- Email: [email protected]
Cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma
Cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma M. McKibbin, FRCOphth, A. Gupta, FRCS, A.D. Atkins, FRCOphth
ABSTRACT We describe nine patients who had phacomorphic or phacolytic glaucoma. After intraocular pressure (lOP) was reduced medically, all patients had extracapsular cataract extraction. All had intraocular lens implantation except one. The surgery improved visual acuity and resulted in normal lOP in all eyes. J Cataract Refract Surg
1996; 22:633-636
S
ince the introduction of small incision techniques and intraocular lenses (IOLs), cataract extraction has been performed at an earlier stage. Despite this, 23% of patients having cataract surgery in the United Kingdom present with a visual acuity of 20/200 or worse in the worse eye. 1 Mature or hypermature cataracts not only cause visual handicaps but may also lead to lens-induced glaucoma. Phacomorphic glaucoma is the result of angle closure by a mature lens, either directly or secondary to pupil block. Phacolytic glaucoma is caused by obstruction of the trabecular meshwork by high-molecularweight proteins leaking from mature or hypermature cataracts. 2 In this paper, we review the case reports of nine patients with phacomorphic or phacolytic glaucoma who presented over a 10 month period.
From the Department of Ophthalmology, Royal Infirmary, Bradford, England. Reprint requests to Martin McKibbin, FRCOphth, Department ofOphthalmology, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, England.
Case Reports Nine patients with lens-induced glaucoma were seen over a 10 month period between 1993 and 1994. Five patients, all Asian, had phacomorphic glaucoma, and four, all Caucasian, had phacolytic glaucoma. All patients had mature or hypermature cataract. Average patient age was 72 years (range 54 to 102 years). Table 1 gives a clinical summary of each case. All the patients presented with visual acuiry of either hand motions or light perception. Intraocular pressure (lOP) was between 26 and 80 mm Hg. Before cataract extraction, lOP was reduced with topical beta blockers and oral or intravenous acetazolamide or both. Cases 1, 5, and 8 also required intravenous mannitol 20%. Cataract extraction was done an average of 2 days after diagnosis in patients with phacomorphic and after an average of 6 days after diagnosis in patients with phacolytic glaucoma. Two patients with phacolytic glaucoma (6 and 7) required further treatment to reduce intraocular inflammation to achieve an adequate view for surgery. Patients 1, 3, 4, 5, 8, and 9 had an uncomplicated extracapsular cataract extraction (ECCE) with posterior chamber IOL implantation through a peripheral corneal incision. Patients 2, 6, and 7 required an anterior vitrectomy because of vitreous loss. All three had pseudoexfoliation; two had an anterior chamber IOL implanted and one had no IOL because the fellow eye was aphakic. Table 2 shows intraoperative and postoperative complications.
J CATARACT REFRACT SURG-VOL 22, JUNE 1996
633
CASE REPORTS: McKIBBIN
Table 1.
Patient
Clinical summary of patients.
Glaucoma Type
Preoperative
Postoperative
Days from Symptom Onset to Presentation
BCVA
lOP (mm Hg)
BCVA
lOP (mmHg)
Age
Sex
82
F
Phacomorphic
3
LP
42
20/60
15
2
67
M
Phacomorphic
5
LP
30
HM
9
3 4 5 6 7
54 64 60 91 102
F M F M F
Phacomorphic Phacomorphic Phacomorphic Phacolytic Phacolytic
3
HM LP HM HM LP
26 50 80 70 48
20/30 20/20 20/30 20/30 20/120
8 10 9 15 17
8 9
72 58
F M
Phacolytic Phacolytic
2
LP LP
62 48
20/30 20/20
17 14
BCVA
= best corrected visual
Table 2.
