Topic outline

  • Grand Rounds

    A middle-aged patient with a past ocular history of retinal detachment status-post repair with a combined pars plana vitrectomy and scleral buckle was managed by an outside ophthalmologist for elevated intraocular pressure (IOP) in the operated eye. The patient reported a maximal IOP of 14 mm Hg and 34 mm Hg in the right and left eye, respectively. The patient had been treated with multiple topical agents as well as serial intravitreal anti-VEGF injections to control iris rubeosis presumed to be secondary to anterior segment ischemia in the setting of the scleral buckle. On initial presentation to our glaucoma service nearly two years following the retinal detachment, the IOP was 15 mm Hg in the affected eye on timolol/brimonidine. Gonioscopic examination revealed an angle open to ciliary body band 360 degrees in the unaffected eye and nearly 360 degrees of peripheral anterior synechiae and neovascularization of the angle in the affected eye. The retina service also evaluated the patient the same day and agreed to continue medical management of the IOP and anterior segment neovascularization, especially given that the patient was not amenable to surgery to remove or reposition the scleral buckle. Over the next eighteen months, the IOP and neovascularization were managed with medical therapy and intravitreal anti-VEGF injections, however eventually the IOP increased to 24 mm Hg despite maximal tolerated medical therapy and the patient had progression on Humphrey visual field, so surgical options were considered. Given the relatively anterior positioning of the scleral buckle, tube shunt surgery proved challenging, so a decision was made to pursue angle-based and cyclodestructive procedures. The patient underwent a combined goniosynechiolysis, 360 degree viscocanaloplasty and 180 degree goniotomy, and 180 degrees of transscleral cyclophotocoagulation. Seven months postoperatively, the IOP was 14 mm Hg on timolol/brimondine and pilocarpine with continued intravitreal anti-VEGF therapy for control of anterior segment neovascularization.

    Presentation Date: 08/17/2023
    Issue Date: 09/01/2023