Reduction in maximum ciliary body thickness could be a pre-existing predictor for pseudophakic malignant glaucoma

Reduction in maximum ciliary body thickness could be a pre-existing predictor for pseudophakic malignant glaucoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reduction in maximum ciliary body thickness could be a pre-existing predictor for pseudophakic malignant glaucoma Yong Jie Qin, Fu Long Luo, Jin Zeng, Yu Lin Zhang, Wen Juan Xie, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4649264/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: Malignant glaucoma is a rare and vision threatening form of glaucoma occurring in certain postoperative patients. It presents difficult diagnostic challenge. Dentification of morphometric indicators enables to predict the development of pseudophakic malignant glaucoma (PMG). Methods: A retrospective cross-sectional study was conducted from June 2016 to May 2023. Patients who originally diagnosed with primary angle closure glaucoma and developed PMG after phacoemulsification were recruited, while those without PMG were matched eyes. The parameters such as central anterior chamber depth (ACD), trabecular-ciliary process angle (TCA), ciliary body thickness (CBTmax, CBT0 and CBT1000), and anterior placement of ciliary body (APCB) were measured by ultrasound biomicroscopy (UBM) at pre-onset, onset and 6-month after settlement of PMG. Results: A total of 60 eyes from 60 patients were recruited. No significant difference was found in the baseline characteristics such as age, best-corrected visual acuity, intraocular pressure, degrees of angle closure and axial length. Lens extraction markedly increased the CBTmax (0.95 ± 0.09 mm vs. 1.05 ± 0.11 mm), CBT0 (0.85 ± 0.11 mm vs. 0.92 ± 0.13 mm) and TCA (62.61 ± 13.17 mm vs. 70.92 ± 10.65 mm) in matched eyes, but no such increases were observed in those developed PMG. Notably, among these parameters at pre-onset of PMG, a significant reduction of CBTmax (0.87 ± 0.09 mm vs. 0.95 ± 0.09 mm, P = 0.001) was only detected in the eyes that developed PMG, when compared to the matched eyes. These findings suggest an early predictor of CBTmax for PMG occurrence. Subsequently, zonulo-hyaloido-vitrectomy was performed to resolve the PMG, which was accompanied with a significant increase in the ACD, CBTmax, CBT0 and TCA, but not CBT1000 and APCB. Moreover, at pre-onset of PMG, CBTmax was the only factor producing significant prognostic value (0.74 [95% CI, 0.61-0.87], P = 0.001), which almost reaches the predictive ability at PMG attack (0.86 ([95% CI, 0.76-0.96], P < 0.001). Conclusion: A reduction in thickness of the ciliary body is pre-existed in the eyes with PMG, of which a reduced CBTmax may serve as an early predictor. Pseudophakic malignant glaucoma Ciliary body thickness Ultrasound biomicroscopy Figures Figure 1 Figure 2 Figure 3 Introduction Malignant glaucoma is a rare but vision-threatening condition that is characterized by the forward displacement of iris-lens diaphragm leading to persistent flattening of the anterior chamber. Most cases develop after glaucoma surgery [1], but some may occur after lens extraction [2,3]. In general, aphakic or pseudophakic eyes are unsusceptible to developing malignant glaucoma because lens removal effectively increases the depth of anterior chamber [4]. Thus, the term malignant glaucoma may not be applied to the glaucoma that occurs in pseudophakia [5]. However, increasing cases of this syndrome were reported in a number of studies [6-8]. The precise pathology of why malignant glaucoma develops in the eyes without the crystalline lens remains unclear. A short axial length (AL) and a narrow anterior chamber depth (ACD) were reported consistently in the eyes with pseudophakic malignant glaucoma [7]. In patients with shorter AL and shallower ACD, malignant glaucoma should be alerted after cataract surgery. However, we currently found that after lens extraction, malignant glaucoma was observed in some patients, but was absent in the others, even when these patients have similar ACD and AL [9]. It suggests that in addition to ACD and AL, other factors should be considered that may associate with the development of malignant glaucoma. Previously, inflammation, zonular weakness and intact anterior hyaloid were proposed as triggering factors causing irido-cilio-vitreal block in aphakic or pseudophakic eyes [10,11]. However, these factors are difficult to quantify in patients. With ultrasound biomicroscopy (UBM), swelling and anterior rotation of the ciliary processes can be readily visualized, which are reported as major causes of ciliary block [2,12]. While UBM was commonly performed during malignant glaucoma attack, it did not equally reflect the condition of a resting ciliary body. Notably, the structure of ciliary body could have been affected by treatment with cycloplegics, anti-inflammatory drugs, and pressure-lowering agents [13]. Thus, if measurement is done before the malignant glaucoma attack, it would be more reasonable and reliable to identify the risk factors for early prediction. We therefore reviewed 60 patients who had UBM done before the onset of malignant glaucoma and found that a reduction of maximum ciliary body thickness (CBTmax) might serve as a reliable pre-existing predictor for pseudophakic malignant glaucoma. Methods Study population This retrospective study was approved by the institutional Human Research Ethics Committee of Guangdong Provincial People's Hospital, Guangzhou, China, and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from each patient upon the final follow-up. A total of 60 eyes from 60 patients were recruited between June 2016 and May 2023. They were diagnosed originally with primary angle-closure glaucoma (PACG) and received an uneventful phacoemulsification with in-the-bag intraocular lens (IOL) placement. The onset of malignant glaucoma was defined as the time after phacoemulsification when the diagnosis of malignant glaucoma was confirmed by experienced glaucoma specialists (HYZ and YJQ). Alternate causes for anterior chamber shallowness, such as pupillary block, capsule block syndrome with retained ophthalmic viscosurgical device behind the IOL, posterior segment mass, suprachoroidal hemorrhage, ciliary body effusion, plateau iris or pseudoplateau phenomenon, and pseudophacodonesis were excluded from the current study. Patients who had combined glaucoma and cataract surgery were also excluded. Patients without occurrence of malignant glaucoma after cataract surgery were recruited as matched eyes . All subjects underwent detailed ocular examinations, including best-corrected visual acuity (BCVA), slit-lamp examination, IOP measurement by Goldmann applanation tonometry, and stereoscopic optic disc examination with a 90-diopter lens. Gonioscopy was performed in the dark using Goldmann 1-mirror lens (Ocular Instruments., Bellevue, WA) and the anterior chamber angle was graded with Scheie system by a single experienced ophthalmologist (HYZ and JZ). Visual field was assessed using the Humphrey perimetry system (24-2 SITA standard test, Humphrey, Carl Zeiss Meditec, CA) if the BCVA was >20/400. The AL was measured by the Lenstar LS900 (Haag-Streit, USA). A minimum of five consecutive measurements of AL were performed until five reliable readings were acquired with a signal to noise ratio (SNR) greater than 2.0 for each measurement. Demographic information was recorded, which includes age, sex, and history of peripheral iridotomy, history of suspicion of primary angle closure, PACG, and number of glaucoma medications. Ultrasound Biomicroscopy Ultrasound biomicroscopy (UBM) (model SW-3200 L; Tianjin Suowei Electronic Technology Co, Ltd., Tianjin, China) was performed at pre-onset, onset and 6-month after settlement of pseudophakic malignant glaucoma. In briefly, patients were anesthetized with topical administration of 0.5% proparacaine hydrochloride. The eye cup without the fundus was placed on the conjunctival sac and an appropriate amount of sterile normal saline was added. The UBM probe was used to examine the eye from 12 o'clock clockwise along its entire circumference, and subsequently two-dimensional images of the anterior segment of the eye were recorded. After capturing images from axial scans and longitudinal scans, the best images were selected to identify the following parameters at every clock position as described previously 12 (Fig. 1) : (1) central anterior chamber depth (ACD) - the distance between inner surface of the central cornea and anterior surface of the lens or artificial lens; (2) anterior chamber width (ACW) - the length between the scleral spurs on two sides; (3) lens vault (LV) - the perpendicular distance between the anterior pole of the lens and the horizontal line joining the temporal and nasal scleral spurs; (4) sulcus to sulcus (STS) length; (5) anterior vault distance (AVD) - the perpendicular distance between anterior pole of the lens and the horizontal line connecting the ciliary sulcus on both sides; (6) maximum ciliary body thickness (CBTmax) - the distance from the most inner point of the ciliary body to the inner border of the sclera or its extended line; (7) CBT0 and CBT1000 - the thickness of ciliary body at the point of the scleral spur (CBT0) and at a distance 1000 μm from the scleral spur (CBT1000); (8) anterior placement of the ciliary body (APCB) - the maximal distance from the anterior margin of the ciliary body to the vertical line extended from the scleral spur; and (9) trabecular-ciliary angle (TCA) - the angle