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   Table of Contents      
ARTICLE
Year : 1983  |  Volume : 31  |  Issue : 5  |  Page : 648-653

Phacomorphic glaucoma-management and visual prognosis


Department of Ophthalmology, Post-graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
I S Jain
Department of Ophthalmology, Post-graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 6671784

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How to cite this article:
Jain I S, Gupta A, Dogra M R, Gangwar D N, Dhir S P. Phacomorphic glaucoma-management and visual prognosis. Indian J Ophthalmol 1983;31:648-53

How to cite this URL:
Jain I S, Gupta A, Dogra M R, Gangwar D N, Dhir S P. Phacomorphic glaucoma-management and visual prognosis. Indian J Ophthalmol [serial online] 1983 [cited 2019 Aug 21];31:648-53. Available from: http://www.ijo.in/text.asp?1983/31/5/648/36619

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Table 1

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Table 1

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  Introduction Top


Secondary glaucoma may be precipitated during the development of senile cataract has drawn little attention in the literature [1],[2],[3] . This phenomenon, the so called "phacomorphic glaucoma" is an acute angle closure glaucoma and results from sudden hydration of an immature cataract which blocks the angle by a forward push of the iris [2] . This problem apparently is peculiar to our country. The main aim of this study was to evaluate the incidence, management and visual prognosis in these cases.


  Material and Methods Top


From January, 1978 to June, 1981, a total of 2719 senile cataracts were operated at the Nehru Hospital of the Postgraduate Institute of Medical Education and Research, Chandigarh and including 108 cases (3.91 %) of phacomorphic glaucoma. Of these 86 cases who had completed atleast 3 months of follow up and whose records were fairly complete were the subjects of this study. Preoperative work up included recording of duration of attack, visual acuity, type of cataract and intraocular pressure (IOP). Preoperatively, all patients were managed on diamox and frequent instillation of pilocarpine. Mannitol was administered if the above measures failed to control the ocular tension or also as a prophylactic measure in some cases. A single stage operation of cataract extraction with peripheral or sector iridectomy was undertaken if the tension could be controlled with above medical measures. Post operatively, diamox was not administered. Optic disc changes, refraction and ocular tension were recorded 6 weeks postoperatively and at the end of the followup period.


  Observations Top


Of the eighty six patients, 40 were males and 46 were females with an (average age 62 years). Duration of attack before reporting to us varied from one day to three months, mode being five days. Follow up varied from three to 31 months with an average of 7 months.

At the time of presentation, light projection was accurate in 58 eyes and inaccurate in 28 eyes. Inaccuracy of projection was significantly related to the duration of attack [Table - 1]. Intraocular pressure varied from 25 to 82 mm of Hg with a mean of 45.50 mm and showed a progressive rise with the duration of acute attack [Table - 1].

Three of the affected eyes had already undergone iris inclusion for chronic angle closure glaucoma before the phacomorphic glaucoma supervened.

12 of the 86 patients (13.95%) showed evidence of phacomorphic glaucoma in the opposite eye, 6 of whom had been operated previously and 6 bad gone into absolute stage.

23 of the 86 opposite eyes (26.7%) were normal or had good aphakia (Visual acuity > 6/12), whereas 40 eyes (46.5%) had some degree of cataractous changes.

Management

In all the 86 eyes, intraocular pressure could be controlled preoperatively with or without mannitol. Intracapsular cataract extraction was done in 49 eyes (57%), planned extracapsular cataract extraction in 9 eyes and combined extraction with trabeculectomy in 9 eyes. 19 eyes (20.2%) had accidental rupture of the lens capsule. Operative and postoperative complica­tions are shown in [Table - 2]. Corneal oedema, hyphaema and uveitis were some of the frequent complications in the group of simple cataract extraction. 6 of the 9 eyes undergoing combined extraction also had these major postoperative complications.

Control of intraocular pressure

80 of the 86 eyes (93%) had normal intraocular pressure at the end of follow up period without any medication and irrespective of the duration of attack and type of surgery.

Final visual acuity

Final visual return was directly related to the duration of attack. [Table - 3],[Table - 4],[Table - 5]. 54.5% of the eyes with less than 2 days of attack regained 6/12 or better visual acuity, whereas if the attack lasted 3 weeks or more, visual return was no better than hand movement or perception of light.

Optic disc changes

Optic disc changes in the form of pallor, glaucomatous cupping and atrophic cupping were directly related to the duration of attack [Table - 6]. Of the 59 eyes in which duration of glaucoma was less than 10 days, 45 eyes (76.2%) had clinically normal optic discs.


  Discussion Top


In the European races, there is a gradual shrinkage of lens with development of cataract and thereby a progressive deepening of the anterior chamber occurs. [3] Phacomorphic glaucoma is unusual in those people. On the other hand, cataract in Indians seems to become intumescent rather commonly. This is evident from the fact that during the period of study, we saw on an average one case of phacomorphic glaucoma for every 25 cases of cataract extrac­tion. It is not as yet clear why the cataract in our population shows sudden hydration and intumescence in contrast to the European people where there is progressive shrinkage of lens with development of cataract. In a previous work [4] we found that mean age in closed angle glaucoma in our population was 49.5 years and females predominates in a ratio of 2:1, whereas in the present study the mean age was 62.5 years with nearly equal distribution among the two sexes. Contrary to the belief of some authors [1] is annarent from our study that phacomorphic glaucoma is a distinct entity from acute closed angle glaucoma.

