American Journal of Ophthalmology Case Reports · Published 2026-07-29 · DOI 10.1016/j.ajoc.2026.102634
Silvio Semeria, Valentina Romani, Alessandro Siligato, Matteo Cacciatori, Giovanni Milano, Giacinto Triolo
Purpose: To report a case of aqueous misdirection occurring shortly after intraluminal ripcord removal in a pseudophakic, previously vitrectomized eye implanted with a PAUL Glaucoma Implant. Case description: A 65-year-old Caucasian woman presented with primary angle-closure glaucoma and previous history of aqueous misdirection following a combined procedure of phacoemulsification and XEN45 gel stent implant, which was managed with pars plana vitrectomy elsewhere. Because of high IOP despite maximum tolerated medical treatment, a PAUL Glaucoma Implant was performed with positioning of a 6-0 Prolene® intraluminal ripcord. Shortly after ripcord removal 6 weeks postoperatively, she presented with significant myopic shift, uniformly shallow anterior chamber, and markedly raised IOP. Anterior-segment OCT showed patent tube in the superotemporal quadrant of the anterior chamber, suggesting the recurrence of aqueous misdirection. Revision of pars plana vitrectomy with extensive peripheral vitreous shaving and irido-zonulo-hyaloidectomy was required to restore anterior chamber depth, to re-establish forward aqueous flow, and to stabilize IOP. Conclusions and importance: This case suggests that intraluminal ripcord removal from a PAUL glaucoma implant can elicit aqueous misdirection in eyes at risk. Furthermore, the final outcomes of the present case suggest that thorough pars plana vitrectomy with irido-zonulo-hyaloidectomy may be the most effective surgical approach to aqueous misdirection.
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Semeria, S., Romani, V., Siligato, A., et al. (2026). Recurrent aqueous misdirection following intraluminal ripcord removal from a Paul Glaucoma Implant. American Journal of Ophthalmology Case Reports. https://doi.org/10.1016/j.ajoc.2026.102634