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Open-Angle Glaucoma Associated With Vitreous Humor Filling the Anterior Chamber
Open-Angle Glaucoma Associated With Vitreous Humor Filling the Anterior Chamber John R. Samples, M.D., and E. Michael Van Buskirk, M.D.
We studied the diagnostic features of vitreous humor filling the anterior chamber in open-angle glaucoma in one patient who developed this phenomenon several years after an intracapsular cataract extraction. In two other patients, vitreous filled the anterior chamber after ocular trauma. These patients had markedly increased intraocular pressures that responded poorly to medical therapy. Follow-up of at least one year with each of our patients suggests that with vitrectomy they have done well. GRANT l WAS THE FIRST to call attention to an uncommon form of glaucoma caused by vitreous filling the anterior chamber. This glaucoma occurred when the anterior chamber became filled with loose vitreous humor. It is not associated with shallowing of the anterior chamber or with closure of the anterior chamber angle. Development of peripheral anterior synechiae does not playa role in this syndrome. Several early publications-" suggested that such a syndrome could occur. Grant reported four clinical cases as well as laboratory experiments on enucleated human eyes in which the vitreous was introduced into the anterior chamber. The vitreous humor had the potential to obstruct the outflow of aqueous humor. We have seen three such cases, which have been treated with vitrectomy.
Accepted for publication Sept. 9, 1986. From the Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon. Reprint requests to John R. Samples, M.D., Department of Ophthalmology, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
102:759-761,
Case Reports Case 1 A 70-year-old woman was struck by a piece of wood in her right eye. The patient was referred for further care when her intraocular pressure was measured at 74 mm Hg. On examination, visual acuity in the right eye was counting fingers and the intraocular pressure was greater than could be measured with a tonometer. The cornea was edematous. The anterior chamber angle was completely open with no peripheral anterior synechia or evidence of angle recession. The lens was dislocated inferiorly, and some intact zonules could be seen. Vitreous filled the anterior chamber of the right eye. Because no aqueous humor could be seen, the glaucoma appeared to result from the position of vitreous against the angle blocking all aqueous outflow. Despite therapy, the intraocular pressure remained over 60 mm Hg. An anterior chamber vitrectomy was performed without incident and the intraocular pressure was reduced to 20 mm Hg. Six weeks after the patient was discharged, visual acuity in the right eye was 20/400 with pinhole. The intraocular pressure was 28 mm Hg. An asymmetry in the cupping of the optic nerve was noted with the larger vertical cup-todisk ratio seen in the right eye. The patient continued to do well and required less medication with each visit. One year after her accident, the intraocular pressure in the right eye was 19 mm Hg with 0.5% timolol twice daily and 250 mg of acetazolamide twice daily. Case 2 A 53-year-old man sustained blunt trauma to his right eye when struck by an elastic band. On examination, the cornea was edematous and the lens was dislocated into the vitreous
DECEMBER,
1986
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760
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AMERICAN JOURNAL OF OPHTHALMOLOGY
cavity. Vitreous humor had migrated anteriorly to fill the anterior chamber. No clear aqueous humor was visible. The anterior chamber angle was completely open with no synechiae and no angle contusion. With medical therapy, the intraocular pressure remained greater than 60 mm Hg for four weeks. The anterior chamber remained filled with vitreous. A vitrectomy performed through a superior limbal wound allowed us to aspirate vitreous from the surfaces of the iris, chamber angle, and cornea, which resulted in the immediate clearing of the corneal edema. After a postsurgical, transient, increased intraocular pressure, the intraocular pressure remained below 20 mm Hg for two years without any ocular antihypertensive medications. The cornea remained clear and the anterior chamber remained deep and quiet. Strands of vitreous remained, extending from the lens into the anterior chamber. One year after the vitrectomy, the patient's dislocated lens was removed. The patient was subsequently fit with a contact lens and had a visual acuity of 20/40. Case 3 A 57-year-old woman with a history of congenital cataracts was referred to us for uncontrolled glaucoma. Ten years earlier, the patient had undergone intracapsular lens extractions in both eyes. She had done well until one year before initial examination. At that time the intraocular pressure was 30 mm Hg in her right eye. Glaucoma medications including acetazolamide, pilocarpine, and epinephrine were used, and the patient achieved good control of the intraocular pressure. At initial examination, visual acuity was 20/20 with correction in both eyes. Intraocular pressures were R.E.: 36 mm Hg and L.E.: 20 mm Hg. The peripheral portion of the right corneal epithelium showed faint epithelial edema, and the central cornea was clear. The anterior chamber was of normal depth but filled with vitreous. Both optic disks were normal. The patient was treated with cycloplegics in an unsuccessful attempt to retract vitreous. A vitrectomy was performed. The intraocular pressure three weeks after surgery was 29 mm Hg. One week later, the intraocular pressure in the right eye was 18 mm Hg. Three months after vitrectomy, the patient had a visual acuity of 20/60, with a rhegmatogenous retinal detachment. It was repaired with a scleral buckle. The patient's intraocular pressures continued to re-
main low with 4% pilocarpine four times a day and a 2% epinephrine solution three times a day. When seen most recently, six years after initial examination, the intraocular pressure in the right eye was 16 mm Hg and the visual acuity was 20/40 with correction.