All cases were managed preoperatively on diamox and frequent instillation of pilocarpine to control the intraocular pressure. In 35 cases intravenous mannitol was administered prior to the lens removal. Fear of postoperative uveitis may be genuine if pilocarpine is used pre­operatively, but this can be overcome to a great extent by concomitant use of local steroids. We believe that pilocarpine plays a vital role in as much as it prevents formation of peripheral synechiae by constricting the pupil. As a result we found that more than 90% of eyes were made normotensive following a sample cataract extraction irrespective of the preoperative duration and level of intra-ocular pressure. Of the 9 cases subjected to combined extraction, as many as 6 were complicated by postoperative hyphaema and severe uveitis and had poorer visual outcome as compared to the group with simple extraction. Thus we strongly feel that filteration surgery has no place in the management of phacomorphic glaucoma.

Though, bilateral phacomorphic glaucoma was encounteted in nearly 14% of the eye cases, we do not recommend prophylactic iridectomy on the fellow eyes of these patients because (a) the occurrence of phacomorphic attack seem to occur almost 10 years later than the acute congestive glaucoma indicating that it is the swollen cataract per se that is respon­sible for this attack rather than a narrow angle alone, (b) the surgical procedure itself may accelerate the formation of a hydrated cataract, (c) our observations of acute phaco­morphic glaucoma in 3 eyes where an iris inclusion had already been done. Thus it appears that in these cases there is an acute angle closure by forward push of the iris root rather than a physiologic pupil block and iris bombe as seen in acute closed angle glaucoma. Peripheral iridectomy in such a situation may be insufficient to prevent an acute attack of phacomorphic glaucoma. Instead these eyes should be kept under observation for develop­ment of cataract and cataract extraction should be done before development of the instumescent stage.

Visual prognosis

We feel as do Avasthi et al [1] that these eyes tend to withstand raised intraocular pressure for a longer period than expected. At least 54% of the eyes with less than 2 days duration of attack recovered 6/12 or better vision, whereas only 32% of the eyes recovered this visual acuity if the duration of attack lasted 3 to 5 days. Thus as the duration of attack increased there was a progressive decline in the recovery of visual acuity and beyond 3 weeks only light preception or hand movemnts could be recovered.

Of the 18 eyes which presented with inaccurate projection of light within 3 weeks of the attack, atleast 15 eyes (83.3%) recovered better than counting finger vision and better than 6/12 in 3 eyes. However, of the 10 eyes with inaccurate projection presenting 3 weeks or more after the attack, 7 eyes could achieve only hand movement or perception of light. Thus in a case of phacomorphic glaucoma who presents early, a good functional visual recovery can be expected despite an initial inaccurate projection of light.

Optic disc also showed changes which were significantly related to the duration of attack glaucoma. Upto 10 days of attack, a large majority of optic discs (76.2%) retained good color. When the attack lasted more than 3 weeks nearly all the eyes developed pallor, cupping or atrophy of the disc.


  Summary Top


Incidence of phacomorphic glaucoma among 2719 senile cataracts undergoing surgery was 3.91 %. Of the 86 cases available for study, 77 eyes underwent simple cataract extraction with peripheral or sector iridectomy. More than 90% of the cases were normotensive at the end of the follow up.

Preoperative rise of intraocular pressure, accuracy of light projection and final visual recovery were significantly related to the duration of glaucoma. A good functional recovery was obtained if the attack lasted less than 20 days, beyond which only a hand movement or perception of light could be recovered. More than 75% of the optic discs retained good color if the attack lasted less than 10 days.

 
  References Top

1.
Avasthi, P., Raizada, V.N., Bhatia, R.P., and Srivastava, S.K., Effect of senile cataract on acute angle closure glaucoma Proceedings XXI, Int. Cong. Ophthal. Mexico, (Ed) M.P., Solanes, Amesterdam, Excerpta Medica, p. 1124-1127, 1970.  Back to cited text no. 1
    
2.
Duke-Elder, S., (Ed), System of Ophthalmology, Vol. Xl, London, Henry Kimpton, 662-663, 1969.  Back to cited text no. 2
    
3.
Lowe, R.F., Angle closure glaucoma and cataract East Arch. Ophthalmol., 1, 80-83, 1973.  Back to cited text no. 3
    
4.
Jain, I.S., Gupta Amod, Gangwar, D.N., Sharma, S.K., and Dhir, S.P., Prophylactic and therapeutic value of iridectomy in closed angle glaucoma, Under publication, Indian J. Ophthalmology.  Back to cited text no. 4
    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]


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Introduction
Material and Methods
Observations
Discussion
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