Patient 1
2 3 4 5 6 7
8 9
acuity; LP
2
= light perception;
HM
Epithelial defect Bullous keratopathy
Age-related macular degeneration
motions
Intraoperative and postoperative complications. Glaucoma Type Phacomorphic Phacomorphic Phacomorphic Phacomorphic Phacomorphic Phacolytic Phacolytic Phacolytic Phacolytic
Complication Intraoperative
Vitreous loss
Postoperative Persistent epithelial defect Bullous keratopathy Fibrinous uveitis Fibrinous uveitis
Associated Factor
Pseudoexfoliation Diabetes mellitus Diabetes mellitus Pseudoexfoliation Pseudoexfoliation, aphakia
Vitreous loss Vitreous loss Fibrinous uveitis
Mter surgery, patients had a mean lOP of 13 mm Hg (9 to 17 mm Hg) on no medications. Six patients had a final best corrected visual acuity of 20/30 or better (Table 1).
Discussion Current treatment of phacomorphic and phacolytic glaucoma is medical control of the lOP followed by ECCE and posterior chamber IOL implantation through a standard peripheral corneal incision. 3 ,4 In this series, all the cataracts were mature or hypermature, with some patients having pseudoexfoliation and questionable zonular support. Furthermore, in several patients, the view at surgery was obscured by corneal edema, intraocular inflammation, or both. Thus, we did not be634
= hand
Comment
lieve small incision surgery and phacoemulsification were appropriate. In our series, an anterior vitrectomy was required in three patients with pseudoexfoliation: one with phacomorphic glaucoma and two with phacolytic glaucoma. Tomey and Al-Rajhi5 reported on a series of 10 patients with phacomorphic glaucoma, 5 of whom had pseudoexfoliation. They postulated that the zonular weakness and forward lens displacement may have contributed to the development of angle closure. No association between phacolytic glaucoma and pseudoexfoliation has been described previously. Pre-existing ocular pathology increases the complication rate of cataract surgery.6 Postoperative complications in our series (Table 2) were more frequent than
J CATARACT REFRACT SURG-VOL 22, JUNE 1996
CASE REPORTS: McKIBBIN
those reported for routine cataract surgery. 6 Phacomorphic glaucoma is caused by pupil block with secondary angle closure or by displacement of the peripheral iris and angle closure without pupil block. When pupil block is the initial mechanism, laser iridotomy may help relieve angle closure if it is performed before significant peripheral anterior synechias have developed. 5 However, angle closure can still occur despite the presence of a patent peripheral iridotomy.5.7 None of our patients had a laser iridotomy during their initial management nor a subsequent surgical iridectomy. Instead, we believe that prompt ECCE and IOL implantation is the definitive treatment and will remove the tendency toward angle closure whatever the initial mechanism. Furthermore, we believe that an iridectomy is not necessary during the subsequent surgery if preoperative gonioscopy shows that significant peripheral anterior synechias have not developed and that it is unhelpful if synechias have developed, in which case definitive drainage surgery is required. Final visual acuity in eyes with phacomorphic glaucoma is variable, although in most cases final lOP is less than 20 mm Hg without treatment. 3 . 5 The one patient with a final acuity of hand motions (#2) was seen 5 days after the onset of pain and reduced vision and at the last examination had a bullous keratopathy and capsular fibrosis. All five patients with phacomorphic glaucoma had a postoperative lOP of 15 mm Hg or less without treatment. Using miotics during the initial management of phacomorphic glaucoma carries a theoretical risk of exacerbating the angle closure by increasing the pupil block and iris bombe or by allowing anterior lens movement, increasing the overall anterior-posterior diameter? We used a mixture of miotics or mydriatics in the initial management of patients with phacomorphic glaucoma. Three patients received pilocarpine and one patient, homatropine. No regime appeared to compromise control of the lOP. In the Tomey and Al-Rajhi5 series, surgery was delayed in one case; when the patient stopped using pilocarpine, the angle closure returned. Preoperative mydriasis before cataract extraction may precipitate a further episode of acute angle closure glaucoma,5 although this did not occur in our series. It would seem logical to use mydriatics to facilitate ECCE and IOL implantation.
