A case of angle-closure glaucoma secondary to lens zonular abnormalities in a patient with high myopia

A case of angle-closure glaucoma secondary to lens zonular abnormalities in a patient with high myopia | 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 Case Report A case of angle-closure glaucoma secondary to lens zonular abnormalities in a patient with high myopia Tao Chen BM, Suhui Zhu, Huizhi Zhang BM, Wenyong Liao BM, Wanjiang Dong, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7348296/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In earlier research on angle-closure glaucoma, high myopia—which is defined by a longer axial length and a deeper anterior chamber depth—has hardly ever been documented. According to a recent study, high myopia and aberrant ciliary body function can cause lens dislocation because the ciliary body's decreased tension on the lens causes angle closure, elevated intraocular pressure, and the need for immediate mydriasis, intraocular pressure reduction, and surgery. It is easy for this illness to be mistaken for primary angle-closure glaucoma. In addition to failing to alleviate the problem, miosis treatment may worsen anterior chamber shallowing and potentially lead to malignant glaucoma. An uncommon case of acute angle-closure glaucoma in a patient with extreme myopia due to lens zonular dysfunction is described in this study. abnormal suspensory ligament function angle-closure glaucoma high myopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Elevated intraocular pressure and angle closure are characteristic hallmarks of angle-closure glaucoma. They are linked to several risk factors, including shallow anterior chamber, decreased axial length, and hyperopia[1]. Highly myopic eyes are uncommon in the general population because of their deeper anterior chambers and longer axial lengths, which have been shown in studies to reduce their susceptibility to angle-closure glaucoma[2]. Barkana[3]and associates found only 20 cases (0.1%) of acute glaucoma. An uncommon case of acute angle-closure glaucoma in a patient with high myopia due to lens zonular dysfunction is described in this study. Case presentation The patient, a 76-year-old man, complained of halos, abrupt ocular pain, and two days of diminished visual acuity in his right eye. He denied having a history of eye injuries, drug side effects, or glaucoma in his family. He had previously worn spectacles for a long time due to myopia. Physical examination: VOD: Finger counting / 20 cm, VOS: 0.12. Right eye: corneal hazy opacity and edema, central anterior chamber depth approximately 1.5 CT, peripheral < 0.5 CT, dilated pupil approximately 5 mm, sluggish light reflex, partial lens opacity with tremor, blurred fundus with pale optic disc, C/D ≈ 0.6, retinal and choroidal atrophy and degenerative changes. Left eye: Cornea transparent, central anterior chamber depth approximately 2.0 CT, peripheral < 0.5 CT, pupil round, diameter approximately 3 mm, acceptable light reflection, lens partially cloudy with tremor, blurred fundus with pale optic disc, C/D ≈ 0.4, retinal and choroidal atrophy and degenerative changes (Fig. 1 )—intraocular pressure: Right eye: 46.0 mmHg; left eye: 24.0 mmHg. A bilateral 360°narrow angle, grade IV, with partial adhesion, was discovered during gonioscopy. Figures 2 and 3 depict corneal topography and ultrasound biomicroscopy, respectively. In Table 1 , biometric measurements are displayed. Bilateral concurrent cataracts, bilateral high myopia, bilateral corneal astigmatism, and bilateral lens zonular laxity with secondary angle-closure glaucoma. Mannitol intravenous infusion, oral acetazolamide, and brinzolamide eye drops were used as a systemic treatment to reduce intraocular pressure. Atropine was then used to treat mydriasis. The right eye's intraocular pressure dropped to 20.0 mmHg during therapy, but the lens remained displaced, increasing the chance of future episodes of high intraocular pressure. Thus, right cataract phacoemulsification with toric intraocular lens implantation and capsular tension ring implantation (alternative surgical options: right eye cataract phacoemulsification with intraocular lens suspension implantation and anterior segment vitrectomy). The left eye will undergo the same procedure at a later time. A month after surgery, VOD: 0.5, VOS: 1.0, the axis position of the bilateral astigmatic intraocular lens is correct, intraocular pressure: right eye: 15.0 mmHg, left eye: 14.0 mmHg. Refraction: OD: 0/-0.75×179 → 0.7, OS: -0.50/-0.25×72 → 1.0. Table 1 Biometric measurements Right eye Left eye Eye axis length 25.59 mm 25.62mm Flat axis corneal curvature 43.32D@79° 44.18D@89° Steep axis corneal curvature 46.23D@169° 45.55D@179° Astigmatism -2.91D@79° -1.37D@89° Artificial lens axis position 172° 4° Discussion The significance of ciliary zonular aberrations in the development of angle-closure glaucoma has been the subject of an increasing number of studies in recent years due to a better knowledge of the disease's pathophysiology. Laxity, rupture, and decreased number are examples of ciliary zonular abnormalities that can be brought on by aging, trauma, heredity, retinal degeneration, and inflammation, among other things[ 4 ]. The thickness and location of the lens are the main areas affected by these anomalies. The lens thickens and moves forward due to weaker traction forces from the zonular fibers, creating a shallower anterior chamber. This can also result in pupillary obstruction, anterior displacement of the lens-iris zonular complex, angle closure, and decreased outflow of aqueous humor. These factors can cause an acute or chronic increase in intraocular pressure, which can cause angle-closure glaucoma. Malignant glaucoma and hidden lens subluxation may also develop in certain patients[ 5 ]. In this case, the patient complained of abrupt pain and loss of vision in the right eye. High intraocular pressure in both eyes, corneal edema in the right eye, dilated pupils, shallow anterior chambers in both eyes, and a narrowed and adherent angle were all seen during the physical examination. The disorder was mistakenly identified as "bilateral primary acute angle-closure glaucoma (right eye acute attack)." At this stage, miotic therapy is currently not only ineffective, but it may also worsen anterior chamber shallowing, lessen suspensory ligament tension, and potentially cause dangerous side effects like malignant glaucoma. We noted that the patient had a history of high myopia, with biometric measurements showing elongated axial length in both eyes. Physical examination revealed lens tremor, and ultrasound biomicroscopy showed significantly sparse and lax zonular ligaments with anterior displacement of the lens-iris zonule. Therefore, the diagnosis was considered to be "zonular laxity-induced angle-closure glaucoma". When Yong[ 6 ]. et al. examined the connection between myopia and angle closure, and they discovered that the myopic group had longer axial lengths than the emmetropic and hyperopic groups, but there was no difference in anterior chamber depth. This could be because of aberrant lens zonular function. Patients with a long axial length and abnormal lens zonular function, despite having a longer axial length, exhibit a shallow anterior chamber depth due to sparse and lax zonular fibers, resulting in a forward displacement of the lens and an increased risk of angle-closure glaucoma[ 7 ]. Therefore, in the diagnosis of angle-closure glaucoma in patients with myopia, a combination of medical history, physical signs, and multiple examination results should be considered, and lens zonular ligament abnormalities should be vigilantly ruled out. In terms of treatment, Miotic drugs should not be used in treatment since they can worsen pupillary obstruction and possibly cause malignant glaucoma. For mild lens dislocation, atropine may be administered to treat local mydriasis; nevertheless, some patients may experience long-term atropine dependence[ 8 ]. However, phacoemulsification cataract extraction in conjunction with intraocular lens implantation is the preferred method of action in cases of considerable lens displacement brought on by severe zonular ligament damage. There are benefits to this method over traditional external filtration glaucoma surgery, including less trauma, fewer problems, and smaller intraoperative intraocular pressure swings. By substituting a thinner intraocular lens for the natural lens, anterior chamber crowding and pupillary obstruction are lessened by increasing anterior chamber depth and angle width and posteriorly shifting the lens-iris barrier[ 9 ]. Furthermore, the IOL can be implanted into the ciliary sulcus, the capsular bag, or suspended for fixation, depending on the state of the capsular bag and the function of the zonular fibers [ 10 ].To improve stability and maintain the capsular bag, a tension ring can also be implanted with the IOL [ 11 , 12 ]. The patient in this case had severe reverse regular astigmatism. It was anticipated that astigmatism would worsen following a traditional corneal incision. We inserted an intraocular lens that corrects astigmatism together with a capsular tension ring after carefully evaluating the condition of the zonular ligament and capsular bag. Following surgery, there was very little displacement of the lens axis, and it was essentially aligned (Fig. 3 ). However, it is challenging to place the intraocular lens into the capsular bag when the