Elschnig’s Pearls as a possible predisposing factor for malignant glaucoma : a case report

Background : Malignant glaucoma (MG) is associated with a narrow angle or pseudoexfoliation (PEX)-induced laxity of the zonule. We describe a rare case of MG in a patient with massive Elschnig’s Pearls (EP) causing aqueous misdirection syndrome. Case presentation : A 78 years-old female was referred with rapidly progressive left ocular pain with redness, blurred vision of 20/100 and intraocular pressure (IOP) of 60 mmHg. She had undergone cataract surgery 5 years prior without complications, with preoperative diagnosis of moderate capsular PEX syndrome. She was first treated by maximal pressure-lowering drops, intravenous ACETAZOLAMIDE and 10% MANNITOL, 1% ISOPTOPILOCARPINE and a patent laser iridotomy. Despite this, IOP remained high for 3 days. Shallow anterior chamber with angle closure, myopic shift and filling of the posterior chamber by massive EP led us to conclude to an aqueous misdirection syndrome. We then switched 1% ISOPTOPILOCARPINE for 1% ATROPINE and performed a posterior capsulotomy with anterior hyaloidotomy. This rapidly controlled the condition with posterior displacement of intraocular lens (IOL) and fading of the high-IOP associated symptoms. Conclusions: Identifying malignant glaucoma could be challenging in the absence of immediate surgical circumstances. This is, to our knowledge, the second description of EPassociated with MG. In this case, EP were thought to narrow the irido-corneal angle and to cause a relative pupillary blockage, subsequently triggering aqueous humour misdirection to the vitreous and forward displacement of the iris-IOL diaphragm in the context of moderate PEX-induced zonular laxity.