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.
An 86-year-old Caucasian female was referred to the VR specialist for deteriorating vision in her right eye (2/200) due to a macular hole. The diagnosis was confirmed on optical coherence tomography, and she underwent a phacovitrectomy with internal limiting membrane peel, posterior chamber IOL implantation and gas tamponade with C2F6. On the first postoperative day, her AC was shallow and IOP 66 mmHg. This was thought to be because of gas overfill as the lower edge of the gas bubble was not visualized. The gas was released on 2 separate occasions by the VR surgeon. Laser and surgical PIs were done, but IOP remained extremely high on maximal medication, oral and intravenous hyperosmotic agents. B-scan ultrasonography ruled out suprachoroidal hemorrhage. Malignant glaucoma was diagnosed and 2 weeks after the VR surgery a ZHV was done. The rationale was that the remaining anterior vitreous was probably blocking communication between the anterior and posterior segments. Postoperatively, the AC deepened, and IOP decreased to 4 mmHg. However, there was no visual recovery, and the eye became phthisical over the next few months.