zonular ligament is severely ruptured. Rather, an intraocular lens suspension implantation treatment in conjunction with an anterior vitrectomy must be carried out following the phacoemulsification of the cataract. Therefore, the patient's actual zonular ligament and capsular bag function should be used to determine if a functional intraocular lens can be placed. Abnormal lens zonules can cause pupillary block and anterior displacement of the lens-iris diaphragm, resulting in a significantly higher incidence of malignant glaucoma than primary angle-closure glaucoma[ 14 ]. Therefore, in this case, we promptly gave mannitol intravenously to relax the ciliary muscle, improve the tension of the lens zonular ligament, rectify lens dislocation, deepen the anterior chamber, and treat atropine for mydriasis to avoid malignant glaucoma. However, anterior segment vitrectomy should be carried done as soon as medication therapy fails in order to clear blockages, reestablish contact between the anterior and posterior chambers, and guarantee unhindered aqueous humor outflow [ 15 ]. The occurrence of shallow anterior chambers and angle closure is currently linked to structural and functional abnormalities of the lens zonules, according to studies. This is especially true for patients with angle-closure glaucoma complicated by high myopia, where careful differentiation is necessary. Mydriasis, intraocular pressure reduction, and the proper surgical procedure must be administered right away in cases of angle-closure glaucoma caused by zonular anomalies. Mydriasis treatment is ineffective and can worsen anterior chamber shallowing, which can result in malignant glaucoma and require an immediate vitrectomy. An intraocular lens can be implanted with a capsular tension ring to strengthen the capsular bag and provide the intraocular lens with a satisfactory level of stability. Functional intraocular lenses should be evaluated according to the patient's real state rather than being a strict no-go for those with ciliary ligament dysfunction. Declarations Ethics approval and consent to participate A written agreement was obtained from the patient. Consent for publication Written informed consent for publication of the clinical details and clinical images was obtained from the patient. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution T.C. and SH.Z. wrote the main manuscript text , HZ.Z andWY. Lprepared figures 1-4,Table 1,Supervision—WJ.D, Editing—DB.C. All authors reviewed the manuscript. Acknowledgements None. Data availability No datasets were generated or analysed during the current study. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. References Jonas JB, Nangia V, Gupta R, Khare A, Sinha A, Agarwal S et al. Anterior chamber depth and its associations with ocular and general parameters in adults. Clin Exp Ophthalmol. 2012;40(6):550-6. Epub 20120220. 10.1111/j.1442-9071.2011.02748.x . PubMed PMID: 22171546. Al-Essa RS, Turjoman AA. Acute Attack of Primary Angle Closure in a Highly Axially Myopic Eye: A Case Report. Am J Case Rep. 2021;22:e931002. Epub 20210623. doi: 10.12659/ajcr 931002. PubMed PMID: 34161310; PubMed Central PMCID: PMCPMC8235671. Barkana Y, Shihadeh W, Oliveira C, Tello C, Liebmann JM, Ritch R. Angle closure in highly myopic eyes. Ophthalmology. 2006;113(2):247–54. 10.1016/j.ophtha.2005.10.006 . Epub 20060120. Li T, Ningli W, Ning F, Xuyang L. Further discussion on the relationship between lens zonular abnormalities and angle-closure glaucoma. Ophthalmology. 2022;31(03):169–74. 10.13281/j.cnki.issn.1004-4469.2022.03.002 . Bassnett S. Zinn's zonule. Prog Retin Eye Res. 2021;82:100902. Epub 20200925. doi: 10.1016/j.preteyeres.2020.100902. PubMed PMID: 32980533; PubMed Central PMCID: PMCPMC8139560. Yong KL, Gong T, Nongpiur ME, How AC, Lee HK, Cheng L, et al. Myopia in asian subjects with primary angle closure: implications for glaucoma trends in East Asia. Ophthalmology. 2014;121(8):1566–71. 10.1016/j.ophtha.2014.02.006 . Epub 20140325. Wu Lan J, Xiaoqin L, Xiongzi X, Sumin Q, Jun P, Zikang. Comparative observation of lens subluxation in patients with angle-closure glaucoma and shallow anterior chamber of different axial lengths. Int J Ophthalmol. 2019;19(12):2135–8. Ning F, Ningli W. Abnormal lens zonules secondary to angle-closure glaucoma. Ophthalmology. 2018;27(01):4–8. 10.13281/j.cnki.issn.1004-4469.2018.01.002 . Huang Canhua W. Observation on the efficacy of phacoemulsification cataract extraction in the treatment of acute angle-closure glaucoma. Chin Med Guide. 2019;17(10):82–3. 10.15912/j.cnki.gocm.2019.10.055 . Liu, Xin. Efficacy analysis of phacoemulsification combined with intraocular lens implantation for the treatment of angle-closure glaucoma complicated by cataracts. Chin J Practical Med. 2021;16(08):88–9. 