Lens-Associated Open-Angle Glaucomas

Lens-Associated Open-Angle Glaucomas

Michele C. Lim

Ashley G. Lesley


Lens-associated open-angle glaucomas are composed of three separate diagnoses with similar clinical presentations. Lens protein glaucoma, lens particle glaucoma, and lens-associated uveitis (LAU) may each present with intraocular inflammation, an abnormal lens, and elevated intraocular pressure (IOP), although hypotony may commonly occur in the latter. Distinguishing among the three entities requires careful examination and an understanding of the mechanisms that define each diagnosis (Table 15-1).

TABLE 15-1. Clinical Presentation of Lens-Associated Open-Angle Glaucomas

Lens Particle Glaucoma

Lens Protein Glaucoma



Lens material obstructs TM

HMW lens proteins obstruct TM

Loss of immune tolerance




Low or elevated


Open angle

Open angle

Open angle

Lens status

Disruption to lens capsule with release of lens particles

Mature or hypermature cataract

Disruption to lens capsule; exposure of large lens fragments


Antiglaucoma medication, steroids, surgical removal of lens material

Antiglaucoma medication, topical steroids, cataract removal

Antiglaucoma topical medication, topical steroids, removal of lens fragments

HMW, heavy-molecular-weight; IOP, intraocular pressure; LAU, lens-associated uveitis; TM, trabecular meshwork.


Lens protein glaucoma occurs in the presence of a mature or a hypermature cataract (Fig. 15-1). Soluble lens proteins seep into the anterior chamber and obstruct the trabecular meshwork, causing an elevation in IOP.

Special Tests

• Samples taken from the aqueous humor and concentrated via Millipore filtration may reveal macrophages and an amorphous substance corresponding to lens protein.

• The diagnosis is usually made on clinical observation alone.


1. Hogan M, Zimmerman L. Ophthalmic Pathology: An Atlas and Textbook. 2nd ed. Philadelphia, PA: WB Saunders; 1962:797.

2. Irvine S, Irvine A. Lens-induced uveitis and glaucoma. Am J Ophthalmol. 1952;35:489.

3. Epstein D, Jedziniak J, Grant W. Identification of heavy-molecular-weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci. 1978;17(5):398-402.

4. Epstein D, Jedziniak J, Grant W. Obstruction of aqueous outflow by lens particles and by heavy-molecular-weight soluble lens proteins. Invest Ophthalmol Vis Sci. 1978;17(3):272-277.

5. Rosenbaum J. Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma. Arch Ophthalmol. 1987;105:1582.

6. Uemura A, Sameshima M, Nakao K. Complications of hypermature cataract: Spontaneous absorption of lens material and phacolytic glaucoma-associated retinal perivasculitis. Jpn J Ophthalmol. 1988;32(1):35-40.

7. Venkatesh R, Tan CS, Kumar T, et al. Safety and efficacy of manual small incision cataract surgery for phacolytic glaucoma. Br J Ophthalmol. 2007;91:279-281.

FIGURE 15-1. Mature cataract. Mature cataract with folds in the anterior capsule. (Courtesy of Donald L. Budenz, MD, MPH University, North Carolina, Chapel Hill.)

FIGURE 15-2. Lens protein glaucoma. Macrophages in the trabecular meshwork in lens protein glaucoma. (Courtesy of Donald L. Budenz, MD, MPH University, North Carolina, Chapel Hill.)

FIGURE 15-3. Lens protein glaucoma. Intense anterior chamber inflammation with mature cataract in lens protein glaucoma. (Courtesy of Donald L. Budenz, MD, MPH University, North Carolina, Chapel Hill.)

FIGURE 15-4. Lens protein glaucoma. Hypermature cataract (A and B) with clumps of inflammatory cells on the lens face (white arrows). (Courtesy James D. Brandt, Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA.)


Lens particle glaucoma occurs when the lens capsule is disrupted and lens cortex and proteins are released into the anterior chamber. This may occur after extracapsular cataract surgery, lens trauma with capsular disruption, and neodymium (Nd):YAG posterior capsulotomy in which liberated lens particles obstruct the trabecular meshwork, reducing aqueous outflow. Lens particle glaucoma after subluxation of a posterior chamber intraocular lens in a patient with pseudoexfoliation syndrome has also been reported1 (Figs. 15-5 and 15-6). Figure 15-7 shows an extreme case of lens particle glaucoma in which a hypermature cataract with phacodonesis progressed to dislocation into the anterior chamber with disruption of the capsular bag and led to high IOP.

May 4, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Lens-Associated Open-Angle Glaucomas

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