Oman Journal of Ophthalmology

CASE REPORT
Year
: 2015  |  Volume : 8  |  Issue : 2  |  Page : 120--121

Surgical management of glaucoma secondary to idiopathic elevated episcleral venous pressure


Zia Sultan Pradhan1, Ashish Kuruvilla2, Pushpa Jacob2,  
1 Department of Ophthalmology, Christian Medical College, Schell Eye Hospital, Vellore, Tamil Nadu, India
2 Christian Medical College, Schell Eye Hospital, Vellore, Tamil Nadu, India

Correspondence Address:
Dr. Zia Sultan Pradhan
Department of Ophthalmology, Christian Medical College, Schell Eye Hospital, Arni Road, Vellore - 632 001, Tamil Nadu
India

Abstract

Idiopathic elevated episcleral venous pressure is characterized by dilated episcleral veins and open angle glaucoma. Trabeculectomies in these eyes are often complicated by uveal effusions (intraoperative or postoperative) at nonhypotonous pressures. We highlight the ability to avoid the need for sclerostomies by preventing intraoperative shallowing of the anterior chamber and the use of tight scleral sutures which should be adjusted postsurgery to gradually reach the target intraocular pressure in a step-wise manner.



How to cite this article:
Pradhan ZS, Kuruvilla A, Jacob P. Surgical management of glaucoma secondary to idiopathic elevated episcleral venous pressure.Oman J Ophthalmol 2015;8:120-121


How to cite this URL:
Pradhan ZS, Kuruvilla A, Jacob P. Surgical management of glaucoma secondary to idiopathic elevated episcleral venous pressure. Oman J Ophthalmol [serial online] 2015 [cited 2022 Oct 3 ];8:120-121
Available from: https://www.ojoonline.org/text.asp?2015/8/2/120/159266


Full Text

 Introduction



Idiopathic elevated episcleral venous pressure (IEEVP) or Radius-Maumenee syndrome is a rare condition of unknown etiology characterized by dilated episcleral veins and open angle glaucoma. [1],[2] Managing the glaucoma is difficult due to poor response to medication and complications associated with filtering surgery. [3],[4] We report a case of bilateral IEEVP and describe the surgical management and complications.

 Case Report



A 40-year-old Indian lady complained of decreased vision in both eyes since 1 year and redness for many years. Best corrected visual acuity was 20/200 and counting fingers at 1 m in the right and left eyes respectively with a left afferent pupillary defect. Both eyes had dilated episcleral veins [Figure 1], intraocular pressures (IOPs) >40 mmHg, open angles on gonioscopy and advanced glaucomatous disc damage. Systemic history and examination were unremarkable. Blood pressure and lipid profile were normal. Orbital ultrasound showed normal caliber superior ophthalmic veins. Magnetic resonance imaging, magnetic resonance angiography, and venography were normal. Following medical control of IOP with oral acetazolamide and glycerol, trabeculectomy with mitomycin was performed on the right eye. There were no intraoperative complications. On the 1 st postoperative day, she had a large bleb with no leak, shallow anterior chamber with IOP of 22 mmHg and 360° peripheral choroidal detachment. She did not respond to conservative treatment with topical atropine 1% and therefore underwent a sclerostomy and drainage of choroidal effusion on the 4 th postoperative day. She continued to have shallow peripheral choroidal detachment with an IOP of 14 mmHg on the next day but also developed an exudative retinal detachment at the posterior pole. Her vision dropped to counting fingers close to face. She was managed with intensive cycloplegic agents, topical corticosteroids and oral glycerol. Over the next week, the chorodial and retinal detachment settled and vision improved to 4/60. Oral glycerol was stopped and topical steroids and cycloplegics were continued.{Figure 1}

She underwent a trabeculectomy with mitomycin on the left eye 1 month later. Two tight sutures and two releasable sutures were placed over the scleral flap. The IOP was 20 mmHg on the 1 st postoperative day with no choroidal effusion. Once the bleb was slightly localized, one releasable suture was removed on the 15 th postoperative day. The second releasable suture was removed on the 28 th postoperative day following which, her anterior chamber become slightly shallow, and she developed a peripheral choroidal detachment which settled spontaneously. She has been reviewed frequently over 6 months during with no further complications occurred. Visual acuity on her last visit remained 20/200 in the right eye and counting fingers in the left eye with IOPs of 13 mmHg and 8 mmHg respectively.

 Discussion



Glaucoma secondary to elevated episcleral venous pressure is often resistant to medication. [3] Trabeculectomy is frequently complicated by uveal effusion-like syndromes and some authors recommend performing sclerotomies with filtering surgery. [3],[4] Others have tried non-penetrating deep sclerectomy and although experienced fewer complications, had poor long-term control of IOP with all cases requiring medication by 2 years. [5] Since our patient was young with advanced disc damage, we set a target IOP of 10-14 mmHg and therefore performed trabeculectomies with mitomycin.

Intraoperative choroidal effusion necessitates performing a sclerostomy. [3],[4] If one is able to prevent this by careful technique, use of visco-elastics or an anterior chamber maintainer, the controversy remains as to whether a prophylactic sclerostomy should be performed as is done for nanophthalmos. [6]

This case highlights the classic presentation of uveal effusions despite nonhypotonous IOPs seen in eyes with elevated episcleral venous pressure. [1] Based on the postoperative course of our patient where the right eye required a sclerostomy due to overfiltration and the left eye did not, we recommend performing a tight trabeculectomy to ensure that IOP does not fall too much too quickly. This may be performed with multiple releasable sutures or sutures that can be lysed with argon laser to gradually titrate the IOP.

 Conclusion



We highlight the ability to avoid the need for sclerostomies by preventing intraoperative shallowing of the anterior chamber and the use of tight scleral sutures which may be adjusted postsurgery to gradually reach the target IOP in a step-wise manner. Although a large prospective case series would be useful to confirm these observations, this is not feasible due to the rarity of this condition.

References

1Rhee DJ, Gupta M, Moncavage MB, Moster ML, Moster MR. Idiopathic elevated episcleral venous pressure and open-angle glaucoma. Br J Ophthalmol 2009;93:231-4.
2Foroozan R, Buono LM, Savino PJ, Sergott RC. Idiopathic dilated episcleral veins and increased intraocular pressure. Br J Ophthalmol 2003;87:652-4.
3Parikh RS, Desai S, Kothari K. Dilated episcleral veins with secondary open angle glaucoma. Indian J Ophthalmol 2011;59:153-5.
4Bhagat N, Lim JI, Minckler DS, Green RL. Posterior uveal effusion syndrome after trabeculectomy in an eye with ocular venous congestion. Br J Ophthalmol 2004;88:153-4.
5Audren F, Abitbol O, Dureau P, Hakiki S, Orssaud C, Bourgeois M, et al. Non-penetrating deep sclerectomy for glaucoma associated with Sturge-Weber syndrome. Acta Ophthalmol Scand 2006;84:656-60.
6Yalvac IS, Satana B, Ozkan G, Eksioglu U, Duman S. Management of glaucoma in patients with nanophthalmos. Eye (Lond) 2008;22:838-43.