between the posterior surface of the cornea and the anterior surface of the ciliary body. The accuracy and repeatability of the ciliary body measurements using UBM have been confirmed previously [12,14]. The quantitative measurements were performed by three experienced physicians (FLL, YLZ, YLC and WJX). Each parameter was measured three times with median recorded and the average from superior, nasal, inferior, and temporal quadrant of the eyeball represented the value for the individual parameter. Treatments of Malignant glaucoma Non-surgical approaches including atropine eye ointment (10.0%) and other anti-glaucoma eye drops were used for the treatment of malignant glaucoma. Surgical zonulo-hyaloido-vitrectomy was performed as described previously [15]. In brief, with a flow of balanced salt solution into the anterior chamber, a 25 Gauge vitreous cutter was used to establish a pathway between the anterior chamber and the vitreous cavity by zonulectomy, hyaloidectomy, and anterior vitrectomy through the peripheral iris defect. The patients were followed up for 6 months. Statistical Analysis Data analysis was conducted using SPSS software version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous data were presented as mean ± SD or medians (IQR), while categorical data were shown as numbers. Independent samples t-test and Mann-Whitney U test were used to compare the data with normal distribution and non-normal distribution, respectively. Chi-squared test was used to compare the categorical data. The diagnostic ability of anterior segment parameters on pseudophakic malignant glaucoma was analyzed by receiver operating characteristic curve (ROC). The average of area under the curve (AUC) and the cutoff point with its sensitivity and specificity were reported. A P values less than 0.05 was considered as statistically significant. Results Clinical characteristics of patients The clinical characteristics of the patients who developed malignant glaucoma after cataract surgery were compared with those without post-operative malignant glaucoma (matched eyes, Table 1). No significant difference was observed in the variables examined, including age, sex, best-corrected visual acuity, intraocular pressure, cup-to disc ratio, degree of angle closure, number of anti-glaucoma eye drops, and axial length between the group with malignant glaucoma and matched eyes. Anterior segment parameters at pre-onset and onset of malignant glaucoma Quantitative measurements from superior, nasal, inferior and temporal quadrant of the eyeball by using ultrasound biomicroscopy were summarized in Supplemental Table 1. Before the onset of malignant glaucoma, no significant difference was observed in ACD, ACW, LV, STS, AVD, CBT0, CBT1000, APCB and TCA between the group of malignant glaucoma and the matched eyes (Table 2). However, the CBTmax (0.87 ± 0.09 mm vs. 0.95 ± 0.09 mm, P = 0.001) was smaller in malignant glaucoma than in matched eyes. At the onset of malignant glaucoma, as shown in Fig. 2 (PACG-2 and PACG-3), the iris-IOL diaphragm was displaced forward across the line connecting the scleral spurs on both sides in the UBM images, leading to a marked decrease in ACD ( P < 0.001) and substantial increase in LV ( P < 0.001) and AVD ( P < 0.001), when compared to the matched eyes (Table 2). In malignant glaucoma lens extraction did not improve the CBTmax (0.87 ± 0.09 mm before vs. 0.87 ± 0.11 mm after), CBT0 (0.82 ± 0.09 mm before vs. 0.81 ± 0.10 mm), CBT1000 (0.57 ± 0.06 mm before vs 0.56 ± 0.07mm after), and TCA (57.59 ± 17.81 before mm vs 53.92 ± 13.41 mm after). Interestingly, in the matched eyes cataract surgery increased the CBTmax from 0.95 ± 0.09 mm to 1.05 ± 0.11 mm, CBT0 from 0.85 ± 0.11 mm to 0.92 ± 0.13 mm, CBT1000 from 0.61 ± 0.08 mm to 0.63 ± 0.08 mm and TCA from 62.61 ± 13.17 mm to 70.92 ± 10.65 mm (Table 2). Anterior segment parameters after settlement of malignant glaucoma There were 30 eyes of 30 patients with malignant glaucoma attack. At 6-month after treatment, 7 eyes (23.3%) were resolved by non-surgical approaches, and 23 eyes (76.7%) required surgical zonulo-hyaloido-vitrectomy. As shown in Fig. 3, compared to those before treatment, non-surgical approaches did not cause significant change to the following parameters: ACD, ACW, LV, STS, AVD, CBTmax, CBT0, CBT1000, APCB and TCA. However, surgical zonulo-hyaloido-vitrectomy significantly increased the ACD from 2.36 ± 0.31 mm to 3.32 ± 0.21 mm, CBTmax from 0.87 ± 0.11 mm to 0.96 ± 0.12 mm, CBT0 from 0.81 ± 0.10 mm to 0.89 ± 0.14 mm and TCA from 53.92 ± 13.41 mm to 70.95 ± 11.89 mm, and decreased the LV from 0.47 ± 0.23 mm to -0.39 ± 0.23 mm and AVD from 0.72 ± 0.29 mm to -0.19 ± 0.19 mm. Also, the surgery improved significantly the above parameters when compared with that treated with non-surgical approaches. The representative cases shown in Fig. 2 (PACG-2 and PACG-3) demonstrated that zonulo-hyaloido-vitrectomy caused a backward shift of the iris-IOL diaphragm, substantially deepening the ACD and reopening the anterior chamber angle. Diagnostic ability of anterior segment parameters on malignant glaucoma The ROC analysis of anterior segment parameters in the eyes at pre-onset (model 1) and onset (model 2) of malignant glaucoma versus individual matched eyes was shown in Table 3. In model 1, CBTmax was the only factor producing significantly prognostic value (AUC, 0.74 [95% CI, 0.61-0.87], P = 0.001). In model 2, at the onset of malignant glaucoma, the AUC of CBTmax (0.86, [95% CI, 0.76-0.96], P < 0.001), CBT0 (0.76, [95% CI, 0.64-0.89], P = 0.001) and CBT1000 (0.73, [95% CI, 0.60-0.85], P = 0.003) were significantly increased. The ACD, LV, AVD, and TCA, but not ACW, STS and APCB, would become a significant risk factor for malignant glaucoma (Table 3). Discussion The exact pathophysiologic mechanism of malignant glaucoma is not fully understood. An anteriorly rotated ciliary body was reported previously in UBM images during an episode of malignant glaucoma [16,17], which was further identified as a larger anterior placement of the ciliary body (APCB) [12]. However, it should be noted that UBM in these studies was performed at the onset of malignant glaucoma, where treatments with anti-glaucoma eye drops often affect the ciliary body [13,18]. Importantly, the forward movement of iris-lens diaphragm has already occurred, causing the formation of larger APCB. In the current study we reviewed 30 cases of pseudophakic malignant glaucoma, which had UBM images captured before the attack. Unexpectedly, in these eyes we did not find a significant increase in APCB and reduction in TCA, both representing anterior positioning of the ciliary body [19]. These findings suggest that the anterior rotation of ciliary body might not be sufficient to serve an early predictor of malignant glaucoma. Nevertheless, we found that the affected eyes had a significant reduction in CBTmax. The CBTs, including CBTmax, CBT0 and CBT1000, are the parameters indicating the thickness of the ciliary body [12]. CBTmax represents the thickness of ciliary crown and CBT1000 represents that of pars plana [20]. In the current study, we found no significant difference in CBT0 and CBT1000, but a marked reduction in thickness of the CBTmax at pre-onset of malignant glaucoma. In an earlier study a thinning of ciliary body (CBTmax, 0.55 ± 0.09 mm) was also reported in malignant glaucoma [12], which were even smaller than our measurements (CBTmax, 0.87 ± 0.09 mm). It is possible that the UBM in that study was done during an episode of malignant glaucoma, while we performed it before the event. Furthermore, we found that malignant glaucoma attack did not further decrease the thickness of ciliary body (CBTmax, 0.87 ± 0.11 mm). However, in eyes without occurrence of malignant glaucoma, the CBTmax, CBT0 and CBT1000 were increased from 0.95 ± 0.09 mm, 0.85 ± 0.11 mm and 0.61 ± 0.08 mm to 1.05 ± 0.11 mm, 0.92 ± 0.13 mm and 0.63 ± 0.08 mm after lens extraction, respectively. These findings suggest that cataract surgery increases the thickness of the ciliary body, but such changes are not observed in the eyes with subsequent development of malignant glaucoma, revealing a reduction in thickness of the ciliary body might be a possible predictor for post-operative development of malignant glaucoma. Thinning of the ciliary body was thought to be atrophied, which causes anterior displacement of ciliary body. Since the ciliary body is firmly attached to the scleral spur, it may prevent ciliary processes from anterior rotation [21]. Therefore, at the onset of malignant glaucoma attack, it is reasonable to argue that the affected eyes with smaller ciliary body may result in an increase of APCB and a reduction of TCA. Occurrence of the anteriorly rotated ciliary body is likely to induce angle closure by loosening the lens zonules [21,22]. The eye with angle closure is more vulnerable to develop postsurgical malignant glaucoma [23]. On the other hand, a thicker ciliary body as observed in the matched eyes maintains the normal position of ciliary processes that contributes to the remission of malignant glaucoma. We thus propose that the thickness of ciliary body plays a crucial role in development of malignant glaucoma, and a reduction in the thickness should be considered as an early predictor. To substantiate this assumption, the parameters were measured again after settlement of malignant glaucoma. We found no significant difference in all variables examined, including ACD, CBTmax and TCA, after treating with non-surgical approaches, probably due to a small