acuity was R.E.: 20/400 and L.E.: 20/25. Her refraction was R.E.: piano and L.E.: +4.25 —1.50 x 89. Intraocular pressure by applanation tonometry
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was 16 mm Hg bilaterally. Both corneas were clear. The anterior chamber was clear and deep (4.5 comeal thicknesses axially and 0.5 thickness pe ripherally) in each eye. Gonioscopy disclosed that each angle was open to the ciliary body band without abnormality. The right lens demonstrated a dense posterior subcapsular opacity that explained the visu al acuity. Ultrasound disclosed the axial length of the right eye to be 22.4 mm. The patient underwent an uncomplicated intracapsular cataract extraction in the right eye with two peripheral iridectomies and insertion of a 21-diopter 13-mm anterior chamber intraocular lens. On the first postoperative day corneal edema and a shallow anterior chamber were noted. Intraocular pressure by applanation tonometry was 53 mm Hg. Both pe ripheral iridectomies appeared to be patent but there seemed to be vitreous behind them. The right pupil was dilated with tropicamide and phenylephrine but the anterior chamber remained shallow, with the intact hyaloid of the vitreous filling the space be tween the pupillary iris margin and intraocular lens optic (Fig. 1). Three iridectomies were performed with the argon laser but the chamber remained shallow (Fig. 1). After obtaining an informed consent from the patient, we focused the neodymium-YAG laser at a setting of 3 mj on the hyaloid in the pupillary margin. After one application of the neodymium-YAG laser the anterior chamber immedi ately deepened. Additional applications were made through the temporal surgical iridectomy to the anterior hyaloid. After the procedure the anterior chamber was of normal depth and loose vitreous was present in the anterior chamber (Fig. 2). The patient had an uneventful postoperative course. However, gonioscopy demonstrated periph eral anterior synechiae covering five clock hours in the right eye. Visual acuity was correctable to 20/30 in the right eye and has remained stable for 15 months. Intraocular pressure has remained < 2 0 mm Hg without therapy. Case 2—This 74-year-old woman noted a gradual decrease in vision in her left eye. With a correction of R.E.: piano and L.E.: +0.75 - 2 . 2 5 x 75, her visual acuity was R. E. : 20/30 and L. E. : counting fingers at 6 feet. Intraocular pressure by applanation tonometry was R.E.: 21 mm Hg and L.E.: 22 mm Hg. Both corneas were clear. The anterior chamber was clear and deep in both eyes. A dense nuclear sclerotic and posterior subcapsuiar cataract was present in the left eye. A 19-diopter anterior chamber intraocular lens was implanted after an uncomplicated intracapsular cata ract extraction with two small peripheral iridecto mies. However, on the first postoperative day the anterior chamber was noted to be shallow, intraocu lar pressure was above 20 mm Hg, and no patent peripheral iridectomy was apparent. A thin area in the wound was identified. Laser iridectomy was attempted but was unsuccessful. However, the chamber deepened after pupillary dilatation. A few weeks later when the dilating eyedrops were
A U G U S T , 1984
Fig. 1 (Epstein, Steinert, and Puliafito). Case 1. The anterior chamber is flat peripherally despite the presence of two patent surgical and three patent laser iridectomies (black arrowheads). The anterior hyaloid fills the space (white arrowhead) between the dilated iris pupillary margin and implant optic.
Fig. 2 (Epstein, Steinert, and Puliafito). Case 1. After neodymium-YAG laser treatment to the ante rior hyaloid, the anterior chamber has dramatically deepened. Loose vitreous is present in the anterior chamber (arrow).
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Fig. 4 (Epstein, Steinert, and Puliafito). Case 2. After neodymium-YAG laser treatment to the ante rior hyaloid through the laser iridectomy, a knuckle of loose vitreous (arrowhead) is present in the ante rior chamber, which is now of normal aphakic depth.
