Sequential Surgical Management of Refractory Primary Angle-Closure Glaucoma in a Functionally Monocular Patient

Primary angle-closure glaucoma (PACG) carries a high risk of irreversible blindness. This case highlights the challenges of managing refractory PACG in a patient with a history of prematurity and the subsequent development of postoperative complications.

A 45-year-old woman with a history of prematurity and monocular vision (no light perception in left eye) presented with acute angle closure in the right eye (RE). Despite maximal medical therapy, the RE intraocular pressure (IOP) remained at 54 mmHg. Less invasive options like laser iridotomy or standalone lens extraction were deemed insufficient, and to achieve efficient IOP lowering, the patient underwent combined phacotrabeculectomy, which was soon complicated by malignant glaucoma (aqueous misdirection) and hyphema. This necessitated a secondary intervention involving pars plana anterior vitrectomy and posterior capsulotomy. Over an 18-month follow-up, the patient suffered recurrent complications, including a spontaneous vitreous hemorrhage and eventually uncontrolled IOP. Management required a vitrectomy and the subsequent implantation of an Ahmed glaucoma valve. Although the valve procedure was followed by a transient early postoperative hyphema, the patient's condition stabilized. At the final 28-month follow-up, the RE best corrected visual acuity was 20/25 with an IOP of 12-18 mmHg without medication.

This case notes an interesting coexistence of advanced adult-onset angle-closure glaucoma and a history of prematurity, though a direct causal or anatomical link remains speculative due to the lack of advanced anterior segment imaging. The clinical course underscores the necessity of aggressive surgical management for aqueous misdirection and the risk of recurrent intraocular hemorrhage in advanced glaucoma. While a definitive developmental relationship cannot be established from a single case, this presentation highlights that an individualized history of prematurity may be a noteworthy consideration during comprehensive long-term ophthalmic evaluations.