October 2019

GLAUCOMA

Presentation Spotlight
Phacomorphic glaucoma and cataract surgery


by Stefanie Petrou Binder, MD EyeWorld Contributing Writer


Secondary angle-closure glaucoma can be caused by lens intumescence.
Source: Pekka Virtanen, MD

 

A case presentation on phacomorphic glaucoma, shown as an e-poster at the 23rd Winter Meeting of the European Society of Cataract and Refractive Surgeons, highlighted the damaging effect this entity can have on intraocular pressure. According to Charikleia Papandreou, MD, lens-induced glaucoma may not only cause a huge, acute rise in IOP but it can pose challenges intraoperatively.
“We presented this case to emphasize the challenges of performing a conventional phacoemulsification operation in a lens-induced glaucoma patient,” she said. “Our take-home message is to underline the role of cataract surgery in the phacomorphic glaucoma patient in terms of the effect on IOP and to point out the challenges it can present intraoperatively.”
Phacomorphic glaucoma (lens swelling) is the term used for secondary angle-closure glaucoma due to lens intumescence. The increase in lens thickness can be caused by a rapidly developing senile cataract, a quickly intumescent lens, or a traumatic cataract, which can further lead to pupillary block and angle closure and needs to be handled carefully and quickly.

Case study

Dr. Papandreou’s case involved an 83-year-old male patient who was referred by his optician due to the presence of an asymmetric mature lens in his left eye. The patient had left-sided visual acuity of counting fingers and right-sided vision of 6/12. Dr. Papandreou observed narrow anterior chamber angles bilaterally and high intraocular pressures of 52 mm Hg in the affected, left eye, which led to the diagnosis of phacomorphic glaucoma. IOP was 22 mm Hg in the patient’s right eye.
Dr. Papandreou’s management of this case focused first on reducing the very high IOP to prevent further damage to the optic nerve, especially in the affected eye, and to prevent synechia formation. The patient was immediately administered mydriatics, corticosteroids, and aqueous suppressants, which addressed the acute nature of the angle closure and successfully lowered the patient’s IOP to 19 mm Hg in his left eye and 13 mm Hg in his right eye.
The following day, the patient underwent peripheral iridotomies and he was scheduled for conventional phacoemulsification surgery within the week. The pupil of the patient’s right eye was partially dilated and minimally reactive, without the existence of an afferent pupillary defect, and there was a shallow, right-sided anterior chamber.
The patient underwent left-sided cataract surgery with phacoemulsification. Dr. Papandreou stained the anterior capsule with trypan blue under an air bubble to protect the endothelium and facilitate the capsulorhexis. She inserted a Malyugin ring to create more space for surgery due to the atrophic small pupil of the left eye. The surgeon noted zonular dehiscence and phacodonesis during the surgery, and then decided to insert a capsular tension ring prior to lens removal. The capsular bag remained intact and the IOL was inserted into the bag.

Postoperative outcomes

One week following cataract surgery, IOP was 15 mm Hg in the patient’s left eye, remaining within normal limits without further interventions. Visual acuity in this eye was 6/12 and the patient was very satisfied with the outcome of the procedure. No other postoperative complications were reported.
Phacomorphic glaucoma can be accompanied by acute pain, blurred vision, rainbow-colored halos around lights, and even nausea and vomiting. As in Dr. Papandreou’s patient, this entity frequently causes decreased vision before the onset of an acute episode related to cataract. Signs associated with phacomorphic glaucoma include: IOP in excess of 35 mm Hg, a sluggish, irregular pupil, corneal edema, injection of conjunctival and episcleral vessels, shallow AC, lens enlargement and forward displacement, and unequal cataract formation between the two eyes.
The development of phacomorphic cataract is more common in smaller hyperopic eyes with a larger crystalline lens and shallower anterior chamber. The angle closure episode can be triggered, for instance, by dim light causing pupil dilatation. Angle closure may also be caused by the encroachment of the lens spatially and the pressure from behind the lens. Zonular weakness from advanced age, trauma, or due to exfoliation can play a causative role as well.
Although the surgery was well managed, a number of factors could have complicated it. “This case was rare, given that zonular dehiscence is often managed with intracapsular cataract extraction with aphakia and secondary lens implantation. Furthermore, it is common practice to perform extracapsular cataract extraction or even intracapsular cataract extraction with trabeculectomy for the management of lens-induced glaucoma. However, we managed to perform conventional phacoemulsification surgery with intraocular lens implantation in the bag successfully and uneventfully,” Dr. Papandreou said.

About the doctor

Charikleia Papandreou, MD
Urgent Eye Clinic, Lister Hospital
Stevenage, U.K.

Phacomorphic glaucoma and cataract surgery Phacomorphic glaucoma and cataract surgery
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