A 75-year-old woman was referred for further treatment for uncontrolled intraocular hypertension following trabeculectomy. The patient had a past medical history significant for hypertension. Her family history was negative for glaucoma. She had a past ocular history significant for cataract in both eyes and lens zonular laxity in right eye. She underwent right phacoemulsification with intraocular lens (IOL) and CTR (Holland, OPHTEC B.V., 13.0 mm in noncompressed diameters) implantation in November of 2017. Following surgery, the best corrected visual acuity (BCVA) was 20/22 and IOP was 11.1 mmHg in the right eye. The slit-lamp examination showed that anterior segment examination was unremarkable. Twelve days after cataract surgery, elevated IOP of 41.2 mmHg in the right eye was noted and she underwent laser peripheral iridotomy and was placed on medical therapy for intraocular hypertension.\nSeveral months with treatment of maximal medical therapy, right IOP remained uncontrolled. She presented with complaints of pain on March 20, 2018. On examination, visual acuity (VA) was 20/200 in the right eye and 20/33 in the left eye. IOPs were 39.5 mmHg in the right and 15.6 mmHg in the left eyes on fixed combination brimonidine 0.2%/timolol 0.5%/brinzolamide 1% bid and bimatoprost 0.03% qn in the right eye, respectively. Slit-lamp examination revealed peripheral AC <1/4 corneal thickness in both eyes, patent peripheral iris incisions (PIs) and narrow closed angles in the right eye, narrow open angles in the left eye, and cup to disc ratios of 0.3 in both eyes. Posterior chamber IOL was in good position in the right eye and early senile cataract was present in the left eye. Axial length is 20.72 mm in the right eye and 20.69 mm in the left eye. Len-star showed that white to white is 11.6 mm in the right eye and 10.4 mm in the left eye. UBM showed shallowing of the AC in both eyes and angle closure in the right eye (Fig. A–D). A diagnosis of secondary angle-closure glaucoma was made. Given her pain and uncontrolled IOP, she underwent trabeculectomy on March 21, 2018.\nThe surgery was uneventful except the presenting of shallow AC of Shaffer grade 1 and relieved by tropicamide. However, the IOP quickly increased to 43.5 mmHg during the first hour after the operation. The slit-lamp examination was significant for 2+ corneal edema. In an effort to reduce her IOP, the filtering bleb was massaged. On postoperative day 1, the patient presented as shallow AC of Shaffer grade 1, uncorrected VA was counting fingers and an elevated IOP of 51.0 mmHg in the right eye. UBM showed ciliary block between CTR and ciliary body (Fig. A and B). Since there were no signs of choroidal detachment or suprachoroidal hemorrhage, a diagnosis of MG was made. Subsequently, the patient underwent posterior capsulotomy by Nd: YAG and accepted oral acetazolamide and maximum topical medical therapy (atropine 1%, prostaglandin analog, timolol, bromonidine, brinzolamide) for 4 days. However, AC remained shallow and IOP was uncontrolled. UBM was done again on March 20, 2018 and high attenuation shadow of CTR was noticed (Fig. C and D).\nGiven presence of unacceptable IOP, it was considered to surgically manage her ciliary block glaucoma. However, whether to remove the CTR was a problem. It seemed that removal of CTR was the most effective way to relive ciliary block as well as the most difficult procedure. Given our personal successful experience with the CP in patients with refractory glaucoma in shallow AC, we decided on performing LDCP first. Pars plana vitrectomy and CTR removal was also prepared in case of the failure of LDCP.\nThe Ethics committee of the eye hospital of Wenzhou Medical University approved the conduct of LDCP as a new therapy for MG (YX2018-015). An informed consent was obtained from the patient.\nLDCP was performed under retrobulbar anesthesia with OcuLight SLx semiconductor diode 810 nm laser and the contact G-probe on March 27, 2018. The ciliary body was identified by transillumination and the contact G-probe was placed at the anterior aspect of the ciliary body which approximately 1.8 mm posterior to the limbus. The treatment consisted of 15 applications of 2.0 W energy applied for 2 seconds over 6 to 9 o’clock (avoiding the 9 o’clock position, 90° total) of the ciliary body. Upon termination of the procedure, atropine and dexamethasone ointments were placed on the eye to reduce the postoperative inflammation.\nThree hours after LDCP treatment, IOP in the right eye decreased to 24.9 mmHg with the ease of corneal edema and improvement of transparency, and uncorrected VA was 20/250 in the right eye. She was treated with atropine, dexamethasone ointments, timolol, and brinzolamide. On postoperative day 2, the IOP was 22.7 mmHg with a clear cornea and 20/167 vision, and bimatoprost 0.03% qn was added. UBM showed the relief of inferior ciliary block (Fig. ) and a suspect communication from the posterior space of the lens to the posterior chamber. On the day 7 visit, the IOP was 15.9 mmHg on 5 medications and 3 medications was reduced. The patient was seen at the 1-month postoperative visit with an IOP of 17.0 mmHg on atropine bid/bimatoprost 0.03% qn, and her uncorrected visual acuity (UCVA) in the right eye improved to 20/100. UBM confirmed a well-relief of ciliary block with an anterior chamber depth (ACD) of 1.70 mm. At 3 months, IOP measured 17.5 mmHg on atropine bid/bimatoprost 0.03% qn. The patient discontinued topical atropine and bimatoprost 4 months postoperatively. During her 6 months of follow-up, her IOP was 18.9 mmHg and ACD was 2.09 mm without any medication. At her last visit on March 29, 2019, VA remained 20/167, IOP measured 16.5 mmHg in the right eye. Slit-lamp examination and UBM showed the depth of central AC in the right eye (Fig. A and B). There was no significant uveitis and other complications observed during 1-year follow-up.
An 83-year-old lady of Indian origin with PAC, bilateral pseudophakia and IOP of 35 mmHg on maximal medical therapy underwent an augmented trabeculectomy with MMC in the right eye. Preoperatively, the AC was moderately shallow in the right eye, and gonioscopy showed a closed angle. The left eye AC was shallow with some peripheral anterior synechiae. A month later, the AC remained shallow, and IOP was 15–20 mmHg on 3 topical glaucoma medications. The patient was referred to the glaucoma clinic where malignant glaucoma was diagnosed, and ZHV preformed. The AC deepened; IOP settled at 15 mmHg and VA was 20/30. 6 months later, she presented with blurred vision for 3 months in the same eye. Her IOP was 23 in the left eye, and the AC was shallow with peripheral irido-corneal touch. Malignant glaucoma was suspected, and she was treated with Atropine 1% drops in that eye. The vision improved to 20/30, the AC deepened, and the IOP was 19 mmHg at 7 days follow-up. However, on a routine follow-up visit 15 months after ZHV, IOP was raised at 34 mmHg and peripheral AC was shallow once more with iridocorneal touch. A repeat ZHV was performed after which the AC deepened []. 2 years after the second ZHV, the IOP was stable at 17 mmHg without medication.