Lens Induced Glaucomas
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Transcript of Lens Induced Glaucomas
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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Lens Induced Lens Induced Secondary Angle Secondary Angle
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
Saleh Al Obeidan, MD
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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]]
Saleh Al Obeidan, MD
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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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Mechanism:Mechanism:
Swollen lensSwollen lens Pupillary block Pupillary block
Angle closureAngle closure Iris bombê Iris bombê
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Stages of PMG:Stages of PMG:
Pupillary BlockPupillary Block Angle crowding Angle crowding Chronic angle closureChronic angle closure
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Diagnosis:Diagnosis:
Clinical pictureClinical picture Gonioscopy of both eyesGonioscopy of both eyes UltrasonographyUltrasonography Paracentesis ?Paracentesis ?
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Risk of Iridotomy:Risk of Iridotomy:
BleedingBleeding Endothelial injuryEndothelial injury Rupture of lens capsuleRupture of lens capsule Failure/InflammationFailure/Inflammation
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
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] DescemetDescemet’’s detachements detachement Weak ZonulesWeak Zonules
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Intraoperative DifficultiesIntraoperative Difficulties
Poor View:Poor View:
Preoperative mannitolPreoperative mannitol Topical preoperative glycerineTopical preoperative glycerine ? Scrapping of epithelium? Scrapping of epithelium
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
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
ContCont’’n next sliden next slide……
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
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
+ POS. pres.):+ POS. pres.): Limited PPV (only cutter)Limited PPV (only cutter) Trypan blueTrypan blue Central circular capsul.Central circular capsul. Start at 12 oStart at 12 o’’clock (can opener tech.)clock (can opener tech.)
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Angle Secondary Angle
Closure Closure GlaucomaGlaucoma
Phacomorphic Glaucoma [PMG]Phacomorphic Glaucoma [PMG]
Intra-operative DifficultiesIntra-operative Difficulties DescemetDescemet’’s Detachment: 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.
Saleh Al Obeidan, MD
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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
Saleh Al Obeidan, MD
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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]
Lens Protein:Lens Protein: 33% of total weight33% of total weight 85% soluble85% soluble
-Alpha crystallin -Alpha crystallin –– 15% 15%
- B Crystallin - B Crystallin –– 55% 55%
- - Crystallin Crystallin –– 15% 15% insoluble insoluble ‘‘albuminoidalbuminoid’’ 15%15%
Saleh Al Obeidan, MD
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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]
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
Saleh Al Obeidan, MD
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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]
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
Saleh Al Obeidan, MD
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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]
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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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Protein Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma][Phacolytic Glaucoma]
Clinical Studies: Clinical Studies: ““Patients with phacolytic Patients with phacolytic glaucomaglaucoma”” 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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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Protein Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma][Phacolytic Glaucoma]
Mehchanism: Mehchanism: Simple obstruction of the Simple obstruction of the
TM by HMWTM by HMWpsps
““MW>150x10MW>150x106 6 daltonsdaltons”” MacrophagesMacrophages
? Obstructors? Obstructors ““normal scavenger responsenormal scavenger response””
Saleh Al Obeidan, MD
Relievers
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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]
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 ContCont’’n next sliden next slide……Saleh Al Obeidan, MD
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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]
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
Saleh Al Obeidan, MD
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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]
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
Saleh Al Obeidan, MD
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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]
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””
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Particle GlaucomaLens Particle Glaucoma
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Particle GlaucomaLens Particle Glaucoma
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 Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
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 Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
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 Acute ““within hourswithin 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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Particle Glaucoma Lens Particle Glaucoma
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
Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Particle Glaucoma Lens Particle Glaucoma
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
ContCont’’n next sliden next slide…… Saleh Al Obeidan, MD
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Lens Induced Lens Induced Secondary Open Secondary Open Angle GlaucomaAngle Glaucoma
Lens Particle Glaucoma Lens Particle Glaucoma
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
Saleh Al Obeidan, MD
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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