BASICS

DESCRIPTION

Swelling of a cataractous lens causing a pupillary block mechanism of angle closure.

EPIDEMIOLOGY

• Elderly patient with advanced cataract

• More common in underdeveloped countries where patients with cataract tend to present late

RISK FACTORS

Shallow anterior chamber—the shorter axial length of the globe and greater axial lens thickness predispose an eye to phacomorphic glaucoma

GENERAL PREVENTION

• Prophylactic laser iridotomy

• Cataract extraction

PATHOPHYSIOLOGY

• The mechanism of phacomorphic glaucoma is that of angle-closure glaucoma from a relative pupillary block.

• As the cataract advances, the lens assumes a greater thickness and curvature to the anterior surface. This causes a shallow anterior chamber as well as greater iridolenticular touch.

• Aqueous fluid continues to be produced causing a rise in the posterior chamber pressure causing the lens iris diaphragm to move forward furthering the rise in intraocular pressure (IOP).

• If the anterior forces are sufficient, the iris will contact the peripheral cornea and an acute angle closure will occur.

ETIOLOGY

• Mature cataract

• Traumatic cataract

• Lens swelling from systemic medications

– Diuretics

– Hemorrhagic fever with renal syndrome

• Miotics constrict the pupil resulting in zonule laxity and forward movement of the lens.

COMMONLY ASSOCIATED CONDITIONS

• Hyperopia

• Miotics—increase zonular laxity causing forward movement of the lens

• Anticholinergics and sympathomimetics cause the pupils to dilate increasing iridolenticular touch especially in the mid dilated state.

DIAGNOSIS

HISTORY

• History of gradually diminishing vision over months or years and recent red, painful eye accompanied with headache, halos around lights, and nausea or vomiting

• History of previous subacute attacks usually at night or in dim illumination.

PHYSICAL EXAM

• Redness

• Diffuse corneal edema

• Shallow anterior chamber

• Mature cataract

• Angle closure

• Elevated IOP

• Cell and flare in the anterior chamber

• Fellow eye usually has a somewhat deeper chamber and a mature cataract as well

DIAGNOSTIC TESTS & INTERPRETATION

Imaging

B-scan ultrasound to ensure that there is no mass or other ocular pathology posterior to the lens.

Initial approach

Aggressive control of inflammation and IOP in preparation for laser or surgical iridectomy

Follow-up & special considerations

• Frequent follow-up and IOP management until definitive treatment is implemented

• Laser iridotomy may close secondary to the subluxated lens, and the preferred definitive treatment is removal of the inciting cataract.

DIFFERENTIAL DIAGNOSIS

• Angle closure secondary to intraocular tumors

• Lens particle glaucoma

• Phacolytic glaucoma

• Uveitic glaucoma

TREATMENT

MEDICATION

• Antiglaucoma therapy to control IOP: with hyperosmotics, topical carbonic anhydrase inhibitors, topical beta-blockers and alpha-2 agonists; topical steroid therapy to reduce inflammation

• Laser iridotomy

• Surgical iridectomy

ADDITIONAL TREATMENT

General Measures

Definitive treatment: Removal of the mature cataract

Issues for Referral

• Uncontrolled open-angle glaucoma or closed-angle glaucoma may necessitate glaucoma filtering surgery.

• Chronic angle-closure glaucoma may persist if there is synechial closure of the angle.

• Alternatively open-angle glaucoma may be present as a result of prior angle closure resulting in a reduction in outflow facility of the trabecular meshwork.

Additional Therapies

Once the cataract is removed IOP must be monitored and treatment instituted if glaucoma persists.

SURGERY/OTHER PROCEDURES

• Most often cataract removal is curative and no further surgery is needed.

• If the IOP remains elevated after surgical removal of the cataract and glaucoma is uncontrolled then glaucoma filtering surgery may be indicated.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Admission and IV mannitol may be necessary to control IOP until definitive surgery

Discharge Criteria

Once the IOP and inflammation is controlled, the patient may be discharged with close follow-up appointments.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Very close follow-up during the initial postoperative period is warranted to manage the IOP and inflammation.

Patient Monitoring

• Once the IOP is controlled, lifelong IOP monitoring and treatment are necessary for glaucoma.

• 3–6-month intervals depending on the severity of disease

PATIENT EDUCATION

The physiology of glaucoma and the importance of adherence to medication should be discussed.

PROGNOSIS

• Eyes with poor vision, even light perception, often obtain good vision after treatment.

• The prognosis depends on the prompt treatment of glaucoma and success of the, often difficult, cataract surgery.

COMPLICATIONS

• Vision loss secondary to glaucoma

• Vision loss secondary to surgical complications either from the complex cataract surgery (i.e., zonular dialysis, iris prolapse, vitreous loss, or corneal endothelial injury) or from glaucoma filtering surgery

ADDITIONAL READING

• Allingham RR, Damji KF, Freedman S, et al. Shields textbook of glaucoma, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2004.

• Lee SJL, Lee CKL, Kim WS. Long-term therapeutic efficacy of phacoemulsification with intraocular lens implantation in patients with phacomorphic glaucoma. J Cataract and Refract Surg 2010;36:783–789.

• Ellant JP, Obstbaum SA. Lens-induced glaucoma. Ophthalmology 1992;81:317–338.

• Epstein DL. Diagnosis and management of lens-induced glaucoma. Am Acad Ophthalmol 1982;89(3):227–230.

CODES

ICD9

Lens-induced angle closure one must use the primary diagnosis of cataract either:

• 365.20 Primary angle-closure glaucoma, unspecified

• 365.59 Glaucoma associated with other lens disorders

CLINICAL PEARLS

• Suspect in patients with mature cataract and hyperopia

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