L. Jay Katz

BASICS

DESCRIPTION

A secondary glaucoma resulting from elevated intraocular pressure (IOP) due to intraocular lens (IOL)–associated chronic inflammation and recurrent hyphemas

EPIDEMIOLOGY

Incidence

Uncommon

Prevalence

Unknown

RISK FACTORS

• Most common with iris-supported or closed-loop anterior chamber lOLs

• Malpositioned haptics of posterior chamber IOLs

• Subluxed IOLs

GENERAL PREVENTION

• Avoid using closed-loop anterior chamber IOLs

• Meticulous placement of posterior chamber lenses in the bag and appropriate lenses in the sulcus to avoid poorly positioned haptics.

PATHOPHYSIOLOGY

IOL-induced iris trauma leads to chronic intraocular inflammation and hemorrhage.

ETIOLOGY

A poorly positioned IOL causes iris chaffing and leads to inflammation and hemorrhage, resulting in elevated IOP.

COMMONLY ASSOCIATED CONDITIONS

Pseudoexfoliation

DIAGNOSIS

HISTORY

• History of cataract surgery with placement of an iris-sutured anterior chamber or a malpositioned posterior chamber IOL

• Transient blurring of vision

• Anticoagulation may exacerbate hemorrhage associated with IOL-induced iris chaffing (1)[C].

PHYSICAL EXAM

• Elevated IOP

• Anterior chamber IOL

• Poorly positioned or subluxed posterior chamber IOL

• Iritis

• Hyphema or microhyphema

• Iris transillumination defects

• Posterior synechiae

• Gonioscopy may be helpful in identifying malpositioned IOL haptics.

• Also perform gonioscopy to rule out neovascularization/peripheral anterior synechiae of the angle.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Consider checking the PT/INR in patients on anticoagulants to rule out supratherapeutic levels.

Imaging

Initial approach

• Ultrasound biomicroscopy (2)[C] may be used to identify IOL malpositioning and facilitate planning for surgical intervention.

• Optic disc photography or imaging (confocal scanning laser ophthalmoscopy, optical coherence tomography, scanning laser polarimetry)

Follow-up & special considerations

Repeat optic nerve photography or imaging periodically.

Diagnostic Procedures/Other

Visual fields

Pathological Findings

• Sterile anterior segment inflammation and hemorrhage

• Iris melanosomes on IOL haptics

DIFFERENTIAL DIAGNOSIS

• Trauma

• Neovascular glaucoma

• Uveitic glaucoma

• Swan syndrome (elevated IOP and recurrent hyphema associated with neovascularization of the corneoscleral surgical wound)

• Fuchs’ heterochromic iridocyclitis

• Ghost cell glaucoma

• Intraocular tumors (such as malignant melanomas) resulting in recurrent hyphemas

• Juvenile xanthogranuloma

TREATMENT

MEDICATION

First Line

• Atropine 1%

• Topical steroids (e.g., prednisolone acetate)

• Topical beta-blockers (e.g., timolol, betaxolol), alpha-2 agonists (e.g., brimonidine), and/or carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide)

• Prostaglandin analogues (e.g., travoprost, latanoprost, bimatoprost) may be used if other topical medications fail to provide adequate IOP control.

Second Line

• Oral or intravenous carbonic anhydrase inhibitors (e.g., acetazolamide)

• Intravenous hyperosmotics (e.g., mannitol)

ADDITIONAL TREATMENT

Issues for Referral

Consider referral to an experienced anterior segment surgeon if surgical intervention is warranted.

SURGERY/OTHER PROCEDURES

• Argon laser ablation of an isolated area of bleeding vessels may be attempted (3)[C].

• Lens exchange or repositioning and/or anterior chamber washout is often required (4)[C].

• Trabeculectomy or tube shunt if IOP remains uncontrolled

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Control the IOP using the medications described previously.

Admission Criteria

Admission is rarely indicated. Consider admission if the IOP remains significantly elevated despite topical and oral medications.

Discharge Criteria

• Reasonable IOP

• Controlled eye pain

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Timing of follow-up is dependent on IOP control.

Patient Monitoring

Periodically monitor IOP, optic nerve appearance, and visual fields.

PROGNOSIS

• Variable depending on:

– Time to diagnosis and treatment

– Preexisting optic nerve damage

COMPLICATIONS

• Glaucomatous visual field loss

• Decreased acuity related to IOL position, glaucomatous optic neuropathy, or both

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