Lens Induced Glaucomas Saleh Al Obeidan, MD.

Lens Induced Secondary Angle Closure Glaucomas A. Condition(s) related to the size of the lens the lens -Intumescent cataract -Intumescent cataract - Traumatic cataract Mechanism: - Pupillary block - Direct angle closure - Combination Phacomorphic Glaucoma [PMG] Saleh Al Obeidan, MD 2

Lens Induced Secondary Angle Closure Glaucomas B. Condition related to the site of the lens the site of the lens - Subluxated - Dislocated Mechanism: - Direct angle closure - Pupillary block Saleh Al Obeidan, MD 3

Lens Induced Secondary Open Angle Glaucomas A. Condition(s) related to soluble lens proteins soluble lens proteinsMechanism: - Heavy Molecular Weight protein [HMW] protein [HMW] - Macrophagic response ?? Lens Protein Glaucoma [ Phacolytic Glaucoma ] Saleh Al Obeidan, MD 4

Lens Induced Secondary Open Angle Glaucomas B. Condition related to lens particles lens particlesMechanism: - Blockage of TM by lens particles e.g-retained lens matter particles e.g-retained lens matter -Post. YAG capsulotomy -Post. YAG capsulotomy Lens Particle Glaucoma Lens Particle Glaucoma Saleh Al Obeidan, MD 5

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG]  More common in smaller eyes (hyperopic) smaller eyes (hyperopic)  Encountered more in developing countries developing countries  Predisposed by rapidly developing intumescent cataract and traumatic cataract Saleh Al Obeidan, MD 6

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG]Mechanism: Swollen lens Pupillary block Angle closure Iris bombê Saleh Al Obeidan, MD 7

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Stages of PMG:  Pupillary Block  Angle crowding  Chronic angle closure Saleh Al Obeidan, MD 8

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Clinical Picture:  Like PACG  Mid-dilated fixed pupil  Shallow A/c  Closed angle  Faulty light projection Saleh Al Obeidan, MD 9

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG]Diagnosis:  Clinical picture  Gonioscopy of both eyes  Ultrasonography  Paracentesis ? Saleh Al Obeidan, MD 10

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG]Management:  Medical treatment to lower IOP  Frequent topical steroid  Pilocarpine  Laser Iridotomy [?PLI]  Cataract extraction + P/C IOL [ + trab. In long standing PMG]  The other eye Saleh Al Obeidan, MD 11

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Advantages of Laser PI:  Relieves acute attack  Allows eye to quiet pre-op  Allows evaluation of angle  Allows safe pre-op medriusis Saleh Al Obeidan, MD 12

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Risk of Iridotomy:  Bleeding  Endothelial injury  Rupture of lens capsule  Failure/Inflammation Saleh Al Obeidan, MD 13

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intra-operative Difficulties:  Difficult capsulotomy  Shallow Alc; pos. pressure  Constricted pupil  Poor view [corneal edema]  Descemet ’ s detachement  Weak Zonules Saleh Al Obeidan, MD 14

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intraoperative Difficulties Intraoperative Difficulties Poor View: Poor View:  Preoperative mannitol  Topical preoperative glycerine  ? Scrapping of epithelium Saleh Al Obeidan, MD 15

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Intra-operative Difficulties Difficult Capsulotomy and (Shallow A/c):  Deepening with viscoelastic mat. through paracentesis  Puncture the lens at the center and aspirate liquefied cortex Cont ’ n next slide … Cont ’ n next slide … Saleh Al Obeidan, MD 16

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Intra-operative Difficulties Difficult Capsulotomy and (Shallow A/c + POS. pres.):  Limited PPV (only cutter)  Trypan blue  Central circular capsul.  Start at 12 o ’ clock (can opener tech.) Saleh Al Obeidan, MD 17

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Intra-operative Difficulties Constricted Pupil: Constricted Pupil:  Mechanical Mydriasis - Visco elastic mat. - Pupil dilator - Pupil retractor - Small sphineteroctomies - Sector iridotomy Saleh Al Obeidan, MD 18

Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Intra-operative Difficulties Descemet ’ s Detachment: Descemet ’ s Detachment:  Avoid repeated A/c entry with sharp instrument  Careful IOL insertion  Viscoelastic mat. Saleh Al Obeidan, MD 19

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma]  A type of lens induced open angle glaucoma open angle glaucoma  Described by Zeeman in  Defined as phacolytic glaucoma by Flocks in 1955 Saleh Al Obeidan, MD 20

