Background: Malignant glaucoma (MG) is associated with a narrow angle or pseudoexfoliation (PEX)-induced laxity of the zonule. We describe a patient with massive posterior capsule opacification (PCO), i.e. Elschnig's Pearls (EP) and Soemmering's ring (SR) causing aqueous misdirection syndrome.

Methods: A 78-year-old female was referred with rapidly progressive left ocular pain, redness, blurred vision of 20/100, and intraocular pressure (IOP) of 60 mmHg. She had undergone cataract surgery 5 years prior without complications, with a preoperative diagnosis of moderate capsular PEX syndrome. She was first treated by intravenous 250 mg acetazolamide along with maximal pressure-lowering drops, 1% pilocarpine and a patent laser iridotomy. Despite adding 500 cc of 10% mannitol, IOP remained high for 3 days. A shallow anterior chamber with angle closure, myopic shift and filling of the posterior chamber by massive PCO led us to conclude an aqueous misdirection syndrome. We promptly switched 1% pilocarpine to 1% atropine and performed a laser iridotomy enlargement with a posterior capsulotomy and anterior hyaloidotomy. This rapidly controlled the condition with posterior displacement of the intraocular lens (IOL) and fading of the high-IOP associated symptoms.

Conclusions: Identifying malignant glaucoma could be challenging in the absence of immediate surgical circumstances. To our knowledge, this is the second description of PCO associated with MG. In this case, PCO was thought to narrow the iridocorneal angle and to cause a relative pupillary blockage, subsequently triggering aqueous humor misdirection to the vitreous and forward displacement of the iris-IOL diaphragm in the context of moderate PEX-induced zonular laxity.