10.14163/j.cnki.11-5547/r.2021.08.033 . Chew P, Sng C, Aquino MC, See J. Surgical treatment of angle-closure glaucoma. Dev Ophthalmol. 2012;50:137 – 45. Epub 20120417. doi: 10.1159/000334795. PubMed PMID: 22517180. White AJ, Orros JM, Healey PR. Outcomes of combined lens extraction and goniosynechialysis in angle closure. Clin Exp Ophthalmol. 2013;41(8):746–52. 10.1111/ceo.12121 . Epub 20130522. Lim D, Aquino MC, Chew P. Surgical Treatment of Angle-Closure Glaucoma. Dev Ophthalmol. 2017;59:147–54. Epub 20170425. doi: 10.1159/000458493. PubMed PMID: 28442694. Muqit MM, Menage MJ. Malignant glaucoma after phacoemulsification: treatment with diode laser cyclophotocoagulation. J Cataract Refract Surg. 2007;33(1):130–2. 10.1016/j.jcrs.2006.07 . .041. PubMed PMID: 17189808. Bitrian E, Caprioli J. Pars plana anterior vitrectomy, hyaloido-zonulectomy, and iridectomy for aqueous humor misdirection. Am J Ophthalmol. 2010;150(1):82 – 7.e1. doi: 10.1016/j.ajo.2010.02.009. PubMed PMID: 20609709. Additional Declarations No competing interests reported. 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15:52:51","extension":"html","order_by":41,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":62235,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/6f8e4d1aa6733ae51d17d7f7.html"},{"id":92008272,"identity":"10aab3b0-aef1-4632-9e65-3d3e53e2c028","added_by":"auto","created_at":"2025-09-23 15:28:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3677710,"visible":true,"origin":"","legend":"\u003cp\u003ePhotographs of the anterior section and fundus of both eyes\u003c/p\u003e\n\u003cp\u003eA: Photography of the anterior section of the right eye. Partial lens opacity, shallow anterior chamber, dilated pupil of about 5 mm, slow light reflex, corneal hazy opacity, and edema. B: Photography of the anterior section of the left eye. Partial lens opacity, shallow anterior chamber, and clear cornea. C: Fundus photography of the right eye. Blurred fundus with a pale optic disc, C/D ≈ 0.6, choroidal and retinal atrophy, and degenerative alterations. D: Fundus photography of the left eye. Blurred fundus with a pale optic disc, C/D ≈ 0.4, choroidal and retinal atrophy, and degenerative alterations.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/51386a033292be2f229c3e56.png"},{"id":92009480,"identity":"81c5103b-765c-4f48-8646-425fffb84b31","added_by":"auto","created_at":"2025-09-23 15:36:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1434389,"visible":true,"origin":"","legend":"\u003cp\u003eBiomicroscopy using binocular ultrasound\u003c/p\u003e\n\u003cp\u003eA: Right eye 3 o'clock position, B: Right eye 12 o'clock position. Shallow anterior chamber, completely closed angle, moderately bulging iris, sparse and lax lens zonular fibers, thickened and anteriorly displaced lens. C: Left eye at 3 o'clock position, D: Left eye at 12 o'clock position. Shallow anterior chamber, angle closed approximately 3/4, mildly bulging iris, sparse and lax lens zonular fibers, thickened and anteriorly displaced lens.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/3e18e23e51e3f450f654a84b.png"},{"id":92008270,"identity":"e5ffd475-9ddf-4b18-ae05-1a4996e96e15","added_by":"auto","created_at":"2025-09-23 15:28:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1885263,"visible":true,"origin":"","legend":"\u003cp\u003eTopography of the cornea\u003c/p\u003e\n\u003cp\u003eA: Right eye, B: Left eye. The bilateral corneal anterior surfaces of both eyes exhibit regular astigmatism in opposite directions.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/992afea12290d64d4af1773f.png"},{"id":92009487,"identity":"59bc1ac1-66e0-4c79-9cf7-6dea03f91720","added_by":"auto","created_at":"2025-09-23 15:36:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1245221,"visible":true,"origin":"","legend":"\u003cp\u003eBoth eyes' postoperative anterior segment photography\u003c/p\u003e\n\u003cp\u003eA: Right eye, B: Left eye. Both eyes' axial alignment with intraocular lenses that correct astigmatism is essentially normal.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/20d7f6c2e21ab6a72243425e.png"},{"id":93558442,"identity":"95394295-348b-45ea-8b73-e226951a3de2","added_by":"auto","created_at":"2025-10-15 07:02:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10657604,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7348296/v1/7493b91a-a908-4fed-b793-f44983f9912c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A case of angle-closure glaucoma secondary to lens zonular abnormalities in a patient with high myopia","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u0026nbsp;Elevated intraocular pressure and angle closure are characteristic hallmarks of angle-closure glaucoma. They are linked to several risk factors, including shallow anterior chamber, decreased axial length, and hyperopia[1]. Highly myopic eyes are uncommon in the general population because of their deeper anterior chambers and longer axial lengths, which have been shown in studies to reduce their susceptibility to angle-closure glaucoma[2]. Barkana[3]and associates found only 20 cases (0.1%) of acute glaucoma. An uncommon case of acute angle-closure glaucoma in a patient with high myopia due to lens zonular dysfunction is described in this study.