Veterinary Ophthalmology (2016) 1–7 DOI:10.1111/vop.

12377

CASE REPORT

Surgical outcome of cats treated for aqueous humor misdirection

syndrome: a case series
Rosalie M. Atkins,* Micki D. Armour† and Jennifer A. Hyman‡
*Eye Care for Animals, 10324 San Pablo Ave, El Cerrito, CA 94530, USA; †Eye Care for Animals, 165 Fort Evans Road NE Suite 107, Leesburg,
VA 20176, USA; and ‡Eye Care for Animals, 808 Bestgate Rd, Annapolis, MD 21401, USA

Address communications to: Abstract

R. M. Atkins Objective To evaluate the clinical outcome of cats treated surgically for aqueous humor
Tel.: (510) 559-1755 misdirection syndrome.
Fax: (510) 559-1757 Methods A retrospective analysis of cats treated surgically between January 1, 2006,
e-mail: and January 1, 2013, for aqueous humor misdirection syndrome was performed. Sig-
[email protected]
nalment, medical therapy, eyes affected, intraocular pressures prior to and after sur-
gery, surgical procedures performed, postoperative complications, and visual status
were evaluated.
Results Seven cats (nine eyes) fit the inclusion criteria. Six of seven cats were female,
and five of seven cats were diagnosed with bilateral aqueous humor misdirection syn-
drome. Three surgical approaches were evaluated as follows: (i) phacoemulsification
and posterior capsulotomy, (ii) phacoemulsification, posterior capsulotomy and ante-
rior vitrectomy, and (iii) phacoemulsification, posterior capsulotomy, anterior vitrec-
tomy, and endocyclophotocoagulation. The mean age at diagnosis was 12.9 years.
Seven of nine eyes had controlled intraocular pressure (≤25 mmHg) during the first
6 months postoperatively. All cats were visual with controlled intraocular inflamma-
tion at 1 year postoperatively; however, one eye had an elevated intraocular pressure.
All cats were continued on topical antiglaucoma and anti-inflammatory medications
following surgery with the mean number of drops per day decreasing from 3.9 drops/
day prior to surgery to 2.2 drops/day postoperatively.
Conclusions Surgical management for feline aqueous humor misdirection syndrome
may be a viable option to maintain a visual and normotensive status in cats that no
longer have successful control of intraocular pressure with medical therapy.

Key Words: cat, endocyclophotocoagulation, feline aqueous humor misdirection

syndrome, malignant glaucoma, phacoemulsification, surgery

glaucoma is often a secondary process with uveitis and

INTRODUCTION
intraocular neoplasia being the two most common
Glaucoma is one of the leading causes of blindness in causes.9–11 Other secondary causes of glaucoma in cats
human and veterinary ophthalmology.1,2 The glaucomas include trauma, intraocular hemorrhage, lens-associated
are a set of diseases that result in vision loss through the glaucoma, feline aqueous humor misdirection syndrome
progressive death of retinal ganglion cells, with the most (FAHMS), orbital space-occupying lesions, and steroid-
significant risk factor being an elevated intraocular pres- induced ocular hypertension/glaucoma.12
sure (IOP).1,3–5 Glaucoma is less frequently diagnosed in Aqueous humor misdirection syndrome or malignant
the cat compared to the dog; however, it may be that glaucoma has been described in humans since 1869.6,13,14
many cases remain undiagnosed due to the insidious nat- It was originally recognized as a complication after glau-
ure and fewer overt clinical signs in the cat.3,6–8 Feline coma surgery. Later the term was used to include cases of

© 2016 American College of Veterinary Ophthalmologists

2 atkins ET AL.