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein:  33% of total weight  85% soluble -Alpha crystallin – 15% - B Crystallin – 55% -  Crystallin – 15%  insoluble ‘ albuminoid ’ 15% Saleh Al Obeidan, MD 21

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Heavy Molecular Weight Protein [HMW]:  Increases with age & cataract formation  Mainly in nuclear region  Absent in infantile & juvenile lenses Saleh Al Obeidan, MD 22

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Experimental Studies: Perfusion of enucleated human eyes with  HMW ps 0.5mg severe obstruction  Perfusion time obstruction  Irrigation with BSS or alphachemotrypsin  LMW ps 1h no obstruction Saleh Al Obeidan, MD 23

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma]  Engorged macrophages after cataract needling in after cataract needling in children no phacolytic children no phacolytic glaucoma glaucoma  Swollen rabbit macrophages failed to elevate IOP failed to elevate IOP Saleh Al Obeidan, MD 24

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Studies: “ Patients with phacolytic glaucoma ” glaucoma ”  HMW ps 35% of total protein (0.8mg) protein (0.8mg)  0.8 mg is well in excess to cause obstruction  No HMW ps in normal subjects with immature & mature cataract Saleh Al Obeidan, MD 25

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma]Mehchanism:  Simple obstruction of the TM by HMW ps TM by HMW ps “ MW>150x10 6 daltons ”  Macrophages ? Obstructors ? Obstructors “ normal scavenger response ” “ normal scavenger response ” Saleh Al Obeidan, MD Relievers 26

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Picture:  Pain  H/o poor vision [faulty L. projection]  Conj. Hyperemia  Corneal Edema  Unilateral [other eye is aphakic or pseudophakic Cont ’ n next slide … Saleh Al Obeidan, MD 27

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Picture:  Mature or hypermature cataract cataract  IOP  Heavy flare  White patches on the Capsule  Open angle with deep A/c Saleh Al Obeidan, MD 28

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma] Differential Diagnosis:  Acute Angle closure glaucoma (PMG)  Neovascular glaucoma  Ghost-cell glaucoma  Angle recesion glaucoma  Uveitic glaucoma Saleh Al Obeidan, MD 29

Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein Glaucoma [Phacolytic Glaucoma]Management:  Medical Therapy  Admission  Anti-glaucoma therapy  Hyperosmotic agents  Topical steroids  Surgical  Cataract Extraction “ Sufficient I/A ” Saleh Al Obeidan, MD 30

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle Glaucoma Usually Follows:  Planned or unplanned extra cap. cataract extra cap. cataract extraction extraction  Penetrating lens injury  Nd: YAG laser capsulotomy Saleh Al Obeidan, MD 31

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle GlaucomaMechanism: Obstruction of T.M. by:  Free lens material  ? Inflammatory response Saleh Al Obeidan, MD 32

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle GlaucomaManagement:  Medical Therapy: - Anti-glaucoma therapy therapy - Topical steroid  Surgical: - A/c wash-out Saleh Al Obeidan, MD 33

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Nd: YAG laser Post. Capsulotomy and IOP Elevation  Is the most common complication  Acute “ within hours ”  Magnitude - 10mmHg above baseline reported in 59% - >40mmHg occurred in 38% - NLP have been reported Saleh Al Obeidan, MD 34

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Nd: YAG laser Post. Capsulotomy and IOP Elevation Risk is greater in:  Glaucoma patients  Eyes without IOL  More energy Saleh Al Obeidan, MD 35

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Nd: YAG laser Post. Capsulotomy and IOP ElevationManagement:  Measure IOP 1h post laser capsulotomy post laser capsulotomy  Prophylactic anti-glaucoma therapy  Topical steroids Cont ’ n next slide … Saleh Al Obeidan, MD 36

Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Management:  Medical Therapy - Anti-glaucoma therapy (avoid meotics) - Hyperosmotic agents  Surgical - Alc wash-out - Filtering procedure Saleh Al Obeidan, MD 38

Lens Induced Glaucomas Saleh Al Obeidan, MD ELEVATED IOP COMPLETELY OPAQUE CATARACT OPEN ANGLECLOSED ANGLE -Pre existing POAG -Lens Protein Glaucoma “phacolytic glaucoma” Deep A/cShallow A/c Very Shallow or Flat A/c -Pre existing angle closure - NVG - Accelerated PACG - True PMG - Advanced PMG - Aqueous misdirection 37