Aqueous Misdirection Syndrome Research Articles

Aqueous misdirection syndrome: clinical outcomes and risk factors for treatment failure.

To evaluate the outcomes of postoperative aqueous misdirection and factors predicting failure of interventions. This retrospective study included 49 eyes from 47 patients with aqueous misdirection following glaucoma or cataract surgery. Resolution of aqueous misdirection (AM) was deepening of the central anterior chamber (AC) and intraocular pressure (IOP) ≤ 21mmHg. The Cox proportional hazards regression model was used to evaluate risk factors for failure of various treatments. 10/49 eyes (20%) resolved with conservative management, and 39/49 eyes (80%) needed multiple intervention, of which 95% (37/39) eyes achieved resolution of aqueous misdirection. Pseudophakia predicted the need for multiple interventions with a hazard ratio of 2.391 (1.158-4.935), p = 0.02). Among the risk factors assessed for resolution of AM, longer axial length (HR: 0.61 (0.414-0.891), p < 0.01) and eyes with prior glaucoma surgery predicted resolution (HR: 0.142 (0.027-0.741), p < 0.01) and delayed presentation predicted failure (HR: 1.002 (1.0002-1.0031), p < 0.02). Pseudophakic eyes were more refractory and predicted the need for multiple interventions. Eyes with prior glaucoma surgery and those with longer axial length had achieved resolution faster, and delayed presentation was a risk factor for failure to resolve.

Management of Late Onset Sequential Pseudophakic Malignant Glaucoma: A Case Report and Review of Literature

Introduction: Malignant glaucoma or aqueous misdirection syndrome (AMS) can present in the immediate post-operative period or even many years after cataract surgery. We report the clinical course and management of a patient who developed the disease in both eyes at different time intervals after uneventful cataract surgery.Patient and Clinical Findings: A 76-year-old man developed diffusely shallow anterior chamber (AC) and high intraocular pressure (IOP) in his right eye after 2 years of pseudophakia, which did not resolve with laser peripheral iridotomy. A similar episode happened in left eye after 3 years of cataract surgery in the presence of a patent laser iridotomy.Diagnosis, Interventions, and Outcome: Shallow anterior chamber in the presence of a patent PI and normal posterior segment confirmed the diagnosis. The right eye was successfully managed with Nd:YAG laser capsulo-hyaloidotomy and pharmacotherapy, whereas in left eye, pars plana vitrectomy (PPV) with irido-zonulo-anterior hyaloidectomy (IZH) was done. Recurrence was noted after PPV also, owing to blockage of surgical iridectomy, which was treated with Nd:YAG laser.Conclusion: Pseudophakic malignant glaucoma can present many years after cataract surgery. Pars plana vitrectomy with IZH is an effective mode of treatment for refractory cases. Laser capsulo-hyaloidotomy may be more useful in the acute phase of the disease.

Aqueous Misdirection Syndrome after Laser Iridotomy in a Patient with Intermediate Uveitis

Purpose: We report a case of aqueous misdirection syndrome triggered by pilocarpine use after laser iridotomy, which was treated by pars plana vitrectomy and phacoemulsification.Case summary: A 48-year-old female patient presented with sudden-onset right eye pain and decreased vision. The patient had presented to another institute with similar symptoms 20 days prior; she had been diagnosed with acute angle closure. Laser iridotomy was performed, followed by administration of pilocarpine twice daily. In the right eye, visual acuity was hand motion, and intraocular pressure was 31 mmHg. The laser iridotomy site was located at the 11 o’clock position; microcysts, anterior chamber cells, corneal endothelium precipitates, and glaukomflecken were observed. The anterior chamber was shallow due to forward movement of the lens and iris. Despite the application of atropine and pressure-lowering eyedrops, anterior chamber shallowing continued along with a progressive myopic shift of -4.5 diopters. Therefore, the patient was diagnosed with aqueous misdirection syndrome. Pars plana vitrectomy was performed, followed by phacoemulsification, intraocular lens insertion, and posterior capsulotomy. During surgery, vitreous inflammation, a peripheral snowball, and an anterior hyaloid inflammatory membrane were observed, indicating the presence of intermediate uveitis.Conclusions: The administration of miotics after laser iridotomy, intraocular inflammation, and uveitis can lead to aqueous misdirection syndrome. Effective treatment of aqueous misdirection syndrome involves controlling inflammation and performing surgery.

Outcomes of Medical and Surgical Management in Aqueous Misdirection Syndrome.