retrovitreal fluid that caused increased intravitreal pres- excluded. An elevated IOP postoperatively was defined as
sure, anterior displacement of the vitreous face, and lens– an IOP > 25 mmHg after the first 24 h. Any elevation in
iris diaphragm, with subsequent closure of the iridocorneal IOP > 25 mmHg within the first 24 h was considered
angle.15 The underlying etiology of this disease process is postoperative ocular hypertension. Data collected on each
still speculative in humans. The proposed mechanism for cat included signalment, medications used at the examina-
FAHMS is an abnormality in the anterior hyaloid mem- tion immediately prior to surgery, medications used at the
brane that allows aqueous humor to enter the vitreal cav- final postoperative examination, eyes affected, IOP prior
ity. The aqueous humor is visualized as discrete pools of to surgery, IOP during the first 6 months postoperatively
fluid in the anterior vitreous, central vitreous, or may be and at the final recheck examination, surgical procedures
trapped diffusely within the vitreous.6 Some cats may also performed, postoperative complications, and visual status.
have aqueous humor flow posteriorly between the retina Postoperative complications were grouped into short term
and vitreous and accumulate between these two struc- (<6 months) and long term (≥6 months). The right eye
tures.6 Regardless of the mechanism, the result is an and left eye in each cat were evaluated separately for bilat-
increase in the vitreal pressure causing anterior displace- eral cases, with the age of diagnosis being the age the first
ment of the lens and iris and a marked narrowing of the eye was diagnosed with FAHMS.
anterior chamber.6,9,16 This causes a ciliovitreolenticular Eyes were grouped based upon the type of surgery per-
block that decreases the normal flow of aqueous humor formed. Group 1 included eyes treated with phacoemulsifi-
through the pupil and instead diverts the aqueous humor cation and posterior capsulotomy alone. Group 2 included
into the vitreous.6,12 A prospective study by Kroll et al.,17 eyes treated with phacoemulsification, posterior capsulo-
which looked at IOP measurements as part of a compre- tomy, and anterior vitrectomy. Group 3 included eyes trea-
hensive geriatric examination, found that FAHMS was the ted with phacoemulsification, posterior capsulotomy,
most common ophthalmic abnormality identified in their anterior vitrectomy, and endocyclophotocoagulation.
population of cats (4/538 cats). Statistical analysis was restricted to patient demograph-
Once AHMS is diagnosed in human patients, medical ics, postoperative follow-up time, IOP, and medications
therapy is initiated with the intention to decrease aqueous used per day. Mean, median, minimum, maximum, and
humor production, move the lens posteriorly into its nor- standard deviation were calculated using Microsoft Excel.
mal location, decrease intraocular inflammation, and All other results were descriptive.
reduce the vitreous volume.14 When medical therapy fails
to control the IOP, surgery may be warranted.6,18–20 Pre-
RESULTS
vious reports of surgical intervention for FAHMS are rare
in the literature.6,21 One cat with FAHMS was treated A total of nine eyes of seven cats were identified that met
with a lens extraction and anterior vitrectomy, but had an the inclusion criteria for this case series. The mean age of
IOP that quickly elevated after the procedure.6 Another the cats at the time of diagnosis was 12.9 years
cat with FAHMS that was treated with phacoemulsifica- (1.28 years). Six of the seven cats were female. Five of
tion retained functional vision for 3 years.6 seven cats were diagnosed with bilateral FAHMS. Breeds
There are currently no studies that look at the clinical represented included domestic short hair (4), domestic
outcome of cats treated surgically for FAHMS. The aims medium hair (2), and domestic long hair (1). A summary
of this case series were to (i) describe the long-term of patients, eyes treated, surgical group, reason for sur-
(>6 months) postoperative control of IOP, inflammation, gery, preoperative IOP, recorded occurrence of elevated
and visual status in cats, (ii) describe the postoperative IOP within the first 6 months postoperatively, mean IOP
complications following surgical intervention for during the postoperative follow-up time, and total follow-
FAHMS, and (iii) determine which medications were up time is provided in Table 1. The mean follow-up time
continued long term following surgical treatment for for the nine eyes was 648 days (median 438 days, range
FAHMS. 230–1313 days). Based on the surgical procedure per-
formed, one eye was identified in Group 1, four eyes were
identified in Group 2, and four eyes were identified in
MATERIALS AND METHODS
Group 3. The reasons for surgery included the severity of
A computerized retrospective search was performed gath- disease, lack of response to medical therapy, and increas-
ering information on all cats that underwent surgical ing IOP despite the use of medical therapy. The reasons
intervention for FAHMS in a multipractice veterinary for a specific interventional surgery being performed were
ophthalmology group (Eye Care for Animals) from Jan- not described in any of the records nor were the specifics
uary 1, 2006, through January 1, 2013. Inclusion criteria on the size of capsulotomy. The amount of anterior vitre-
included a diagnosis of FAHMS by a veterinary ophthal- ous removed was described in three cats: patient 3 had
mologist, the presence of preoperative elevated IOP (doc- approximately 1/3 the vitreous removed, both eyes of
umented as IOP > 25 mmHg), and interventional surgery patient 4 had an anterior and central vitrectomy, and
for FAHMS. Cats with <6 months of follow-up were patient 7 had a focal anterior vitrectomy performed. Both

