Late-onset malignant glaucoma associated with Soemmering’s ring: A case report

Abstract

Malignant glaucoma typically presents immediately after angle-closure surgery. However, late-onset malignant glaucoma can occur after various ocular procedures. This report describes the case of an African–American woman in her late 70s who developed malignant glaucoma 7 years after cataract surgery. She initially presented with signs of acute angle-closure glaucoma. Symptoms began a few days earlier with unilateral blurred vision and a dull orbital ache. The patient was initially managed with maximum aqueous humor suppressants. Imaging and ocular examination raised suspicion of malignant glaucoma, and a Soemmering’s ring was noted on examination. Laser peripheral iridotomy was attempted in the operating room; however, definitive treatment involving iridozonulohyaloidectomy with vitrectomy was necessary. Patient intraocular pressure, vision, and examination findings improved following intervention, showing continuous postoperative improvements. This case highlights Soemmering’s ring as a potential precipitant of malignant glaucoma as well as the effectiveness of iridozonulohyaloidectomy as a definitive treatment for pseudophakic malignant glaucoma.

Introduction

Malignant glaucoma, also known as aqueous misdirection syndrome, is an aggressive form of postoperative glaucoma. ¹ It is characterized by aqueous humor misdirection into the vitreous, leading to a uniformly shallow anterior chamber (AC), increased intraocular pressure (IOP), and normal posterior segment anatomy. ¹ In some cases, the IOP may even be normal or low. ¹ The condition more frequently occurs following angle-closure glaucoma surgery; however, it has also been documented to occur after several other ocular procedures or even spontaneously.^2–5

We report the case of a patient with Soemmering’s ring who developed malignant glaucoma several years after cataract surgery. Based on our review of the literature, there are only a few publications on delayed presentation of malignant glaucoma, especially concurrent with Soemmering’s ring.^6,7 To the best of our knowledge, there are only two cases in which posterior capsular opacification (PCO), which arises via a similar mechanism as Soemmering’s ring, was found to contribute to malignant glaucoma.^8,9 We believe that our case is unique and contributes to the existing literature, highlighting that Soemmering’s ring, similar to PCO, may be a risk factor for malignant glaucoma.

Methods

This case report was conducted in accordance with the CARE (CAse REport) guidelines. The complete checklist has been submitted as supplementary material. ¹⁰

Case presentation

An African–American woman in her late 70 s presented to another ophthalmologist with blurry vision and a mild, dull, orbital ache in the right eye. The IOP was elevated to approximately 35 mmHg, and the patient was noted to have microcystic corneal edema. She was started on 0.1% brimonidine (Alphagan) BID, 0.01% bimatoprost (Lumigan) nightly, and acetazolamide (250 mg; Diamox) daily.

The patient’s medical history included phacoemulsification cataract extraction with posterior chamber intraocular lens (IOL) placement in both eyes approximately 7 years ago. She also had a history of left breast lumpectomy followed by radiation several years ago, excision of a left flank lipoma, hypertension, and hypercholesterolemia. She was previously on 0.05% difluprednate (Durezol) for intermittent uveitis; uveitis and prolonged corticosteroid usage are both known risk factors for glaucoma. She had no ocular medication history. Other medications included atorvastatin, triamterene–hydrochlorothiazide, and nifedipine, none of which contributed to glaucoma or were relevant to this case. The patient also reported not drinking alcohol and denied ever smoking or using illicit drugs.

Four days later, this patient presented to the Kittner Eye Center in May 2025 for acute angle-closure glaucoma consultation. On initial evaluation, she presented with best corrected visual acuity (BCVA) of 20/400 in the right eye (OD), which was significantly worse than baseline. Her left eye (OS) was reported to be at baseline with BCVA of 20/30 −2. IOP was measured at 22 mmHg (OD) and 14 mmHg (OS) with applanation, although the patient was already taking several IOP-lowering medications. The AC, examined via gonioscopy, was noted to be closed (AC angle, 360°) and noncompressible. The superior gonioscopic view also indicated that the central AC was shallow because of the anterior bowing of the iris. Figure 1 illustrates the shallow AC through a slit-lamp image. Ultrasound biomicroscopy (UBM) was performed to better visualize the anterior segment for potential secondary angle-closure. UBM showed signs of uniform angle narrowing, anterior rotation of the ciliary body, and suspicion of a mass anterior to the ciliary body of the right eye (Figure 2). Due to suspicion of a mass lesion, a B-scan was performed; however, it revealed no overt masses or signs of choroidal pathology in either eye. These findings helped rule out potential neoplastic or structural causes of secondary angle-closure.

Figure 1.

A shallow anterior chamber (AC) visible on the slit-lamp photograph.

Figure 2.

