lens induced glaucomas saleh al obeidan, md.. lens induced secondary angle closure glaucomas a....

Lens Induced Glaucomas

Saleh Al Obeidan, MD.

Lens Induced Lens Induced Secondary Angle Secondary Angle

Closure Closure GlaucomasGlaucomas

A.A. Condition(s) related to the size ofCondition(s) related to the size of the lensthe lens -Intumescent cataract-Intumescent cataract

- Traumatic cataract- Traumatic cataractMechanism: Mechanism:

- Pupillary block- Pupillary block- Direct angle closure- Direct angle closure- Combination- Combination

Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]

Saleh Al Obeidan, MD

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Closure Closure GlaucomasGlaucomas

B.B. Condition related to Condition related to

the site of the lensthe site of the lens

- Subluxated- Subluxated

- Dislocated- Dislocated

Mechanism: Mechanism:

- Direct angle closure- Direct angle closure

- Pupillary block- Pupillary block


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Lens Induced Lens Induced Secondary Secondary Open Angle Open Angle GlaucomasGlaucomas

A.A. Condition(s) related toCondition(s) related to soluble lens proteinssoluble lens proteins

Mechanism: Mechanism: - Heavy Molecular Weight - Heavy Molecular Weight

protein [HMW]protein [HMW]- Macrophagic response ??- Macrophagic response ??

Lens Protein Glaucoma [Lens Protein Glaucoma [Phacolytic Phacolytic

GlaucomaGlaucoma]]


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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomasAngle Glaucomas

B.B. Condition related toCondition related to

lens particles lens particles

Mechanism: Mechanism:

- Blockage of TM by lens - Blockage of TM by lens

particles e.g-retained lens matterparticles e.g-retained lens matter

-Post. YAG capsulotomy-Post. YAG capsulotomy

Lens Particle GlaucomaLens Particle Glaucoma


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Closure Closure GlaucomaGlaucoma

Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG] More common in More common in

smaller eyes (hyperopic)smaller eyes (hyperopic) Encountered more in Encountered more in

developing countriesdeveloping countries Predisposed by rapidly developing Predisposed by rapidly developing

intumescent cataract and traumatic intumescent cataract and traumatic cataractcataract


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Mechanism:Mechanism:

Swollen lensSwollen lens Pupillary block Pupillary block

Angle closureAngle closure Iris bomb Iris bombêê


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Stages of PMG:Stages of PMG:

Pupillary BlockPupillary Block Angle crowding Angle crowding Chronic angle closureChronic angle closure


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Clinical Picture:Clinical Picture:

Like PACGLike PACG Mid-dilated fixed pupilMid-dilated fixed pupil Shallow A/cShallow A/c Closed angleClosed angle Faulty light projectionFaulty light projection


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Diagnosis:Diagnosis:

Clinical pictureClinical picture Gonioscopy of both eyesGonioscopy of both eyes UltrasonographyUltrasonography Paracentesis ?Paracentesis ?


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Management:Management: Medical treatment to lower IOPMedical treatment to lower IOP Frequent topical steroidFrequent topical steroid PilocarpinePilocarpine Laser Iridotomy [?PLI]Laser Iridotomy [?PLI] Cataract extraction + P/C IOL [ + trab. In Cataract extraction + P/C IOL [ + trab. In

long standing PMG]long standing PMG] The other eyeThe other eye


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Advantages of Laser PI:Advantages of Laser PI:

Relieves acute attackRelieves acute attack Allows eye to quiet pre-opAllows eye to quiet pre-op Allows evaluation of angleAllows evaluation of angle Allows safe pre-op medriusisAllows safe pre-op medriusis


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Risk of Iridotomy:Risk of Iridotomy:

BleedingBleeding Endothelial injuryEndothelial injury Rupture of lens capsuleRupture of lens capsule Failure/InflammationFailure/Inflammation


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Intra-operative Difficulties:Intra-operative Difficulties: Difficult capsulotomyDifficult capsulotomy Shallow Alc; pos. pressureShallow Alc; pos. pressure Constricted pupilConstricted pupil Poor view [corneal edema]Poor view [corneal edema] Descemet’s detachementDescemet’s detachement Weak ZonulesWeak Zonules