© 2016 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 1–7

 surgical outcome of fahms: a case series 7

26. Gelatt KN, Gelatt JP. Veterinary Ophthalmic Surgery. Elsevier, 38. Dietrich UM, Chandler MJ, Cooper T et al. Effects of topical
China, 2011. 2% dorzolamide chydrochloride alone and in combination
27. Nasisse MP, Guy JS, Davidson MG et al. Experimental ocular with 0.5% timolol maleate on intraocular pressure in
herpes virus infection in the cat: sites of virus replication, clinical normal feline eyes. Veterinary Ophthalmology 2007; 10(Suppl 1):
features and effects of corticosteroid administration. Investigative 95–100.
Ophthalmology and Visual Science 1989; 30: 1758–1768. 39. Sigle KJ, Camano-Garcia G, Carriquiry AL et al. The effect of
28. Muqit MMK, Menage MJ. Malignant glaucoma after dorzolamide 2% on circadian intraocular pressure in cats with
phacoemulsification: treatment with diode laser primary congenital glaucoma. Veterinary Ophthalmology 2011; 14
cyclophotocoagulation. Journal of Cataract and Refractive Surgery (Suppl 1): 48–53.
2007; 33: 130–132. 40. Rankin AJ, Crumley WR, Allbaugh RA. Effects of ocular
29. Bitrian E, Caprioli J. Pars plana anterior vitrectomy, hyaloido- administration of ophthalmic 2% dorzolamide hydrochloride
zonulectomy, and iridectomy for aqueous humor misdirection. solution on aqueous humor flow rate and intraocular pressure in
American Journal of Ophthalmology 2010; 150: 82–87. clinically normal cats. American Journal of Veterinary Research
30. Sharma AS, Sii F, Shah P et al. Vitrectomy-phacoemulsification- 2012; 73: 1074–1078.
vitrectomy for the management of aqueous misdirection 41. Silver LH. Clinical efficacy and safety of brinzolamide, a new
syndromes in phakic eyes. Ophthalmology 2006; 113: 1968–1973. topical carbonic anhydrase inhibitor for primary open-angle
31. Stumpf TH, Austin M, Bloom PA et al. Transscleral cyclodiode glaucoma and ocular hypertension. American Journal of
laser photocoagulation in the treatment of aqueous misdirection Ophthalmology 1998; 126: 400–408.
syndrome. Ophthalmology 2008; 115: 2058–2061. 42. Wilkie DA, Latimer CA. Effects of topical administration of
32. Melamed S, Ashkenazi I, Blumenthal M. Nd-YAG laser timolol maleate on intraocular pressure and pupil size in cats.
hyaloidotomy for malignant glaucoma following one-piece 7 mm American Journal of Veterinary Research 1991; 52: 436–440.
intraocular lens implantation. British Journal of Ophthalmology 43. Lannek EB, Miller PE. Development of glaucoma after
1991; 75: 501–503. phacoemulsification for removal of cataracts in dogs: 22 cases
33. Sigle KJ, Nasisse MP. Long-term complications after (1987-1997). Journal of the American Veterinary Medical Association
phacoemulsification for cataract removal in dogs: 172 cases 2001; 218: 70–76.
(1995-2002). Journal of the American Veterinary Medical Association 44. Zhan G, Miranda OB, Bito LZ. Steroid glaucoma:
2006; 228: 74–79. corticosteroid-induced ocular hypertension in cats. Experimental
34. Biros DJ, Gelatt KN, Brooks DE et al. Development of Eye Research 1992; 54: 211–218.
glaucoma after cataract surgery in dogs: 220 cases (1987-1998). 45. Walton DS. Pediatric aphakic glaucoma: a study of 65 patients.
Journal of the American Veterinary Medical Association 2000; 216: Transactions of the American Ophthalmological Society 1995; 93:
1780–1786. 403–420.
35. George R, Arvind H, Baskaran M et al. The Chennai glaucoma 46. Robin AL, Covert D. Does adjunctive glaucoma therapy affect
study: prevalence and risk factors for glaucoma in cataract adherence to the initial primary therapy? Ophthalmology 2005;
operated eyes in urban Chennai. Indian Journal of Ophthalmology 112: 863–868.
2010; 53: 243–245. 47. Robin AL, Davinder SG. Compliance and adherence in glaucoma
36. Agarwal HC, Sood NN, Dayal N. Aphakic glaucoma. Indian management. Indian Journal of Ophthalmology 2011; 59(Suppl 1):
Journal of Ophthalmology 1981; 29: 221–225. S93–S96.
37. Rainbow ME, Dziezyc J. Effects of twice daily application of 2% 48. Davidson MG, Murphy CJ, Nasisse MP et al. Refractive state of
dorzolamide on intraocular pressure in normal cats. Veterinary aphakic and pseudophakic eyes of dogs. American Journal of
Ophthalmology 2003; 6: 147–150. Veterinary Research 1993; 54: 174–177.