To report the outcomes of medical and surgical management in patients diagnosed with aqueous misdirection syndrome (AMS). A retrospective chart review of all cases diagnosed with AMS at a single tertiary care eye center during the period from 2014 to 2021. Outcome measures were anatomical success (deepening of the anterior chamber (AC)), functional success (improvement in visual acuity), and treatment success (control of intraocular pressure (IOP)). A total of 26 eyes with AMS from 24 patients were included. The patients were followed for a mean duration of 24 ± 18 months. Although some patients initially responded to medical and laser therapy, all but one (3.8%) eventually required surgery during the first 3 months after presentation. The mean duration from presentation until surgery was 45.9 ± 45.8 days (range: 2-119 days). The majority of cases (69.2%) were managed by pars plana vitrectomy. At the last follow-up visit, anatomical success was achieved in 20 (76%) eyes, 15 (57%) eyes had a final visual acuity that was either similar to or better than baseline, and successful control of IOP was achieved in 17 (65%) eyes. Univariate analysis revealed that a history of trabeculectomy as a cause of AMS was a risk factor for treatment failure (OR, 7.8; 95% CI, 1.16-52.35; P, 0.02). Our findings indicate that medical and laser management of AMS provide temporary control, and almost all patients eventually require surgery within the first 3 months. A history of trabeculectomy was found to be a risk factor for treatment failure.

Синдром девиации инфузионных потоков: современное состояние вопроса

Relevance. Description of the infusion misdirection syndrome (IMS) was first published by R. Mackool in 1993. Nowadays many definitions of this syndrome are used by different authors that sometimes leads to confusion in understanding of clinical situations. Purpose. To summarize current understanding of the etiological factors, the specific pathogenic mechanisms of the infusion misdirection syndrome and possible treatment and prophylaxis methods of this condition. Material and methods. The PubMed web platform was used to find relevant studies since 1992 until 2022 using the following keywords: infusion misdirection syndrome, aqueous misdirection syndrome, intraoperative fluid misdirection syndrome, subcapsular fluid entrapment, acute intraoperative rock-hard eye syndrome. Search query found 167 papers, only 10 papers were relevant for the topic of search. Other publications were also considered as a potential source of information when referenced in relevant articles. Results. Authors of this article support the opinion that IMS etiologically relates to irido-zonular dehiscence and disturbance of the vitreolenticular interface barrier. Manifestations of the IMS include retrocapsular lens fragments migration after uneventful phacoemulsification with intact capsular bag and vitreous hydration. The most severe IMS consequence is the acute intraoperative rock-hard eye syndrome. In intact capsules the zonular dehiscence may enable fluid to flow in an unusual pattern, facilitating its penetration to the posterior chamber. The role of vitreolenticular interface should be mentioned in the aspect of the IMS. Anterior hyaloid membrane detachment or Wieger's ligament destruction are risk factors for IMS development during phacoemulsification. Conclusion. IMS is the object of insufficient research in ophthalmology nowadays. There are many descriptions of IMS in literature, but no solutions to avoid this hidden complication of cataract surgery are proposed. Key words: infusion misdirection syndrome, phacoemulsification, irido-zonular dehiscence, vitreolenticular interface.

Ocular Hypotony after Glaucoma Surgery

Background: Postoperative hypotony is associated with choroidal effusion, suprachoroidal haemorrhage, aqueous misdirection syndrome (malignant glaucoma), choroidal folds and hypotony maculopathy, anterior chamber (AC) shallowness or loss and subsequent failure of the original filtration of procedure. This work aimed to study the causes, risk factors, adverse effects, and management plans of ocular hypotony after different glaucoma surgeries.&#x0D; Methods: This retrospective study was carried out on 205 eyes underwent glaucoma surgery with follow up for more than 3 months. Patients were divided into two groups: 30 cases were diagnosed with post-operative hypotony, 175 eyes were without hypotony. Patients were subjected to glaucoma diagnosis, type of glaucoma operation and recorded IOP for 3 months at least.&#x0D; Results: CPC, Visco-Trab, Phaco Visco-Trab Visco and express valve were significantly different between the two groups (P=0.049, P=0.012, P=0.043 and P&lt;0.001 respectively) and other types of operation were insignificantly different between the two groups. IOP was significantly decreased at first diagnosis of hypotony and at last follow up compared to before operation (P value &lt;0.001). IOP at last follow up was significantly increased compared to first diagnosis of hypotony (P value &lt;0.001). Criteria of hypotony eyes were insignificantly different between patients needed surgical intervention and no surgical intervention.&#x0D; Conclusions: Postoperative hypotony was most common in pseudo-exfoliative glaucoma cases compared to other glaucoma types. While the most type of glaucoma surgery that was associated with postoperative hypotony was viscocanalostomy combined with express shunt. The adverse effects reported in our study were choroidal effusion and hypotony maculopathy.