Fig. 3 (Epstein, Steinert, and Puliafito). Case 2. There is a bombé configuration to the iris and the anterior chamber is very shallow peripherally. discontinued the anterior chamber shallowed again. At that time visual acuity in the left eye was 20/50 with an intraocular pressure by applanation tonometry of R.E.: 18 mm Hg and L.E.: 23 mm Hg. The left iris contained a bombé configuration and the chamber was shallow (Fig. 3). Two argon laser iridectomies were performed and appeared to be patent but the chamber did not deepen. The neodymiumYAG laser was then used to perform a laser iridecto my superonasally, but the chamber did not deepen until the neodymium-YAG laser (3 mj) was applied to
the anterior hyaloid behind the iridectomy. The anterior chamber immediately deepened and loose vitreous was observed in the anterior chamber, herniating through the iridectomy (Fig. 4). One hour after treatment the intraocular pressure of the left eye was 23 mm Hg and there was minimal inflammation. One month later the patient's visual acuity was 20/30, intraocular pressure in the left eye was 21 mm Hg, and the anterior chamber was deep. Case 3—This 65-year-old woman with known in terstitial keratitis developed progressive cataract for mation bilaterally. She had open-angle glaucoma but treatment with acetazolamide and timolol kept the intraocular pressure "well-controlled." The anterior chamber was observed to be deep and the angles were open. The patient underwent combined penetrating ker-
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atoplasty and intracapsular cataract extraction in her right eye. The patient's pupil had been widely dilat ed preoperatively and peripheral iridectomy was therefore omitted at the time of surgery. The intraoc ular pressure in the right eye was judged to be "normal" at the time the patient left the hospital (three days postoperatively) on a regimen of timolol, pilocarpine 2%, and acetazolamide. Five days post operatively it was 25 mm Hg and the anterior cham ber depth was normal. However, the next day the patient had acute pain in and around her right eye accompanied by nausea and vomiting, 360-degree angle closure, and a flat chamber axially with the central iris approximately 1 corneal thickness behind the graft. The hyaloid face appeared to be intact and flat approximately 2 mm behind the pupil. There was no vitreous bulge. The intraocular pressure was 60 inm Hg. An argon laser iridectomy was done in the mid-periphery at the 9 o'clock position and ap peared to be patent but no change in the chamber depth was observed. The YAG laser was therefore used to deliver a single application of 11 mj through the argon laser iridectomy. This resulted in an immediate "puff" of loose vitreous through the pupil and instant deepen ing of the central anterior chamber. Within 15 min utes the angle from the 12 to the 6 o'clock positions appeared to be open. The intraocular pressure was 45 mm Hg and treatment with timolol, pilocarpine, and acetazolamide had decreased this to 25 mm Hg .three days later. This case was particularly remarkable because of a nonbulging hyaloid face well behind the pupil associ ated with angle closure. Case 4—This 76-year-old woman had undergone an intracapsular cataract extraction with anterior chamber intraocular lens implantation six months previously. Because the implant's size and position were incorrect, the intraocular lens had been re moved and a second one implanted three months after the first procedure. This second implant was removed, however, three weeks after insertion. The patient was first examined here for corneal edema five months after the initial surgery. Her visual acuity was R.E.: counting fingers at 3 feet and L. E.: 20/60. The intraocular pressure was 17 mm Hg in both eyes. The right eye was mildly injected with difluse bullous keratopathy and iris to corneal apposi tion from the 8 to the 11 o'clock positions and from the 2 to the 4 o'clock positions with a moderately deep anterior chamber centrally, vitreous touch su periorly, and an open angle inferiorly. A superior sector iridectomy was apparent. Fibrin and hemor rhage were visible along the border of the iris sphincter to the vitreous from the 3 to the 6 o'clock positions. In the left eye moderate cataract formation and mild corneal guttata were observed. The left anterior chamber was deep. The right eye was being treated with fluorometholone, timolol 0.5%, and 5% sodium chloride ointment. The patient was next seen one month later when her intraocular pressure was 20 mm Hg in the right eye. At that time peripheral angle closure was pres
