|Year : 1975 | Volume
| Issue : 1 | Page : 12-15
Lens extraction in secondary chronic congestive glaucoma due to intumescent cataract- A modified technique of iridectomy
Department of Ophthalmology, S.S. Medical College, Rewa, (M.P.), India
S P Srivastava
Department of Ophthalmology, S.S. Medical College, Rewa, (M.P.)
|How to cite this article:|
Srivastava S P. Lens extraction in secondary chronic congestive glaucoma due to intumescent cataract- A modified technique of iridectomy. Indian J Ophthalmol 1975;23:12-5
|How to cite this URL:|
Srivastava S P. Lens extraction in secondary chronic congestive glaucoma due to intumescent cataract- A modified technique of iridectomy. Indian J Ophthalmol [serial online] 1975 [cited 2013 May 23];23:12-5. Available from: http://www.ijo.in/text.asp?1975/23/1/12/31339
Acute congestive glaucoma associated with senile cataract is fairly common in India. This is mostly secondary to a rapidly developing intumescent cataract of the senile type.
The accepted treatment of such cases, if brought under treatment early before peripheral anterior synechiae develop, is the same as for primary acute closed angle glaucoma. The tension should be reduced by medical means followed by extraction of lens with peripheral or broad basal (complete sector) iridectomy.
Many of these cases of secondary glaucoma due to intumescent cataract come under observation late when anterior peripheral synechiae have developed and the closure of angle is either partly or totally structural rather than functional.
The continued use of Diamox keeps the tension under control but masks the formation of anterior peripheral synechiae. Ultimately by the time the patients come under the observation of an eye surgeon anterior peripheral synechiae have developed. The usual surgical treatment recommended for such cases is to control the intraocular pressure first by a drainage operation and to extract the lens later by performing a second operation. Performing a drainage operation in an eye with secondary congestive glaucoma due to intumescent lens and its later extraction is not always, easy and has its own drawbacks.
In cases of primary chronic congestive (angle closure) glaucoma, where anterior peripheral synechiae have developed Jervey  Torok  , and Wootton  originally suggested an iridectomy combined with freeing of the adhesions at the angle through the same incision with a blunt instrument. More recently Chandler  and Barkan  also advised freeing of the adhesions by a combined procedure of cyclodialysis and iridectomy done through the same incision at the limbus.
Based on the above procedures lens extraction combined with a modified iridectomy done after freeing the adhesions at the angle and after performing an iridodialysis before excising the iris (rather than a detachment of root after one pillar is cut) is described in the present articles as a surgical procedure suitable for long standing cases of secondary angle closure Glaucoma due to intumescence of lens or primary chronic congestive glaucoma, associated with mature senile cataract.
| Material and Methods|| |
Lens extraction with modified iridectomy has been performed in 25 such cases during the last five years with very satisfactory results. Out of these 25 cases, 18 patients reported after a period varying from 5 days to 21 days after the attack of glaucoma without taking any treatment. 5 cases had received medical treatment consisting of Diamox and miotics before reporting in our hospital. The pain and tension in all these cases was fairly controlled but the pupils were moderately dilated and the angle was closed on gonioscopic examination with formation of anterior peripheral synechiae. 2 cases had a history of repeated exacerbation of pain and redness during the last one and half to two months.
In all these cases initial medical treatment was instituted after admission to the hospital and the intra ocular pressure was normalized preoperatively. But in all of them the angle was still closed as revealed by gonioscopy. This series does not include those cases of secondary glaucoma due to intumescent lens in which initial medical treatment opened the angle and where extraction of lens with the usual peripheral or complete broad basal iridectomy was done.
| Technique|| |
A limbus based conjunctival flap is prepared and an ab-externo incision made just outside and concentric with the limbos from 3 to 9 O'clock, with two preplaced sutures. The assistant everts the conjunctivocorneal flap with a forceps to expose the iris sufficiently. With an iris forceps the iris is then caught mid-way between the pupillary margins and the root and put on stretch by slightly pulling it downwards. At the same time the tip of a fine iris repositor or a fine cyclodialysis spatula is passed between the anterior surface of the iris and the posterior surface of posterior lip of the wound, that is, in the angle of the anterior chamber and swept to each side to effect a cleavage and to break the anterior peripheral synechiae in the upper quadrant from 10 O'clock to 2 O'clock position. The iris is then caught again at 12 O'clock position just near the periphery and pulled gently downwards towards 6 O'clock with a little zigzag movement of the iris forceps till an iridodialysis results from 10.30 to 1-30 position. Many times the operator will be surprised at the amount of iris tissue which is pulled out in this way. The iridodialyses iris is then lifted out by the iris forceps and with two radial cuts at temporal and nasal end of iridodialysis, iridectomy is completed. The pillars of the coloboma are replaced.
An intracapsular extraction of the lens is then performed. Conjunctival flap is reposited and sutures tied. Air is injected in the anterior chamber and a subconjunctival injection of penicillin is given and the eye is bandaged.
| Results|| |
No untoward post-operative complication was seen in any case. Three cases developed hyphaema and two had delayed formation of anterior chamber. One case in whom the capsule had ruptured during lens extraction developed post-operative iritis.