Discussion The important diagnostic features of this syndrome of glaucoma associated with vitreous humor filling the anterior chamber include an intraocular pressure that does not repond to medications, an open anterior chamber angle, and the absence of visible free aqueous humor in the anterior chamber. It may be difficult by clinical examination to determine the extent of vitreous in the anterior chamber because of the difficulty in visualizing transparent vitreous by gonioscopy. Occasionally, cells, inflammatory debris, or pigment particles located within the vitreous may indicate its presence. Typically these particles are adherent to the vitreous and do not circulate but remain fixed because of the vitreous structure. The clinician is more likely to recognize the occasional loose strands where the strands tug or pull on the iris. Two of our patients had blunt trauma, and, although we did not detect any angle recession on gonioscopy, damage to the angle may have contributed to the increase in intraocular pressure. The prompt and sustained reduction in intraocular pressure after vitrectomy in each case suggests that vitreous in the anterior chamber was a significant component in the obstruction of outflow. Chandler and johnson" studied pupillary block by vitreous humor, which they thought could cause shallowing of the anterior chamber and probable closure of the anterior chamber angle. They pointed out that, in certain instances, glaucoma could be induced by vitreous coming forward to fill the anterior chamber and block the angle. In their case, the anterior chamber appeared to be almost filled with vitreous and only slightly shallowed. Grant' observed during in vitro experimental studies that vitreous humor, when placed in the anterior chamber of enucleated human eyes, obstructs aqueous outflow. He was able to relieve this obstruction by using enzymes that specifically reduce the viscosity of vitreous. Not all cases of vitreous filling the anterior
Vol. 102, No.6
Anterior Chamber, Vitreous Humor, and Glaucoma
chamber require surgical treatment. Simmons" reported that some cases will resolve spontaneously over several months. It may be possible to manipulate the vitreous in the anterior chamber by either mydriasis to minimize pupillary block or miosis to draw vitreous away from the angle.' Characteristically, strands of vitreous humor may strip away from the chamber angle during vitrectomy, followed postoperatively by a dramatic reduction in intraocular pressure. However, all three of our patients had residual glaucoma that required medical therapy and gradually improved over time. After a minimum of one year follow-up, one patient now uses no medication and intraocular pressure is controlled in the other two with medications alone. In cases that do not respond to medical therapy, anterior vitrectomy appears to be the surgical therapy of choice.
761
References 1. Grant, W. M.: Open-angle glaucoma associated with vitreous filling the anterior chamber. Trans. Am. Ophthalmol. Soc. 61:196, 1963. 2. Lawford, J. B.: Cases of dislocation of crystalline lens. Royal London Ophthalmic Hospital R.E.P.
11:330, 1886-1887.
3. Hudson, A. c.: Injury to the vitreous body as a factor in the production of secondary glaucoma. Royal London Ophthalmic Hospital R.E.P. 18:203, 1911.
4. Chandler, P. A., and Johnson, C. c.: A neglected cause of secondary glaucoma in eyes in which the lens is absent or sub-luxated. Arch. Ophthalmol. 37:740, 1947.
5. Grant, W. M.: Experimental aqueous profusia in enucleated human eyes. Arch. Ophthalmol.
69:783, 1963.