Vitreoretinal Surgery in Glaucoma.

Glaucoma is associated with the demise of retinal ganglion cells and their axons, primarily located in the retina. Vitreoretinal and glaucoma surgery overlap to a not inconsiderable extent in certain diseases. This overview article aims to present these diseases and highlight treatment strategies and the respective modes of action collectively. This article describes malignant glaucoma or aqueous misdirection syndrome, retinal surgery for choroidal detachment and expulsive choroidal hemorrhage, postoperative blebitis and endophthalmitis after glaucoma surgery, and vitrectomy after glaucoma surgery, along with the therapeutic paths for managing complications. The areas of glaucoma and vitreoretinal surgery are tightly linked. Colleagues from both subspecialties should be familiar with a certain overview of diseases concerning both subject areas.

Coincidental finding of pars plana primary neuro-epithelial cyst in an elderly woman with aqueous misdirection syndrome

Coincidental finding of pars plana primary neuro-epithelial cyst in an elderly woman with aqueous misdirection syndrome

Bilateral sequential pseudophakic aqueous misdirection syndrome presenting as a myopic shift in refraction

A 63-year-old woman with high hyperopia developed acute myopia of − 5.50 D with axial shallowing of anterior chamber and high intraocular pressure (IOP) in her left eye after 2 weeks of phacoemulsification surgery. She developed a myopic shift after 4 weeks in the right eye also which was operated 8 months ago for cataract. Laser peripheral iridotomy was ineffective in both eyes. Cycloplegic therapy was started for presumed aqueous misdirection syndrome (AMS) with antiglaucoma drugs in both eyes. A laser capsulo-hyaloidotomy was attempted in LE with no result. Pars plana vitrectomy (PPV) with iridectomy-zonulectomy-hyloidectomy (IZH) was done in both eyes after 2 years of onset and multiple recurrences associated with atropine withdrawal. Pseudophakic AMS can present as a myopic shift in refraction without a significant rise in IOP. Cycloplegic therapy is not well tolerated by multifocal intraocular lens patients. PPV with IZH has been effective in preventing relapses in our patient for 20 months (RE) and 23 months (LE).

Topiramate Induced Aqueous Misdirection Syndrome Presenting as Bilateral Elevated Intraocular Pressure-A Case Report

Topiramate (brand name Topamax) is a commonly prescribed oral sulphamate medication. It is usually prescribed for prophylaxis against migraine and epileptic seizures. Few practitioners have started using it off-label as an effective treatment for various disorders, including neuropathic pain, binge eating disorder, alcohol use disorder, bulimia nervosa, obesity, borderline personality disorder, and idiopathic intracranial hypertension [1-3].

Current Concepts on Aqueous Misdirection

To review the current understanding of the pathophysiology and management of aqueous misdirection syndrome. Aqueous misdirection syndrome represents a spectrum of disorders that converge on a common pathway of increasing posterior segment pressure and secondary angle closure glaucoma. Although the etiology of aqueous misdirection remains unclear and is likely multifactorial, recent data supports choroidal expansion as an inciting event in the pathogenesis of the syndrome. As such, the term aqueous misdirection may be a misnomer. Some would argue that the use of terminology such as acute and chronic fluid misdirection may better characterize the full spectrum of the disease process as it is known to occur at varying time points from intraoperatively to years postoperatively. Chronic fluid misdirection most commonly occurs following incisional surgery for primary angle closure glaucoma but has also been associated with numerous laser and invasive ocular surgeries. Regardless of the mechanism, many patients require incisional surgery for complete resolution. Recent literature suggests that variants of anterior vitrectomy with irido-zonulo-hyaloidectomy offer comparable rates of success when compared to pars plana vitrectomy. Aqueous misdirection is a rare, and incompletely understood, form of secondary glaucoma characterized by diffuse shallowing of the anterior chamber in the presence of a patent iridotomy/iridectomy. It represents a spectrum of disorders that result in a cycle of increasing posterior segment pressure and secondary angle closure glaucoma that is notoriously refractory to medical intervention. Regardless of the mechanism, the syndrome can be well managed with incisional procedures that disrupt the anterior hyaloid face, debulk the vitreous, and establish an anterior-posterior communication either by a core or more complete anterior vitrectomy.