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4 atkins ET AL.

combination (1), brinzolamide (1), timolol (1), dorzo- been associated with general anesthesia in animals, and
lamide (2), prednisolone acetate (7), flurbiprofen (1), and this may be a contributing factor with the two cases that
diclofenac (1). Cats received a mean of 2.2 drops per day occurred within 1 week of surgery.25 Some additional con-
(median 2.4 drops/day, range 1.3–3.4 drops/day) at the last tributing factors may include decreased tear production,
examination. At the last examination, all cats were on one self-trauma, delayed healing of small abrasions due to cor-
topical anti-inflammatory medication and at least one ticosteroid therapy, and reactivation of herpes virus.26,27
topical antiglaucoma medication. All complications were recorded; however, it is unlikely
Short-term postoperative complications included cor- that the long-term complications such as the two corneal
neal ulceration, anterior and posterior capsular opacities, ulcerations that occurred approximately 8–9 months after
and elevated intraocular pressure and intraocular inflam- surgery and the corneal perforation approximately 3 years
mation. Long-term complications included corneal ulcera- after surgery were directly due to surgery. The time frame
tion, corneal perforation, and elevated intraocular for the reactivation of herpes virus with topical corticos-
pressure. Three cats had a corneal ulceration within teroid usage has not been defined, but it is considered a
6 months of surgery with two occurring within the first likely etiology of the corneal ulcers as they were concur-
5 days and one at 35 days. Two cats had corneal ulcera- rently described as either geographic or dendritic.
tions after 6 months, which occurred at 246 days and The proposed therapeutic benefit of surgical interven-
276 days postoperatively. At the time of diagnosis, all tion for AHMS is to create a direct connection between
ulcers were described as either geographic or dendritic, the anterior chamber and the vitreous space, thereby dis-
and all healed with medical therapy. One patient exhibited rupting any blockage and restoring the flow of aqueous
anterior and posterior capsular opacities at 54 days post- humor into the anterior chamber.28 The reported success
operatively, and one patient had a corneal perforation at rates in humans vary between 25 and 100% depending
1064 days postoperatively. All eyes that were diagnosed upon the procedure performed and the follow-up
with either a corneal ulceration or corneal perforation time.20,22,28–31 In human studies, phakic patients have been
were on topical prednisolone acetate or prednisolone acet- shown to have a lower success rate than pseudophakic
ate with gentamicin at the time of diagnosis. All eyes patients.20 The reason for this difference has been specu-
remained aphakic after surgery. Intraocular inflammation lated to relate to the inability to excise the vitreous near
occurred in all cats postoperatively and was no longer the posterior capsule, and the lack of adequate drainage of
recorded in the ocular examination at a mean of 35 days trapped fluid from the vitreous.18,20 It has also been
(median 31 days, range 5–56 days) postoperatively. hypothesized that the placement of larger optics in
To evaluate the long-term outcome of surgical interven- humans may increase the risk of developing malignant
tion, the final examination of each patient was evaluated. glaucoma by blocking the flow of aqueous from the vitre-
At the final examination, eight of nine eyes were nor- ous to the anterior chamber.18,32 None of the cats in this
motensive, all eyes were visual, and all eyes had controlled series had an intraocular lens placed during surgery, and
intraocular inflammation. Patient number 5 had an ele- all had a posterior capsulotomy performed. In human
vated IOP of 30 mmHg at the final examination. patients, it is recommended to remove the posterior cap-
sule and anterior vitreous face so that the relationship
between the ciliary body and vitreous is disrupted.14 This
DISCUSSION
recommendation was performed in all cats in our series
Patient demographics in the current series were consistent except for patient 1.
with previous reports of FAHMS. As in the study by To the authors’ knowledge, surgical intervention has
Czederpiltz et al.,6 most of the cats in this series were only been reported in two cats with FAHMS previously in
female. In humans, malignant glaucoma is more common the literature. One cat was treated with a lens removal;
in women than men by a 70/30 ratio.22 This predisposi- however, the method of lens removal was not specified.6
tion is believed to be due to the more anterior location of Another cat in the same study was treated with pha-
the lens that results in a 4% shallower anterior chamber coemulsification and maintained vision for 3 years; how-
and a narrower space between the lens and ciliary body in ever, no report of IOP control was provided.6 While all of
human females compared to males.22 In dogs, the angle- the cases in this series retained vision, two of the nine eyes
opening distance has been shown to be smaller in females experienced an elevated IOP within the first 6 months of
than males, but this same study has not been performed in surgery, and one of the nine eyes had an elevated IOP at
cats who have a larger anterior chamber depth than dogs the final examination. The presumed cause of the elevated
and humans.23,24 The mean age of the cats in this series IOP, which was both a short-term and long-term compli-
was 12.9 years which is similar to the 11.7 years reported cation, was not recorded in any case and leads to specula-
by Czederpiltz et al.6 tion about possible causes at each of these time points.
Superficial corneal ulceration was a common short-term Glaucoma has been reported to occur in 10–16.8% of
complication postoperatively with two cases occurring dogs after cataract surgery.33,34 Some of the possible
within the first 5 days of surgery. Corneal ulceration has causes of glaucoma after phacoemulsification include

