Mechanisms of Pupillary Block

To the Editor. —I read with interest the report by Tomey et al.1However, certain claims made in the article do not appear to be consistent with the currently accepted pathophysiologic mechanisms that result in the development of pupillary block or aqueous misdirection syndrome, nor with my own observations of these conditions. As described by Levene2in his classic article, to which Tomey et al refer, "malignant glaucoma" occurs when aqueous is unable to enter the posterior chamber and therefore accumulates somewhere posterior to the ciliary body-zonule-crystalline lens plane. This results in an anterior shift of the crystalline lens in the phakic eye. In eyes containing posterior chamber lenses, pseudophakic malignant glaucoma would indicate that the obstruction is occurring at the level of the ciliary body-capsule-pseudophakos plane. The anterior hyaloid may or may not participate in the obstructive process. One fact unalterably remains—there must be a pressure differential