Aqueous humor misdirection syndrome after glaucoma filtering surgery in patient with bilateral acute iris transillumination (BAIT) syndrome

Abstract Case report Bilateral Acute Iris Transillumination (BAIT) is a disease characterized by bilateral acute, severe pigment dispersion of the iris, and pupil sphincter paralysis. The case is reported of a 51-year-old female who was diagnosed with BAIT syndrome, with refractory ocular hypertension in the left eye, and who needed filtering surgery. Aqueous misdirection was developed a week after surgery, then pars plana vitrectomy was performed and the complication was solved. Conclusion This is the first case described in the literature of aqueous humor misdirection syndrome secondary to glaucoma filtering surgery in a patient diagnosed of BAIT syndrome. This is a recently defined disease with a few cases currently described.

Síndrome de misdirección del humor acuoso tras cirugía filtrante de glaucoma en paciente con síndrome de transiluminación aguda iridiana bilateral (BAIT)

Case reportBilateral Acute Iris Transillumination (BAIT) is a disease characterised by bilateral acute, severe pigment dispersion of the iris, and pupil sphincter paralysis. The case is reported of a 51-year-old female who was diagnosed with BAIT syndrome, with refractory ocular hypertension in the left eye, and who needed filtering surgery. Aqueous misdirection was developed a week after surgery, then pars plana vitrectomy was performed and the complication was solved. ConclusionThis is the first case described in literature of aqueous humor misdirection syndrome secondary to glaucoma filtering surgery in a patient diagnosed of BAIT syndrome. This is a recently defined disease with a few cases currently described.

Acute and chronic fluid misdirection syndrome: pathophysiology and treatment

PurposeTo summarize our current understanding of the specific pathogenic mechanisms of the fluid misdirection syndrome and possible treatment methods.MethodsWe used the PubMed web platform to find relevant studies using the following keywords: infusion misdirection syndrome, aqueous misdirection syndrome, ciliary block, ciliovitreal block, capsular block, intraoperative fluid misdirection, subcapsular fluid entrapment, acute intraoperative rock-hard eye syndrome, positive vitreous pressure glaucoma, and malignant glaucoma. Other publications were also considered as a potential source of information when referenced in relevant articles.ResultsWe collected and analyzed 55 articles dated from 1951 to 2016. Acute intraoperative rock-hard eye syndrome is characterized by a very shallow anterior chamber with the absence of suprachoroidal effusion or hemorrhage and no noticeable pathology of the iris–lens diaphragm. It usually occurs during uneventful phacoemulsification, particularly in hyperopic eyes. The pathophysiology of acute fluid misdirection syndrome is based on inappropriate movement of balanced salt solution via the zonular fibers. This syndrome has also been described as occurring from hours to months, or years, after the initial surgery. The pathophysiology of malignant glaucoma is based on similar mechanisms of cilio-lenticular block of aqueous flow leading to the misdirection of aqueous posteriorly into or besides the vitreous gel. Faced with these situations, vitreous decompression is required, preferably with hyaloido-capsulo-iridectomy. In phakic eyes, concomitant cataract extraction would be desirable.ConclusionsWe believe both of these clinical conditions should be considered as one syndrome. We suggest the term acute fluid misdirection syndrome for the cascade of events during phacoemulsification surgery. Chronic fluid misdirection syndrome better describes the nature of malignant glaucoma.

Refractory aqueous misdirection syndrome: A possible complication of penetrating keratoplasty

An 85-year-old woman presented with a flat anterior chamber of the left eye, severe ocular hypertension, and a normal ultrasound examination in the day following a penetrating keratoplasty (PK). The clinical status did not respond to maximum medical therapy, laser posterior capsulotomy, anterior hyaloidotomy, and complete 23 G vitrectomy. The patient refused further intervention, and light perception was lost after 6 months of follow-up. This is the first report of refractory aqueous misdirection syndrome following primary PK. Despite maximum medical and surgical management efforts, aqueous misdirection syndrome subsequent to primary PK may have a catastrophic outcome. Una mujer de 85 años presentó atalamia del ojo izquierdo e hipertensión ocular grave con ecografía normal al día siguiente de la queratoplastia penetrante (QP). Este estado clínico no ha respondido a la terapia médica máxima, con láser y a la vitrectomía 23 G completa. La paciente rechazó otras intervenciones quirúrgicas y la percepción de la luz se perdió después de 6 meses de seguimiento. Esta es la primera descripción de síndrome de dirección inadecuada del humor acuoso refractario tras la QP no precedida de trasplante corneal previo. A pesar de los esfuerzos médicos y quirúrgicos máximos, el síndrome de dirección inadecuada del humor acuoso tras QP puede tener una evolución catastrófica.