6. Simmons, J. R.: The vitreous in glaucoma. Trans. Ophthalmol. Soc. U.K. 95:422, 1975.
We studied the diagnostic features of vitreous humor filling the anterior chamber in open-angle glaucoma in one patient who developed this phenomenon several years after an intracapsular cataract extraction. In two other patients, vitreous filled the anterior chamber after ocular trauma. These patients had markedly increased intraocular pressures that responded poorly to medical therapy. Follow-up of at least one year with each of our patients suggests that with vitrectomy they have done well. GRANT l WAS THE FIRST to call attention to an uncommon form of glaucoma caused by vitreous filling the anterior chamber. This glaucoma occurred when the anterior chamber became filled with loose vitreous humor. It is not associated with shallowing of the anterior chamber or with closure of the anterior chamber angle. Development of peripheral anterior synechiae does not playa role in this syndrome. Several early publications-" suggested that such a syndrome could occur. Grant reported four clinical cases as well as laboratory experiments on enucleated human eyes in which the vitreous was introduced into the anterior chamber. The vitreous humor had the potential to obstruct the outflow of aqueous humor. We have seen three such cases, which have been treated with vitrectomy.
Accepted for publication Sept. 9, 1986. From the Department of Ophthalmology, Oregon Health Sciences University, Portland, Oregon. Reprint requests to John R. Samples, M.D., Department of Ophthalmology, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201.
©AMERICAN JOURNAL OF OPHTHALMOLOGY
102:759-761,
Case Reports Case 1 A 70-year-old woman was struck by a piece of wood in her right eye. The patient was referred for further care when her intraocular pressure was measured at 74 mm Hg. On examination, visual acuity in the right eye was counting fingers and the intraocular pressure was greater than could be measured with a tonometer. The cornea was edematous. The anterior chamber angle was completely open with no peripheral anterior synechia or evidence of angle recession. The lens was dislocated inferiorly, and some intact zonules could be seen. Vitreous filled the anterior chamber of the right eye. Because no aqueous humor could be seen, the glaucoma appeared to result from the position of vitreous against the angle blocking all aqueous outflow. Despite therapy, the intraocular pressure remained over 60 mm Hg. An anterior chamber vitrectomy was performed without incident and the intraocular pressure was reduced to 20 mm Hg. Six weeks after the patient was discharged, visual acuity in the right eye was 20/400 with pinhole. The intraocular pressure was 28 mm Hg. An asymmetry in the cupping of the optic nerve was noted with the larger vertical cup-todisk ratio seen in the right eye. The patient continued to do well and required less medication with each visit. One year after her accident, the intraocular pressure in the right eye was 19 mm Hg with 0.5% timolol twice daily and 250 mg of acetazolamide twice daily. Case 2 A 53-year-old man sustained blunt trauma to his right eye when struck by an elastic band. On examination, the cornea was edematous and the lens was dislocated into the vitreous
DECEMBER,
1986
759
760
December, 1986
AMERICAN JOURNAL OF OPHTHALMOLOGY
cavity. Vitreous humor had migrated anteriorly to fill the anterior chamber. No clear aqueous humor was visible. The anterior chamber angle was completely open with no synechiae and no angle contusion. With medical therapy, the intraocular pressure remained greater than 60 mm Hg for four weeks. The anterior chamber remained filled with vitreous. A vitrectomy performed through a superior limbal wound allowed us to aspirate vitreous from the surfaces of the iris, chamber angle, and cornea, which resulted in the immediate clearing of the corneal edema. After a postsurgical, transient, increased intraocular pressure, the intraocular pressure remained below 20 mm Hg for two years without any ocular antihypertensive medications. The cornea remained clear and the anterior chamber remained deep and quiet. Strands of vitreous remained, extending from the lens into the anterior chamber. One year after the vitrectomy, the patient's dislocated lens was removed. The patient was subsequently fit with a contact lens and had a visual acuity of 20/40. Case 3 A 57-year-old woman with a history of congenital cataracts was referred to us for uncontrolled glaucoma. Ten years earlier, the patient had undergone intracapsular lens extractions in both eyes. She had done well until one year before initial examination. At that time the intraocular pressure was 30 mm Hg in her right eye. Glaucoma medications including acetazolamide, pilocarpine, and epinephrine were used, and the patient achieved good control of the intraocular pressure. At initial examination, visual acuity was 20/20 with correction in both eyes. Intraocular pressures were R.E.: 36 mm Hg and L.E.: 20 mm Hg. The peripheral portion of the right corneal epithelium showed faint epithelial edema, and the central cornea was clear. The anterior chamber was of normal depth but filled with vitreous. Both optic disks were normal. The patient was treated with cycloplegics in an unsuccessful attempt to retract vitreous. A vitrectomy was performed. The intraocular pressure three weeks after surgery was 29 mm Hg. One week later, the intraocular pressure in the right eye was 18 mm Hg. Three months after vitrectomy, the patient had a visual acuity of 20/60, with a rhegmatogenous retinal detachment. It was repaired with a scleral buckle. The patient's intraocular pressures continued to re-
main low with 4% pilocarpine four times a day and a 2% epinephrine solution three times a day. When seen most recently, six years after initial examination, the intraocular pressure in the right eye was 16 mm Hg and the visual acuity was 20/40 with correction.