sample size in this group. However, surgical zonulo-hyaloido-vitrectomy increased substantially the ACD and markedly decreased the LV and AVD. At 6-month after the surgery, none of these eyes developed recurrence, which agrees with the reports that zonulo-hyaloido-vitrectomy resolves pseudophakic malignant glaucoma with a 100% success rate [15,24]. Notably, in these eyes the surgery significantly increased the CBTmax, CBT0 and enlarged the TCA, but did not alter the CBT1000 and APCB. The mechanism on CBTmax improvement by surgery remains unknown. As mentioned above, when CBTmax increases, the ciliary body may attach more strongly to the scleral spur that likely contributes to the expansion of TCA and subsequent alleviation of the malignant glaucoma. Among these parameters, the CBTmax could be considered as the most critical factor for the development of pseudophakic malignant glaucoma, as it becomes thinner during the attack and is thickened when the attack subsides in our cohorts. Moreover, at pre-onset of malignant glaucoma, CBTmax is the only factor that produces significant prognostic value (AUC, 0.74 [95% CI, 0.61-0.87]) for the malignant glaucoma, which almost reaches the predictive ability at its attack (AUC, 0.86 ([95% CI, 0.76-0.96]). These results support strongly that a reduced CBTmax could be a pre-existing predictor for pseudophakic malignant glaucoma. Conclusion This study was limited by the small sample size, but was strengthened by the results obtained before malignant glaucoma attack and follow-up post-surgical assessments. The findings provide the first evidence that a reduced CBTmax may serve as an early predictor for vulnerability to pseudophakic malignant glaucoma. Determination of the CBTmax using UBM is suggested if patient is diagnosed with short AL and still has a shallow ACD after ocular surgery. Declarations Acknowledgement s The authors would like to thank the staff of Department of Ophthalmology, Guangdong Provincial People's Hospital, who assisted with data collection; and the Statistics Office, Information and Statistics Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences) for the excellent support in statistical analysis in this work. Author contributions All the authors included in this paper fulfill the criteria of authorship. HYZ designed this study, did all surgical processes and revised the manuscript. YJQ designed this study, processed the data and drafted the manuscript. FLL processed the data and drafted the manuscript. YLZ, YLC and WJX collected the data and measured the UBM parameters. SOC and JZ revised the manuscript. All authors read and approved the final manuscript. Fundings This work was supported by a grant from National Natural Science Foundation of China (grant number, 82171036 to HYZ)；National Natural Science Foundation Incubation Program of Guangdong Provincial People's Hospital (grant number, KY01201146 to YJQ); The Research Project of the Guangdong Provincial Administration of Traditional Chinese Medicine (grant number, 20231012 to YLC). Data availability The datasets generated and analyzed during the current study are available. The materials used in this study are available. Requests for access to the data and materials should be directed to the corresponding author (Hong Yang Zhang, [email protected] ). Ethics approval and consent to participate This study protocol was reviewed and approved by Guangdong Provincial People’s Hospital, approval number KY-Q-2022-476-03. Informed consent was obtained from each patient upon the final follow-up. Competing interests The authors declare no competing interests. References Krix-Jachym K, Żarnowski T, Rękas M. Risk Factors of Malignant Glaucoma Occurrence after Glaucoma Surgery. J Ophthalmol. 2017;2017:9616738. Shahid H, Salmon JF. Malignant glaucoma: a review of the modern literature. J Ophthalmol. 2012;2012:852659. Wilde C, Morales MU, Kumudhan D, Sim J, Amoaku W. Spontaneous onset pseudophakic malignant glaucoma secondary to zonular weakness and cilio-lenticular block. Oman J Ophthalmol. 2018;11(2):178-180. Man X, Chan NC, Baig N, Kwong YY, Leung DY, Li FC, et al. 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Variables Malignant glaucoma (n=30) Matched eyes (n=30) P value Age (yrs) 60.50 (52.75, 69.00) 64.00 (61.75, 72.25) 0.083 Sex (male/female) 10/20 8/22 0.573 BCVA (LogMAR) 0.30 (0.00, 1.00) 0.10 (0.04, 0.40) 0.252 IOP (mmHg) 18.57 ± 4.26 17.10 ± 5.22 0.236 C/D ratio 0.70 (0.50, 0.93) 0.70 (0.40, 0.83) 0.540 Degrees of angle closure 180.00 (150.00, 247.50) 240.00 (120.00, 330.00) 0.676 No. of anti-glaucoma eye drops 3.00 (2.00, 3.00) 2.50 (2.00, 3.00) 0.871 Axial length (mm) 21.96 ± 0.61 22.25 ± 0.71 0.101 BCVA, best-corrected visual acuity; IOP, intraocular pressure; C/D ratio, cup-to-disc ratio. Data are expressed as means ± SD for normal continuous variables, median (Q1, Q3) for non-normal variables or numbers. P value was calculated by independent samples t-test, Mann-Whitney U test or Chi-squared test. Table 2.Quantitative measurements by ultrasound biomicroscopy (UBM) in recruited eyes before and at the onset of malignant glaucoma Before cataract surgery (means from 4 quadrants in UBM) After cataract surgery (means from 4 quadrants in UBM) Pre-onset of malignant glaucoma Matched eyes P value Onset of malignant glaucoma Matched eyes P value Parameters (n=30) (n=30) (n=30) (n=30) ACD 1.97 ± 0.12 1.99 ± 0.27 0.638 2.41 (2.25, 2.53) 3.54 (3.39, 3.75) <0.001* ACW 10.34 ± 0.43 10.14 ± 0.35 0.058 10.17 ± 0.36 10.26 ± 0.40 0.389 LV 0.65 ± 0.19 0.71 ± 0.09 0.101 0.46 (0.32, 0.58) -0.60 (-0.75, -0.52) <0.001* STS 9.88 (9.75, 10.08) 9.75 (9.45 10.08) 0.133 9.90 ± 0.35 9.72 ± 0.39 0.069 AVD 1.02 ± 0.09 1.04 ± 0.16 0.531 0.69 (0.54, 0.74) -0.35 (-0.48, -0.21) <0.001* CBTmax 0.87 ± 0.09 0.95 ± 0.09 0.001* 0.87 ± 0.11 1.05 ± 0.11 <0.001* CBT0 0.82 ± 0.09 0.85 ± 0.11 0.347 0.81 ± 0.10 0.92 ± 0.13 <0.001* CBT1000 0.57 ± 0.06 0.61 ± 0.08 0.069 0.56 ± 0.07 0.63 ± 0.08 0.001* APCB 0.45 ± 0.19 0.48 ± 0.19 0.595 0.44 ± 0.14 0.44 ± 0.20 0.923 TCA 57.59 ± 17.81 62.61 ± 13.17 0.220 53.92 ± 13.41 70.92 ± 10.65 <0.001* ACD, central anterior chamber depth; ACW, anterior chamber width; LV, lens vault; STS, sulcus to sulcus; AVD = anterior vault distance; CBTmax, maximum ciliary body thickness; CBT0, ciliary body thickness at point of the scleral spur; CBT1000, ciliary body thickness at 1000 mm from the scleral spur; APCB, anterior placement of ciliary body; TCA, trabecular ciliary process angle. Data are expressed as means ± SD for normal continuous variables and median (Q1, Q3) for non-normal variables. The mean in each parameter is the average of superior, nasal, inferior, and temporal quadrant of the eyeball in UBM. P value was calculated by independent samples t-test or Mann-Whitney U test. * indicates P value less than 0.05. Table 3. Receiver operating characteristic (ROC) curves of the parameters in anterior segment of the recruited eyes. AUC 95% CI P value Model 1. Before cataract surgery Eyes with pre-onset of malignant glaucoma vs. Matched eyes ACD 0.51 0.35-0.66 0.923 ACW 0.61 0.47-0.76 0.128 LV 0.58 0.43-0.74 0.268 STS 0.61 0.47-0.76 0.133 AVD 0.52 0.37-0.67 0.756 CBTmax 0.74 0.61-0.87 0.001 * CBT0 0.54 0.39-0.69 0.589 CBT1000 0.59 0.45-0.74 0.212 APCB 0.53 0.39-0.68 0.663 TCA 0.59 0.44-0.73 0.237 Model 2. After cataract surgery Eyes with onset of malignant glaucoma vs. Matched eyes ACD 1.00 0.99-1.00 <0.001 * ACW 0.57 0.43-0.72 0.322 LV 1.00 1.00-1.00 <0.001 * STS 0.65 0.50-0.79 0.053 AVD 1.00 1.00-1.00 <0.001 * CBTmax 0.86 0.76-0.96 <0.001 * CBT0 0.76 0.64-0.89 0.001 * CBT1000 0.73 0.60-0.85 0.003 * APCB 0.52 0.36-0.67 0.830 TCA 0.83 0.73-0.93 <0.001 * AUC, area under the curve; CI, confidence interval; ACD, central anterior chamber depth; ACW, anterior chamber width; LV, lens vault; STS, sulcus to sulcus; AVD, the perpendicular distance between the anterior lens pole and the horizontal line of ciliary sulcus; CBTmax, maximum ciliary body thickness; CBT0, ciliary body thickness at point of the scleral spur; CBT1000, ciliary body thickness at 1000 mm from the scleral spur; APCB, anterior placement of ciliary body; TCA, trabecular ciliary process angle; * indicates P value less than 0.05. Additional Declarations No competing interests reported. Supplementary Files SupplementalTable1.docx Cite Share Download PDF Status: Published Journal Publication published 28 Apr, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 28 Jun, 2024 Editor assigned by journal 28 Jun, 2024 Submission checks completed at journal 28 Jun, 2024 First submitted to journal 27 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4649264","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":320250789,"identity":"e0bab53c-a18d-4cd3-864a-90bf0ad75d40","order_by":0,"name":"Yong Jie Qin","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yong","middleName":"Jie","lastName":"Qin","suffix":""},{"id":320250790,"identity":"e5bacd50-5a96-45b3-b168-1f9eeef41c09","order_by":1,"name":"Fu Long Luo","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fu","middleName":"Long","lastName":"Luo","suffix":""},{"id":320250791,"identity":"c85fb585-bea3-466e-b091-64f340a3a218","order_by":2,"name":"Jin Zeng","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Zeng","suffix":""},{"id":320250792,"identity":"0fdc2b3e-90a8-4287-9942-890e49f2455a","order_by":3,"name":"Yu Lin Zhang","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"Lin","lastName":"Zhang","suffix":""},{"id":320250794,"identity":"3a750d71-4287-4db4-a553-ddaaf842df69","order_by":4,"name":"Wen Juan