Anterior segment approach for the surgical management of aqueous misdirection syndrome

We describe the surgical management of the aqueous misdirection syndrome through clear corneal incisions. A 20-gauge microvitreoretinal blade is used to create 2 side-port incisions. The same blade is inserted through the cornea and the iris for the main incision; it is then directed toward the center of the eyeball, passing through the zonular fibers to the vitreous cavity behind the pupil. Irrigation is delivered to the anterior chamber, the vitrector is placed in the vitreous cavity, and vitrectomy is performed. With this technique, aqueous misdirection can be resolved and adequate IOP control achieved.

Síndrome de dirección inadecuada del humor acuoso refractario: una posible complicación de la queratoplastia penetrante

Clinical caseAn 85 year-old woman presented with a flat anterior chamber of the left eye, severe ocular hypertension, and a normal ultrasound examination in the day following a penetrating keratoplasty (PK). The clinical status did not respond to maximum medical therapy, laser posterior capsulotomy, anterior hyaloidotomy, and complete 23 G vitrectomy. The patient refused further intervention, and light perception was lost after 6 months of follow-up. DiscussionThis is the first report of refractory aqueous misdirection syndrome following primary PK. Despite maximum medical and surgical management efforts, aqueous misdirection syndrome subsequent to primary PK may have a catastrophic outcome.

Aqueous misdirection syndrome in persistent fetal vasculature (PFV)

We report a case of a 5-year-old girl with persistent fetal vasculature who presented with unilateral acute angle closure caused by aqueous misdirection syndrome that was apparently associated with regression of cycloplegia. Initial treatment with topical steroids, anti-glaucomatous drops, and atropine showed insufficient control of the intraocular pressure (IOP). Surgical treatment with lensectomy and vitrectomy resulted in satisfactory IOP control and no complications at the 6-month follow-up.

Aqueous misdirection following pars plana vitrectomy and silicone oil injection.

PurposeTo report a retrospective series of seven phakic eyes of seven patients suffering from a malignant glaucoma-like syndrome following pars plana vitrectomy and silicone oil (SO) injection.Materials and methodsSeven eyes with retinal detachment treated with pars plana vitrectomy with or without scleral buckling with SO tamponade. This was followed by cataract extraction to manage the elevated intraocular pressure (IOP).ResultsThis was a retrospective review of seven cases that received pars plana vitrectomy and SO with or without scleral buckling for different causes of retinal detachment (three were rhegmatogenous and four were tractional). After a period ranging from 1 week to 1 month, they presented with malignant glaucoma-like manifestations; high IOP, shallow axial anterior chamber, and remarkable decrease of visual acuity. Atropine eye drops and anti-glaucoma medical treatment (topical and systemic) had been tried but failed to improve the condition. Dramatic decrease of IOP and deepening of the axial anterior chamber was observed in all cases in the first postoperative day after phacoemulsification and posterior chamber foldable intraocular lens implantation with posterior capsulotomy.ConclusionAqueous misdirection syndrome may be observed following pars plana vitrectomy and SO tamponade. This must be differentiated from other causes of post vitrectomy glaucoma. Cataract extraction with posterior capsulotomy controls the condition.

Clinical Analysis of 50 Chinese Patients with Aqueous Misdirection Syndrome: A Retrospective Hospital-Based Study

To evaluate the efficacy of treatments for aqueous misdirection syndrome and explore possible risk factors influencing prognosis. Data including demographics, initial clinical characteristics and ocular outcomes at follow-up were collected for patients treated for aqueous misdirection syndrome. Main outcome measures were: best-corrected visual acuity (BCVA); intraocular pressure (IOP); number of antiglaucoma medications; recurrence; complications. Data were available for 50 patients (57 eyes). Final mean BCVA improved significantly and correlated with baseline BCVA (mean follow-up, 34.47±28.65 months). Final mean IOP and mean number of antiglaucoma medications were significantly reduced. Treatment failure rates were higher in patients with significantly higher IOP at baseline and/or shorter axial length. Following pars plana vitrectomy (PPV), recurrence occurred in two of 10 pseudophakic and one of 40 phakic eyes; complications were observed in 12/50 eyes (choroidal detachment, corneal decompensation, retinal detachment, vitreous haemorrhage, hyphaema). PPV and laser treatments, augmented by pharmacotherapy, were effective in treating aqueous misdirection syndrome. Surgical intervention should be undertaken early in eyes with higher baseline IOP and/or shorter axial length. Total vitrectomy-zonulectomy-iridectomy is a potential approach for recalcitrant cases.