Acute intraoperative fluid misdirection managed with anterior approach irido-zonulo-hyaloido-vitrectomy

Abstract

Purpose: To evaluate the causes of acute fluid misdirection (AFM) and the role of irido-zonulo-hyaloido-vitrectomy (IZHV) in the management of AFM. Methods: Among the 95,712 cataract surgeries performed between April 2017 and August 2022 at a tertiary center, six eyes of six patients developed intraoperative AFM and underwent IZHV through the anterior approach. AFM was diagnosed intraoperatively when there was sudden shallowing of the anterior chamber with markedly elevated intraocular pressures (IOPs) not attributable to external causes or choroidal effusion/hemorrhage. The condition resolved with deepening of AC following IZHV. Results: Five eyes had angle closure disease (one of them also had pseudoexfoliation), and one eye had open-angle glaucoma. The mean preop IOP was 25.8 ± 7.3 mmHg, with an IOP range of 18–36. The mean number of preop AGM was 3 ± 1.7. Four eyes developed AFM during combined cataract and trabeculectomy, and two eyes during cataract surgery. Four eyes had aqueous misdirection during or after cortical aspiration, and two eyes after creation of internal trabeculectomy ostium. IZHV was performed for all eyes through an anterior approach using a 23G vitrector, which resulted in instant resolution and deepening of the anterior chamber. The mean follow-up was 8.75 months (1–48 months), the mean postoperative IOP was 16.1 ± 2.6 mmHg, and the mean number of AGM at the last follow-up was 2.8 ± 2.2. The anterior chamber was deep, and IOP was under control in all eyes with four eyes needing AGM. One eye developed postoperative aqueous misdirection due to blockade of the IZHV opening. Conclusion: IZHV can be an effective solution for acute intraoperative AFM, which can be performed via an anterior approach by the anterior segment surgeon.

Keywords

• acute fluid misdirection
• aqueous misdirection
• irido-zonulo-hyaloido-vitrectomy
• malignant glaucoma
• shallow anterior chamber