Xie","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wen","middleName":"Juan","lastName":"Xie","suffix":""},{"id":320250798,"identity":"b8902033-7471-4c6b-8d60-27d1bdb39092","order_by":5,"name":"Yan Lei Chen","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"Lei","lastName":"Chen","suffix":""},{"id":320250800,"identity":"f70976d6-c756-4f69-a115-f508539777bb","order_by":6,"name":"Sun On Chan","email":"","orcid":"","institution":"The Chinese University of Hong Kong","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sun","middleName":"On","lastName":"Chan","suffix":""},{"id":320250802,"identity":"20e05400-1a72-452b-9b5d-a741d3b816e9","order_by":7,"name":"Hong Yang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIie3QMQrCMBSA4ScFuzypY0qlNxAiBUtB6lUSBLs6OlaEuHgAxXuIY0SwSw9Qt2Z3qLugdXRKRsF8c/6XvABY1g+i4ErJny/03NVKNWYJ8vqROwN/e1lHxCyBaLTPnQndZaKPJklM2DzonbpIfSWAQBoOc02S7Pg16JWIccBFvYBZNJa6h1XtLdglmBz4hhKQ/GiQjNuEIr2dBUHDpF1fMKRVxzQp77xuSon+lrefTE12KTIp2VJOPbdQqlmmoTaBPvuaoDv+4WmHWpZl/b03cfRGJYLxZBoAAAAASUVORK5CYII=","orcid":"","institution":"Southern Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hong","middleName":"Yang","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-06-27 14:36:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4649264/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4649264/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-04100-0","type":"published","date":"2025-04-28T15:57:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60811530,"identity":"3a6094cd-fabe-49ad-9508-eb0caf0f0c34","added_by":"auto","created_at":"2024-07-22 10:56:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150687,"visible":true,"origin":"","legend":"\u003cp\u003eDetermination of the following anterior segment parameters by ultrasound biomicroscopy. (1) central anterior chamber depth (ACD), the distance between central inner corneal surface and anterior surface of the lens or artificial lens; (2) lens vault (LV), the perpendicular distance between the anterior crystalline lens or intraocular lens (IOL) pole and the horizontal line of scleral spurs (SS, green dot line); (3) anterior vault distance (AVD), the perpendicular distance between the anterior lens pole and the horizontal line of ciliary sulcus (red dot line); (4) maximum ciliary body thickness (CBTmax), the distance from the most inner point of the ciliary body to the inner border of the sclera or its extended line; (5) ciliary body thickness at the point of the scleral spur (CBT0) and at a distance of 1000 mm (CBT1000) from the scleral spur; (6) anterior placement of the ciliary body (APCB), the maximal distance from the anterior margin of the ciliary body to the vertical line extended from the scleral spur; and (7) trabecular-ciliary angle (TCA), the angle between the posterior surface of the cornea and the anterior surface of the ciliary body.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4649264/v1/801758afaa081ac6d69d4f0c.png"},{"id":60810440,"identity":"0d67153d-b742-4a09-9470-551140ba73c5","added_by":"auto","created_at":"2024-07-22 10:48:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":265348,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound biomicroscopy images of the anterior segments in the patients with primary angle-closure glaucoma (PACG). In a patient without malignant glaucoma indicated as PACG-1, the depth of the anterior chamber (ACD, the distance between central inner corneal surface and anterior surface of the lens or artificial lens) was 1.42 mm with an extremely occluded angle (arrows) before phacoemulsification (Phaco). But the lens extraction with implantation of an artificial intraocular lens (IOL) significantly increased the ACD to 3.50 mm and widened the angle (arrows in After Phaco). A dotted line between the scleral spurs (SS) served as the base line of reference for the position of the IOL. Normally, the IOL was located below the dotted line and the iris tilted toward but without touching the IOL. However, in PACG-2 and PACG-3 with onset of malignant glaucoma, lens extraction did not significantly increase the ACD (2.06 mm before Phaco vs. 2.25 after Phaco in PACG-2, 1.78 mm before Phaco vs. 1.83 after Phaco in PACG-3) and open the angle. The iris of these two patients touched the IOL’s surface and were pushed forward exceeding the dotted line. After zonulo-hyaloido-vitrectomy (ZHV), the iris-IOL diaphragm was shifted backward, substantially deepening the ACD (3.30 mm in PACG-2 and 3.66 mm in PACG-3) and reopening the angle.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4649264/v1/803c6be7f253c7d3740092d9.png"},{"id":60810439,"identity":"e741e63e-68d5-46ac-ad13-ba7ed37b9d64","added_by":"auto","created_at":"2024-07-22 10:48:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":118062,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes of the anterior segments after treatment with non-surgical approach (Non-S) and surgical zonulo-hyaloido-vitrectomy (ZHV). Treatment with anterior vitrectomy significantly produced an increase in central anterior chamber depth (ACD), maximum ciliary body thickness (CBTmax), ciliary body thickness at point of the scleral spur (CBT0), and trabecular ciliary process angle (TCA) but generated a decrease in the lens vault (LV), anterior vault distance (AVD) when compared to those at the onset of malignant glaucoma (MG) and in the group treated with atropine eye ointment. However, no significant change was observed in these parameters after treatment with atropine eye ointment. ACW, anterior chamber width; LV, lens vault; STS, sulcus to sulcus; AVD, the perpendicular distance between the anterior lens pole and the horizontal line of ciliary sulcus; CBT1000, ciliary body thickness at 1000 mm from the scleral spur; APCB, anterior placement of ciliary body; Data are expressed as means ± SD, The mean in each parameter is the average of superior, nasal, inferior, and temporal quadrant of the eyeball in ultrasound biomicroscopy. \u003cem\u003eP\u003c/em\u003evalue was calculated by independent samples t-test\u003c/p\u003e","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4649264/v1/fe622eba2e63943b6bf9e2be.png"},{"id":81987469,"identity":"34b3946c-f0b2-4854-ab97-868587a6a4bb","added_by":"auto","created_at":"2025-05-05 16:03:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1529167,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4649264/v1/aeb1f9d5-f8d0-43a2-bb44-bf6e7ff8ddf5.pdf"},{"id":60810438,"identity":"f61e8a66-2778-463b-8bb8-41683660c513","added_by":"auto","created_at":"2024-07-22 10:48:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32200,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4649264/v1/9ce7b2c4e2fe96704f3bec29.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reduction in maximum ciliary body thickness could be a pre-existing predictor for pseudophakic malignant glaucoma","fulltext":[{"header":"Introduction ","content":"\u003cp\u003eMalignant glaucoma is a rare but vision-threatening condition that is characterized by the forward displacement of iris-lens diaphragm leading to persistent flattening of the anterior chamber. Most cases develop after glaucoma surgery [1], but some may occur after lens extraction [2,3]. In general, aphakic or pseudophakic eyes are unsusceptible to developing malignant glaucoma because lens removal effectively increases the depth of anterior chamber [4]. Thus, the term malignant glaucoma may not be applied to the glaucoma that occurs in pseudophakia [5]. However, increasing cases of this syndrome were reported in a number of studies [6-8]. The precise pathology of why malignant glaucoma develops in the eyes without the crystalline lens remains unclear. A short axial length (AL) and a narrow anterior chamber depth (ACD) were reported consistently in the eyes with pseudophakic malignant glaucoma [7]. In patients with shorter AL and shallower ACD, malignant glaucoma should be alerted after cataract surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, we currently found that after lens extraction, malignant glaucoma was observed in some patients, but was absent in the others,\u0026nbsp;even when these patients have similar ACD and AL [9].\u0026nbsp;It suggests that in addition to ACD and AL, other factors should be considered that may associate with the development of malignant glaucoma. Previously, inflammation, zonular weakness and intact anterior hyaloid were proposed as triggering factors causing irido-cilio-vitreal block in aphakic or pseudophakic eyes [10,11]. However, these factors are difficult to quantify in patients. With ultrasound biomicroscopy (UBM), swelling and anterior rotation of the ciliary processes can be readily visualized, which are reported as major causes of ciliary block [2,12]. While UBM was commonly performed during malignant glaucoma attack, it did not equally reflect the condition of a resting ciliary body. Notably, the structure of ciliary body could have been affected by treatment with cycloplegics, anti-inflammatory drugs, and pressure-lowering agents [13]. Thus, if measurement is done before the malignant glaucoma attack, it would be more reasonable and reliable to identify the risk factors for early prediction. We therefore reviewed 60 patients who had UBM done before the onset of malignant glaucoma and found that a reduction of maximum ciliary body thickness (CBTmax) might serve as a reliable pre-existing predictor for pseudophakic malignant glaucoma.