Examination of the anterior chamber via ultrasound biomicroscopy (UBM). This figure shows signs of angle narrowing and possible ciliary body mass.

Although posterior pathology was excluded by the B-scan, a plan was established to better visualize the ciliary body through a dilated examination. Dilation at the follow-up visit required a stable IOP, as dilation can exacerbate angle closure. Therefore, she was started on dorzolamide–timolol (22.3–6.8 mg/mL; Cosopt) BID and instructed to continue acetazolamide, brimonidine, and bimatoprost, as prescribed.

Three days later, the patient’s pupils were dilated at the follow-up visit as the IOP was well-controlled (10 mmHg). On slit-lamp examination, she appeared to have a large amount of fibrotic cortical material in the shape of a ring around the lens capsule equator, consistent with the features of Soemmering’s ring, pushing the lens forward. Additionally, the AC was shallow, the IOL was dislocated, and a lamellar hole was identified on fundus examination in both eyes. These findings helped rule out a ciliary body mass and identify Soemmering’s ring as the “mass effect” leading to angle closure. Slit-lamp photographs of the right eye were obtained (Figure 3), and she was referred for surgical evaluation of possible IOL replacement and lens material washout. Follow-up at a retina clinic for lamellar holes would be conducted after successful resolution of angle closure and normalization of IOP.

Figure 3.

Slit-lamp examination revealing a Soemmering’s ring in our patient.

The next day, at the surgical consultation visit, the patient was scheduled for lens material washout to restore normal anatomy, potential IOL replacement for her dislocated lens, and laser peripheral iridotomy (LPI) to resolve the pupillary block mechanism driving IOP elevation. Subsequently, the patient was also counseled regarding the risk of needing additional vision-optimizing surgical interventions such as a keratoplasty. Based on the surgical evaluation, there was a high chance of zonular deficiency, and concomitant signs of phacoantigenic glaucoma were also identified, making this a challenging case. The patient understood the plan, risks, and benefits associated with the intervention, ultimately providing her informed consent to the procedure.

Two days later, in the operating room, the Soemmering’s ring was a full circle (360°), adhered to the capsule in all directions. It could not be safely dissected from the capsule due to dense adhesions between the anterior and posterior capsules. LPI was conducted temporally to alleviate any pupillary block mechanism underlying the angle closure. Unfortunately, after a period of observation, the iridotomy was not helpful. This suggested that malignant glaucoma, not pupillary block, was driving the disease presentation. Surgical intervention was necessary to achieve the best visual potential for this patient. Using a vitrector, iridozonulohyaloidectomy (IZH) was performed superiorly using a low-cut setting to pass through the iris and zonules. Then, the cut rate was increased to break the anterior hyaloid face followed by pars plana vitrectomy (PPV). This procedure resulted in automatic realignment of the IOL to the correct position, not necessitating an IOL exchange. Intracameral moxifloxacin was administered into the AC of the operative eye; the eye was shielded and followed up the next day at the clinic.

The next day, the patient presented to the postoperative clinic with a good red reflex and attached retina, with no retinal breaks or other major complications. The AC was deep and quiet, and the IOP was 10 mmHg, indicating that the surgery was successful. Moderate corneal edema was noted (2+); apart from this, the patient was doing well and was sent home with continued medications: 1% atropine TID, 1% prednisolone QID, and 0.5% moxifloxacin QID.

At the 1-week follow-up visit, BCVA had improved to 20/300; however, this may not reflect her true visual potential as the patient’s pupils were pharmacologically dilated from the atropine prescribed postoperatively. IOP remained well-controlled at 7 mmHg. Currently, steroids are being tapered, and all other postoperative drops were discontinued at the follow-up appointment.

This patient will be continually monitored as an outpatient in case additional vision-optimizing interventions are necessary. However, she had no complaints regarding the surgery, and she understood that all her current symptoms were part of the normal healing process. She was satisfied with the care she had received and was optimistic regarding continued vision improvement.

Discussion

Although the underlying mechanism of malignant glaucoma remains largely unknown, with various proposed pathophysiologic mechanisms, it is ultimately driven by increased posterior segment pressure.^1,11 This leads to a self-propagating cycle of increasing pressure that cannot be equalized via aqueous drainage.^1,11 The pressure leads to anterior displacement of the lens–iris diaphragm and secondary angle closure.^1,11 Although malignant glaucoma is typically considered an early postoperative phenomenon, delayed presentations have been reported, particularly in pseudophakic patients.^5–7 The average age of onset for this condition is reportedly 70 years, with a female-to-male ratio of 11:3, matching the demographics of our patient.^11,12 Unfortunately, patients with malignant glaucoma are often at increased risk of malignant glaucoma in their other eye as well. ¹²