Most patients with phacolytic glaucoma achieve a normal lOP without treatment and a good visual acuity.4.g The definitive treatment is medical control of the lOP and ECCE and posterior chamber IOL implantation. Prolonged treatment was required in two cases to control inflammation before surgery. At presentation, patient 7 had a creamy liquid throughout the anterior chamber that obscured the iris details. We believed the liquid to be soft lens matter. After two days, it settled in the lower half of the anterior chamber, improving the view for surgery. Patient 6 was given systemic steroids. Although surgery was not performed in eyes with phacolytic glaucoma until 6 days after admission on average, the delay did not appear to be associated with any problems. Intraocular pressure was often raised in the immediate postoperative period and was controlled only after inflammation had subsided. Final lOP was 17 mm Hg without treatment in all cases. Final best corrected visual acuity was good in all but one patient who had age-related macular degeneration and a final acuity of 20/120. All nine patients had had poor visual acuity in the affected eye for some time. All five patients with phacomorphic glaucoma were Asian. In Bradford, ethnic minorities make up 20% of the population. Patients from these ethnic groups often present late and with mature cataracts. Of the five cases, four had been referred to a hospital for assessment. Two had been given appointments but had not yet been seen, one failed to attend an outpatient appointment, and one had been seen and listed for cataract surgery already. Cataract surgery had been performed on the fellow eye in three of the four patients with phacolytic glaucoma. One of these patients had been referred to the hospital for further evaluation. The median waiting time for outpatient assessment in the United Kingdom is 2.64 months, and the median waiting time for cataract surgery once the patient has been listed is 4.8 months. 1 In Bradford, the routine outpatient waiting time is 9 months on average and the waiting time for routine cataract surgery is 12 to 14 months. It could be argued that some cases of lensinduced glaucoma could be prevented if the waiting times were shorter. Priority is usually given to patients with mature cataracts or very poor visual acuity, which depends, however, on the visual acuity recorded in the referral letter. Furthermore, some delay occurs when patients or their general practitioners wait to begin the
J CATARACT REFRACT SURG-VOL 22. JUNE 1996
635
CASE REPORTS: McKIBBIN
referral process. Patient education would help reduce delay by encouraging patients to present earlier. More resources would be required to deal with the current waiting times and the extra workload of earlier referrals. In summary, we recommend ECCE and 10L implantation in cases of phacomorphic and phacolytic glaucoma to improve visual acuity and resolve the glaucoma. Surgery should be done within a few days of presentation, especially with phacomorphic glaucoma.
References 1. Desai P. The National Cataract Surgery Survey: III. Process features. Eye 1993; 7:667-671 2. Epstein DL, Jedziniak JA, Grant WM. Identification of heavy-molecular-weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci 1978; 17:398-402 3. Civerchia LL, Balem A. Intraocular lens implantation in
636
acute angle closure glaucoma associated with cataract.