\u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;retrospective\u0026nbsp;study was approved by the institutional Human Research Ethics Committee of Guangdong Provincial People's Hospital, Guangzhou, China, and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from each patient upon the final follow-up. A total of 60 eyes from 60 patients were recruited between June 2016 and May 2023. They were diagnosed originally with primary angle-closure glaucoma (PACG) and received an uneventful phacoemulsification with in-the-bag intraocular lens (IOL) placement.\u0026nbsp;The onset of malignant glaucoma was defined as the time after phacoemulsification when the diagnosis of malignant glaucoma was confirmed by experienced glaucoma specialists (HYZ and YJQ). Alternate causes for anterior chamber shallowness, such as pupillary block, capsule block syndrome with retained ophthalmic viscosurgical device behind the IOL, posterior segment mass, suprachoroidal hemorrhage, ciliary body effusion, plateau iris or pseudoplateau phenomenon, and pseudophacodonesis were excluded from the current study. Patients who had combined glaucoma and cataract surgery were also excluded. Patients without occurrence of\u0026nbsp;malignant glaucoma after cataract surgery were recruited as matched eyes\u003cstrong\u003e.\u003c/strong\u003e All subjects underwent detailed ocular examinations, including best-corrected visual acuity (BCVA), slit-lamp examination, IOP measurement by Goldmann applanation tonometry, and stereoscopic optic disc examination with a 90-diopter lens. Gonioscopy was performed in the dark using Goldmann 1-mirror lens (Ocular Instruments., Bellevue, WA) and the anterior chamber angle was graded with Scheie system by a single experienced ophthalmologist (HYZ and JZ). Visual field was assessed using the Humphrey perimetry system (24-2 SITA standard test, Humphrey, Carl Zeiss Meditec, CA) if the BCVA was \u0026gt;20/400. The AL was measured by the Lenstar LS900 (Haag-Streit, USA). A minimum of five consecutive measurements of AL were performed until five reliable readings were acquired with a signal to noise ratio (SNR) greater than 2.0 for each measurement. Demographic information was recorded, which includes age, sex, and history of peripheral iridotomy, history of suspicion of primary angle closure, PACG, and number of glaucoma medications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUltrasound Biomicroscopy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUltrasound biomicroscopy (UBM) (model SW-3200 L; Tianjin Suowei Electronic Technology Co, Ltd., Tianjin, China) was performed at pre-onset, onset and 6-month after settlement of pseudophakic malignant glaucoma. In briefly, patients were anesthetized with topical administration of 0.5% proparacaine hydrochloride. The eye cup without the fundus was placed on the conjunctival sac and an appropriate amount of sterile normal saline was added. The UBM probe was used to examine the eye from 12 o'clock clockwise along its entire circumference, and subsequently two-dimensional images of the anterior segment of the eye were recorded. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter capturing images from axial scans and longitudinal scans, the best images were selected to identify the following parameters at every clock position as described previously\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e (Fig. 1)\u003cstrong\u003e:\u003c/strong\u003e (1) central anterior chamber depth (ACD) - the distance between inner surface of the central cornea and anterior surface of the lens or artificial lens; (2) anterior chamber width (ACW) - the length between the scleral spurs on two sides; (3) lens vault (LV) -\u0026nbsp;the perpendicular distance between the anterior pole of the lens and the horizontal line joining the temporal and nasal scleral spurs; (4) sulcus to sulcus (STS) length; (5) anterior vault distance (AVD) - the perpendicular distance between anterior pole of the lens and the horizontal line connecting the ciliary sulcus on both sides; (6)\u0026nbsp;maximum ciliary body thickness (CBTmax) - the distance from the most inner point of the ciliary body to the inner border of the sclera or its extended line; (7) CBT0 and CBT1000 - the thickness of ciliary body at the point of the scleral spur (CBT0) and at a distance 1000 μm from the scleral spur (CBT1000); (8) anterior placement of the ciliary body (APCB) - the maximal distance from the anterior margin of the ciliary body to the vertical line extended from the scleral spur; and (9) trabecular-ciliary angle (TCA) - the angle between the posterior surface of the cornea and the anterior surface of the ciliary body. The accuracy and repeatability of the ciliary body measurements using UBM have been confirmed previously [12,14]. The quantitative measurements were performed by three experienced physicians (FLL, YLZ, YLC and WJX). Each parameter was measured three times with median recorded and the average from superior, nasal, inferior, and temporal quadrant of the eyeball represented the value for the individual parameter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatments of Malignant glaucoma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-surgical approaches including atropine eye ointment (10.0%) and other anti-glaucoma eye drops were used for the treatment of malignant glaucoma. Surgical zonulo-hyaloido-vitrectomy was performed as described previously [15]. In brief, with a flow of balanced salt solution into the anterior chamber, a 25 Gauge vitreous cutter was used to establish a pathway between the anterior chamber and the vitreous cavity by zonulectomy, hyaloidectomy, and anterior vitrectomy through the peripheral iris defect. The patients were followed up for 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was conducted using SPSS software version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous data were presented as mean ± SD or medians (IQR), while categorical data were shown as numbers. Independent samples t-test and Mann-Whitney U test were used to compare the data with normal distribution and non-normal distribution, respectively. Chi-squared test was used to compare the categorical data. The diagnostic ability of anterior segment parameters on pseudophakic malignant glaucoma was analyzed by receiver operating characteristic curve (ROC). The average of area under the curve (AUC) and the cutoff point with its sensitivity and specificity were reported. A \u003cem\u003eP\u003c/em\u003e values less than 0.05 was considered as statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eClinical characteristics of patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical characteristics of the patients who developed malignant glaucoma after cataract surgery were compared with those without post-operative malignant glaucoma (matched eyes, Table 1). No significant difference was observed in the variables examined, including age, sex, best-corrected visual acuity, intraocular pressure, cup-to disc ratio, degree of angle closure, number of anti-glaucoma eye drops, and axial length between the group with malignant glaucoma and matched eyes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnterior segment parameters at pre-onset and onset of malignant glaucoma\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative measurements from superior, nasal, inferior and temporal quadrant of the eyeball by using ultrasound biomicroscopy were summarized in Supplemental Table 1. Before the onset of malignant glaucoma, no significant difference was observed in ACD, ACW, LV, STS, AVD, CBT0, CBT1000, APCB and TCA between the group of malignant glaucoma and the matched eyes (Table 2). However, the CBTmax (0.87 ± 0.09 mm \u003cem\u003evs.\u003c/em\u003e 0.95 ± 0.09 mm, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.001) was smaller in malignant glaucoma than in matched eyes. At the onset of malignant glaucoma, as shown in Fig. 2 (PACG-2 and PACG-3), the\u0026nbsp;iris-IOL diaphragm was displaced forward across the line connecting the scleral spurs on both sides in the UBM images, leading to a marked decrease in ACD (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001) and substantial increase in LV (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001) and AVD (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001), when compared to the matched eyes (Table 2). In malignant glaucoma lens extraction did not improve the CBTmax (0.87 ± 0.09 mm before \u003cem\u003evs.\u003c/em\u003e 0.87 ± 0.11 mm after), CBT0 (0.82 ± 0.09 mm before \u003cem\u003evs.\u003c/em\u003e 0.81 ± 0.10 mm), CBT1000 (0.57 ± 0.06 mm before \u003cem\u003evs\u003c/em\u003e 0.56 ± 0.07mm after), and TCA (57.59 ± 17.81 before mm \u003cem\u003evs\u0026nbsp;\u003c/em\u003e53.92 ± 13.41 mm after). Interestingly, in the matched eyes cataract surgery increased the CBTmax from 0.95 ± 0.09 mm to 1.05 ± 0.11 mm, CBT0 from 0.85 ± 0.11 mm to 0.92 ± 0.13 mm, CBT1000 from 0.61 ± 0.08 mm to 0.63 ± 0.08 mm and TCA from 62.61 ± 13.17 mm to 70.92 ± 10.65 mm (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnterior segment parameters after settlement of malignant glaucoma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 30 eyes of 30 patients with malignant glaucoma attack. At 6-month after treatment, 7 eyes (23.3%) were resolved by non-surgical approaches, and 23 eyes (76.7%) required surgical zonulo-hyaloido-vitrectomy. As shown in Fig. 3, compared to those before treatment, non-surgical approaches did not cause significant change to the following parameters: ACD, ACW, LV, STS, AVD, CBTmax, CBT0, CBT1000, APCB and TCA. However, surgical zonulo-hyaloido-vitrectomy significantly increased the ACD from 2.36 ± 0.31 mm to 3.32 ± 0.21 mm, CBTmax from 0.87 ± 0.11 mm to 0.96 ± 0.12 mm, CBT0 from 0.81 ± 0.10 mm to 0.89 ± 0.14 mm and TCA from 53.92 ± 13.41 mm to 70.95 ± 11.89 mm, and decreased the LV from 0.47 ± 0.23 mm to -0.39 ± 0.23 mm and AVD from 0.72 ± 0.29 mm to -0.19 ± 0.19 mm. Also, the surgery improved significantly the above parameters when compared with that treated with non-surgical approaches. The representative cases shown in Fig. 2 (PACG-2 and PACG-3) demonstrated that zonulo-hyaloido-vitrectomy caused a backward shift of the iris-IOL diaphragm, substantially deepening the ACD and reopening the anterior chamber angle.