Recurrent aqueous misdirection following intraluminal ripcord removal from a Paul Glaucoma Implant

To report a case of aqueous misdirection occurring shortly after intraluminal ripcord removal in a pseudophakic, previously vitrectomized eye implanted with a PAUL Glaucoma Implant.

A 65-year-old Caucasian woman presented with primary angle-closure glaucoma and previous history of aqueous misdirection following a combined procedure of phacoemulsification and XEN45 gel stent implant, which was managed with pars plana vitrectomy elsewhere. Because of high IOP despite maximum tolerated medical treatment, a PAUL Glaucoma Implant was performed with positioning of a 6-0 Prolene® intraluminal ripcord. Shortly after ripcord removal 6 weeks postoperatively, she presented with significant myopic shift, uniformly shallow anterior chamber, and markedly raised IOP. Anterior-segment OCT showed patent tube in the superotemporal quadrant of the anterior chamber, suggesting the recurrence of aqueous misdirection. Revision of pars plana vitrectomy with extensive peripheral vitreous shaving and irido-zonulo-hyaloidectomy was required to restore anterior chamber depth, to re-establish forward aqueous flow, and to stabilize IOP.

This case suggests that intraluminal ripcord removal from a PAUL glaucoma implant can elicit aqueous misdirection in eyes at risk. Furthermore, the final outcomes of the present case suggest that thorough pars plana vitrectomy with irido-zonulo-hyaloidectomy may be the most effective surgical approach to aqueous misdirection.