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient, a 76-year-old man, complained of halos, abrupt ocular pain, and two days of diminished visual acuity in his right eye. He denied having a history of eye injuries, drug side effects, or glaucoma in his family. He had previously worn spectacles for a long time due to myopia. Physical examination: VOD: Finger counting\u003cb\u003e/\u003c/b\u003e20 cm, VOS: 0.12. Right eye: corneal hazy opacity and edema, central anterior chamber depth approximately 1.5 CT, peripheral\u0026thinsp;\u0026lt;\u0026thinsp;0.5 CT, dilated pupil approximately 5 mm, sluggish light reflex, partial lens opacity with tremor, blurred fundus with pale optic disc, C/D\u0026thinsp;\u0026asymp;\u0026thinsp;0.6, retinal and choroidal atrophy and degenerative changes. Left eye: Cornea transparent, central anterior chamber depth approximately 2.0 CT, peripheral\u0026thinsp;\u0026lt;\u0026thinsp;0.5 CT, pupil round, diameter approximately 3 mm, acceptable light reflection, lens partially cloudy with tremor, blurred fundus with pale optic disc, C/D\u0026thinsp;\u0026asymp;\u0026thinsp;0.4, retinal and choroidal atrophy and degenerative changes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u0026mdash;intraocular pressure: Right eye: 46.0 mmHg; left eye: 24.0 mmHg. A bilateral 360\u0026deg;narrow angle, grade IV, with partial adhesion, was discovered during gonioscopy. Figures\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e depict corneal topography and ultrasound biomicroscopy, respectively. In Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, biometric measurements are displayed. Bilateral concurrent cataracts, bilateral high myopia, bilateral corneal astigmatism, and bilateral lens zonular laxity with secondary angle-closure glaucoma. Mannitol intravenous infusion, oral acetazolamide, and brinzolamide eye drops were used as a systemic treatment to reduce intraocular pressure. Atropine was then used to treat mydriasis. The right eye's intraocular pressure dropped to 20.0 mmHg during therapy, but the lens remained displaced, increasing the chance of future episodes of high intraocular pressure. Thus, right cataract phacoemulsification with toric intraocular lens implantation and capsular tension ring implantation (alternative surgical options: right eye cataract phacoemulsification with intraocular lens suspension implantation and anterior segment vitrectomy). The left eye will undergo the same procedure at a later time. A month after surgery, VOD: 0.5, VOS: 1.0, the axis position of the bilateral astigmatic intraocular lens is correct, intraocular pressure: right eye: 15.0 mmHg, left eye: 14.0 mmHg. Refraction: OD: 0/-0.75\u0026times;179 \u0026rarr; 0.7, OS: -0.50/-0.25\u0026times;72 \u0026rarr; 1.0.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBiometric measurements\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight eye\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLeft eye\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEye axis length\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.59 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.62mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFlat axis corneal curvature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.32D@79\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.18D@89\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSteep axis corneal curvature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46.23D@169\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.55D@179\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAstigmatism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-2.91D@79\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.37D@89\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArtificial lens axis position\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe significance of ciliary zonular aberrations in the development of angle-closure glaucoma has been the subject of an increasing number of studies in recent years due to a better knowledge of the disease's pathophysiology. Laxity, rupture, and decreased number are examples of ciliary zonular abnormalities that can be