1	Malignant Glaucoma Robyn E. Horowitz, MD Harkness Eye Institute
2	History 61 y.o HF c/o 10 day history of progressive left eye redness, pain and decreased vision, associated with tearing and nausea (began while cooking).
3	History cont. PMH/ PSH: denies Meds: Advil All: NKDA Social hx: denies alcohol, drugs or tobacco use POHx: +bifocals, glaucoma s/p laser PI ou 1.5 years ago (outside hospital) GTT: Lumigan 2/2 FHx: Denies
4	Initial Exam Va: (cc) OD: 20/40 OS: 20/400 ph 20/100 Pupils: OD: 5 à 3.5mm OS: 5.5 à5.5, mid-dilated no APD EOM: full ou SLE: L/L, – wnl ou S/C – OD: wnl/ OS: 2+ injection K – OD: wnl/ OS: microcystic edema AC – shallow ou, OS>OS I/L – +NS ou, +PI ou DFE: C/D: 0.3 ou, D/M/V/P wnl ou
5	Initial exam cont. Ta: OD: 16 OS: 56 Gonio: OD: grade 0-1, no PAS OS: grade 0, unable to open with indentation, ciliary precesses visible all around DFE: full ou Pt. was given Cosopt, Xalatan and Diamox until pressure decreased to 16 os; pilocarpine was then instilled.
6	Further testing A-scan: OD: acd: 2.82/ lens: 5.33/ axl:22.4 OS: acd: 1.62/ lens: 5.53/ axl:22.7 B-scan: wnl ou, no mass lesions seen ACD measurement by optical pachimetry: OD: 2.40 OS: 1.05 (minimal change post homatropine)
7	Scheimflug OD
8	Scheimflug OS (pre-cycloplegic)
9	Scheimflug OS (post-cycloplegic)
10	Slit lamp photos
11	2 Days later Pt. returned with recurrent severe HA and pain OS since the AM Va: OD: 20/25 OS: 20/400 SLE: OD: wnl OS: microcystic edema and 2+ injection Ta: OD: 15 OS: 58 Pt. was then given osmoglyn; diamox 500mg, cosopt, alphagan, lumigan and atropine 1% and the pressure decr. to 32. The pt. was told to f/u in AM NPO
12	Malignant Glaucoma Dx: shallow or flat AC with patent PI (no pupillary block) and increased IOP (w/o choroidal effusion or hemorrhage) Path: Abn. Bt. The vitreous permeability, ant. hyaloid face, cilliary processes and lens à causing aqueous misdirection into mid or post. Vitreous UBM: ant rotation of ciliary processes with forward movement of lens/ IOL and ciliary body
13	Risk Factors Simple or combined filtration procedures in eyes with angle closure glaucom Post laser iridotomy, capsulotomy, or photocoagulation Post cataract extraction Post miotic Rx (or cessation of cycloplegic)
14	Differential Diagnosis Malignant glaucoma Pupillary block glaucoma Choroidal effusion Suprachoroidal hemorrhage
15	Treatment Meds: cycloplegics, aqueous suppressants, steroids, hyperosmotics Laser: (refractory pseudophakic or aphakic) 1. Nd:YAG ant hyaloidotomy 2. Direct argon laser 3. Diode laser cyclophotocoagulation (Carassa et al.) Surgery: 1. PPV +/- lensectomy 2. Zonulo-hyaloido-vitrectimy
16	Subsequent course The pt. returned with IOP OS 66 on maximum medications. Emergency pars plana vitrectomy with cataract extraction was then performed Post-op day 1 the patient was pain free with an IOP os of 10.