The condition typically presents unilaterally, reflecting the fact that it is usually a postoperative complication. The condition can also occur in other postoperative states, including after cataract surgery, surgical iridotomy, and after laser iridotomy. A recent retrospective review of 24 eyes found the incidence to be 2% after glaucoma surgery the condition was also found to be more common in females (which may coincide with higher incidence of angle closure in women). If medical therapy should fail, surgical management may eventually be required.Īqueous misdirection classically occurs during the early post-operative period after incisional surgery for acute angle closure with an incidence of 0.6 to 4%. Miotics should be avoided as they can worsen the condition. Appropriate timely medical intervention with cycloplegics and ocular antihypertensives needs to be initiated to avoid progression to blindness. The pressure is often elevated but can be normal or low. The exact mechanism resulting in aqueous misdirection is unknown but appears to be related to the relationship between the ciliary body, anterior hyaloid, and lens as well as the permeability of the vitreous. Other common terms that are used to describe the entity are cilary block glaucoma or lens block glaucoma. Von Graefe described the condition in 1869 using the phrase “malignant glaucoma” but in this article we will use the term aqueous misdirection. Aqueous misdirection is a diagnosis of exclusion, and requires exclusion of other clinical entities such as choroidal hemorrhage, choroidal effusion, and pupillary block.Įlevation of intraocular pressure and axial shallowing of the anterior chamber from posterior pressure characterize aqueous misdirection. Aqueous misdirection is a challenging form of secondary angle closure that presents with elevated intraocular pressure (IOP) and shallowing of the central and peripheral anterior chamber despite the presence of a peripheral iridotomy.
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