Am Intra-Ocular Implant Soc J 1985; 11:171-173 4. Lane SS, Kopietz LA, Lindquist TO, Leavenworth N. Treatment of phacolytic glaucoma with extracapsular cataract extraction. Ophthalmology 1988; 95:749-753 5. Tomey KF, Al-Rajhi AA. Neodymium:YAG laser iridotomy in the initial management of phacomorphic glaucoma. Ophthalmology 1992; 99:660-665 6. Desai P. The National Cataract Surgery Survey: II. Clinical outcomes. Eye 1993; 7:489-494 7. Liebmann JM, Ritch R. Glaucoma secondary to lens intumescence and dislocation. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas. St Louis, CV Mosby, 1989; 1027-1028 8. Moschos M, Brouzas 0, Papantonis F. Extracapsular cataract extraction and posterior chamber lens in the management of phacolytic glaucoma. Eur J Implant Refract Surg 1993; 5:145-147
J CATARACT REFRACT SURG-VOL 22, JUNE 1996
ABSTRACT We describe nine patients who had phacomorphic or phacolytic glaucoma. After intraocular pressure (lOP) was reduced medically, all patients had extracapsular cataract extraction. All had intraocular lens implantation except one. The surgery improved visual acuity and resulted in normal lOP in all eyes. J Cataract Refract Surg
1996; 22:633-636
S
ince the introduction of small incision techniques and intraocular lenses (IOLs), cataract extraction has been performed at an earlier stage. Despite this, 23% of patients having cataract surgery in the United Kingdom present with a visual acuity of 20/200 or worse in the worse eye. 1 Mature or hypermature cataracts not only cause visual handicaps but may also lead to lens-induced glaucoma. Phacomorphic glaucoma is the result of angle closure by a mature lens, either directly or secondary to pupil block. Phacolytic glaucoma is caused by obstruction of the trabecular meshwork by high-molecularweight proteins leaking from mature or hypermature cataracts. 2 In this paper, we review the case reports of nine patients with phacomorphic or phacolytic glaucoma who presented over a 10 month period.
From the Department of Ophthalmology, Royal Infirmary, Bradford, England. Reprint requests to Martin McKibbin, FRCOphth, Department ofOphthalmology, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, England.
Case Reports Nine patients with lens-induced glaucoma were seen over a 10 month period between 1993 and 1994. Five patients, all Asian, had phacomorphic glaucoma, and four, all Caucasian, had phacolytic glaucoma. All patients had mature or hypermature cataract. Average patient age was 72 years (range 54 to 102 years). Table 1 gives a clinical summary of each case. All the patients presented with visual acuiry of either hand motions or light perception. Intraocular pressure (lOP) was between 26 and 80 mm Hg. Before cataract extraction, lOP was reduced with topical beta blockers and oral or intravenous acetazolamide or both. Cases 1, 5, and 8 also required intravenous mannitol 20%. Cataract extraction was done an average of 2 days after diagnosis in patients with phacomorphic and after an average of 6 days after diagnosis in patients with phacolytic glaucoma. Two patients with phacolytic glaucoma (6 and 7) required further treatment to reduce intraocular inflammation to achieve an adequate view for surgery. Patients 1, 3, 4, 5, 8, and 9 had an uncomplicated extracapsular cataract extraction (ECCE) with posterior chamber IOL implantation through a peripheral corneal incision. Patients 2, 6, and 7 required an anterior vitrectomy because of vitreous loss. All three had pseudoexfoliation; two had an anterior chamber IOL implanted and one had no IOL because the fellow eye was aphakic. Table 2 shows intraoperative and postoperative complications.
J CATARACT REFRACT SURG-VOL 22, JUNE 1996
633
CASE REPORTS: McKIBBIN
Table 1.
Patient
Clinical summary of patients.
Glaucoma Type
Preoperative
Postoperative
Days from Symptom Onset to Presentation
BCVA
lOP (mm Hg)
BCVA
lOP (mmHg)
Age
Sex
82
F
Phacomorphic
3
LP
42
20/60
15
2
67
M
Phacomorphic
5
LP
30
HM
9
3 4 5 6 7
54 64 60 91 102
F M F M F
Phacomorphic Phacomorphic Phacomorphic Phacolytic Phacolytic
3
HM LP HM HM LP
26 50 80 70 48
20/30 20/20 20/30 20/30 20/120
8 10 9 15 17
8 9
72 58
F M
Phacolytic Phacolytic
2
LP LP
62 48
20/30 20/20
17 14
BCVA
= best corrected visual
Table 2.
