Aqueous misdirection is a serious condition with potentially higher prevalence than expected. Predominantly observed after ocular surgery, especially filtration surgery (1), it manifests clinically as shallowing of the anterior chamber both centrally and peripherally by forward displacement of the lens-iris diaphragm. Here, the composition of the anterior chamber cell depth, its asymmetry between the eyes (unless bilateral (2)) and the myopic shift allows for differentiation of the condition from pupillary block. Consequently, some patients report an increase in near vision. This “myopic surprise” may be the only initial tip, which the patient offers towards the correct diagnosis (3).

Contributor: Timothy Hamann, MD – University Hospital Zurich, Zurich, Switzerland

References

1. Grzybowski A, Kanclerz P. Acute and chronic fluid misdirection syndrome: pathophysiology and treatment. Graefes Arch Clin Exp Ophthalmol. 2018 Jan;256(1):135-154. doi:10.1007/s00417-017-3837-0. Epub 2017 Nov 6. PMID: 29110086; PMCID: PMC5748435.
   
2. Pathak-Ray V, Bansal AK, Malhotra V. Bilateral aqueous misdirection syndrome after routine cataract surgery in angle closure. J Cataract Refract Surg. 2019 Dec;45(12):1826-1829. doi: 10.1016/j.jcrs.2019.07.034. PMID: 31856996.
   
3. Chung Shen Chean, Duminda Gabadage, Subhanjan Mukherji; Aqueous misdirection syndrome masking as myopic surprise: a case report and review of literature. Invest. Ophthalmol. Vis. Sci. 2021;62(8):584.
   

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