Cavallari Elena, Clemente Antonella, Muraca Andrea, Rabiolo Alessandro, De Cillà Stefano
Department of Health Sciences, Università del Piemonte Orientale "Amedeo Avogadro", Novara, Italy.
Department of Ophthalmology, AOU Maggiore della Carità, Novara, Italy.
Am J Ophthalmol Case Rep. 2025 Jun 9;39:102361. doi: 10.1016/j.ajoc.2025.102361. eCollection 2025 Sep.
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).
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).
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.
人工晶状体植入术后继发性房角关闭是一种罕见情况，尤其是在白内障手术顺利多年后才出现。我们报告一例患者，其在手术后数年出现眼压突然升高，突出了相关的诊断挑战。我们对潜在病因进行了系统回顾，包括自发性房水错向和囊袋阻滞综合征（CBS）。
一名91岁的白种男性，其左眼（唯一有视力的眼睛）视力突然降至30厘米数指。14年前，该患者接受了无并发症的超声乳化白内障吸除联合人工晶状体植入术。裂隙灯检查显示角膜水肿和前房浅。用Goldmann压平眼压计测量的眼压为55mmHg。房角镜检查不可行，尽管所呈现的解剖特征高度提示迟发性CBS伴瞳孔阻滞或自发性房水错向，但对于特定诊断并不明确。该患者左眼接受了激光周边虹膜切开术，但证明无效。尽管近期没有手术干预且眼轴明显延长至32mm，但该患者仍接受了房水错向治疗，进行了睫状体平坦部玻璃体切除术联合虹膜 - 悬韧带 - 玻璃体切除术。术后4个月的最后一次随访时，患者病情显著改善。左眼最佳矫正视力提高到20/40，眼压良好控制在10mmHg。系统的文献回顾确定了24例自发性房水错向病例和2例眼压升高的迟发性CBS病例（若考虑早发性则为5例）。
该病例强调了在人工晶状体植入患者继发性房角关闭病例中进行准确诊断的重大挑战，尤其是在白内障手术顺利多年后才出现症状的情况。罕见病症（如房水错向和迟发性CBS）之间临床特征的重叠使诊断过程更加复杂。及时识别和及时干预对于预防该病症的潜在严重后果仍然至关重要。