brought on by aging, trauma, heredity, retinal degeneration, and inflammation, among other things[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The thickness and location of the lens are the main areas affected by these anomalies. The lens thickens and moves forward due to weaker traction forces from the zonular fibers, creating a shallower anterior chamber. This can also result in pupillary obstruction, anterior displacement of the lens-iris zonular complex, angle closure, and decreased outflow of aqueous humor. These factors can cause an acute or chronic increase in intraocular pressure, which can cause angle-closure glaucoma. Malignant glaucoma and hidden lens subluxation may also develop in certain patients[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this case, the patient complained of abrupt pain and loss of vision in the right eye. High intraocular pressure in both eyes, corneal edema in the right eye, dilated pupils, shallow anterior chambers in both eyes, and a narrowed and adherent angle were all seen during the physical examination. The disorder was mistakenly identified as \"bilateral primary acute angle-closure glaucoma (right eye acute attack).\" At this stage, miotic therapy is currently not only ineffective, but it may also worsen anterior chamber shallowing, lessen suspensory ligament tension, and potentially cause dangerous side effects like malignant glaucoma.\u003c/p\u003e\u003cp\u003eWe noted that the patient had a history of high myopia, with biometric measurements showing elongated axial length in both eyes. Physical examination revealed lens tremor, and ultrasound biomicroscopy showed significantly sparse and lax zonular ligaments with anterior displacement of the lens-iris zonule. Therefore, the diagnosis was considered to be \"zonular laxity-induced angle-closure glaucoma\". When Yong[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. et al. examined the connection between myopia and angle closure, and they discovered that the myopic group had longer axial lengths than the emmetropic and hyperopic groups, but there was no difference in anterior chamber depth. This could be because of aberrant lens zonular function. Patients with a long axial length and abnormal lens zonular function, despite having a longer axial length, exhibit a shallow anterior chamber depth due to sparse and lax zonular fibers, resulting in a forward displacement of the lens and an increased risk of angle-closure glaucoma[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, in the diagnosis of angle-closure glaucoma in patients with myopia, a combination of medical history, physical signs, and multiple examination results should be considered, and lens zonular ligament abnormalities should be vigilantly ruled out.\u003c/p\u003e\u003cp\u003eIn terms of treatment, Miotic drugs should not be used in treatment since they can worsen pupillary obstruction and possibly cause malignant glaucoma. For mild lens dislocation, atropine may be administered to treat local mydriasis; nevertheless, some patients may experience long-term atropine dependence[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, phacoemulsification cataract extraction in conjunction with intraocular lens implantation is the preferred method of action in cases of considerable lens displacement brought on by severe zonular ligament damage. There are benefits to this method over traditional external filtration glaucoma surgery, including less trauma, fewer problems, and smaller intraoperative intraocular pressure swings. By substituting a thinner intraocular lens for the natural lens, anterior chamber crowding and pupillary obstruction are lessened by increasing anterior chamber depth and angle width and posteriorly shifting the lens-iris barrier[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, the IOL can be implanted into the ciliary sulcus, the capsular bag, or suspended for fixation, depending on the state of the capsular bag and the function of the zonular fibers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].To improve stability and maintain the capsular bag, a tension ring can also be implanted with the IOL [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The patient in this case had severe reverse regular astigmatism. It was anticipated that astigmatism would worsen following a traditional corneal incision. We inserted an intraocular lens that corrects astigmatism together with a capsular tension ring after carefully evaluating the condition of the zonular ligament and capsular bag. Following surgery, there was very little displacement of the lens axis, and it was essentially aligned (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, it is challenging to place the intraocular lens into the capsular bag when the zonular ligament is severely ruptured. Rather, an intraocular lens suspension implantation treatment in conjunction with an anterior vitrectomy must be carried out following the phacoemulsification of the cataract. Therefore, the patient's actual zonular ligament and capsular bag function should be used to determine if a functional intraocular lens can be placed.