Malignant glaucoma: new views on its etiopathogenesis and management

Main Article Content

Dorota Pożarowska
Tomasz Żarnowski


Malignant glaucoma is a rare but serious complication of intraocular surgery. Most frequently it occurs after penetrating antiglaucoma procedures, but may also be present after intraocular procedures. Its presence ia associated with very bad prognosis with high risk of painful blindness. The essence of this disease is abnormal aqueous flow to vitreous cavity with leads to the forward displacement of iridolenticular or iridovitreal diaphragm and anterior angle closure. The crucial aim of treatment is to reverse abnormal aqueous flow and improve anterior segment anatomical relationships. Medical therapy (aqueous suppressants, cycloplegics, hyperosmotic agents), lasers techniques and surgery are used for this treatment. Due to the development of new surgical techniques the prognosis for malignant glaucoma has significantly improved.


Download data is not yet available.

Article Details

How to Cite
Pożarowska D, Żarnowski T. Malignant glaucoma: new views on its etiopathogenesis and management. Ophthatherapy [Internet]. 2019Sep.30 [cited 2021Oct.16];6(3):160-7. Available from:


1. Krix-Jachym K, Żarnowski T, Rękas M. Risk Factors of Malignant Glaucoma Occurrence after Glaucoma Surgery. J Ophthalmol. 2017; 2017: 9616738.
2. Graefe A. Beiträge zur Pathologie und Therapie des Glaucoms. Albrecht von Graefes Archiv für Ophthalmologie. 1869; 15: 108-252.
3. Grzybowski A, Kanclerz P. Acute and chronic fluid misdirection syndrome: pathophysiology and treatment. Graefes Arch Clin Exp Ophthalmol. 2018; 256(1): 135-54.
4. Foreman-Larkin J, Netland PA, Salim S. Clinical Management of Malignant Glaucoma. J Ophthalmol. 2015; 2015: 283707.
5. Balekudaru S, Choudhari NS, Rewri P et al. Surgical management of malignant glaucoma: a retrospective analysis of fifty eight eyes. Eye. (Lond) 2017; 31(6): 947-55.
6. Burgansky-Eliash Z, Ishikawa H, Schuman JS. Hypotonous malignant glaucoma: aqueous misdirection with low intraocular pressure. Ophthalmic Surg Lasers Imaging. 2008; 39(2): 155-9.
7. Sahoo NK, Balijepalli P, Singh SR et al. Retina and glaucoma: surgical complications. Int J Retina Vitreous. 2018; 4: 29.
8. Kaplowitz K, Yung E, Flynn R et al. Current concepts in the treatment of vitreous block, also known as aqueous misdirection. Surv Ophthalmol. 2015; 60(3): 229-41.
9. Rękas M, Krix-Jachym K, Żarnowski T. Evaluation of the Effectiveness of Surgical Treatment of Malignant Glaucoma in Pseudophakic Eyes through Partial PPV with Establishment of Communication between the Anterior Chamber and the Vitreous Cavity. J Ophthalmol. 2015; 2015: 873124.
10. Greenfield DS, Tello C, Budenz DL et al. Aqueous misdirection after glaucoma drainage device implantation. Ophthalmology. 1999; 106(5): 1035-40.
11. Shahid H, Salmon JF. Malignant glaucoma: a review of the modern literature. J Ophthalmol. 2012; 2012: 852659.
12. Ghoraba HH, Ghali AA, Mansour HO. Aqueous misdirection following pars planavitrectomy and silicone oil injection. Clin Ophthalmol. 2015; 9: 903-6.
13. Varma DK, Belovay GW, Tam DY et al. Malignant glaucoma after cataract surgery. J Cataract Refract Surg. 2014; 40(11): 1843-9.
14. Francis BA, Babel D. Malignant glaucoma (aqueous misdirection) after pars planavitrectomy. Ophthalmology. 2000; 107(7): 1220-2.
