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Pars Plana Vitrectomy in the Management of Ghost Cell Glaucoma

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Pars Plana Vitrectomy in the Management of Ghost Cell Glaucoma InternationalOphthalmology 19: 121-124, 1995. 121 1995 KluwerAcademicPublishers. Printedin theNetherlands. Case report Pars plana vitrectomy in the management of ghost cell glaucoma Ahmed M. Abu E1-Asrar & Saleh A. A1-Obeidan Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia Accepted6 February 1995 Key words: ghost cell glaucoma, vitrectomy, trauma, vitreous hemorrhage Abstract In this report we describe, herewith, 5 cases of ghost cell glaucoma that followed spontaneous vitreous hemorrhage complicating branch retinal vein occlusion in a phakic eye (one case), and traumatic vitreous hemorrhage (4 cases). Because intraocular pressure was uncontrolled, pars plana vitrectomy was performed to remove the reservoir of ghost cells. Vitrectomy resulted in successful control of intraocular pressure without medications and visual improvement. Introduction ous hemorrhage. Examination revealed a visual acuity of light perception, with good light projection in all Ghost cell glaucoma is a recently described form of quadrants in the right eye and 20/20 in the left eye. secondary open angle glaucoma that occurs as a con- The intraocular pressure was 48 mmHg in the right sequence of vitreous hemorrhage. Following vitreous eye and 14 mmHg in the left eye. Examination of the hemorrhage, the red blood cells (RBCs) degenerate left eye was normal. The right eye had moderate cil- into ghost blood cells (GBCs) and pass slowly into the iary injection, and slit lamp examination showed mild anterior chamber through a disruption in the anterior bullous keratopathy and corneal stromal edema. The hyaloid face [1]. The pressure rise is due to primary anterior chamber showed 4+ khaki-colored GBCs. The obstruction of the intertrabecular spaces by the nonpli- GBCs layered in the angle inferiorly, creating a 20% able GBCs [2, 3]. khaki-colored 'pseudohypopyon'. There were no evi- When medical therapy fails in cases of dense and dence of rubeosis iridis. The lens showed mild poste- old vitreous hemorrhage, vitrectomy is effective in rior subcapsular opacities. There was no lens sublaxa- controlling the intraocular pressure by removing the tion, and no clinical evidence of anterior hyaloid face source of ghost cells and also in improving vision by disruption. On gonioscopic examination the anterior clearing the intraocular opacities [4]. In this report we chamber angle was open without evidence of neovas- present our experience in 5 cases with this infrequent cularization. The anterior vitreous gel showed dense indication for pars plana vitrectomy. yellow-colored blood. The retina could not be visu- alized because of the dense vitreous hemorrhage. B- scan ultrasonography showed a dense vitreous hemor- Case 1 rhage without evidence of retinal detachment. A clini- cal diagnosis of ghost cell glaucoma was made. Despite A 45-year-old hypertensive man was referred with the maximum antiglaucoma therapy intraocular pressure chief complaint of decreased vision, severe pain, and was 30 mmHg. A pars plana vitrectomy was performed redness in the right eye of one week duration. The and as much of the opaque vitreous gel as possible was patient underwent laser photocoagulation for branch excised. The retina was seen to be attached and the retinal vein occlusion in the right eye elsewhere 5 macula appeared normal. The blood vessels along the months prior to presentation that was followed by vitre- upper temporal arcades were noted to be sheathed with 122 patches of neovascularization. Argon laser endopho- Case 3 tocoagulation was applied in a scatter pattern along the distribution of the obstructed upper temporal vein. A 38-year-old male was referred 5 days after repair of One year after surgery the intraocular pressure was a corneo-scleral laceration that followed blunt trauma 12 mmHg without medications, and visual acuity was to the fight eye. Examination revealed a visual acu- 20/30. ity of counting fingers at one foot in the right eye, and 20/30 in the left eye. The intraocular pressure was 34 mmHg in the fight eye, and 15 mmHg in the left Case 2 eye. Examination of the left eye was unremarkable. Slit lamp examination of the right eye showed moderate cil- An 8-year-old boy was struck in the left eye by a iary injection, and the corneo-scleral laceration seemed piece of stone 5 days prior to referral. Examination well healed. The anterior chamber showed 60% hyphe- revealed a visual acuity of 20/20 in the right eye and ma. There were posterior synechiae and the lens was light perception, with good light projection in all quad- clear. B-scan ultrasonography revealed a dense vitre- rants in the left eye. The intraocular pressure was 16 ous hemorrhage. No evidence of retinal detachment mmHg in the right eye, and 35 mmHg in the left eye. or an intraocular foreign body was seen. Sickle cell Examination of the right eye was unremarkable. The disease