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   Table of Contents      
ORIGINAL ARTICLE
Year : 1991  |  Volume : 39  |  Issue : 3  |  Page : 97-101

Cataract induced glaucoma-An insight into management


Dr. R.P. Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, N. Delhi, India

Correspondence Address:
S K Angra
Dr. R.P. Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, N. Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 1841901

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  Abstract 

The problem of phacomorphic glaucoma is a rather common entity in rural India owing to the delay in getting the cataract removed and the preponderance of cortical matter, compared with the Western world. The authors in India, South East Asia and Australia, have managed the problem differently leading to controversies. The pathogenesis has been investigated and is well understood. An aspect of phacomorphic glaucoma that remains quite unanswered, is of the relatively poor visual outcome and increased incidence of operative and post-operative complications. We endeavour to evaluate the management, intraoperative and post-operative complications of phacomorphic glaucoma (senile cataract induced). The effect of high intraocular pressure (I.O.P) and surgical trauma on the corneal endothelium is also assessed.


How to cite this article:
Angra S K, Pradhan R, Garg S P. Cataract induced glaucoma-An insight into management. Indian J Ophthalmol 1991;39:97-101

How to cite this URL:
Angra S K, Pradhan R, Garg S P. Cataract induced glaucoma-An insight into management. Indian J Ophthalmol [serial online] 1991 [cited 2019 Nov 19];39:97-101. Available from: http://www.ijo.in/text.asp?1991/39/3/97/24439



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  Material and methods Top


40 cases of phacomorphic glaucoma secondary to senile cataract were randomly divided into two surgical groups of 20 each i.e. ICCE (Intracapsular Cataract Extraction) and combined ICCE and trabeculectomy. The preoperative parameters for evaluation were recorded i.e. detailed history, I.O.P. (intraocular pres­sure mm Hg Sch), facility of outflow (C-value) and gonioscopy. After this the cases were treated medi­cally with topical pilocarpine, oral glycerol and diamox, as well as intravenous mannitol. After achieving medical control of IOP, the parameters were repeated along with the endothelial cell count using the video corneal endothelial microscope (Model HS-CEM 4). The eyes them underwent surgery according to the group they were assigned to randomly. The in­traoperative complications like capsule rupture, vitreous loss, hyphema were noted. Postoperatively, they were followed up by recording all the parameters, repeated at 15 days, 6 weeks and 3 months intervals. The primary glaucoma in the fellow eye was ruled out by investigations.


  Observations Top


The age of the patients ranged from 50 to 80 years with the mean age being 64 years. 55% cases were in the age group between 50 and 60. 30% between 61 and 70 years and 15% between 71 and 80 years. The female to male ratio was almost 3 to 1. Type of cataract were 23 intumescent (immature) senile cataract and 17 hypermature swollen cataracts.

The intraocular pressure ranged from 34 to 83 mm Hg. Schiotz. There was no relationship between the duration of attack and height of LOP However there was a strong correlation of the duration of the attack with the preoperative visual status [Table - 1].

Evaluation Of Medical Management

i) I.O.P. - The mean I.O.P could be brought down to 20.5 mm Hg. Schiotz whereas in 15 eyes the I.O.P could not be controlled immediately.

ii) Visual status after medical management: Of the 16 eyes with inaccurate light projection, 7 eyes improved to accurate projection of light after medical management [Table - 1]

iii) Gonioscopy grade improved from a mean of 0.55

• 0.74 to a mean of 1.88 ± 0.44 (Group A) and from 0.92 + 1.19 to 1.64

.33 (Group B)

iv) Facility of outflow improved from a mean of 0.88

• 0.09 ml/min/mm Hg to 0.09 ± 0.03 ml/min/mm Hg.

v) Endothelial cell loss due to the glaucomatous attack preoperatively was 14.8% [Table - 2] when compared to the fellow non-glaucomatous eye.