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Intraoperative DifficultiesIntraoperative Difficulties

Poor View:Poor View:

Preoperative mannitolPreoperative mannitol Topical preoperative glycerineTopical preoperative glycerine ? Scrapping of epithelium? Scrapping of epithelium


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Closure Closure GlaucomaGlaucoma Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]

Intra-operative DifficultiesIntra-operative Difficulties

Difficult Capsulotomy and Difficult Capsulotomy and (Shallow A/c):(Shallow A/c):

Deepening with viscoelastic mat. Deepening with viscoelastic mat. through paracentesis through paracentesis

Puncture the lens at the center and Puncture the lens at the center and aspirate liquefied cortexaspirate liquefied cortex

Cont’n next slide…Cont’n next slide…


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Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG] Intra-operative DifficultiesIntra-operative Difficulties

Difficult Capsulotomy and Difficult Capsulotomy and (Shallow A/c(Shallow A/c

+ POS. pres.):+ POS. pres.): Limited PPV (only cutter)Limited PPV (only cutter) Trypan blueTrypan blue Central circular capsul.Central circular capsul. Start at 12 o’clock (can opener tech.)Start at 12 o’clock (can opener tech.)


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Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG] Intra-operative DifficultiesIntra-operative Difficulties Constricted Pupil: Constricted Pupil: Mechanical MydriasisMechanical Mydriasis

-- Visco elastic mat.Visco elastic mat.- Pupil dilator- Pupil dilator- Pupil retractor- Pupil retractor- Small sphineteroctomies- Small sphineteroctomies- Sector iridotomy- Sector iridotomy


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Intra-operative DifficultiesIntra-operative Difficulties Descemet’s Detachment: Descemet’s Detachment:

Avoid repeated A/c entry with sharp Avoid repeated A/c entry with sharp

instrumentinstrument Careful IOL insertionCareful IOL insertion Viscoelastic mat.Viscoelastic mat.


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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma

Lens Protein Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma][Phacolytic Glaucoma]

A type of lens induced A type of lens induced

open angle glaucomaopen angle glaucoma Described by Zeeman in Described by Zeeman in

19431943 Defined as phacolytic glaucoma by Defined as phacolytic glaucoma by

Flocks in 1955Flocks in 1955


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Lens Protein:Lens Protein: 33% of total weight33% of total weight 85% soluble85% soluble

-Alpha crystallin – 15%-Alpha crystallin – 15%

- B Crystallin – 55%- B Crystallin – 55%

- - Crystallin – 15% Crystallin – 15% insoluble ‘albuminoid’insoluble ‘albuminoid’ 15%15%


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Heavy Molecular Weight Protein [HMW]:Heavy Molecular Weight Protein [HMW]: Increases with age & cataract Increases with age & cataract

formationformation Mainly in nuclear regionMainly in nuclear region Absent in infantile & juvenile lensesAbsent in infantile & juvenile lenses


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Experimental Studies:Experimental Studies:

Perfusion of enucleated human eyes withPerfusion of enucleated human eyes with HMWHMWpsps 0.5mg0.5mg severe obstruction severe obstruction Perfusion time obstructionPerfusion time obstruction Irrigation with BSS or alphachemotrypsinIrrigation with BSS or alphachemotrypsin LMWLMWps ps 1h1h no obstruction no obstruction


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Engorged macrophages Engorged macrophages

after cataract needling in after cataract needling in

children no phacolytic children no phacolytic

glaucomaglaucoma Swollen rabbit macrophages Swollen rabbit macrophages

failed to elevate IOPfailed to elevate IOPSaleh Al Obeidan, MD

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Clinical Studies: Clinical Studies: ““Patients with phacolytic Patients with phacolytic glaucoma”glaucoma” HMWHMWps ps 35% of total 35% of total protein (0.8mg)protein (0.8mg) 0.8 mg is well in excess to cause obstruction0.8 mg is well in excess to cause obstruction No HMWNo HMWps ps in normal subjects with immature in normal subjects with immature

& mature cataract& mature cataractSaleh Al Obeidan, MD

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Mehchanism: Mehchanism: Simple obstruction of the Simple obstruction of the

