Lens Induced Glaucomas

Saleh Al Obeidan, MD.

 Lens Induced
Secondary Angle
Closure Glaucomas
A.Condition(s) related to the size of
the lens
-Intumescent cataract
- Traumatic cataract
Mechanism:
- Pupillary block
- Direct angle closure
- Combination
Phacomorphic Glaucoma [PMG]

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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucomas
B.Condition related to
the site of the lens
- Subluxated
- Dislocated
Mechanism:
- Direct angle closure
- Pupillary block

3
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucomas
A. Condition(s) related to
soluble lens proteins

Mechanism:
- Heavy Molecular Weight
protein [HMW]
- Macrophagic response ??
Lens Protein Glaucoma [Phacolytic Glaucoma]
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucomas
B.Condition related to
lens particles
Mechanism:
- Blockage of TM by lens
particles e.g-retained lens matter
-Post. YAG capsulotomy
Lens Particle Glaucoma
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
 More common in
smaller eyes (hyperopic)
 Encountered more in
developing countries
 Predisposed by rapidly developing
intumescent cataract and traumatic cataract

6
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]

Mechanism:

Swollen lens Pupillary block

Angle closure Iris bombê

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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Stages of PMG:
 Pupillary Block
 Angle crowding
 Chronic angle closure

8
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Clinical Picture:
 Like PACG
 Mid-dilated fixed pupil
 Shallow A/c
 Closed angle
 Faulty light projection
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Diagnosis:
 Clinical picture
 Gonioscopy of both eyes
 Ultrasonography
 Paracentesis ?
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Management:
 Medical treatment to lower IOP
 Frequent topical steroid
 Pilocarpine
 Laser Iridotomy [?PLI]
 Cataract extraction + P/C IOL [ + trab. In long
standing PMG]
 The other eye
11
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Advantages of Laser PI:
 Relieves acute attack
 Allows eye to quiet pre-op
 Allows evaluation of angle
 Allows safe pre-op medriusis
12
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Risk of Iridotomy:
 Bleeding
 Endothelial injury
 Rupture of lens capsule
 Failure/Inflammation
13
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intra-operative Difficulties:
 Difficult capsulotomy
 Shallow Alc; pos. pressure
 Constricted pupil
 Poor view [corneal edema]
 Descemet’s detachement
 Weak Zonules
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intraoperative Difficulties
Poor View:
 Preoperative mannitol
 Topical preoperative glycerine
 ? Scrapping of epithelium
15
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intra-operative Difficulties
Difficult Capsulotomy and (Shallow A/c):
 Deepening with viscoelastic mat. through
paracentesis
 Puncture the lens at the center and
aspirate liquefied cortex
Cont’n next slide…

16
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intra-operative Difficulties
Difficult Capsulotomy and (Shallow A/c

+ POS. pres.):
 Limited PPV (only cutter)
 Trypan blue
 Central circular capsul.
 Start at 12 o’clock (can opener tech.)
17
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intra-operative Difficulties
Constricted Pupil:
 Mechanical Mydriasis
- Visco elastic mat.
- Pupil dilator
- Pupil retractor
- Small sphineteroctomies
- Sector iridotomy 18
Saleh Al Obeidan, MD
 Lens Induced
Secondary Angle
Closure Glaucoma
Phacomorphic Glaucoma [PMG]
Intra-operative Difficulties
Descemet’s Detachment:
 Avoid repeated A/c entry with sharp
instrument
 Careful IOL insertion
 Viscoelastic mat.
19
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]
 A type of lens induced
open angle glaucoma
 Described by Zeeman in
1943
 Defined as phacolytic glaucoma by Flocks in
1955
20
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Lens Protein:
 33% of total weight
 85% soluble
-Alpha crystallin – 15%
- B Crystallin – 55%
-  Crystallin – 15%
 insoluble ‘albuminoid’ 15% 21
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Heavy Molecular Weight Protein [HMW]:

 Increases with age & cataract formation
 Mainly in nuclear region
 Absent in infantile & juvenile lenses

22
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Experimental Studies:
Perfusion of enucleated human eyes with
 HMWps 0.5mg severe obstruction
 Perfusion time obstruction
 Irrigation with BSS or alphachemotrypsin
 LMWps 1h no obstruction 23
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

 Engorged macrophages
after cataract needling in
children no phacolytic
glaucoma
 Swollen rabbit macrophages
failed to elevate IOP 24
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Clinical Studies:
“Patients with phacolytic
glaucoma”
 HMWps 35% of total
protein (0.8mg)
 0.8 mg is well in excess to cause obstruction
 No HMWps in normal subjects with immature &
mature cataract 25
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Mehchanism:
 Simple obstruction of the
TM by HMWps
“MW>150x106 daltons”
 Macrophages

? Obstructors Relievers
“normal scavenger response” 26
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Clinical Picture:
 Pain
 H/o poor vision [faulty L. projection]
 Conj. Hyperemia
 Corneal Edema
 Unilateral [other eye is aphakic or
pseudophakic Cont’n next slide… 27
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Clinical Picture:
 Mature or hypermature
cataract
 IOP
 Heavy flare
 White patches on the Capsule
 Open angle with deep A/c 28
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Differential Diagnosis:
 Acute Angle closure glaucoma (PMG)
 Neovascular glaucoma
 Ghost-cell glaucoma
 Angle recesion glaucoma
 Uveitic glaucoma 29
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Protein Glaucoma
[Phacolytic Glaucoma]

Management:
 Medical Therapy
 Admission
 Anti-glaucoma therapy
 Hyperosmotic agents
 Topical steroids
 Surgical
 Cataract Extraction “Sufficient I/A” 30
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Usually Follows:
 Planned or unplanned
extra cap. cataract
extraction
 Penetrating lens injury
 Nd: YAG laser capsulotomy
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Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma

Mechanism:
Obstruction of T.M. by:
 Free lens material
 ? Inflammatory response

32
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Management:
 Medical Therapy:
- Anti-glaucoma
therapy
- Topical steroid
 Surgical:
- A/c wash-out 33
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Nd: YAG laser Post. Capsulotomy
and IOP Elevation
 Is the most common complication
 Acute “within hours”
 Magnitude
- 10mmHg above baseline reported in
59%
- >40mmHg occurred in 38%
- NLP have been reported 34
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Nd: YAG laser Post. Capsulotomy
and IOP Elevation

Risk is greater in:

 Glaucoma patients
 Eyes without IOL
 More energy 35
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Nd: YAG laser Post. Capsulotomy
and IOP Elevation
Management:
 Measure IOP 1h
post laser capsulotomy
 Prophylactic anti-glaucoma therapy
 Topical steroids
36
Cont’n next slide…
Saleh Al Obeidan, MD
 Lens Induced
Secondary Open
Angle Glaucoma
Lens Particle Glaucoma
Nd: YAG laser Post. Capsulotomy and IOP Elevation
Management:
 Medical Therapy
- Anti-glaucoma therapy (avoid meotics)
- Hyperosmotic agents
 Surgical
- Alc wash-out
- Filtering procedure
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Saleh Al Obeidan, MD
 Lens Induced
Glaucomas
ELEVATED IOP COMPLETELY
OPAQUE CATARACT

OPEN ANGLE CLOSED ANGLE

-Pre existing POAG

-Lens Protein Glaucoma
“phacolytic glaucoma”

Deep A/c Shallow A/c Very Shallow or Flat A/c

-Pre existing angle - Accelerated PACG - Advanced PMG

closure - True PMG - Aqueous misdirection
- NVG

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Saleh Al Obeidan, MD