This case is unusual for several reasons. First, the patient developed malignant glaucoma more than 7 years after cataract extraction without any recent intraocular surgery or trauma. Second, the condition appeared to be precipitated by a prominent Soemmering’s ring, a ring-shaped collection of retained cortical material densely adhered to the capsular bag. Although often asymptomatic, large or fibrotic Soemmering’s rings have been documented to cause forward displacement of the IOL, iris crowding, and angle closure, potentially mimicking or exacerbating aqueous misdirection.^13–15 Inflammation, a known contributor to aqueous misdirection, may have also played a role in this case, as suggested by the patient’s Soemmering’s ring and episodes of intermittent uveitis.^16–18 Disruption in the normal aqueous flow pathway caused by a fibrotic ring structure and inflammatory debris may redirect some aqueous humor into the posterior segment.^13–18 This increases IOP and displaces the iris–lens diaphragm forward, resulting in a secondary angle-closure without pupillary block mechanism, consistent with malignant glaucoma.

Initial examination revealed 360° angle closure, a uniformly shallow AC, and anterior bowing of the iris on gonioscopy. UBM suggested anterior displacement of the ciliary body and lens; however, a B-scan ruled out posterior pathologies such as choroidal effusions or mass lesions. Moreover, there were no signs of inflammation or hypotony that suggest choroidal effusions, detachments, or posterior scleritis. Pupillary block was also strongly considered in the differential diagnosis; however, the AC did not deepen with LPI. Additionally, the patient was pseudophakic, effectively ruling out phacomorphic glaucoma as a differential diagnosis. These findings, combined with the need for maximum topical aqueous suppressants for initial IOP management, strongly support a diagnosis of malignant glaucoma. No other diagnostic tests were performed or considered for this case.

IZH with vitrectomy—a procedure that breaks through the iris, zonules, and anterior hyaloid followed by removal of the vitreous gel—was performed to restore normal aqueous flow by establishing communication between the posterior and anterior segments. Postoperatively, the AC deepened, corneal edema began to resolve, and IOP stabilized without the need for aqueous suppressants. The patient is currently satisfied with her care and is being followed up as an outpatient in case of further visual needs. In the past, surgeons have used neodymium-doped yttrium aluminum garnet (Nd:YAG) laser hyaloidectomy to treat malignant glaucoma in pseudophakic eyes by opening the anterior hyaloid membrane, allowing fluid to pass between anterior and posterior segments.^12,19–21 If Nd:YAG hyaloidectomy is ineffective, PPV is often performed.^12,22 However, laser treatment is more likely to result in recurrence, while a combination of PPV and IZH is not likely to cause recurrence.^12,16,23 IZH with vitrectomy is often considered the definitive treatment in cases of malignant glaucoma, especially in refractory cases or if other treatment options are not possible. Nd:YAG hyaloidectomy was not possible in our case due to the distorted anatomy posed by the Soemmering’s ring. Therefore, IZH with vitrectomy was appropriate for treating the malignant glaucoma in this case.

This case is an example of malignant glaucoma occurring late after cataract surgery, a reminder that this diagnosis should not be excluded based on timing alone. The patient’s presentation 7 years after cataract surgery should encourage clinicians to consider malignant glaucoma as a differential diagnosis in pseudophakic patients with angle closure. Additionally, Soemmering’s ring should be considered as a potential mechanical trigger for aqueous misdirection in pseudophakic patients with unexplained AC shallowing. We hypothesize that the fibrotic Soemmering’s ring may have acted as a physical barrier, misdirecting fluid into the vitreous cavity, exerting pressure and displacing the lens–iris diaphragm forward.

The rare and novel presentation of our case, along with our stepwise approach toward diagnosis, is a strength of our report. The diagnostic workup was also comprehensive, with a thorough discussion about the differentials and therapeutic options available. Unfortunately, as with all case reports, this report lacks generalizability. Additionally, because the patient was lost to follow-up, there are no data available on the patient’s recovery after 1 week postoperatively.

Conclusion

To the best of our knowledge, this is among the few reported cases of late-onset malignant glaucoma associated with a large Soemmering’s ring. This case underscores the importance of a surgical approach in managing complex secondary angle-closure mechanisms. Ophthalmologists encountering similar cases should consider IZH with vitrectomy as an effective treatment option.

Author contributions

All authors made significant contributions to the creation of the manuscript. They all meet the ICMJE criteria and approved the final version of this case report.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Data availability

Data other than those already available in this case report are not publicly available due to patient privacy and confidentiality concerns. We have de-identified all patient details.

Declaration of conflicting interests

The authors declare that they have no conflicts of interest.

Ethical considerations

Our institution has waived the requirement for ethical approval for reporting individual cases.

Funding

The authors declare that they received no funds, grants, or other support for this manuscript.