© 2016 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 1–7

 surgical outcome of fahms: a case series 5

pigment dispersion, ciliary cleft collapse, pre-iridal A consideration in postoperative treatment for veteri-
fibrovascular membranes, peripheral anterior or posterior nary patients undergoing phacoemulsification is the use of
synechiae, pupillary occlusion, vitreal prolapse, and aque- anti-inflammatory medications, which are important for
ous misdirection.34 Clinical examination and follow-up is controlling uveitis. Intraocular inflammation was the most
imperative for cases of FAHMS treated with phacoemulsi- common short-term complication in the current case ser-
fication, posterior capsulotomy, and anterior vitrectomy to ies, occurring in all cats. Anti-inflammatory medications
evaluate for these possible causes. In humans, aphakia, are commonly used postoperatively in dogs with some
older age, higher IOP, and longer duration from surgery dogs staying on them permanently after surgery.43 A justi-
have been found to be significant risk factors for glaucoma fication for long-term administration of anti-inflammatory
after cataract surgery.35 A study by Agarwal et al.36 medications is related to the relative instability of the
described cases of aphakic glaucoma and reported that blood aqueous barrier in various species and its correlation
peripheral anterior synechia, pupillary block, vitreal pro- with uveitis and postoperative glaucoma. The two eyes in
lapse, epithelialization of the anterior chamber, and malig- this case series that had an elevated IOP within the first
nant glaucoma were the most common etiologic factors 6 months of surgery were receiving a miotic drug (patient
contributing to glaucoma after cataract extraction. Records 1 – timolol, patient 3 – demecarium bromide) and pred-
in the current case series did not describe any suspected nisolone acetate. Corticosteroids have been shown to
cause for the elevations in postoperative IOP, and possible increase IOP in cats within 2–3 weeks of initiating treat-
causes of long-term failure in cats warrants further investi- ment.44 As five of the other seven eyes were also on pred-
gation. While the elevations in IOP may have been due to nisolone acetate after surgery and did not have a recorded
complications from the surgery such as those described by elevation in IOP, the contribution of the corticosteroid to
Agarwal et al., it is important to consider that the eleva- the elevated IOP may not be the primary factor. A study
tion in IOP may have been due to lack of control of the by Walton revealed pupillary block, pigment and sus-
primary disease process. pected residual lens fragments within the iridocorneal
Historically, conservative medical management has been angle, and anterior synechia in children with aphakic glau-
the favored treatment for FAHMS.12 The rationale for coma without evidence of chronic inflammation.45 As cats
this approach includes the slow progression of the disease, have postoperative inflammation that is easier to control
the age of affected patients, and the cost-effectiveness of and uvea that responds less intensely than dogs after catar-
