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Editors Selection IGR 18-1

Surgical Treatment: Clinical outcomes in aqueous misdirection syndrome

Comment by Luciano Quaranta on:

117916 Aqueous misdirection syndrome: clinical outcomes and risk factors for treatment failure, Senthil S; Goyal S; Mohamed A et al., Graefe's Archive for Clinical and Experimental Ophthalmology, 2024; 262: 2209-2217

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The study presents a detailed analysis of Aqueous Misdirection (AM) outcomes following various intraocular surgeries, with a focus on the differential impacts observed in phakic versus pseudophakic patients. The findings underscore the complexity of managing AM, particularly in the context of prior ocular surgeries, and offer valuable insights for clinical practice.

One of the key strengths of this study is its rigorous examination of treatment responses, highlighting the significantly higher success rates of iridozonulo-hyaloido-vitrectomy (IZHV) combined with Pars Plana Vitrectomy (PPV) compared to Laser Hyaloidotomy and Transscleral Cyclophotocoagulation (TSCPC). This suggests that IZHV may be a preferable intervention for patients with AM, particularly those with complex surgical histories.

Additionally, the identification of pseudophakia as a significant predictor of treatment failure for conservative management emphasizes the necessity for heighted vigilance in this patient demographic. The association of shorter axial lengths with an increased risk of treatment failure further suggests that anatomical considerations must play a central role in individualizing patient management.

The study emphasizes the critical role of early diagnosis and timely intervention, with delayed presentation correlated with poorer outcomes. This finding serves as a reminder for clinicians to prioritize prompt referral and comprehensive evaluation strategies for patients exhibiting signs of AM.

While the article presents valuable findings regarding the management and outcomes of AM in phakic and pseudophakic patients, several aspects warrant critical examination: the study includes a relatively small sample size (49 eyes from 47 patients), which may limit the generalizability of the findings.

The treatment modalities varied greatly between patients, which may introduce variability in outcomes. Without standardized treatment protocols, it becomes challenging to draw direct comparisons between the effectiveness of different interventions. While the study reports success rates in terms of anatomical resolution and intraocular pressure (IOP) control, it lacks a comprehensive evaluation of visual outcomes and patient-reported quality of life measures. These aspects are critical in understanding the full impact of AM and its treatment on patients.

Several risk factors are evaluated, but the analysis could benefit from a more thorough consideration of confounding variables. For instance, the impact of comorbid ocular diseases or systemic conditions that could influence treatment outcomes is not adequately addressed.

While the study uses statistical comparisons to assess the efficacy of different treatments, there might be room for a different statistical model (such as multivariate analyses) that could further clarify the effect of the various factors on treatment outcomes.

As a personal comment on the topic, in my clinical practice, when I have to explain the risks/benefits of cataract or glaucoma surgery in patients with small eyes (i.e., potential higher risk of AM), I always illustrate the possibility, although infrequent, not predictable and not preventable, of the onset of aqueous misdirection even after a perfectly successful surgery. I also explain the possible need for further surgery (IZHV) to solve the problem. I almost always propose an IZHV to solve the problem, as almost all other procedures analyzed in the paper have a low success rate and a higher probability of AM recurrence.¹

In small eyes after cataract surgery, I use atropine eye drops in the first three days after surgery to prevent the onset of AM. If, upon suspension of atropine, I notice a reduction in the depth of the anterior chamber and consequent onset of myopia associated or not with an increase in IOP, I always propose an IZHV in a short time. This is because the best results, including refractive ones, are obtained only if the procedure is performed in a short time. I do not believe that the chronic use of atropine, as is still proposed by some ophthalmologists, is a current solution today.²

Overall, this article enriches the existing literature on anterior segment complications following ocular surgery and highlights the importance of personalized approaches to optimize patient outcomes.

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