Chat Highlights
Malignant Glaucoma
(Aqueous Misdirection Syndrome)
October 4, 2000

Norma Devine, Editor

On Wednesday, October 4, 2000, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Malignant Glaucoma." 

Moderator:  Dr. Rick, will you explain what malignant glaucoma is?

Dr. Wilson:  Malignant glaucoma is more aptly called aqueous misdirection syndrome. There is no malignancy associated with that glaucoma.   It is seen usually in small, far-sighted eyes.   In that affliction, the eye is made in such a way that a small shift forward in the position of  the lens in the eye redirects the flow of aqueous back into the central cavity of the eye, rather than forward through the pupil into the anterior chamber of the eye where the drain is.  As the fluid builds up in the back of the eye, it pushes the iris and lens forward, blocking off the drain so that the pressure rises dramatically. 

P:  Is malignant glaucoma more likely to happen to someone with angle closure or open angle or doesn't it make any difference? 

Dr. Wilson:  It has been said by experienced old-timers that they have never seen aqueous misdirection in patients who do not have a few spots of angle closure from a narrow angle.  

P:   What are the chances of developing malignant glaucoma if you have plateau iris or very narrow, occludable angles?

Dr. Wilson:  The chances are low, but it is possible.  Aqueous misdirection usually follows some type of surgery or the start of medication.

P:  How did the term "malignant glaucoma" originate?

Dr. Wilson:  In the past, the cause or cure were not known: once it started, it usually progressed "malignantly" to blindness.

P:  Is malignant glaucoma the worst kind of glaucoma? 

Dr. Wilson:  Not now, because the eye itself is usually healthy, and with present knowledge can almost always be saved, as a patient here can testify. 

P:  What is the treatment for malignant glaucoma?  Meds or surgery?

Dr. Wilson:  Meds first.  If that's unsuccessful, then surgery.

P:  Can aqueous misdirection happen many years after a laser or surgery, or does it usually  happen right away?

Dr. Wilson:  Usually right away.

P:  After surgery for what?  Another type of glaucoma?

Dr. Wilson:   Usually a surgical procedure for glaucoma.

P:  Can the areas of the anterior chamber that are touching scar and cause pain?

Dr. Wilson:  The iris can seal to the drain (trabecular meshwork), but pain is unusual.  

P:  Isn't the cornea sensitive?

Dr. Wilson:   The outside is very sensitive, but not the inside, particularly.

P:  Doctor, you mentioned that malignant glaucoma could start after starting a medication. Do you mean an ophthalmic med?

Dr. Wilson:  Yes.  Pilocarpine can pull the lens forward and push people who are prone to aqueous misdirection in that direction.

P:  If an eye that had a trab became malignant and had high pressure again, would the risk of another trab or a revision be high?

Dr. Wilson:  Certainly that is a much more difficult situation, and the risks would be increased.

P:  If the disease starts right away, what are the symptoms?

P:  I can tell you what they are:  intense pain, blurred vision, high pressure, flat anterior chamber, cloudy cornea.

Dr. Wilson:  Pain, red eye, blurred vision.

P:  How often should someone with malignant glaucoma be examined with a gonioscope? 

Dr. Wilson:  That depends upon how narrow the angle is and whether the eye has had surgery.

P:  How is the angle of the eye rated?  Isn't there a scale -- A, B, C, D, and E -- with E being good?  And can only certain parts be more closed, like, say, the angle is open at the top of the eye but more closed at the bottom?  

Dr. Wilson:  Yes, there is a scale, with C, D and E being normal and A and B being closed. The angle is usually more narrow at the top and more open inferiorly.

P:  Is that scale used in practice?

Dr. Wilson:  Yes, every day at Wills.

P:  Is it narrow at the top due to gravity?

Dr. Wilson:  Probably.  I think it allows the lens to lean forward and narrow the angle above.

P:  If  C, D, and E  are normal, why are there three levels and not just one? 

Dr. Wilson:  Each letter stands for a different level that the iris can insert into the wall of the eye.  E is deep in the ciliary body and C is at the scleral spur. This may not mean much to you if you don't know the angle structures.

P:  Doctor, I have never heard of the scale A to E.  However, my doctor said I have angle recession.  Does that mean I have a narrow angle?

Dr. Wilson:  No.  It means that your iris has been recessed posteriorly and the angle structures and drain were injured.  Have you had trauma?

P:  Yes.  Traumatic angle recession.

P:   In my case, pilocarpine opens my angles.  So could it at the same time cause malignant glaucoma?

Dr. Wilson:  Not unless the angle is quite narrow.

End of highlights for October 4th chat.

On October 11th, Dr. Rick Wilson discussed "Life After a Trab" in the Chat room. Click here for highlights of that meeting.

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