TM by HMWTM by HMWpsps

““MW>150x10MW>150x106 6 daltons”daltons” MacrophagesMacrophages

? Obstructors? Obstructors ““normal scavenger responsenormal scavenger response””


Relievers

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Clinical Picture: Clinical Picture: PainPain H/o poor vision H/o poor vision [faulty L. projection][faulty L. projection]

Conj. HyperemiaConj. Hyperemia Corneal EdemaCorneal Edema Unilateral [other eye is aphakic or Unilateral [other eye is aphakic or

pseudophakic pseudophakic Cont’n next slide…Cont’n next slide…Saleh Al Obeidan, MD

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Clinical Picture: Clinical Picture: Mature or hypermature Mature or hypermature

cataractcataract IOPIOP Heavy flareHeavy flare White patches on the CapsuleWhite patches on the Capsule Open angle with deep A/cOpen angle with deep A/c


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Differential Diagnosis: Differential Diagnosis: Acute Angle closure glaucoma (PMG)Acute Angle closure glaucoma (PMG) Neovascular glaucomaNeovascular glaucoma Ghost-cell glaucomaGhost-cell glaucoma Angle recesion glaucomaAngle recesion glaucoma Uveitic glaucomaUveitic glaucoma


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Management: Management: Medical TherapyMedical Therapy AdmissionAdmission Anti-glaucoma therapyAnti-glaucoma therapy Hyperosmotic agentsHyperosmotic agents Topical steroidsTopical steroids SurgicalSurgical Cataract Extraction “Cataract Extraction “Sufficient I/ASufficient I/A””


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Usually Follows:Usually Follows: Planned or unplanned Planned or unplanned

extra cap. cataract extra cap. cataract

extractionextraction Penetrating lens injuryPenetrating lens injury Nd: YAG laser capsulotomyNd: YAG laser capsulotomy


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Mechanism:Mechanism:

Obstruction of T.M. by:Obstruction of T.M. by:

Free lens materialFree lens material ? Inflammatory response ? Inflammatory response


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Lens Particle Glaucoma Lens Particle Glaucoma

Management:Management: Medical Therapy:Medical Therapy:

- Anti-glaucoma - Anti-glaucoma

therapytherapy

- Topical steroid- Topical steroid Surgical:Surgical:

- A/c wash-out - A/c wash-out Saleh Al Obeidan, MD

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Lens Particle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy Nd: YAG laser Post. Capsulotomy

and IOP Elevation and IOP Elevation Is the most common complicationIs the most common complication Acute “within hours”Acute “within hours” MagnitudeMagnitude

- 10mmHg above baseline reported in - 10mmHg above baseline reported in 59%59%

- >40mmHg occurred in 38%- >40mmHg occurred in 38%- NLP have been reported- NLP have been reported


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Nd: YAG laser Post. Capsulotomy Nd: YAG laser Post. Capsulotomy and IOP Elevation and IOP Elevation

Risk is greater in:Risk is greater in: Glaucoma patientsGlaucoma patients Eyes without IOLEyes without IOL More energyMore energy


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Nd: YAG laser Post. Capsulotomy Nd: YAG laser Post. Capsulotomy and IOP Elevation and IOP Elevation

Management:Management: Measure IOP 1h Measure IOP 1h

post laser capsulotomypost laser capsulotomy Prophylactic anti-glaucoma therapyProphylactic anti-glaucoma therapy Topical steroidsTopical steroids

Cont’n next slide…Cont’n next slide… Saleh Al Obeidan, MD

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Nd: YAG laser Post. Capsulotomy and IOP Nd: YAG laser Post. Capsulotomy and IOP ElevationElevation

Management:Management: Medical TherapyMedical Therapy

- Anti-glaucoma therapy (avoid meotics)- Anti-glaucoma therapy (avoid meotics)

- Hyperosmotic agents- Hyperosmotic agents SurgicalSurgical

- Alc wash-out- Alc wash-out

- Filtering procedure- Filtering procedureSaleh Al Obeidan, MD

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Lens Induced Lens Induced GlaucomasGlaucomas


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 closure- NVG

- Accelerated PACG- True PMG

- Advanced PMG

- Aqueous misdirection

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lens induced glaucomas saleh al obeidan, md.. lens induced secondary angle closure glaucomas a....

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