I. Definition Malignant glaucoma is also known as ciliary ring block glaucoma. Pupil constrictor is a common triggering factor. Pupil constrictor causes contraction of the ciliary muscle, relaxation of the crystal suspensory ligament, adhesion of the ciliary body to the equatorial part of the crystal, secondary ciliary ring block, retention of atrial water behind the crystal, the crystal and iris move forward, the iris becomes highly dilated, the anterior chamber becomes generally shallow atrial water discharge is obstructed, at this time the atrial water can only be directed to the rear. This leads to the vitreous detachment from the front, so that the crystal is pushed forward even more, the anterior chamber is more shallow, the atrial angle is closed again to form a vicious circle, and the intraocular pressure becomes higher and higher, so ciliary ring block glaucoma is also called malignant glaucoma. Etiology 1. Endogenous factors: anatomical and physiological factors. (1) anatomical variation and genetic defects: such as small eye, small cornea, hyperopia, shallow anterior chamber, high pleated iris end volume, which makes the anterior chamber shallow and the atrial angle narrow, resulting in atrial aqueous drainage obstruction. (2) Physiological changes: pupillary block, shallow anterior chamber with narrow atrial angle, and moderate dilatation of the pupil are important conditions. In addition to age, the crystal grows with age and gradually presses against the pupillary margin, causing a pupillary block between the iris and the crystal, resulting in a higher pressure in the posterior chamber than in the anterior chamber, plus a weakened corneoscleral elasticity, with no compensatory ability for the sudden increase in pressure, thus pushing the peripheral iris forward and the iris bulging to occlude the atrial angle, resulting in an increase in intraocular pressure. 2, external causes (1) emotional hormone: central nervous system dysfunction, cortical excitation and inhibition dysregulation, mesencephalic IOP regulation center disorders. The vasomotor nerve disorder makes the pigment membrane congested and edematous, and sympathetic excitation makes the pupil dilated, both of which can make the iris root embrace to the circumferential connection and block the atrial angle. (2) Point dilatation pupil freezing, dark room test or watching movies or TV for too long to dilate the pupil, the atrial angle is obstructed and the intraocular pressure is increased. III. Diagnosis Malignant glaucoma is a type of intractable glaucoma that is difficult to diagnose and the intraocular pressure is not easily controlled. It is generally considered to be a serious complication after anti-glaucoma surgery. It is characterized by an increase in postoperative intraocular pressure and an anterior shift of the crystalline iris septum, causing the entire anterior chamber to become significantly shallower or even disappear. Typically, it occurs hours, days, or months after surgery. In some cases, however, the glaucoma is not treated with antiglaucoma surgery, but rather with topical pupil constrictors that cause an increase in IOP or after trauma or uveitis. All of these factors can lead to ciliary muscle contraction or ciliary body edema thickening and ciliary ring block. The disease often occurs in closed-angle glaucoma, especially when the atrial angle is occluded despite low intraocular pressure at the time of surgery. It often occurs in both eyes, i.e., after malignant glaucoma has occurred in one eye, the other eye may develop malignant glaucoma as a result of pupil constrictor spotting. If a prophylactic iris peripheral resection is performed in one eye, it not only cannot prevent the occurrence of malignant glaucoma, but also has the possibility of inducing it. The sudden outflow of atrial aqueous during surgery and the sudden drop in high intraocular pressure cause the sudden expansion of the vitreous humor that caused edema in the original high intraocular pressure state to impact the lens and rupture the suspensory ligament, sometimes the suspensory ligament is damaged during surgery, and the suspensory ligament itself is brittle and easily broken, causing the lens to move forward, resulting in pupillary blockage and blocking the atrial angle or surgical filtration tract. Pupil constriction is induced by causing ciliary muscle contraction to send ciliary ring block, crystal suspensory ligament relaxation, adhesion of the ciliary body to the equatorial part of the crystal, atrial water retention behind the crystal, both the crystal and the iris move forward, the iris appears highly dilated, the anterior chamber generally becomes shallow atrial water drainage is obstructed, at this point only to the posterior inflow. This leads to the vitreous detachment from the front (atrial aqueous aggregation after the vitreous), so that the crystal pushes forward more, the anterior chamber becomes more shallow, and the atrial angle closes again to form a vicious circle, so it is ciliary ring blocked closed angle glaucoma. V. Treatment For malignant glaucoma, emergency measures should be taken early to reduce the pressure at the back of the eye and break the ciliary ring block. At the same time, pharmacological treatment including hypertonic agents, carbonic anhydrase inhibitors and ciliary muscle paralyzing agents, supplemented with corticosteroids, must be taken to reduce the inflammatory reaction and ciliary edema. If the anterior chamber is formed and the intraocular pressure is normal after medication, the various medications can be reduced one by one, stopping the hyperosmolar agents first and then the carbonic anhydrase inhibitors, while the ciliary muscle paralyzing agents should be continued for a longer period of time. If medication does not work after 4-5 days, surgical treatment can be changed. Surgical treatment includes vitreous puncture and anterior chamber inflation, and if it is not effective, crystal removal or vitrectomy can be performed after the ciliary ring block is relieved, and if the IOP is still high, oral vincristine and thimerosal can be used. Precautions during surgery 1. Because the anterior chamber of malignant glaucoma is very shallow, it is very difficult to do corneal puncture. The knife must be parallel to the iris when entering the knife. 2. The site of the scleral incision should be avoided at the site of the original glaucoma surgery. Generally, the site of glaucoma surgery is above, so when performing this surgery, the inferior temporal and inferior nasal quadrants are chosen to make the scleral incision. 3.The central part of the scleral incision is the posterior edge of the angular scleral margin of 3mm The scleral incision must not be too far back. 4.When puncturing the vitreous cavity with a thin sharp blade, the blade should be radiolucent with the corneoscleral margin, which can reduce damage to the choroidal vessels. 5.When puncturing the vitreous with a knife or needle, be sure to operate carefully to avoid damage to the lens and retina. 6.When the aspiration of the vitreous is finished and balanced saline is injected into the front to partially restore the shape of the eye, be sure not to inject too much. This is because in some cases, the injected balanced saline may flow into the vitreous cavity, prompting the recurrence of malignant glaucoma. 7. Use 1% atropine eye drops 3 to 4 times daily at the end of surgery and for several weeks or months after surgery. If the eye condition is stable, gradually reduce the number of drops until the drug is completely discontinued. However, anterior chamber depth must be closely monitored. If you find that the anterior chamber becomes shallow, continue the 1% atropine eye drops immediately. Apply antibiotic drops and glucocorticoid eye drops.