Abstract: Aqueous misdirection, a rare but challenging complication in ophthalmology, poses diagnostic and therapeutic dilemmas for clinicians. This article provides an in-depth exploration of aqueous misdirection, covering its etiology, clinical presentation, diagnostic approaches, treatment modalities, and recent advancements. By delving into the complexities of this condition, ophthalmologists can better manage patients and improve outcomes.

Introduction: Aqueous misdirection, also known as malignant glaucoma, is characterized by the abnormal accumulation of aqueous humor in the posterior segment of the eye, leading to elevated intraocular pressure (IOP) and potential vision loss. Despite its rarity, aqueous misdirection presents significant clinical challenges, necessitating a thorough understanding of its pathophysiology and management strategies.

Etiology: Aqueous misdirection can occur spontaneously or following intraocular surgery, particularly after procedures involving the anterior chamber, such as cataract extraction or trabeculectomy. Predisposing factors include anatomical variations, such as a shallow anterior chamber or a large ciliary body, as well as inflammatory processes or disturbances in aqueous dynamics.

Clinical Manifestations: Patients with aqueous misdirection typically present with a gradual increase in IOP despite a patent iridotomy, accompanied by shallowing of the anterior chamber and anterior displacement of the lens-iris diaphragm. Symptoms may include decreased visual acuity, ocular discomfort, and, in advanced cases, corneal edema and optic nerve compromise.

Diagnostic Modalities: Diagnosis of aqueous misdirection relies on a combination of clinical examination and imaging studies. Anterior segment optical coherence tomography (AS-OCT) can provide valuable insights into anterior chamber configuration and identify anatomical abnormalities contributing to aqueous misdirection. Gonioscopy and ultrasound biomicroscopy (UBM) are also useful adjuncts in assessing angle anatomy and identifying ciliary body pathology.

Treatment Strategies: Management of aqueous misdirection aims to restore normal aqueous dynamics and lower IOP while preserving vision. Therapeutic options include pharmacological agents to reduce aqueous production, such as topical aqueous suppressants and oral carbonic anhydrase inhibitors. Surgical interventions, including anterior chamber reformation, pars plana vitrectomy with or without anterior hyaloidectomy, and cyclodestructive procedures, may be necessary in refractory cases.

Recent Innovations: Recent advancements in the management of aqueous misdirection have focused on minimally invasive techniques and targeted therapies. Novel surgical approaches, such as endoscopic cyclophotocoagulation and microinvasive glaucoma surgery (MIGS) devices targeting the ciliary body, offer potential alternatives to traditional interventions. Additionally, emerging pharmacotherapeutic agents targeting specific molecular pathways involved in aqueous dynamics hold promise for more targeted and effective treatment.

Conclusion: Aqueous misdirection remains a challenging entity in ophthalmology, requiring a multidisciplinary approach for optimal management. By staying abreast of the latest research and innovations in diagnosis and treatment, ophthalmologists can better serve patients affected by this complex condition, ultimately improving visual outcomes and quality of life.

For further reading and reference:

• American Academy of Ophthalmology – Malignant Glaucoma: https://www.aao.org/eye-health/diseases/malignant-glaucoma
• Glaucoma Research Foundation – Malignant Glaucoma: https://www.glaucoma.org/glaucoma/malignant-glaucoma.php
• National Eye Institute – Aqueous Misdirection: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/glaucoma/aqueous-misdirection