\u003c/p\u003e\u003cp\u003eAbnormal lens zonules can cause pupillary block and anterior displacement of the lens-iris diaphragm, resulting in a significantly higher incidence of malignant glaucoma than primary angle-closure glaucoma[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, in this case, we promptly gave mannitol intravenously to relax the ciliary muscle, improve the tension of the lens zonular ligament, rectify lens dislocation, deepen the anterior chamber, and treat atropine for mydriasis to avoid malignant glaucoma. However, anterior segment vitrectomy should be carried done as soon as medication therapy fails in order to clear blockages, reestablish contact between the anterior and posterior chambers, and guarantee unhindered aqueous humor outflow [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe occurrence of shallow anterior chambers and angle closure is currently linked to structural and functional abnormalities of the lens zonules, according to studies. This is especially true for patients with angle-closure glaucoma complicated by high myopia, where careful differentiation is necessary. Mydriasis, intraocular pressure reduction, and the proper surgical procedure must be administered right away in cases of angle-closure glaucoma caused by zonular anomalies. Mydriasis treatment is ineffective and can worsen anterior chamber shallowing, which can result in malignant glaucoma and require an immediate vitrectomy. An intraocular lens can be implanted with a capsular tension ring to strengthen the capsular bag and provide the intraocular lens with a satisfactory level of stability. Functional intraocular lenses should be evaluated according to the patient's real state rather than being a strict no-go for those with ciliary ligament dysfunction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eA written agreement was obtained from the patient.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written informed consent for publication of the clinical details and clinical images was obtained from the patient.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.C. and SH.Z. wrote the main manuscript text , HZ.Z andWY. Lprepared figures 1-4,Table 1,Supervision\u0026mdash;WJ.D, Editing\u0026mdash;DB.C. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJonas JB, Nangia V, Gupta R, Khare A, Sinha A, Agarwal S et al. Anterior chamber depth and its associations with ocular and general parameters in adults. Clin Exp Ophthalmol. 2012;40(6):550-6. 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PubMed PMID: 20609709.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"abnormal suspensory ligament function, angle-closure glaucoma, high myopia","lastPublishedDoi":"10.21203/rs.3.rs-7348296/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7348296/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn earlier research on angle-closure glaucoma, high myopia\u0026mdash;which is defined by a longer axial length and a deeper anterior chamber depth\u0026mdash;has hardly ever been documented. According to a recent study, high myopia and aberrant ciliary body function can cause lens dislocation because the ciliary body's decreased tension on the lens causes angle closure, elevated intraocular pressure, and the need for immediate mydriasis, intraocular pressure reduction, and surgery. It is easy for this illness to be mistaken for primary angle-closure glaucoma. In addition to failing to alleviate the problem, miosis treatment may worsen anterior chamber shallowing and potentially lead to malignant glaucoma. An uncommon case of acute angle-closure glaucoma in a patient with extreme myopia due to lens zonular dysfunction is described in this study.\u003c/p\u003e","manuscriptTitle":"A case of angle-closure glaucoma secondary to lens zonular abnormalities in a patient with high myopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 15:28:45","doi":"10.21203/rs.3.rs-7348296/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c57ee4c1-4e01-4a41-ac54-7dd909ea5afc","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T06:54:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 15:28:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7348296","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7348296","identity":"rs-7348296","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}