LENS INDUCED
GLAUCOMA
BY
DR. KASTHOORIBHAEE
INTRODUCTION
Lens induced glaucoma is a secondary glaucoma in which the crystalline lens
is involved in the mechanism of intraocular pressure ( IOP ) increase.
The glaucoma may occur in open – angle or angle – closure
There are few distinct variant :
Phacolytic
Lens – particle
Phacoantigenic
Phacomorphic
lens dislocation
PHACOLYTIC GLAUCOMA
Secondary open‐angle glaucoma associated with a hypermature cataract
MECHANISM
Heavy Molecular Weight lens protein (HMW) released through microscopic defects in
the capsule of immature/hyper mature lens
Causes direct obstruction of outflow pathways
Macrophages attempt to remove this material
Macrophages laden with phagocytosed HMW lens material‐ cause blockage at the angle
of the anterior chamber
Increase in IOP
PHACOLYTIC
GLAUCOMA
SYMPTOMS :
Acute ocular Pain
• History of slow vision loss for
months or years prior to the
acute onset of pain
• Inaccurate light perception
due to the density of the
cataract
PHACOLYTIC
GLAUCOMA
SIGNS:
Lid edema
Conjunctival hyperemia
Corneal edema
Anterior chamber containing
Flare
Aqueous cells
Lens particles may precipitate
on the corneal endothelium
Sluggishly reacting Pupil
Mature/Hypermature
/Morgagnian Cataract
pseudo hypopyon
lens particle on the lens endothelium
pseudohypopyon
Differential Diagnosis:
Acute Angle closure glaucoma
Phacoanaphylactic uveitis with secondary glaucoma
Lens particle glaucoma
PHACOLYTIC GLAUCOMA
MANAGEMENT
Principle of management
Reduce IOP
Remove the cause : cataract extraction
Phacolytic glaucoma should be handled as an emergency
Initial treatment – acute lowering of IOP
Combination of topical and systemic IOP lowering agents
Hyperosmotic agents – [Link] 20% 1 to 2g/ kg in 30 to 40 mins
Systemic Carbonic anhydrate inhibitors – Acetazolamide 250‐500mg bd
aqueus suppressant ( alpha 2 agonist, beta blocker , carbonic anhydrase inhibitors)
Topical steroids – Eye drops Prednisolone acetate 1% (reduces inflammation)
Cycloplegic drugs‐ eye drops Homatropine 2% bd
Definitive treatment‐ Cataract extraction
PHACOMORPHIC GLAUCOMA
Acute secondary angle‐closure glaucoma
precipitated by an intumescent cataractous lens
More common in smaller eyes (hyperopic)
Predisposing factor‐ rapidly developing
intumescent cataract and traumatic cataract
More often seen as compared to other lens induced
glaucoma.
PHACOMORPHIC GLAUCOMA
senile cataractous lens can become intumescent , increase
in thickness and cause pupillary block
this iridolenticular apposition disrupts the flow of
aqueous humor from the posterior chamber to the anterior
chamber
this result in the accumulation of aqueous in the posterior
chamber , pushing the iris root forward which ultimately
contact the trabecular meshwork and lead to angle
closure
PHACOMORPHIC GLAUCOMA MECHANISM
Swollen lens
Pupilarry block
Iris bombe
angle closure
Outflow obstruction
Raised IOP
PHACOMORPHIC GLAUCOMA
SYMPTOMS SIGNS
Acute ocular pain Inaccurate light
perception
Blurred vision
Reduced visual acuity
Colored halos around lights
Lid edema
Decreased vision before the
acute episode because of Chemosis
cataract Circumcorneal
congestion
Corneal edema
Anterior chamber
appears shallow both
centrally and peripherally
PHACOMORPHIC GLAUCOMA
Investigation
On tonometry ‐Raised intraocular pressure(30‐ 50 mmHg)
On Gonioscopy –closed angles
On ultrasonographic biomicroscopy‐iris bombe and angle
closure
UBM showing phacomorphic glaucoma with cataract causing angle closure
PHACOMORPHIC GLAUCOMA
MANAGEMENT
Principles of management
Reduce IOP
Remove the cause : cataract extraction
Medical treatment to lower IOP :
Combination of topical and systemic IOP lowering agents
Hyperosmotic agents – [Link] 20% 1 to 2g/ kg in 30 to 40 mins
Systemic Carbonic anhydrate inhibitors – Acetazolamide 250‐500mg bd
Aqueus suppressant ( alpha 2 agonist, beta blocker , carbonic anhydrase inhibitors)
Definitive treatment – cataract extraction
LENS PARTICLE GLAUCOMA
Secondary open angle glaucoma
associate with grossly disrupted lens capsule and liberated
fragments of lens material in the anterior chamber.
