Pseudophakic angle-closure 14 Years after cataract surgery: a case report and systematic review of the literature

Purpose: Pseudophakic secondary angle closure is an uncommon event, especially when it manifests itself many years after uneventful cataract surgery. We report a case of a patient who presented with a sudden increase in intraocular pressure (IOP) several years after surgery, highlighting the diagnostic challenges associated. We performed a systematic review of potential etiologies, including spontaneous aqueous misdirection and capsular block syndrome (CBS). Observation: A 91-year-old Caucasian male presented with sudden visual acuity reduction to counting fingers at 30 cm in the left eye (LE), his only seeing eye. Fourteen years earlier, the patient had undergone uncomplicated phacoemulsification with intraocular lens implantation. The slit-lamp examination showed corneal edema and a shallow anterior chamber. IOP measured by Goldmann applanation tonometry was 55 mmHg. Gonioscopy was not feasible, and the anatomical features were at presentation were not univocal for a specific diagnosis, though they were highly suggestive of late-onset CBS with pupillary block or spontaneous aqueous misdirection. The patient underwent laser peripheral iridotomy in the LE, which proved ineffective. Despite the absence of recent surgical interventions and the presence of a markedly elongated axial length of 32 mm, the patient was treated for aqueous misdirection, undergoing pars plana vitrectomy combined with irido-zonulo-hyaloid-vitrectomy. At the last follow-up visit, 4 months postoperatively, the patient's condition significantly improved. Best-corrected visual acuity in the LE improved to 20/40, and the IOP was well-controlled at 10 mmHg. A systematic literature review identified 24 cases of spontaneous aqueous misdirection and 2 cases of late-onset CBS with IOP elevation (5 when early onset was considered). Conclusion and importance: This case underscores the significant challenges in establishing an accurate diagnosis in cases of secondary angle closure in pseudophakic patients, particularly when presentation occurs many years after uncomplicated cataract surgery. The overlap of clinical features among rare entities, such as aqueous misdirection and late-onset CBS, further complicates the diagnostic process. Prompt recognition and timely intervention remain essential to prevent the potentially severe consequences of the condition.