Discussion The important diagnostic features of this syndrome of glaucoma associated with vitreous humor filling the anterior chamber include an intraocular pressure that does not repond to medications, an open anterior chamber angle, and the absence of visible free aqueous humor in the anterior chamber. It may be difficult by clinical examination to determine the extent of vitreous in the anterior chamber because of the difficulty in visualizing transparent vitreous by gonioscopy. Occasionally, cells, inflammatory debris, or pigment particles located within the vitreous may indicate its presence. Typically these particles are adherent to the vitreous and do not circulate but remain fixed because of the vitreous structure. The clinician is more likely to recognize the occasional loose strands where the strands tug or pull on the iris. Two of our patients had blunt trauma, and, although we did not detect any angle recession on gonioscopy, damage to the angle may have contributed to the increase in intraocular pressure. The prompt and sustained reduction in intraocular pressure after vitrectomy in each case suggests that vitreous in the anterior chamber was a significant component in the obstruction of outflow. Chandler and johnson" studied pupillary block by vitreous humor, which they thought could cause shallowing of the anterior chamber and probable closure of the anterior chamber angle. They pointed out that, in certain instances, glaucoma could be induced by vitreous coming forward to fill the anterior chamber and block the angle. In their case, the anterior chamber appeared to be almost filled with vitreous and only slightly shallowed. Grant' observed during in vitro experimental studies that vitreous humor, when placed in the anterior chamber of enucleated human eyes, obstructs aqueous outflow. He was able to relieve this obstruction by using enzymes that specifically reduce the viscosity of vitreous. Not all cases of vitreous filling the anterior
Vol. 102, No.6
Anterior Chamber, Vitreous Humor, and Glaucoma
chamber require surgical treatment. Simmons" reported that some cases will resolve spontaneously over several months. It may be possible to manipulate the vitreous in the anterior chamber by either mydriasis to minimize pupillary block or miosis to draw vitreous away from the angle.' Characteristically, strands of vitreous humor may strip away from the chamber angle during vitrectomy, followed postoperatively by a dramatic reduction in intraocular pressure. However, all three of our patients had residual glaucoma that required medical therapy and gradually improved over time. After a minimum of one year follow-up, one patient now uses no medication and intraocular pressure is controlled in the other two with medications alone. In cases that do not respond to medical therapy, anterior vitrectomy appears to be the surgical therapy of choice.
761
References 1. Grant, W. M.: Open-angle glaucoma associated with vitreous filling the anterior chamber. Trans. Am. Ophthalmol. Soc. 61:196, 1963. 2. Lawford, J. B.: Cases of dislocation of crystalline lens. Royal London Ophthalmic Hospital R.E.P.
11:330, 1886-1887.
3. Hudson, A. c.: Injury to the vitreous body as a factor in the production of secondary glaucoma. Royal London Ophthalmic Hospital R.E.P. 18:203, 1911.
4. Chandler, P. A., and Johnson, C. c.: A neglected cause of secondary glaucoma in eyes in which the lens is absent or sub-luxated. Arch. Ophthalmol. 37:740, 1947.
5. Grant, W. M.: Experimental aqueous profusia in enucleated human eyes. Arch. Ophthalmol.
69:783, 1963.
6. Simmons, J. R.: The vitreous in glaucoma. Trans. Ophthalmol. Soc. U.K. 95:422, 1975.