medical management.12 Treatment has focused on medi- act surgery, the long-term use and possible complications
cations that decrease the production of aqueous humor. of anti-inflammatories should be evaluated.9 The postop-
Beta blockers and carbonic anhydrase inhibitors have been erative uveitis in this case series was assumed to be
shown to decrease production of aqueous humor.1 Car- resolved after surgery at a mean of 35 days when it was
bonic anhydrase inhibitors were effective in retaining no longer recorded in the records; however, all cats were
vision and controlling IOP (<25 mmHg) in 13/20 visual continued on one anti-inflammatory medication long
eyes in cats with FAHMS in one retrospective study.6 term. Further studies that examine the postoperative med-
One of the cats in that study treated with 2% dorzo- ical management of FAHMS are warranted to evaluate
lamide three times a day had a reported deepening of the response to different medications, and monitoring is rec-
anterior chamber after treatment.6 Carbonic anhydrase ommended in all cats treated long term with corticos-
inhibitors were the most common class of antiglaucoma teroids.6,12
medication used preoperatively in the current case series, Compliance to therapy is a contributing factor to suc-
either alone or in combination with a beta blocker. Dor- cessful treatment of glaucoma.46,47 Frequent application of
zolamide, which has been shown to be effective in both topical medications to cats can be challenging primarily
normal and glaucomatous cats in lowering IOP, was the because of the necessity of restraint, but also due to an
most commonly used carbonic anhydrase inhibitor.37–40 aversive taste response in cats receiving topical medica-
Brinzolamide was used in one eye prior to surgery and tions that ultimately reach the oral cavity via the naso-
one eye after surgery. As a topical carbonic anhydrase lacrimal system.12 In this case series, the number of drops
inhibitor, its mechanism of action is the same as dorzo- per day decreased in all but one cat postoperatively when
lamide; however, it is less effective in cats.7 Currently compared with the number of drops per day prescribed
published studies have shown no significant decrease in prior to surgery. The mean drops/day decreased from 3.9
IOP in normal cats when given twice a day; however, it prior to surgery to 2.2 postoperatively. By decreasing the
may be easier to administer to cats because it is less irri- number and frequency of medications, postoperative com-
tating and has been reported to have fewer side effects.7,41 pliance may improve, helping with the control of IOP and
Timolol was used alone or in combination with dorzo- maintenance of vision.
lamide in this series. It has been shown to decrease IOP All of the cats in this series were left aphakic. Most of
in cats but results in miosis, which can exacerbate some the owners reported being happy with the cat’s behavior
forms of glaucoma.42 at home; however, the owner of patient 4 reported trouble

© 2016 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 1–7

6 atkins ET AL.

