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 lady with PAC and an IOP of 34 mmHg without medication underwent a phacoemulsification in her right eye. The procedure was difficult with positive pressure and iris prolapsed through the temporal corneal section. 2 weeks postoperatively, IOP rose to 44 mmHg and AC shallowed significantly []. Nd: YAG laser anterior and posterior capsulotomy and hyaloidotomy were done through an inadvertent temporal PI. The AC deepened immediately after the procedure, and the IOP dropped to 34 mmHg. Over the next 2 weeks, the AC was deep, and IOP stabilized at 15 mmHg on topical latanoprost. In the meantime, she also underwent a routine phacoemulsification in the fellow eye. 4 months after her phacoemulsification, the right eye IOP had crept up to 32 mmHg on maximal tolerated medications and AC shallowed. ZHV was performed. Postoperatively, the AC deepened but the IOP control was inadequate, and CMO was noted. The CMO resolved on oral acetazolamide, topical prednisolone 1%, and ketorolac eye drops. However, gradually she developed intolerance to most topical medications. A year after ZHV, she noted blurred vision in the right eye. The IOP was over 30 mmHg, the AC moderately shallow and CMO had recurred. This time 270° cyclodiode laser was done, leading to resolution of the malignant glaucoma. The CMO partially resolved on oral acetazolamide. 2 years after the ZHV, her VA was 20/60 and IOP 22 mmHg without medication.