A 63-year-old Caucasian gentleman with schizophrenia was referred to the glaucoma clinic by his optician with bilateral pale optic discs, IOPs over 60 mmHg and vision of counting fingers in both eyes. In both eyes, AC was shallow; the angle completely closed, and the optic discs cupped and pale. A diagnosis of chronic angle closure was made, and bilateral LPIs done. The patient was started on oral acetazolamide and 3 topical glaucoma medications. A month later, the IOP had reduced to 21 mmHg in the right eye. Right eye phacotrabeculectomy under general anesthesia was done with prior explanation of the poor prognosis for visual recovery to the relatives. Intraoperatively, a floppy iris was noted which responded to intracameral phenylephrine. Postoperatively, the AC was shallow and IOP 16 mmHg. A week later, the IOP crept to 23 mmHg, the AC remained shallow with a fibrinous deposit over the pupil. Malignant glaucoma was considered to be the cause and ZHV performed. The AC deepened on the table, but the next morning, the AC was shallow with fibrin covering the pupil and the PI. Nd: YAG laser lysis of the fibrin and anterior hyaloidotomy through the PI was done. The AC deepened immediately. The IOP has been stable over the next 4 years at 18 mmHg without glaucoma medications. However, VA was counting fingers.
A 77-year-old Caucasian male who had a routine extracapsular cataract extraction with a surgical PI in his right eye 15 years ago, was seen with complaints of blurred vision. His BCVA was 20/30. Nd: YAG laser posterior capsulotomy was done twice. It was repeated after a year as he was still complaining of blurred vision, and the ophthalmologist thought that the central capsular clearance was inadequate. A month later, he had no improvement, and his VA was 20/60. The AC was deep, and some vitreous was herniating though the inferotemporal pupillary margin. He was managed conservatively. A further 6 months later his VA had decreased to 20/200 and IOP was 32 mmHg. He was started on topical beta-blockers, but the IOP remained high. He was referred to the glaucoma clinic where a shallow AC with peripheral iris-cornea touch and vitreous herniation through the inferotemporal pupillary margin was noted. Malignant glaucoma was diagnosed, and ZHV performed. By the 6th postoperative week, the IOP increased to 40 mmHg. It was controlled on topical travoprost and brinzolamide. Gonioscopy showed that the angle was >270° closed. He also developed nonresponsive cystoid macular edema (CMO). On the last visit, 67 months after ZHV, his IOP was 14 mmHg on the aforementioned medications and BCVA was 20/120.