with near field vision. The refractive error in aphakic cats 3. Dubielzig RR, Ketring KL, McLellan GL et al. The Glaucomas.
has not been reported to the authors’ knowledge; aphakic In: Veterinary Ocular Pathology: A Comparative Review. Saunders,
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dogs have been documented to experience a mean refrac-
4. Gelatt KN, Brooks DE, Kallberg ME. The Canine Glaucomas.
tive error of +14.4 diopters.48 In the study by Czederpiltz
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and found to be myopic ( 10 to 16.5 diopters) which 5. Herring IP. Hanbook of Small Animal Practice, 5th edn.. Saunders,
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severe FAHMS most likely suffered from a refractive error 6. Czederpiltz JMC, La Croix NC, van der Woerdt A et al.
prior to and after surgery. Putative aqueous humor misdirection syndrome as a cause of
glaucoma in cats: 32 cases (1997-2003). Journal of the American
All records indicated the reason for surgery in this
Veterinary Medical Association 2005; 227: 1434–1441.
case series was either due to lack of adequate response
7. McLellan GJ, Miller PE. Feline glaucoma- a comprehensive
to topical medical therapy, gradual elevation in IOP review. Veterinary Ophthalmology 2011; 14(Suppl 1): 15–29.
despite the use of antiglaucoma medications, or due to 8. Ridgway MD, Brightman AH. Feline glaucoma: a retrospective
the severity of the disease. Although medical therapy can study of 29 clinical cases. Journal of the American Animal Hospital
maintain vision and comfort for extended periods of 1989; 25: 485–490.
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10. Blocker T, van der Woerdt A. The feline glaucomas: 82 cases
the Czederpiltz et al.6 study retained vision for a mean (1995–1999). Veterinary Ophthalmology 2001; 4: 81–85.
of 14.7 months (range 1–72 months) prior to vision loss. 11. Wilcock BP, Peiffer RL, Davidson MG. The causes of glaucoma
All of the cats in this series maintained vision for the in cats. Veterinary Pathology 1990; 27: 35–40.
duration of follow-up, which occurred at a mean of 12. McLellan GJ, Teixeira LBC. Feline glaucoma. Veterinary Clinics
648 days (21 months). Due to the retrospective nature of of North America Small Animal Practice 2015; 45: 1307–1333.
13. Chandler PA. Malignant glaucoma. Transactions of the American
this series, it is unknown whether these cats would have
Ophthalmological Society 1950; 48: 128–143.
remained visual with controlled IOP on medical therapy.
14. Simmons RJ. Malignant glaucoma. The British Journal of
There may be a subset of cats where surgical therapy is Ophthalmology 1972; 56: 263–272.
indicated to save vision. 15. Schwartz AL, Anderson DR. “Malignant glaucoma” in an eye
Due to the paucity of the literature on FAHMS, future with no antecedent operation or miotics. Archives of
studies are warranted. Studies should include response to Ophthalmology 1975; 93: 379–381.
medical therapy, imaging of both the anterior and poste- 16. Shahid H, Salmon JF. Malignant glaucoma: a review of modern
literature. Journal of Ophthalmology 2012; 852659: 1–6.
rior segments to evaluate the structural differences in
17. Kroll MM, Miller PE, Rodan I. Intraocular pressure measurements
affected cats, and gonioscopy to evaluate for possible
obtained as part of a comprehensive geriatric health examination
residual material or pigment within the iridocorneal angle. from cats seven years of age or older. Journal of the American
Complimentary studies in cats describing phacoemulsifica- Veterinary Medical Association 2001; 219: 1406–1410.
tion, refraction of normal cats, preoperative and postoper- 18. Ruben S, Tsai J, Hitchings R. Malignant glaucoma and its
ative phacoemulsification with intraocular lens management. British Journal of Ophthalmology 1997; 81: 163–167.
implantation versus aphakic cats, as well as long-term 19. Sengupta R, Morgan J. Treatment of aqueous misdirection by
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20. Tsai JC, Barton KA, Miller MH et al. Surgical results in
tion for treatment of FAHMS.
malignant glaucoma refractory to medical or laser therapy. Eye
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CONCLUSIONS 21. Sapienza JS. Feline lens disorders. Clinical Techniques in Small
Animal Practice 2005; 20: 102–107.
The cats with FAHMS in this series tended to be bilater- 22. Debrouwere V, Stalmans P, Van Calster J et al. Outcomes of
ally affected older females. Surgery may be an appropriate different management options for malignant glaucoma: a
treatment option for severely affected cats that have an retrospective study. Graefes Archive for Clinical and Experimental
Ophthalmology 2012; 250: 131–141.
elevated IOP due to FAHMS despite the use of appropri-
23. Aubin ML, Powell CC, Gionfriddo JR et al. Ultrasound
ate medications. Although the number of drops decreased biomicroscopy of the feline anterior segment. Veterinary
after surgery, all cats remained on topical medications Ophthalmology 2003; 6: 15–17.
long term. 24. Tsai S, Bentley E, Miller PE et al. Gender differences in
iridocorneal angle morphology: a potential explanation for the
female predisposition to primary angle closure glaucoma in dogs.
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