15. Montolío Marzo S, Lanzagorta Aresti A, Davó Cabrera JM et al. Malignant glaucoma after XEN45 implant. Arch Soc Esp Oftalmol. 2019; 94(3): 134-7.
16. Senthil S, Choudhari NS, Vaddavalli PK et al. Etiology and Management of Raised Intraocular Pressure following Posterior Chamber Phakic Intraocular Lens Implantation in Myopic Eyes. PLoS One. 2016; 11(11): e0165469.
17. Arya SK, Sonika, Kochhar S et al. Malignant glaucoma as a complication of Nd:YAG laser posterior capsulotomy. Ophthalmic Surg Lasers Imaging. 2004; 35(3): 248-50.
18. Greenfield JA, Smiddy WE, Greenfield DS. Malignant Glaucoma After Laser Peripheral Iridotomy. J Glaucoma. 2019; 28(3): e44-5.
19. Premsenthil M, Salowi MA, Siew CM et al. Spontaneous malignant glaucoma in a patient with patent peripheral iridotomy. BMC Ophthalmol. 2012; 12: 64.
20. Brooks AM, Harper CA, Gillies WE. Occurrence of malignant glaucoma after laser iridotomy. Br J Ophthalmol. 1989; 73(8): 617-20.
21. Harbour JW, Rubsamen PE, Palmberg P. Pars planavitrectomy in the management of phakic and pseudophakic malignant glaucoma. Arch Ophthalmol. 1996; 114(9): 1073-8.
22. Chandler PA. Malignant glaucoma. Am J Ophthalmol. 1951; 34(7): 993-1000.
23. Faucher A, Hasanee K, Rootman DS. Phacoemulsification and intraocular lens implantation in nanophthalmic eyes: report of a medium-size series. J Cataract Refract Surg. 2002; 28(5): 837-42.
24. Żarnowski T, Wilkos-Kuc A, Tulidowicz-Bielak M et al. Efficacy and safety of a new surgical method to treat malignant glaucoma in pseudophakia. Eye. (Lond) 2014; 28(6): 761-4.
25. Sharma A, Sii F, Shah P et al. Vitrectomy-phacoemulsification-vitrectomy for the management of aqueous misdirection syndromes in phakic eyes. Ophthalmology. 2006; 113(11): 1968-73.
26. Debrouwere V, Stalmans P, Van Calster J et al. Outcomes of different management options for malignant glaucoma: a retrospective study. Graefes Arch Clin Exp Ophthalmol. 2012; 250(1): 131-41.
27. Prata TS, Dorairaj S, De Moraes CG et al. Is preoperative ciliary body and iris anatomical configuration a predictor of malignant glaucoma development? Clin Exp Ophthalmol. 2013; 41(6): 541-5.
28. He F, Qian Z, Lu L et al. Clinical efficacy of modified partial pars plana vitrectomy combined with phacoemulsification for malignant glaucoma. Eye. (Lond) 2016; 30(8): 1094-100.
29. Wang Z, Huang J, Lin J et al. Quantitative measurements of the ciliary body in eyes with malignant glaucoma after trabeculectomy using ultrasound biomicroscopy. Ophthalmology. 2014; 121(4): 862-9.
30. Razeghinejad MR, Amini H, Esfandiari H. Lesser anterior chamber dimensions in women may be a predisposing factor for malignant glaucoma. Med Hypotheses. 2005; 64(3): 572-4.
31. Heindl LM, Koch KR, Cursiefen C et al. Optical coherence tomography and ultrasound biomicroscopy in the management of pseudophakic malignant glaucoma. Graefes Arch Clin Exp Ophthalmol. 2013; 251(9): 2261-3.
32. Quigley HA, Friedman DS, Congdon NG. Possible mechanisms of primary angle-closure and malignant glaucoma. J Glaucoma. 2003; 12(2): 167-80.
33. Quigley HA. Angle-closure glaucoma-simpler answers to complex mechanisms: LXVI Edward Jackson Memorial Lecture. Am J Ophthalmol. 2009; 148(5): 657-9.e1.