was ruled out. The patient was treated with left eye showed total hyphema. B-scan ultrasonogra- antiglaucoma medications, and topical atropine and phy revealed dense vitreous hemorrhage and flat retina. steroid compounds. Twenty days later, the intraocular Sickle cell disease was ruled out. The patient was treat- pressure of the right eye was 30 mmHg despite max- ed with oral acetazolamide, topical timptol 0.5%, and imum medical therapy. The anterior chamber showed propine 0.1%, and the antifibrinolytic agent tranexamic 4+ GBCs. The hyphema cleared, but a dense yellow acid. Twelve days later, the hyphema cleared, and the fibrinous clot was left on the anterior lens capsule in intraocular pressure was controlled. The antiglaucoma the pupillary area. Gonioscopy revealed an open angle medications and tranexamic acid were discontinued. for 3600 without recession. A clinical diagnosis of Gonioscopy revealed an open angle for 3600 without ghost cell glaucoma was made. Tissue plasminogen recession. Two weeks later, the patient presented with a activator 25 #g in 0.1 ml was injected into the anterior painful, red left eye. Visual acuity was counting fingers chamber, that resulted in complete dissolution of the at 2 feet. The intraocular pressure was 40 mmHg. Slit fibrinous clot. The lens was clear, and there was no lamp examination revealed moderate ciliary injection, sublaxation. There was no clinical evidence of anteri- and mild, diffuse bullous keratopathy. The anterior or hyaloid disruption. A dense yellowish brown blood chamber showed 4+ GBCs. The lens was clear with- was seen in the anterior vitreous gel. Two days later, a out evidence of sublaxation. There were no clinically pars plana vitrectomy was performed on the fight eye. detectable discontinuities of the anterior hyaloid face. The vitreous hemorrhage was removed and no compli- Dense hemorrhage was present in the anterior vitre- cations occurred. Postoperatively, vision improved to ous gel. The retina could not be visualized because 20/60, and intraocular pressure was 20 mmHg with- of the dense vitreous hemorrhage. B-scan ultrasonog- out antiglaucoma medications during a follow-up of 7 raphy revealed a dense vitreous hemorrhage with a months. shallow retinal detachment noted inferiorly. A diagno- sis of ghost cell glaucoma was made and the patient underwent a pars plana vitrectomy. A retinal dialysis Case 4 was noted inferiorly, that was treated with cryotherapy and supported on a scleral buckle. An intraocular gas A 20-year-old male was referred with the chief com- bubble was used to tamponade the retinal break dur- plaint of decreased vision, pain, and redness in the ing the initial postoperative time. Postoperatively the fight eye. The patient sustained a blunt trauma to the eye healed without complications. The retina became right eye by a wooden stick 25 days prior to presen- reattached, and the retinal break was sealed. When tation. Examination revealed a visual acuity of hand the patient was last seen one year later, the intraocu- motions, with good light projection in all quadrants in lar pressure was 14 mmHg without medications, and the right eye and 20/25 in the left eye. The intraoc- visual acuity was 20/80. ular pressure was 47 mmHg in the right eye and 12 mmHg in the left eye. Examination of the left eye 123 intraocular pressure was 12 mmHg in the right eye, and 38 mmHg in the left eye. Examination of the right eye was unremarkable. The left eye s~owed70% hyphema. B-scan ultrasonography revealed dense vitreous hem- orrhage. No evidence of retinal detachment was seen. Two weeks later, evacuation of the anterior chamber clot was performed. Fifty days after the procedure, the patient was referred to us for consultation. Visual acu- ity in the left eye was hand motions, with good light projection in all quadrants. The intraocular pressure was 30 mmHg. Slit lamp examination showed a cen- tral localized rounded area of corneal blood staining 1.5 mm in diameter. The anterior chamber showed 4+ GBCs. The lens showed moderate posterior subcapsu- lar opacities and a localized anterior capsular opacity, Fig. 1. Lightmicrograph of vitreous sample showing ghost red and there was no sublaxation. A dense yellow-colored blood cells with Heinzbodies (Giemsa stain x 100). blood was present in the anterior vitreous gel. The retina could not be visualized because of the dense vitreous hemorrhage. Gonioscopy revealed the pres- was normal. The right eye had moderate ciliary injec- ence of 30% angle recession. B-scan ultrasonography tion, and slit lamp examination showed epithelial and showed dense vitreous hemorrhage without evidence stromal corneal edema. The anterior chamber showed of retinal detachment. A diagnosis of ghost cell glau- 4+ GBCs. The GBCs layered in the angle inferior- coma was made. The patient underwent a pars plana ly, creating a 10% khaki-colored 'pseudohypopyon'. lensectorny, and vitrectomy. During surgery, a chori- Gonioscopy showed a small area of peripheral anterior oretinal scar was noted in the macular area.
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