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic ability of anterior segment parameters on malignant glaucoma\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ROC analysis of anterior segment parameters in the eyes at pre-onset (model 1) and onset (model 2) of malignant glaucoma versus individual matched eyes was shown in Table 3. In model 1, CBTmax was the only factor producing significantly prognostic value (AUC, 0.74 [95% CI, 0.61-0.87], \u003cem\u003eP\u003c/em\u003e = 0.001). In model 2, at the onset of malignant glaucoma, the AUC of CBTmax (0.86, [95% CI, 0.76-0.96],\u003cem\u003e\u0026nbsp;P\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001), CBT0 (0.76, [95% CI, 0.64-0.89], P = 0.001) and CBT1000 (0.73, [95% CI, 0.60-0.85], \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.003) were significantly increased. The ACD, LV, AVD, and TCA, but not ACW, STS and APCB, would become a significant risk factor for malignant glaucoma (Table 3).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe exact pathophysiologic mechanism of\u0026nbsp;malignant glaucoma\u0026nbsp;is not fully understood. An\u0026nbsp;anteriorly rotated ciliary body\u0026nbsp;was reported previously in UBM images during an episode of\u0026nbsp;malignant glaucoma [16,17], which was further\u0026nbsp;identified as a larger anterior placement of the ciliary body (APCB) [12]. However, it should be noted that UBM in these studies was performed at the onset of malignant glaucoma, where treatments with anti-glaucoma eye drops often affect the ciliary body [13,18]. Importantly, the\u0026nbsp;forward movement of iris-lens diaphragm has already occurred, causing the formation of larger APCB. In the current study we reviewed 30 cases of\u0026nbsp;pseudophakic\u0026nbsp;malignant glaucoma, which had UBM images captured before the attack. Unexpectedly, in these eyes we did not find a significant increase in APCB and reduction in TCA, both representing anterior positioning of the ciliary body [19]. These findings suggest that the anterior rotation of ciliary body might not be sufficient to serve an early predictor of malignant glaucoma. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNevertheless,\u0026nbsp;we found that the affected eyes had a significant reduction in CBTmax. The CBTs, including CBTmax, CBT0 and CBT1000, are the parameters indicating the thickness of the ciliary body [12]. CBTmax represents the thickness of ciliary crown and CBT1000 represents that of pars plana [20]. In the current study, we found no significant difference in CBT0 and CBT1000, but a marked reduction in thickness of the CBTmax at pre-onset of malignant glaucoma. In an earlier study a thinning of ciliary body (CBTmax, 0.55 ± 0.09 mm) was also reported in malignant glaucoma [12], which were even smaller than our measurements (CBTmax, 0.87 ± 0.09 mm). It is possible that the UBM in that study was done during an episode of malignant glaucoma, while we performed it before the event. Furthermore, we found that malignant glaucoma attack did not further decrease the thickness of ciliary body\u0026nbsp;(CBTmax, 0.87 ± 0.11 mm).\u0026nbsp;However,\u0026nbsp;in eyes without occurrence of malignant glaucoma, the CBTmax, CBT0 and CBT1000 were increased from 0.95 ± 0.09 mm, 0.85 ± 0.11 mm and 0.61 ± 0.08 mm to 1.05 ± 0.11 mm, 0.92 ± 0.13 mm and 0.63 ± 0.08 mm after lens extraction, respectively. These findings suggest that cataract surgery increases the thickness of the ciliary body, but such changes are not observed in the eyes with subsequent development of malignant glaucoma, revealing a reduction in thickness of the ciliary body might be a possible predictor for\u0026nbsp;post-operative development of malignant glaucoma. Thinning of the ciliary body was thought to be atrophied, which causes anterior displacement of ciliary body. Since the ciliary body is firmly attached to the scleral spur, it may prevent ciliary processes from anterior rotation [21]. Therefore, at the onset of malignant glaucoma attack, it is reasonable to argue that the affected eyes with smaller ciliary body may result in an increase of APCB and a reduction of TCA. Occurrence of the anteriorly rotated ciliary body is likely to induce angle closure by loosening the lens zonules [21,22]. The eye with angle closure is more vulnerable to develop postsurgical malignant glaucoma [23]. On the other hand, a thicker ciliary body as observed in the matched eyes maintains the normal position of ciliary processes that contributes to the remission of malignant glaucoma. We thus propose that the thickness of ciliary body plays a crucial role in development of malignant glaucoma, and a reduction in the thickness should be considered as an early predictor. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo substantiate this assumption, the parameters were measured again after settlement of malignant glaucoma. We found no significant difference in all variables examined, including ACD, CBTmax and TCA, after treating with non-surgical approaches, probably due to a small sample size in this group. However, surgical zonulo-hyaloido-vitrectomy increased substantially the ACD and markedly decreased the LV and AVD. At 6-month after the surgery, none of these eyes developed recurrence, which agrees with the reports that zonulo-hyaloido-vitrectomy resolves pseudophakic malignant glaucoma with a 100% success rate [15,24]. Notably, in these eyes the surgery significantly increased the CBTmax, CBT0 and enlarged the TCA, but did not alter the CBT1000 and APCB. The mechanism on CBTmax improvement by surgery remains unknown. As mentioned above, when CBTmax increases, the ciliary body may attach more strongly to the scleral spur that likely contributes to the expansion of TCA and subsequent alleviation of the malignant glaucoma. Among these parameters, the CBTmax could be considered as the most critical factor for the development of\u0026nbsp;pseudophakic\u0026nbsp;malignant glaucoma, as it becomes thinner during the attack and is thickened when the attack subsides in our cohorts. Moreover, at pre-onset of malignant glaucoma, CBTmax is the only factor that produces significant prognostic value (AUC, 0.74 [95% CI, 0.61-0.87]) for\u0026nbsp;the\u0026nbsp;malignant glaucoma, which almost reaches the predictive ability at its attack (AUC, 0.86 ([95% CI, 0.76-0.96]). These results support strongly that a reduced CBTmax could be a pre-existing predictor for pseudophakic malignant glaucoma. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study was limited by the small sample size, but was strengthened by the results obtained before malignant glaucoma attack and follow-up post-surgical assessments. The findings provide the first evidence that a reduced CBTmax may serve as an early predictor for vulnerability to pseudophakic malignant glaucoma. Determination of the CBTmax using UBM is suggested if patient is diagnosed with short AL and still has a shallow ACD after ocular surgery. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the staff of Department of Ophthalmology, Guangdong Provincial People\u0026apos;s Hospital, who assisted with data collection; and the Statistics Office, Information and Statistics Center, Guangdong Provincial People\u0026apos;s Hospital (Guangdong Academy of Medical Sciences) for the excellent support in statistical analysis in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors included in this paper fulfill the criteria of authorship. HYZ designed this study, did all surgical processes and revised the manuscript. YJQ designed this study, processed the data and drafted the manuscript. FLL processed the data and drafted the manuscript. YLZ, YLC and WJX collected the data and measured the UBM parameters. SOC and JZ revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a grant from National Natural Science Foundation of China (grant number, 82171036 to HYZ)；National Natural Science Foundation Incubation Program of Guangdong Provincial People\u0026apos;s Hospital (grant number, KY01201146 to YJQ); The Research Project of the Guangdong Provincial Administration of Traditional Chinese Medicine (grant number, 20231012 to YLC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available. The materials used in this study are available. Requests for access to the data and materials should be directed to the corresponding author (Hong Yang Zhang, [email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study protocol was reviewed and approved by Guangdong Provincial People\u0026rsquo;s Hospital, approval number KY-Q-2022-476-03. Informed consent was obtained from each patient upon the final follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKrix-Jachym K, Żarnowski T, Rękas M. Risk Factors of Malignant Glaucoma Occurrence after Glaucoma Surgery. J Ophthalmol. 2017;2017:9616738.\u003c/li\u003e\n\u003cli\u003eShahid H, Salmon JF. Malignant glaucoma: a review of the modern literature. J Ophthalmol. 