Pseudophakic angle-closure 14 Years after cataract surgery: a case report and systematic review of the literature

Abstract

Purpose: Pseudophakic secondary angle closure is an uncommon event, especially when it manifests itself many years after uneventful cataract surgery. We report a case of a patient who presented with a sudden increase in intraocular pressure (IOP) several years after surgery, highlighting the diagnostic challenges associated. We performed a systematic review of potential etiologies, including spontaneous aqueous misdirection and capsular block syndrome (CBS).

Observation: A 91-year-old Caucasian male presented with sudden visual acuity reduction to counting fingers at 30 cm in the left eye (LE), his only seeing eye. Fourteen years earlier, the patient had undergone uncomplicated phacoemulsification with intraocular lens implantation. The slit-lamp examination showed corneal edema and a shallow anterior chamber. IOP measured by Goldmann applanation tonometry was 55 mmHg. Gonioscopy was not feasible, and the anatomical features were at presentation were not univocal for a specific diagnosis, though they were highly suggestive of late-onset CBS with pupillary block or spontaneous aqueous misdirection. The patient underwent laser peripheral iridotomy in the LE, which proved ineffective. Despite the absence of recent surgical interventions and the presence of a markedly elongated axial length of 32 mm, the patient was treated for aqueous misdirection, undergoing pars plana vitrectomy combined with irido-zonulo-hyaloid-vitrectomy. At the last follow-up visit, 4 months postoperatively, the patient's condition significantly improved. Best-corrected visual acuity in the LE improved to 20/40, and the IOP was well-controlled at 10 mmHg. A systematic literature review identified 24 cases of spontaneous aqueous misdirection and 2 cases of late-onset CBS with IOP elevation (5 when early onset was considered).

Conclusion and importance: This case underscores the significant challenges in establishing an accurate diagnosis in cases of secondary angle closure in pseudophakic patients, particularly when presentation occurs many years after uncomplicated cataract surgery. The overlap of clinical features among rare entities, such as aqueous misdirection and late-onset CBS, further complicates the diagnostic process. Prompt recognition and timely intervention remain essential to prevent the potentially severe consequences of the condition.

Keywords: Anterior segment optical coherence tomography; Capsular block syndrome; Glaucoma; Irido-zonulo-hyaloid-vitrectomy; Pupillary block; Secondary angle closure; Spontaneous aqueous misdirection; Systematic review.

Fig. 1

Preoperative Findings in the Right and Left Eyes. A) Color photograph, slit-lamp examination of the right eye at presentation: The cornea is clear with vertical striae; the anterior chamber is deep. B) Color photograph, slit-lamp examination of the left eye at presentation: Conjunctival injection is notable, along with mild corneal edema. The anterior chamber is shallow and the pupil is mid-dilated and the iris-bag-IOL complex is displaced anteriorly. C) Vertical AS-OCT scan of the right eye: The anterior chamber is deep. No irido-trabecular contact is observed. D) Vertical AS-OCT scan of the left eye: Significant shallowing of anterior chamber is evident, with anterior displacement of the iris-lens diaphragm. Capsular bag distension syndrome is confirmed by the presence of hyper-reflective fluid between the IOL and the posterior capsule (red arrow). Additionally, peripheral iridocorneal contact is observed in 360° (yellow arrow). A marked asymmetry between the anterior chamber depths of the right eye and left is noted. E) B-scan ultrasound of the right eye: Hyper-echoic material is detected in the vitreous chamber, consistent with vitreous opacities or degeneration. F) B-scan ultrasound of the left eye: The retina and choroid are flat. Hyper-echoic material is observed in the vitreous chamber, consistent with vitreous opacities or degeneration. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

Postoperative Examination of the Left Eye, 4 Months after Irido-Zonulo-Hyaloid-Vitrectomy Surgery A) Slit-lamp examination of the left eye: The cornea is clear, and the iridectomy is visible at the 3 o'clock position. The anterior chamber is deep, and the IOL is slightly inferiorly dislocated. B) Fundus photograph (EIDON, Centervue, Padua): The image is slightly out of focus due to IOL subluxation; however, the optic nerve appears excavated. C-D) Vertical AS-OCT scan: Restoration of the anterior segment is demonstrated. The anterior chamber appears deep, and the bag-IOL complex is no longer displaced anteriorly. However, lens subluxation remains apparent (D). Irido-trabecular contact has fully resolved, and the iridectomy is patent. E) Vertical OCT foveal scan: Mild chorioretinal folds are visible, along with the presence of an early epiretinal membrane. F) B-scan ultrasound: The retina and choroid appear flat, and the vitreous chamber is anechoic.

Fig. 3

Retinal Nerve Fiber Layer – Optical Coherence Tomography (RNFL-OCT) Scans and Visual Field of the Left Eye A) RNFL-OCT scan acquired one week after the procedure: The retinal nerve fiber layer appears thickened, making the fiber loss percentage unassessable. B) RNFL-OCT scan acquired two months after the procedure: Initial RNFL thinning is observed in the superior temporal and inferior temporal sectors. C)24-2SITA StandardstimulusIII visual field test: The visual field shows diffuse profound threshold sensitivity reduction with a mean deviation of −17.49 dB.

Fig. 4

PRISMA flowchart illustrating the number of case reports identified and included in the analysis.