A peculiar case of aqueous misdirection from a pseudophakic secluded pupil in a patient with chronic angle closure glaucoma

PURPOSE: To explore the course of a pseudophakic and pseudoiridic 61-year-old man with a history of open angle glaucoma in his right eye who developed a sub-totally secluded pupil then later presented with angle closure, a significant pressure spike, and a marked myopic refractive shift, consistent with aqueous misdirection. OBSERVATIONS: Goniosynechialysis, surgical removal of much of the native peripheral iris, and zonulohyaloidectomy led to a return to his prior refraction and improve intraocular pressure (IOP) control. CONCLUSIONS AND IMPORTANCE: This case demonstrates that a diagnosis of aqueous misdirection should not be disregarded in the presence of a prior vitrectomy and that aqueous misdirection should be strongly considered in cases of elevated IOP with a patent peripheral iridotomy, myopic shift and angle narrowing.