2012;2012:852659.\u003c/li\u003e\n\u003cli\u003eWilde C, Morales MU, Kumudhan D, Sim J, Amoaku W. Spontaneous onset pseudophakic malignant glaucoma secondary to zonular weakness and cilio-lenticular block. Oman J Ophthalmol. 2018;11(2):178-180.\u003c/li\u003e\n\u003cli\u003eMan X, Chan NC, Baig N, Kwong YY, Leung DY, Li FC, et al. Anatomical effects of clear lens extraction by phacoemulsification versus trabeculectomy on anterior chamber drainage angle in primary angle-closure glaucoma (PACG) patients. Graefes Arch Clin Exp Ophthalmol. 2015;253(5):773-8.\u003c/li\u003e\n\u003cli\u003eSnydacker D. Pseudophakic malignant glaucoma--is it really pseudo-malignant? Am J Ophthalmol. 1987;103(6):843-4. doi: 10.1016/s0002-9394(14)74415-0\u003c/li\u003e\n\u003cli\u003eShrader CE, Belcher CD 3rd, Thomas JV, Simmons RJ, Murphy EB. Pupillary and iridovitreal block in pseudophakic eyes. Ophthalmology. 1984;91(7):831-7.\u003c/li\u003e\n\u003cli\u003eVarma DK, Belovay GW, Tam DY, Ahmed II. Malignant glaucoma after cataract surgery. J Cataract Refract Surg. 2014;40(11):1843-9.\u003c/li\u003e\n\u003cli\u003eNaderi BA, Fesharaki H, Ghanbari H, Kianersi F, Naderi BF, Naderi BB. Clinical efficacy of inferior peripheral irido-capsulo-hyaloidotomy for pseudophakic malignant glaucoma. Int Ophthalmol. 2021;41(9):3153-3161.\u003c/li\u003e\n\u003cli\u003eZhang Y, Wang S, Lin H, He B, Liu Y, Yang B, et al. Ocular Characteristics of Pseudophakic Eyes with Malignant Glaucoma. Ophthalmic Res. 2023;66(1):1159-1168.\u003c/li\u003e\n\u003cli\u003eSteinert RF, Epstein DL, Puliafito CA. Surgical vitrectomy for pseudophakic malignant glaucoma. Am J Ophthalmol. 1986;102(6):803-4.\u003c/li\u003e\n\u003cli\u003eȘtefănescu-Dima AȘ, Tănasie CA, Mercuț MF, Mercuț IM, Ionete M, Mocanu CL. Pseudophakic malignant glaucoma - a case report. Rom J Ophthalmol. 2019;63(3):268-272\u003c/li\u003e\n\u003cli\u003eWang Z, Huang J, Lin J, Liang X, Cai X, Ge J. Quantitative measurements of the ciliary body in eyes with malignant glaucoma after trabeculectomy using ultrasound biomicroscopy. Ophthalmology. 2014;121(4):862-9.\u003c/li\u003e\n\u003cli\u003eHong J, Sun X, Xu J, Liu Z. Re: Wang et al.: Quantitative measurements of the ciliary body in eyes with malignant glaucoma after trabeculectomy using ultrasound biomicroscopy (Ophthalmology 2014;121:862-9). Ophthalmology. 2015;122(1):e4.\u003c/li\u003e\n\u003cli\u003eLi X, Wang W, Huang W, Chen S, Wang J, Wang Z, et al. Difference of uveal parameters between the acute primary angle closure eyes and the fellow eyes. Eye (Lond). 2018;32(7):1174-1182.\u003c/li\u003e\n\u003cli\u003eLois N, Wong D, Groenewald C. New surgical approach in the management of pseudophakic malignant glaucoma. Ophthalmology. 2001;108(4):780-3.\u003c/li\u003e\n\u003cli\u003eTello C, Chi T, Shepps G, Liebmann J, Ritch R. Ultrasound biomicroscopy in pseudophakic malignant glaucoma. Ophthalmology. 1993;100(9):1330-4.\u003c/li\u003e\n\u003cli\u003eTrope GE, Pavlin CJ, Bau A, Baumal CR, Foster FS. Malignant glaucoma. Clinical and ultrasound biomicroscopic features. Ophthalmology. 1994;101(6):1030-5.\u003c/li\u003e\n\u003cli\u003eMishima HK, Shoge K, Takamatsu M, Kiuchi Y, Tanaka J. Ultrasound biomicroscopic study of ciliary body thickness after topical application of pharmacologic agents. Am J Ophthalmol. 1996;121(3):319-21.\u003c/li\u003e\n\u003cli\u003eHenzan IM, Tomidokoro A, Uejo C, Sakai H, Sawaguchi S, Iwase A, et al. Ultrasound biomicroscopic configurations of the anterior ocular segment in a population-based study the Kumejima Study. Ophthalmology. 2010;117(9):1720-8, 1728.e1.\u003c/li\u003e\n\u003cli\u003eChen SY, Wu LL. [Effect of anatomic features of ciliary body on primary angle closure]. Zhonghua Yan Ke Za Zhi. 2018;54(9):716-720.\u003c/li\u003e\n\u003cli\u003eGohdo T, Tsumura T, Iijima H, Kashiwagi K, Tsukahara S. Ultrasound biomicroscopic study of ciliary body thickness in eyes with narrow angles. Am J Ophthalmol. 2000;129(3):342-6.\u003c/li\u003e\n\u003cli\u003eChen SY, He N, Yan YJ, Fan X, Wu LL. Ultrasound biomicroscopic imaging demonstrate thinner ciliary body thickness in eyes with angle closure. Int J Ophthalmol. 2022;15(9):1476-1482.\u003c/li\u003e\n\u003cli\u003eRuben ST, Tsai J, Hitchings RA. Malignant glaucoma and its management. Br J Ophthalmol, 1997;81:163.\u003c/li\u003e\n\u003cli\u003eTosi R, Kilian R, Rizzo C, Pagnacco C, Marchini G. A case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy. Am J Ophthalmol Case Rep. 2022;28:101719.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseline characteristics of the patients with primary angle closure glaucoma (PACG).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"117%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalignant glaucoma (n=30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatched eyes (n=30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eAge (yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e60.50 (52.75, 69.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e64.00 (61.75, 72.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eSex (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e10/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e8/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eBCVA (LogMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e0.30 (0.00, 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e0.10 (0.04, 0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eIOP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e18.57 \u0026plusmn; 4.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e17.10 \u0026plusmn; 5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eC/D ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e0.70 (0.50, 0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e0.70 (0.40, 0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eDegrees of angle closure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e180.00 (150.00, 247.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e240.00 (120.00, 330.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.676\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eNo. of anti-glaucoma eye drops\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e3.00 (2.00, 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e2.50 (2.00, 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.871\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.632653061224488%\"\u003e\n \u003cp\u003eAxial length (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.612244897959183%\"\u003e\n \u003cp\u003e21.96 \u0026plusmn; 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.53061224489796%\"\u003e\n \u003cp\u003e22.25 \u0026plusmn; 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBCVA, best-corrected visual acuity; IOP, intraocular pressure; C/D ratio, cup-to-disc ratio. Data are expressed as means \u0026plusmn; SD for normal continuous variables, median (Q1, Q3) for non-normal variables or numbers. \u003cem\u003eP\u003c/em\u003e value was calculated by independent samples t-test, Mann-Whitney U test or Chi-squared test.\u003c/p\u003e\n\u003cp\u003eTable 2.Quantitative measurements by ultrasound biomicroscopy (UBM) in recruited eyes before and at the onset of malignant glaucoma\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore cataract surgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(means from 4 quadrants in UBM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter cataract surgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(means from 4 quadrants in UBM)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePre-onset of malignant glaucoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMatched eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOnset of malignant glaucoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMatched eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eACD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.97 \u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.99 \u0026plusmn; 0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.41 (2.25, 2.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.54 (3.39, 3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eACW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.34 \u0026plusmn; 0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.14 \u0026plusmn; 0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.17 \u0026plusmn; 0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.26 \u0026plusmn; 0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.65 \u0026plusmn; 0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.71 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.46 (0.32, 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.60 (-0.75, -0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSTS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.88 (9.75, 10.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.75 (9.45 10.