Scheimpflug%20imaging%20in%20a%20case%20of%20Aqueous%20Misdirection%20Syndrome

1

• Scheimpflug imaging in a case of Aqueous
  Misdirection Syndrome
• Michael R. Gagnon, M.D.
• Valley EyeCare Center
• Clinical Instructor
• Stanford University School Of Medicine
• Maneesh H. Singh, B.S.
• Stanford University School Of Medicine
• We have no financial interests in the subject
  matter.

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Introduction

• Aqueous misdirection syndrome (malignant
  glaucoma) is a rare condition. It is
  characterized by a shallow axial anterior chamber
  (AC), a patent peripheral iridotomy and absence
  of suprachoroidal fluid.1
• To our knowledge we describe the first case of
  aqueous misdirection syndrome documented with
  Scheimpflug imaging (Pentacam HROculus, Wetzlar,
  Germany).

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Case Report

• An 88-year-old woman with prior history of
  bilateral cataract extraction 15 years ago
  presented to the emergency department with left
  eye pain and nausea and vomiting.
• Visual acuity was 20/25 OD and Count Fingers OS.
  Examination of the right eye revealed a deep AC
  and an intraocular pressure (IOP) of 18 mmHg. The
  left eye had corneal edema, a flat AC with
  iridocorneal touch, and an IOP of 66 mmHg.
• Gonioscopy revealed a wide-open angle in the
  right eye and 360 degrees of angle closure in the
  left eye. The posterior segment examination was
  normal with no evidence of choroidals.

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Pentacam Scheimpflug image of anterior segment
Right Eye
Red arrow - Intraocular Lens Green arrows- Iris
5
Pentacam Scheimpflug image of anterior segment
Left Eye
Red arrow - Intraocular Lens Green arrows- Iris
6
Case Report

• Topical medications were started consisting of
  Combigan (brimonidine tartrate 0.2/ timolol
  maleate 0.5), brinzolamide 1, prednisolone
  acetate1, as well as oral acetazolamide 500 mg.
  
• Two neodymiumyttrium-aluminum-garnet (NdYAG)
  laser peripheral iridotomies were performed.
• The AC did not deepen but the IOP was controlled
  at 26 mmHg. The patient was discharged on
  Combigan twice daily, brinzolamide 1 twice
  daily, prednisolone acetate 1 four times daily,
  and acetazolamide 500 mg extended-release
  capsules every twelve hours.

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Case Report

• The patient experienced eye pain as well as
  nausea and vomiting and presented the following
  morning. The IOP in the left eye was 40 mmHg and
  the AC was still flat despite two patent
  peripheral iridotomies.
• The diagnosis of aqueous misdirection was made
  and a NdYAG laser capsulotomy and hyaloidotomy
  was performed and was unsuccessful.
• Cycloplegia was started with topical atropine 1
  four times daily and phenylephrine 2.5 four
  times daily.
• The aqueous misdirection resolved with medical
  therapy after 2 days.The vision in the left eye
  was Hand Motions and the IOP was 6 mm Hg. The
  anterior chamber was deep (2.88 mm) and cornea
  was edematous with central pachymetry of 946
  microns

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Pentacam Scheimpflug image of anterior segment
Left Eye
Red arrow - Intraocular Lens Green arrows- Iris
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Case Report

• The corneal edema slowly resolved over two months
  and the vision improved to 20/60 The patient was
  diagnosed with cystoid macular edema which
  resolved over four months with prednisolone 1
  and bromfenac 0.09 and her vision improved to
  20/20. She has been continued on atropine 1 once
  daily.

Pentacam Scheimpflug image of anterior segment
Left Eye
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Discussion

• Aqueous misdirection syndrome is a rare type of
  secondary angle-closure glaucoma. It is poorly
  understood but thought to occur because of the
  diversion of aqueous behind the lens and
  anterior hyaloid and into the posterior segment
  with swelling of the vitreous and anterior
  rotation of the ciliary body processes.2
• Medical therapy includes topical mydriasis and
  cycloplegia, aqueous suppression, and
  hyperosmotic agents.3 Surgical treatments include
  NdYag laser posterior capsulotomy with
  hyaloidotomy,4 argon laser ablation of the
  ciliary processes,5 transscleral cyclodiode laser
  photocoagulation,6 and surgical vitrectomy.7

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Conclusion

• This case demonstrates the utility of the
  Pentacam Scheimpflug imaging of the anterior
  chamber in aqueous misdirection syndrome .
• The Pentacam can be helpful in making the
  diagnosis of aqueous misdirection syndrome.

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References

• 1. Sharma A, Sii F, Shah P, Kirkby
  G.R.Vitrectomy-phacoemulsification-vitrectomy for
  the management of aqueous misdirection syndromes
  in phakic eyes. Ophthalmology 2006113(11)1968-73
  .
• 2. Tello C, Chi T, Shepps G, Liebmann J, Ritch R.
  Ultrasound biomicroscopy in pseudophakic
  malignant glaucoma. Ophthalmology
  1993100(9)1330-4.
• 3. Chandler PA, Grant WM. Mydriatic-cycloplegic
  treatment in malignant glaucoma. Arch Ophthalmol
  196268-353-9.
• 4. Lockie P. Ciliary-block glaucoma treated by
  posterior capsulotomy. Aust N Z J Ophthalmol
  198715207-9.
• 5. Herschler J. Laser shrinkage of the ciliary
  processes A treatment for malignant (ciliary
  block) glaucoma. Ophthalmology 871155, 1980.
• 6. Stumpf TH, Austin M, Bloom PA, McNaught A, et
  al. Transscleral cyclodiode laser
  photocoagulation in the treatment of aqueous
  misdirection syndrome. Ophthalmology
  20081152058-2061.
• 7. Lynch MG, Brown RH, Michels RG, et al.
  Surgical vitrectomy for pseudophakic
  malignant glaucoma. Am J Ophthal
  1986102149-53.