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ent from the 8 to 11 o'clock positions and from the 2 to 5 o'clock positions. The central chamber was shal low. Vitreous bulge and endothelial touch were present centrally. Cyclopentolate and phenylephrine were instilled and reexamination showed broken synechiae at the 4 o'clock position and a deeper anterior chamber with less vitreous bulge. The inferi or angle appeared to be deeper as well. The patient was treated with atropine 1% and dexamethasone. Five days later the patient returned with severe pain in her right eye. Her visual acuity had decreased to hand motions and the intraocular pressure was now 35 mm Hg. The right eye was injected and had increased corneal edema. The anterior chamber was flat in the periphery for 360 degrees and vitreous was in contact with the endothelium across the upper two thirds of the cornea. The pupil appeared widely dilated. The diagnosis of probable aphakic malignant glaucoma was made. The YAG laser was used to make four applications of 6 mj to the hyaloid face. The anterior chamber deepened immediately. Examination the next day disclosed the hyaloid face was broken and that the inferior central chamber had returned to normal aphakic depth. Intraocular pressure was still increased at 37 mm Hg, but treat ment with timolol and acetazolamide had decreased it to 20 mm Hg three days later. Thereafter the anterior chamber depth was stable and the inferior angle remained open. Best visual acuity was 20/400. Two months after the YAG laser procedure a pene trating keratoplasty was performed with anterior vitrectomy. Case 5—This 76-year-old man with advanced open-angle glaucoma in both eyes with only central islands of remaining vision underwent full-thickness filtration surgery in his left eye. Preoperatively visual acuity was R E . : 20/50 and L.E.: 20/60. Intraocular pressure was R. E.: 22 mm H g and L. Ε,: 18 mm Hg. Gonioscopy disclosed wide open angles in each eye with ciliary body band easily visible. The anterior chamber was deep centrally. Total glaucomatous cupping was present in each eye. Laser trabeculoplasty had been without effect. The patient was in good health except for locally recurrent transitional cell carcinoma, grade II, of the bladder for which he was receiving treatment. At the time of filtration surgery (posterior lip sclerectomy with peripheral iridectomy, limbalbased flap) in the left eye, an inadvertent conjunctival buttonhole was observed and repaired with 10-0 nylon. Postoperatively the anterior chamber re mained flat with no apparent wound leak (negative Seidel test) and on the fourth postoperative day the patient underwent a choroidal tap (posterior sclerotomy) and re-formation of the anterior chamber. Much choroidal fluid was evacuated and at the conclusion of this procedure the anterior chamber was noted to be deep with a well-elevated, sustained bleb without leakage. However, postoperatively the chamber to tally flattened again despite placement of a glaucoma scierai shell to tamponade the filtration area and a second choroidal tap was performed, after which the
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chamber was observed to be formed although still somewhat shallow. One month later the patient's visual acuity had decreased to hand movements because of a dense cataract in his left eye. The intraocular pressure was 14 mm Hg but there was no discernible bleb. The anterior chamber was deep with a patent peripheral iridectomy. Gonioscopy showed that the angle was open. However, two months postoperatively, de spite the absence of any bleb, the chamber was totally flat again. Ultrasound demonstrated a choroidal detachment in the left eye. There was no obvious wound leak. The intraocular pressure was 0 mm Hg. A repeat choroidal tap was then performed with the final re-formation of the anterior chamber with sodi um hyaluronate. A cleft was tested for by placing fluorescein in the anterior chamber but no dye appeared in the suprachoroidal fluid. The bleb was well formed without any wound leak at the end of the procedure. However, the anterior chamber flattened again within a few days and the patient underwent a repeat choroidal tap (with evacuation of copious amounts of fluid) combined with intracapsular cata ract extraction from the side. This