Transcript Slide 1

Management of Combined
Phacolytic/Phacomorphic Glaucoma as
a Complication of Nd:YAG Laser
Peripheral Iridotomy in a Patient with
Mature Cataract
K. Camille DiMiceli, MD
Herbert J. Ingraham, MD
Department of Ophthalmology, Geisinger Health System
Danville, PA
Authors have no financial interest
Purpose/Methods:
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To discuss the management of a complicated
phacolytic/ phacomorphic glaucoma case
incited by Nd:YAG laser peripheral iridotomy
with accidental disruption of the anterior
capsule.
A retrospective study of the patient’s chart was
performed as well as photo documentation.
The patient was followed over the course of
several weeks before and after cataract surgery.
Case Presentation
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An 87 year old female with a history of mature
cataracts, narrow angle glaucoma, and chronic
macular holes OU presents with severe right eye
pain, nausea and vomiting.
Yag:Nd LPI was performed OD at an outside
office for narrow angle one day prior. Leakage
of white milky material was noted from LPI site
post laser. Patient was referred to Geisinger for
further management.
Exam:
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Va: OD: CF at ½ foot; OS: CF
at 1 foot
Pressure: OD: 62mmHg; OS:
8mmHg
Pupils: OD: 3mm, fixed and
mid-dilated, extensive synechiae;
OS: 3mm reactive
Conj: 1+ injection OU
Cornea: OD: 1+ edema OS:
clear
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AC: OD: very shallow; crystalline
material; OS: narrow angle
Iris: OU: patent PI superiorly; OD
with white crystalline material
Lens: OD: fluffy cortical material
with 4+brunescent nucleus; OS: 4+
brunescent cataract
Fundus: OU: no view
Pathophysiology
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Our patient had refused cataract surgery in the past
because of multiple medical problems and poor visual
prognosis secondary to bilateral chronic macular holes.
The mature intumescent lenses that developed caused
phacomorphic angle closure glaucoma.
Traumatic rupture of the anterior capsule with Yag:Nd
laser released high molecular weight proteins, which
blocked the trabecular meshwork and caused acute severe
elevated IOP. (4,7)
Macrophages are the main cellular component of the AC
reaction that ensues upon release of the lens proteins. 7
Treatment:
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Medical Therapy: It is recommend to always attempt to
lower IOP and allow time for inflammation to subside prior
to lens removal. Our treatment consisted of the following:
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Topical beta-adrenergic antagonist
Oral carbonic anhydrase inhibitors (Acetazolamide) are faster and
slightly more effective than topical agents. There is no additive
effect of using the two together. When using Acetazolamide, the
250mg tabs act more quickly than 500mg sustained release caps.
Aggressive topical steroids to quell inflammation
Mydriatic v. Miotic: We used Pilocarpine which took effect once the
IOP was under better control. Miotics can theoretically worsen
IOP by increasing pupillary block and anterior displacement of the
lens-iris diaphragm. Mydriatics can worsen angle closure, but are
helpful for use prior to surgery. There is no clinical difference when
either agent is used. 5
IV Mannitol is the next step, but was not necessary in our case.
Surgical Options:
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Removal of the inciting lens and debris is the definitive
treatment of lens induced glaucomas. We were able to
stabilize the patient and manage medically for one week prior
to surgery.
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ICCE was historically done to prevent phacoanaphylaxis, 1 but was
replaced by ECCE as early as 1957.
ECCE is the most commonly performed procedure.4 Peripheral
iridectomy is not necessary if a PCIOL is placed and there are no
significant PAS. 5
Phacoemulsification may be appropriate if the view is sufficient,
if the zonules are secure, and the lens is not excessively dense.
MSICS (manual small incision cataract surgery) is advocated as a
safe, efficient and cost-effective treatment in developing countries. 8
Spontaneous recovery: uncommon, but reported in patient who
refused surgery. 3
Surgery:
 In our patient we chose to do ECCE with iris stretch
based on the presence of the following:
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An extremely dense mahogany nucleus
Extensive synechiae from chronic angle closure
Poorly dilating pupil
Ruptured anterior capsule
 ECCE was performed on the fellow eye to treat the
phacomorphic glaucoma.
Results:
 Final Results: on Travatan qhs OU
 OD: BCVA: 4/400 (large stage 4 macular hole) IOP:
12mmHg
 OS: BCVA: 20/50+ (small stage 4 macular hole); IOP:
12mmHg
Conclusions:
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In lens induced glaucomas the preoperative IOPs are
markedly elevated (generally 40mmHg and higher) and
visual acuity can be quite poor (average HM-LP). 5
Despite this dismal presentation, after lens extraction the
IOP can be adequately controlled, often without
medication, and the vision can be restored if there is no
other significant ocular pathology.
In the management of this case we systematically went
through our armamentarium of medications to control
IOP and inflammation prior to and in preparation for
the definitive treatment of cataract extraction. When
possible, medical therapy should be used to temporize
this tenuous condition and to create a safer surgical
environment.
References:
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1. Mandal AK and Gothwal VK. “Intraocular Pressure Control and Visual Outcome in
Patients with Phacolytic Glaucoma Managed by Extracapsular Cataract Extraction with or
without Posterior Chamber Intraocular Lens Implantation.” Ophthalmic Surgery and
Lasers, Nov. 1998, vol 29, no. 11, pp 880-889.
2. Epstein David. “Diagnosis and Management of Lens-induced Glaucoma.
Ophthalmology, Mar 1982, vol 89, no. 3 pp 227-229.
3. Blaise P, Duchesne B, Guillaume S and Galand A. “Spontaneous Recovery in Phacolytic
Glaucoma.” Journal of Cataract and Refractive Surgery, Sept 2005, vol 31, pp 1829-1830.
4. Lane S, Kopietz L, Lindquist T, Leavenworth N. “Treatment of Phacolytic Glaucoma
with Extracapsular Cataract Extraction.” Ophthalmology, June 1988, vol. 95, no. 6, pp 749753.
5. McKibbin M, Gupta A, Atkins AD. “Cataract Extraction and Intraocular Lens
Implantation in Eyes with Phacomorphic or Phacolytic Glaucoma.” Journal of Cataract and
Refractive Surgery, June 1996, vol. 22, 633-636.
6. Rosenberg LF, Krupin T, Tang LiQi, Hong PH, Ruderman JM. “Combination of
Systemic Acetazolamide and Topical Dorzolamide in Reducing Intraocular Pressure and
Aqueous Humor Formation.” Ophthalmology, vol. 105, no. 1, pp 88-92.
7. Ueno H, Tamai A, Iyota K, and Moriki T. “Electron Microscopic Observation of the
Cells Floating in the Anterior Chamer in a Case of Phacolytic Glaucoma.” Japanese Journal
of Ophthalmology, vol 33: 103-113, 1989.
8. Venkatesh R, Tan CSH, Kumar TT, Ravindran RD. “Safety and Efficacy of Manual Small
Incision Cataract Surgery for Phacolytic Glaucoma.” British Journal of Ophthalmology
2007, 91: 279-281.