Usually follows after:
Cataract extraction
Penetrating lens injury
YAG laser posterior capsulotomy
lens particle glaucoma
LENS PARTICLE GLAUCOMA
CLINICAL FEATURES
Present with monocular eye pain
Redness
Blurring of vision
Variable degree of inflammation: –
Corneal edema
Keratic precipitates
Hypopyon
Often associated with posterior and anterior synechiae and inflammatory pupillary
membranes
LENS PARTICLE GLAUCOMA
DIAGNOSIS
Patient often gives recent history of trauma or
intraocular surgery, particularly cataract
extraction
Can also occur many years after cataract surgery
LENS PARTICLE GLAUCOMA
MANAGEMENT
PRINCIPLE OF MANAGEMENT
Reduce IOP
Remove the cause via irrigation and aspiration of lens particles
MEDICAL THERAPY
Anti‐glaucoma therapy
Topical steroids
SURGICAL
Anterior chamber wash‐out: irrigation and aspiration of lens particles
PHACOANTIGENIC GLAUCOMA
Also known as phacoanaphylatic glaucoma
Is the rarest type of lens –induced glaucoma
It does not involve an allergic or anaphylactic reaction; rather, the underlying
mechanism may be an Arthus-type immune complex reaction, mediated by
IgG and the complement system, against lens proteins
These proteins are normally immune privileged antigens sequestered within
the lens capsule
Typically occurs 1 to 14 days after cataract surgery, although there may be a
longer latent period after sensitization to lens proteins.
PHACOANTIGENIC GLAUCOMA
CLINICAL FEATURES
Lid edema
Chemosis
Conjuctival injection
Corneal edema
Mutton fat keratic precipitates
Heavy anterior chamber reaction
Posterior synechiae
PHACOANTIGENIC GLAUCOMA
MANAGEMENT
PRINCIPLE
Reduce IOP
Treat the cause
CONTROL THE INFLAMMATION
Inflammation is intense(cells>+3)‐ oral steroids ( prednisolone 1mg/kg once daily)
Inflammation is mild – topical steroids ( prednisolone acetate 1% hourly)
Raised IOP if present – requires antiglaucoma drugs
Surgical – irrigation and aspiration of lens particles
PHACOTOPIC GLAUCOMA
Secondary angle closure glaucoma to the site of the lens
SUBLUXATED
DISLOCATED
PHACOTOPIC GLAUCOMA
MECHANISM
Dislocation/subluxation
cause pupillary block
result in angle‐closure glaucoma
Dislocated lens may directly encroach
upon the angle
PHACOTOPIC GLAUCOMA
CLINICAL FEATURES
SYMPTOMS SIGNS
REDNESS Shallowing of the anterior chamber
either symmetrically or
PAINFUL EYE
asymmetrically
DECREASED VISUAL ACUITY Iridodonesis
Phacodonesis
Subuxation / dislocation
Difference in the depth of the
anterior chamber between the two
eyes
PHACOTOPIC GLAUCOMA
MANAGEMENT
Therapeutic approach – degree of dislocation and the symptoms
If no pupillary block glaucoma – conservative non intervention strategy
If accompanied by pupillary block – laser peripheral iridectomy
Principle of management
Reduce IOP
Remove the cause – Lens extraction
For acute attack – initial treatment – acute lowering of IOP
Combination of topical and systemic IOP lowering agents
Total anterior dislocation requires removal of the lens
THANK YOU