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.90 \u0026plusmn; 0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.72 \u0026plusmn; 0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.02 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.04 \u0026plusmn; 0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.69 (0.54, 0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.35 (-0.48, -0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCBTmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.87 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.95 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.87 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.05 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCBT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.82 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.85 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.81 \u0026plusmn; 0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.92 \u0026plusmn; 0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCBT1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.57 \u0026plusmn; 0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.61 \u0026plusmn; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.56 \u0026plusmn; 0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.63 \u0026plusmn; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAPCB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.45 \u0026plusmn; 0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.48 \u0026plusmn; 0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.44 \u0026plusmn; 0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.44 \u0026plusmn; 0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.59 \u0026plusmn; 17.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.61 \u0026plusmn; 13.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53.92 \u0026plusmn; 13.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70.92 \u0026plusmn; 10.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eACD, central anterior chamber depth; ACW, anterior chamber width; LV, lens vault; STS, sulcus to sulcus; AVD = anterior vault distance; CBTmax, maximum ciliary body thickness; CBT0, ciliary body thickness at point of the scleral spur; CBT1000, ciliary body thickness at 1000 mm from the scleral spur; APCB, anterior placement of ciliary body; TCA, trabecular ciliary process angle. Data are expressed as means \u0026plusmn; SD for normal continuous variables and median (Q1, Q3) for non-normal variables. The mean in each parameter is the average of superior, nasal, inferior, and temporal quadrant of the eyeball in UBM. \u003cem\u003eP\u003c/em\u003e value was calculated by independent samples t-test or Mann-Whitney U test. * indicates \u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue less than 0.05.\u003c/p\u003e\n\u003cp\u003eTable 3. Receiver operating characteristic (ROC) curves of the parameters in anterior segment of the recruited eyes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eModel 1. Before cataract surgery\u003c/p\u003e\n \u003cp\u003eEyes with pre-onset of malignant glaucoma vs. Matched eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eACD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.35-0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eACW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.47-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.43-0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eSTS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.47-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eAVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.37-0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBTmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.61-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.39-0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.589\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBT1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.45-0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eAPCB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.39-0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.663\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eTCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.44-0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.237\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eModel 2. After cataract surgery\u003c/p\u003e\n \u003cp\u003eEyes with onset of malignant glaucoma vs. Matched eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eACD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.99-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eACW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.43-0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eSTS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.50-0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eAVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBTmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.76-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.64-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eCBT1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.60-0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eAPCB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.36-0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.830\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.408163265306122%\" valign=\"top\"\u003e\n \u003cp\u003eTCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.73-0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAUC, area under the curve; CI, confidence interval; ACD, central anterior chamber depth; ACW, anterior chamber width; LV, lens vault; STS, sulcus to sulcus; AVD, the perpendicular distance between the anterior lens pole and the horizontal line of ciliary sulcus; CBTmax, maximum ciliary body thickness; CBT0, ciliary body thickness at point of the scleral spur; CBT1000, ciliary body thickness at 1000 mm from the scleral spur; APCB, anterior placement of ciliary body; TCA, trabecular ciliary process angle; * indicates \u003cem\u003eP\u003c/em\u003e value less than 0.05.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pseudophakic malignant glaucoma, Ciliary body thickness, Ultrasound biomicroscopy","lastPublishedDoi":"10.21203/rs.3.rs-4649264/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4649264/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Malignant glaucoma is a rare and vision threatening form of glaucoma occurring in certain postoperative patients. It presents difficult diagnostic challenge. Dentification of morphometric indicators enables to predict the development of pseudophakic malignant glaucoma (PMG).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective cross-sectional study was conducted from June 2016 to May 2023. Patients who originally diagnosed with primary angle closure glaucoma and developed PMG after phacoemulsification were recruited, while those without PMG were matched eyes. The parameters such as central anterior chamber depth (ACD), trabecular-ciliary process angle (TCA), ciliary body thickness (CBTmax, CBT0 and CBT1000), and anterior placement of ciliary body (APCB) were measured by ultrasound biomicroscopy (UBM) at pre-onset, onset and 6-month after settlement of PMG.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 60 eyes from 60 patients were recruited. No significant difference was found in the baseline characteristics such as age, best-corrected visual acuity, intraocular pressure, degrees of angle closure and axial length. Lens extraction markedly increased the CBTmax (0.95 ± 0.09 mm \u003cem\u003evs.\u003c/em\u003e 1.05 ± 0.11 mm), CBT0 (0.85 ± 0.11 mm \u003cem\u003evs.\u003c/em\u003e0.92 ± 0.13 mm) and TCA (62.61 ± 13.17 mm \u003cem\u003evs.\u003c/em\u003e 70.92 ± 10.65 mm) in matched eyes, but no such increases were observed in those developed PMG. Notably, among these parameters at pre-onset of PMG, a significant reduction of CBTmax (0.87 ± 0.09 mm \u003cem\u003evs.\u003c/em\u003e 0.95 ± 0.09 mm, \u003cem\u003eP\u003c/em\u003e = 0.001) was only detected in the eyes that developed PMG, when compared to the matched eyes. These findings suggest an early predictor of CBTmax for PMG occurrence. Subsequently, zonulo-hyaloido-vitrectomy was performed to resolve the PMG, which was accompanied with a significant increase in the ACD, CBTmax, CBT0 and TCA, but not CBT1000 and APCB. Moreover, at pre-onset of PMG, CBTmax was the only factor producing significant prognostic value (0.74 [95% CI, 0.61-0.87], \u003cem\u003eP\u003c/em\u003e = 0.001), which almost reaches the predictive ability at PMG attack (0.86 ([95% CI, 0.76-0.96], \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA reduction in thickness of the ciliary body is pre-existed in the eyes with PMG, of which a reduced CBTmax may serve as an early predictor.\u003c/p\u003e","manuscriptTitle":"Reduction in maximum ciliary body thickness could be a pre-existing predictor for pseudophakic malignant glaucoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-22 10:48:20","doi":"10.21203/rs.3.rs-4649264/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-28T12:33:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-28T07:16:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-28T07:16:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2024-06-27T14:33:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6d71cb5-9f12-4689-b412-d2757f3d1b7a","owner":[],"postedDate":"July 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T15:59:02+00:00","versionOfRecord":{"articleIdentity":"rs-4649264","link":"https://doi.org/10.1186/s12886-025-04100-0","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-04-28 15:57:08","publishedOnDateReadable":"April 28th, 2025"},"versionCreatedAt":"2024-07-22 10:48:20","video":"","vorDoi":"10.1186/s12886-025-04100-0","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04100-0","workflowStages":[]},"version":"v1","identity":"rs-4649264","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4649264","identity":"rs-4649264","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}