was uneventful but when the comeal scierai sutures were being tied the chamber suddenly shallowed and the eye firmed. The posterior sclerotomy sites were inspected but no blood or additional fluid was found. Only a red reflex was observed with indirect ophthalmoscopy. A Barkan knife was then used to slash the anterior hyaloid through an air bubble after which the ante rior chamber appeared to deepen. During the next two weeks, however, the anterior chamber gradually flattened again with a fibrotic and seemingly intact hyaloid up to the cornea centrally and iris up to the cornea peripherally. The chamber was totally flat. The intraocular pressure was 11 mm Hg, no bleb was apparent, and ultrasound failed to demonstrate a choroidal detachment. A patent surgical iridectomy was apparent but there appeared to be fibrotic hyaloid immediately behind it. Intense treatment with topical and systemic corticosteroids and dilatation and cycloplegia did not deepen the chamber. The YAG laser was then fo cused just posterior to the anterior hyaloid and applications of 1 to 3 mj were made. The anterior hyaloid was thus disrupted and the anterior chamber immediately deepened nasally to one corneal thick ness over the central iris. The temporal chamber did not deepen. However, the next day the hyaloid appeared to have recondensed and the chamber was shallow again. A small hemorrhage from the iris was apparent. Repeat YAG treatment to the hyaloid in the pupillary area with 3 to 4 mj produced notable deepening of the axial chamber nasally and temporal ly over the iris. During the next week the axial chamber depth remained formed—one quarter to two thirds of a corneal thickness—but peripherally iris remained up to the cornea. One week later the chamber flattened again axially in association with fibrotic recondensation of the hyaloid despite contin ued topical corticosteroid therapy. Subsequently a pars plana vitrectomy and anterior segment recon
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struction were performed with lysis of anterior synechiae. Despite this, the iris remained adherent to the cornea temporally with only a small space (one quarter of a corneal thickness) present between iris and cornea nasally. Intraocular pressure has re mained < 1 5 mm Hg with no visible bleb and visual acuity is only counting fingers. DISCUSSION
Malignant (ciliovitreal block) glaucoma in an aphakic eye can be thought of as the total obliteration of the posterior cham ber by the vitreous body which comes forward into apposition with the posterior surface of the iris and ciliary body 5 (Fig. 5). Aqueous humor, secreted by the ciliary body, moves into the vitreous body and must pass across the anterior hyaloid to enter into the anterior cham ber. The anterior hyaloid in affected pa tients may be abnormally "thickened" in texture or inherently less permeable, or there may be a limited hyaloid surface area available for fluid transfer. 4 · 6 In any case, the hyaloid restricts fluid move ment into the anterior chamber and thus aqueous humor is retained diffusely with in the vitreous body, which then acts as a mass to maintain a shallowed anterior chamber. A surgical or laser iridectomy does not reverse this condition because the hyaloid is present directly behind the iris, and there is no posterior chamber space filled with aqueous humor that al lows free communication through the iri dectomy from the ciliary body to the anterior chamber (Fig. 5). To treat this condition the anterior hyaloid must be disrupted 1 and bypassed as a fluid barri er, thus allowing equalization of pressure between the vitreous body and anterior chamber. The neodymium-YAG laser is a simple, effective way to accomplish this disrup tion, for its energy effects do not depend on pigmentation of ocular tissues. Thus it is well suited for "cutting" and disrupting the anterior hyaloid. In Cases 1 and 2 one application of the neodymium-YAG laser
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Fig. 5 (Epstein, Steinert, and Puliafito). Concept of aphakic malignant (ciliovitreal block) glaucoma. The vitreous is apposed to the posterior iris surface and there is no posterior chamber space filled with aqueous humor. Aqueous humor moves into the vitreous (arrows) from the ciliary body and must pass across a limited surface area of anterior hyaloid (arrows) to enter the anterior chamber. The anterior hyaloid can act as a restrictive barrier to such fluid movement.