34. Chen X, Guo X, Xu X et al. Is Thicker Choroid a Risk Factor for Malignant Glaucoma? Ophthalmic Res. 2018; 60(3): 161-8.
35. Trope GE, Pavlin CJ, Bau A et al. Malignant glaucoma. Clinical and ultrasound biomicroscopic features. Ophthalmology. 1994; 101(6): 1030-5.
36. Liebmann JM, Weinreb RN, Ritch R. Angle-closure glaucoma associated with occult annular ciliary body detachment. Arch Ophthalmol. 1998; 116(6): 731-75.
37. Wirbelauer C, Karandish A, Häberle H et al. Optical coherence tomography in malignant glaucoma following filtration surgery. Br J Ophthalmol. 2003; 87(8): 952-5.
38. Wu ZH, Wang YH, Liu Y. Management strategies in malignant glaucoma secondary to antiglaucoma surgery. Int J Ophthalmol. 2016; 9(1): 63-8.
39. Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol. 1968; 66(3): 495-502.
40. Pakravan M, Esfandiari H, Amouhashemi N et al. Mini-vitrectomy; a Simple Solution to a Serious Condition. J Ophthalmic Vis Res. 2018; 13(3): 231-5.
41. Tsai JC, Barton KA, Miller MH et al. Surgical results in malignant glaucoma refractory to medical or laser therapy. Eye. (Lond) 1997; 11(Pt 5): 677-81.
42. Chandler PA. A New Operation for Malignant Glaucoma: a Preliminary Report. Trans Am Ophthalmol Soc. 1964; 62: 408-24.
43. Dave P, Rao A, Senthil S et al. Recurrence of aqueous misdirection following pars plana vitrectomy in pseudophakic eyes. BMJ Case Rep. 2015; 2015. pii: bcr2014207961.
44. Little BC, Hitchings RA. Pseudophakic malignant glaucoma: Nd:YAG capsulotomy as a primary treatment. Eye. (Lond) 1993; 7(Pt 1): 102-4.
45. Madgula IM, Anand N. Long-term follow-up of zonulo-hyaloido-vitrectomy for pseudophakic malignant glaucoma. Indian J Ophthalmol. 2014; 62(12): 1115-20.
46. Lois N, Wong D, Groenewald C. New surgical approach in the management of pseudophakic malignant glaucoma. Ophthalmology. 2001; 108(4): 780-3.
47. Tang J, Du E, Li X. Combined Surgical Techniques for the Management of Malignant Glaucoma. J Ophthalmol. 2018; 2018: 9189585.
48. Meng L, Wei W, Li Y et al. 25-Gauge pars plana vitrectomy for ciliary block (malignant) glaucoma. Int Ophthalmol. 2015; 35(4): 487-93.
49. Chaudhry NA, Flynn HW Jr, Murray TG et al. Pars plana vitrectomy during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes. Am J Ophthalmol. 2000; 129(3): 387-8.
50. Yu J, Chen X, Zhou D et al. Clinical Efficacy of Ciliary Ring Incision Combined with Modified Partial Pars Plana Vitrectomy for Malignant Glaucoma. Med Sci Monit. 2018; 24: 3916-21.
51. Rani PK, Gulati I, Rao HL et al. 25g pars plana vitrectomy and irido-zonulo-hyaloido-vitrectomy in the management of malignant glaucoma in phakic eyes following trabeculectomy. Retin Cases Brief Rep. 2018; 12(1): 33-5.
52. Graber M, Khoueir Z, Beauchet A et al. High intensity focused ultrasound as first line treatment in patients with chronic angle closure glaucoma at risk for malignant glaucoma. J Fr Ophtalmol. 2017; 40(4): 264-9.
53. Thompson AC, Challa P. Prophylactic anterior vitrectomy during cataract surgery in eyes at increased risk for aqueous misdirection. Am J Ophthalmol Case Rep. 2018; 12: 24-7.
54. Pathak Ray V, Gulati I, Choudhari N. Intra-Operative Ostial Irido-Zonulo-Hyaloido-Vitrectomy with Primary Posterior Capsulectomy for Prevention of Post-Operative Aqueous Misdirection in Combined Phaco-Trabeculectomy in Primary Angle Closure Glaucoma. Curr Eye Res. 2019: 1-4.