Patient 1
2 3 4 5 6 7
8 9
acuity; LP
2
= light perception;
HM
Epithelial defect Bullous keratopathy
Age-related macular degeneration
motions
Intraoperative and postoperative complications. Glaucoma Type Phacomorphic Phacomorphic Phacomorphic Phacomorphic Phacomorphic Phacolytic Phacolytic Phacolytic Phacolytic
Complication Intraoperative
Vitreous loss
Postoperative Persistent epithelial defect Bullous keratopathy Fibrinous uveitis Fibrinous uveitis
Associated Factor
Pseudoexfoliation Diabetes mellitus Diabetes mellitus Pseudoexfoliation Pseudoexfoliation, aphakia
Vitreous loss Vitreous loss Fibrinous uveitis
Mter surgery, patients had a mean lOP of 13 mm Hg (9 to 17 mm Hg) on no medications. Six patients had a final best corrected visual acuity of 20/30 or better (Table 1).
Discussion Current treatment of phacomorphic and phacolytic glaucoma is medical control of the lOP followed by ECCE and posterior chamber IOL implantation through a standard peripheral corneal incision. 3 ,4 In this series, all the cataracts were mature or hypermature, with some patients having pseudoexfoliation and questionable zonular support. Furthermore, in several patients, the view at surgery was obscured by corneal edema, intraocular inflammation, or both. Thus, we did not be634
= hand
Comment
lieve small incision surgery and phacoemulsification were appropriate. In our series, an anterior vitrectomy was required in three patients with pseudoexfoliation: one with phacomorphic glaucoma and two with phacolytic glaucoma. Tomey and Al-Rajhi5 reported on a series of 10 patients with phacomorphic glaucoma, 5 of whom had pseudoexfoliation. They postulated that the zonular weakness and forward lens displacement may have contributed to the development of angle closure. No association between phacolytic glaucoma and pseudoexfoliation has been described previously. Pre-existing ocular pathology increases the complication rate of cataract surgery.6 Postoperative complications in our series (Table 2) were more frequent than
J CATARACT REFRACT SURG-VOL 22, JUNE 1996
CASE REPORTS: McKIBBIN
those reported for routine cataract surgery. 6 Phacomorphic glaucoma is caused by pupil block with secondary angle closure or by displacement of the peripheral iris and angle closure without pupil block. When pupil block is the initial mechanism, laser iridotomy may help relieve angle closure if it is performed before significant peripheral anterior synechias have developed. 5 However, angle closure can still occur despite the presence of a patent peripheral iridotomy.5.7 None of our patients had a laser iridotomy during their initial management nor a subsequent surgical iridectomy. Instead, we believe that prompt ECCE and IOL implantation is the definitive treatment and will remove the tendency toward angle closure whatever the initial mechanism. Furthermore, we believe that an iridectomy is not necessary during the subsequent surgery if preoperative gonioscopy shows that significant peripheral anterior synechias have not developed and that it is unhelpful if synechias have developed, in which case definitive drainage surgery is required. Final visual acuity in eyes with phacomorphic glaucoma is variable, although in most cases final lOP is less than 20 mm Hg without treatment. 3 . 5 The one patient with a final acuity of hand motions (#2) was seen 5 days after the onset of pain and reduced vision and at the last examination had a bullous keratopathy and capsular fibrosis. All five patients with phacomorphic glaucoma had a postoperative lOP of 15 mm Hg or less without treatment. Using miotics during the initial management of phacomorphic glaucoma carries a theoretical risk of exacerbating the angle closure by increasing the pupil block and iris bombe or by allowing anterior lens movement, increasing the overall anterior-posterior diameter? We used a mixture of miotics or mydriatics in the initial management of patients with phacomorphic glaucoma. Three patients received pilocarpine and one patient, homatropine. No regime appeared to compromise control of the lOP. In the Tomey and Al-Rajhi5 series, surgery was delayed in one case; when the patient stopped using pilocarpine, the angle closure returned. Preoperative mydriasis before cataract extraction may precipitate a further episode of acute angle closure glaucoma,5 although this did not occur in our series. It would seem logical to use mydriatics to facilitate ECCE and IOL implantation.