to the anterior hyaloid resulted in imme diate deepening of the anterior chamber. In both cases we deliberately proceeded in stages to rule out pupillary block 7 as the mechanism for the angle closure by performing initially at least two laser iri-
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dectomies. (In Case 1 there were thus two patent surgical iridectomies and three patent laser iridectomies, and in Case 2 there were three patent laser iridectomies.) This failing, the immediate deepening of the anterior chamber which occurred after application of the neodymium-YAG laser to the anterior hy aloid confirmed the importance of the hyaloid in the pathogenesis of this apha kic malignant glaucoma condition. The rapid reversal of the flat chamber in these cases suggests that such neodymium-YAG "hyaloidotomy" may be the procedure of choice rather than pene trating surgery when argon laser iridectomy fails to deepen the anterior cham ber (and choroidal detachment is not present). In most cases we suspect that this procedure will cure such a condition. However, in Case 5 only temporary deepening of the anterior chamber was achieved and surgical vitrectomy was ul timately required (which unfortunately was also only partially successful in main taining anterior chamber depth). We sus pect that in such a case there was not free communication of fluid within the vitre ous space but rather sequestered spaces in the vitreous because of inflammatory membrane formation that may have held the iris forward. Nevertheless, the tem porary deepening of the condition after neodymium-YAG treatment confirmed again the importance of the hyaloid as a restrictive barrier to fluid flow into the anterior chamber. Similarly, we suspect that abnormali ties in the hyaloid are involved in the pathogenesis of malignant (ciliary block) glaucoma in phakic eyes. 4 However, we have not yet treated such a patient. Be cause of the presence of the lens, zonules, and, frequently, a small pupil, ac cess to the hyaloid in such phakic eyes is often limited. Still, we wonder whether such treatment might not prove similarly efficacious in a patient with a large colo-
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boma of the iris where the hyaloid could be visualized. It is possible that argon laser therapy to the ciliary processes, which has been proposed for both phakic 8,9 and aphakic 10 malignant glauco ma, may actually work by disturbing the adjacent peripheral anterior hyaloid. W h e t h e r or not this is the case, in pa tients with aphakic malignant (ciliovitreal block) glaucoma neodymium-YAG laser treatment directly to the anterior hyaloid represents a major advance in therapy and an effective alternative to surgical intervention. REFERENCES 1. Shaffer, R. N.: The role of vitreous detachment in aphakic and malignant glaucoma. Trans. Am. Acad. Ophthalmol. Otolaryngol. 58:217, 1954. 2. Shaffer, R. N., and Hoskins, H. D., Jr.: Ciliary block (malignant) glaucoma. Trans. Am. Acad. Oph thalmol. Otolaryngol. 85:215, 1978.
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3. Simmons, R. J. : Malignant glaucoma. In Chan dler, P. A., and Grant, W. M. (eds.): Glaucoma. Philadelphia, Lea & Febiger, 1979, pp. 172-182. 4. Epstein, D. L., Hashimoto, J. M., Anderson, P. J., and Grant, W. M.: Experimental perfusions through the anterior and vitreous chambers with possible relationships to malignant glaucoma. Am. J. Ophthalmol. 88:1078, 1979. 5. Epstein, D. L.: Malignant glaucoma. In Jakobiec, F., and Sigelman, J. (eds.): Advanced Tech niques in Ocular Surgery. Philadelphia, W. B. Saunders. In press. 6. Grant, W. M.: Experimental aqueous perfu sion in enucleated human eyes. Arch. Ophthalmol. 69:783, 1963. 7. Van Buskirk, E. M.: Pupillary block after intra ocular lens implantation. Am. J. Ophthalmol. 95:55, 1983. 8. Herschler, J.: Laser shrinkage of the ciliary processes. Ophthalmology 87:1155, 1980. 9. Simmons, R. J., in discussion, Herschler, J.: Laser shrinkage of ciliary processes. A treatment for malignant (ciliary block) glaucoma. Ophthalmology 87:1158, 1980. 10. Weber, P. A., Henry, M. A., Kapetansky, F. M., and Lohman, L. F.: Argon laser treatment of the ciliary processes in aphakic glaucoma with flat anterior chamber. Am. J. Ophthalmol. 97:82, 1984.