The intra-ocular pressure was completely normalized in 22 cases which were followed for a period varying from 3 months to 3 years. In three cases when the patients reported after six weeks of the operation, the tension was high again. Two of these had presentation of vitreous in the anterior chamber during the operation and the slit lamp examination showed vitreous bands adhering to the corneoscleral wound at the time of followup. The third case was the one who had capsule rupture with post operative iritis.
| Discussion|| |
The rational treatment in cases of chronic congestive (angle closure) glaucoma where anterior peripheral synechiae have developed is to perform a drainage operation but when it is secondary to an intumescent cataract, a drainage operation will have to be followed by a lens extraction at a later date Both these procedures, that is, a drainage operation in an eye with chronic congestive glaucoma due to intumescent lens and cataract extraction in an eye in which a fistulizing operation has already been done, have their own drawbacks. In the former, complications such as malignant glaucoma, loss of anterior chamber and formation of more peripheral synechiae can occur and in the latter the difficulty of making a suitable section to avoid the filtering bleb has to be faced, apart from the fact that the patient has to undergo two operations.
Weber  as far back as 1877, asserted that iridectomy detaches the adhesions between the iris and chamber angle and re-establishes normal drainage of the fluid from the eye. Sugar  stated that during the performance of an iridectomy a direct pull on the iris above may open portions of the angle below and at sides even when iridectomy is not basal and even when the angle in the area remains blocked. Gorin  has also recommended an iridectomy for the chronic closed angle glaucoma due to peripheral synechia.
Forbes and Becker  also recommended an iridectomy even in long standing and neglected cases of angle closure glaucoma. They stated that it is of considerable interest that some angle closure glaucoma eyes with extreme peripheral anterior synechia formation can be controlled by iridectomy with normalization of pressure and outflow facility. In their cases iridectomy has been successful where acute congestive glaucoma has been present for longer than 48 hours, where both intra ocular pressure and facility of outflow were well outside the normal range of miotics and carbonic anhydrase inhibitors. They are also of the view that iridectomy also permits the use of stronger miotics and epinephrine without any danger of increasing pupillary block, should their administration become necessary due to residual post iridectomy glaucoma. They further state that although long standing apposition between iris and trabecular meshwork produces progressive increase in synechia formation, no hard and fast rule can be made regarding a specified duration of acute attack and the degree of structural alteration within the angle. Even extreme conditions may be largely reversed by an iridectomy. Duke Elder  also states that more recently it has been suggested that it is safer to do an iridectomy in order to relieve pupillary block and then to treat any residual raised tension by medical means.
Therefore it may be safe to assume that it is not necessary to do a drainage operation in eyes with anterior peripheral synechiae. Any technique of iridectomy which can help in opening the angle by breaking the peripheral synechiae will be welcome because then the lens can be extracted at the same sitting without much chance of serious complications. For this purpose any one of the techniques of doing iridectomy for cases where anterior peripheral synechiae have developed as described by Torok  Jervey  Woottan  , Chandler  and Barkan  or the one described in present series can be utilised with good results. The only precaution one should take is to prevent a capsule rupture of lens during its extraction and vitreous prolapse, as these complications are likely to cause higher incidence of residual glaucoma requiring further -medical or surgical treatment. Capsule rupture can be totally prevented by doing a cryoextraction of the lens.
This present technique of iridectomy can also be used for cases of chronic congestive (angle closure) glaucoma without cataract but when the section is large as made for a lens extraction it is more easy to perform iridodialysis than with a small section and hence the author has only tried it in cases with cataract.
| Summary|| |
A technique of iridectomy has been described for cases of chronic congestive (angle closure) glaucoma where anterior peripheral synechiae have developed. This has been tried in 25 cases of secondary glaucoma due to intumescent cataract where anterior peripheral synechiae have developed. The results obtained are good. This avoids the doing of a drainage operation first to control glaucoma and a second operation of lens extraction both of which have many drawbacks.
| References|| |
|1.||Barkan, O., 1954, Amer. J. Ophthal. 37, 504. |
|2.||Chandler, P. A., 1952, Arch Ophtha/. 47 695. |
|3.||Duke-Elder, S., 1969, System of Ophalmology Vol. XI. 663. Henry Kimpton, London. |
|4.||Duke-Elder, S., 1969, System of Ophthalmology Vol. XI. 621. Henry Kimpton, London. |
|5.||Forbes and Becker, 1964, Amer. J. Ophthal 57, 57. |
|6.||Gorin. G., 1960, Amer. J. Ophthal. 49, 141. |
|7.||Jervey, J. W. 1927, Jr. Amer. Ophthal. Soc. 25, 160. |
|8.||Priestley Smith., 1879, Quoted by Duke-Elder, S., 1969, System of Ophthalmalogy Vol. XI. 662. Henry Kimpton, London. |
|9.||Sugar, H. S., 1957, The Glaucomas, 2nd Edition, 370. A. Hoeber Harber Baok. New York. |
|10.||Torok, E., 1923, Arch. Ophthal. 52, 574. |
|11.||Weber, A., 1877, Arch. Ophthal. 23, 1. |
|12.||Wootton, H. W., 1932, Jr. Amer. Ophthal. Soc. 30, 64. |