Most patients with phacolytic glaucoma achieve a normal lOP without treatment and a good visual acuity.4.g The definitive treatment is medical control of the lOP and ECCE and posterior chamber IOL implantation. Prolonged treatment was required in two cases to control inflammation before surgery. At presentation, patient 7 had a creamy liquid throughout the anterior chamber that obscured the iris details. We believed the liquid to be soft lens matter. After two days, it settled in the lower half of the anterior chamber, improving the view for surgery. Patient 6 was given systemic steroids. Although surgery was not performed in eyes with phacolytic glaucoma until 6 days after admission on average, the delay did not appear to be associated with any problems. Intraocular pressure was often raised in the immediate postoperative period and was controlled only after inflammation had subsided. Final lOP was 17 mm Hg without treatment in all cases. Final best corrected visual acuity was good in all but one patient who had age-related macular degeneration and a final acuity of 20/120. All nine patients had had poor visual acuity in the affected eye for some time. All five patients with phacomorphic glaucoma were Asian. In Bradford, ethnic minorities make up 20% of the population. Patients from these ethnic groups often present late and with mature cataracts. Of the five cases, four had been referred to a hospital for assessment. Two had been given appointments but had not yet been seen, one failed to attend an outpatient appointment, and one had been seen and listed for cataract surgery already. Cataract surgery had been performed on the fellow eye in three of the four patients with phacolytic glaucoma. One of these patients had been referred to the hospital for further evaluation. The median waiting time for outpatient assessment in the United Kingdom is 2.64 months, and the median waiting time for cataract surgery once the patient has been listed is 4.8 months. 1 In Bradford, the routine outpatient waiting time is 9 months on average and the waiting time for routine cataract surgery is 12 to 14 months. It could be argued that some cases of lensinduced glaucoma could be prevented if the waiting times were shorter. Priority is usually given to patients with mature cataracts or very poor visual acuity, which depends, however, on the visual acuity recorded in the referral letter. Furthermore, some delay occurs when patients or their general practitioners wait to begin the
J CATARACT REFRACT SURG-VOL 22. JUNE 1996
635
CASE REPORTS: McKIBBIN
referral process. Patient education would help reduce delay by encouraging patients to present earlier. More resources would be required to deal with the current waiting times and the extra workload of earlier referrals. In summary, we recommend ECCE and 10L implantation in cases of phacomorphic and phacolytic glaucoma to improve visual acuity and resolve the glaucoma. Surgery should be done within a few days of presentation, especially with phacomorphic glaucoma.
References 1. Desai P. The National Cataract Surgery Survey: III. Process features. Eye 1993; 7:667-671 2. Epstein DL, Jedziniak JA, Grant WM. Identification of heavy-molecular-weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci 1978; 17:398-402 3. Civerchia LL, Balem A. Intraocular lens implantation in
636
acute angle closure glaucoma associated with cataract.
Am Intra-Ocular Implant Soc J 1985; 11:171-173 4. Lane SS, Kopietz LA, Lindquist TO, Leavenworth N. Treatment of phacolytic glaucoma with extracapsular cataract extraction. Ophthalmology 1988; 95:749-753 5. Tomey KF, Al-Rajhi AA. Neodymium:YAG laser iridotomy in the initial management of phacomorphic glaucoma. Ophthalmology 1992; 99:660-665 6. Desai P. The National Cataract Surgery Survey: II. Clinical outcomes. Eye 1993; 7:489-494 7. Liebmann JM, Ritch R. Glaucoma secondary to lens intumescence and dislocation. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas. St Louis, CV Mosby, 1989; 1027-1028 8. Moschos M, Brouzas 0, Papantonis F. Extracapsular cataract extraction and posterior chamber lens in the management of phacolytic glaucoma. Eur J Implant Refract Surg 1993; 5:145-147
J CATARACT REFRACT SURG-VOL 22, JUNE 1996