The Evaluation Of Surgery [Table - 3]

i) Intraoperative complications:- Capsule rupture oc­curred in 3 cases each in both groups. The vitreous face was broken in 3 cases in ICCE group and 2 cases in ICCE + trabeculectomy group. Vitreous loss occurred in one case each in both the groups. There was excessive bleeding in 3 cases in ICCE group and in 5 cases of the ICCE + trabeculectomy group.

ii) Post operative complications: Striate Keratopathy occurred in 8 cases of ICCE group and 5 cases of ICCE + trabeculectomy group. Postoperative shallow or flat anterior chamber occurred in 4 cases of ICCE group and 2 cases of ICCE + trabeculectomy group.

iii) Control of I.O.P: In the ICCE group from an initial mean IOP of 42.95 mm Hg Schiotz (range 34-83), the tension reduced to 19 mm Hg Schiotz (range 6-35). In ICCE trabeculectomy group from an initial mean of 53.2 mm Hg Sch. (range 36-80) it came down to 18.6 mm Hg Sch. (range 15-25). Comparing the two groups it was significant at t=2.2734, p 0.05 [Table - 6]. The gonioscopy grades and C-value improved after surgery more so in the combined surgery group [Table - 4][Table - 5].

iv) Final visual acuity: The visual acuity after surgery improved almost equally in both the groups [Table - 6][Table - 7]. Various causes for poor visual recovery were persistent corneal oedema (1 case), senile macular degeneration (5 cases), glaucomatous optic atrophy (6 cases) in 30% cases.

v) Endothelial cell loss : It was 26.8% in ICCE group and 16.10% in ICCE + trabeculectomy group. This was statistically significant at t = 4.078, P =.001 [Table - 2].


  Discussion Top


Senile cataract induced phacomorphic glaucoma is not very common in the European countries' while quite frequent in India, (3.91% of all cataract opera­tions done) [2],[3] . We found the mean age to be 64 years with none occurring below 50 years, showing that phacomorphic glaucoma is a disease of old age with preponderance between 50-60 years. The dura­tion of attack is related to the type of cataract: lesser with intumescent cataract, whereas no relation could be found with the height of raised intraocular pressure. This is in conformity with the findings of Angra et al [3]sub (1985). Female preponderance was found to be almost three times more which has already been shown by other workers [1][2][3],[5] One reason could be the lesser attention received by old women in rural India and also anatomically, females having shallower anterior chamber depth thus making them more prone for angle closure [1],[3].The incidence and rise of I.O.P was related to the maturity of cataract in a series of Varma et al [5 ] which we could not substantiate.

Medical management constitutes an important step in the care of phacomrphic glaucoma. We found that in our series intraocular pressure in 37.5% eyes could not be controlled medically. These eyes were found to have extensive peripheral anterior synechiae (P.A.S), and a longer duration of attack. Varma et a1 [5]sub were able to control IOP in all their cases.

The medical therapy improves the gonioscopy grading but will not lower the IOP significantly where PAS are 180 o or more [Table - 4]. Visual status also could be improved after medical management in the sense that out of the 16 cases which presented with faulty projection of light, 9 cases could be made to have accurate light projection by bringing down the I.O.P. We feel this was because of the sudden high LOP that had caused optic nerve ischaemia leading to conduction defects. The endothelial cell loss of 14.8% was found after the glaucomatous attack. As the preglaucoma endothelial count was not available, we compared the cell count of the fellow eye assuming that the endothelial cell counts in the two eyes are comparable [6].

There is no significant difference in the incidence of capsule rupture, vitreous loss and hyphema in the two surgical groups. The striate keratopathy was more in the ICCE group as compared with ICCE + trabeculectomy group. We do not agree with Jain et a1 [4], who found more postoperative complications in the combined extraction group. The postoperative shallow anterior chamber was more in ICCE group than in ICCE + trabeculectomy group because of better control of IOP Jain et a1 [4] got shallow anterior chamber in 11.1 % of patients which is in conformity with our series.

When the control of IOP in the two groups was compared there was a better control in ICCE + trabeculectomy group (p 0.05). This control also had a definite relationship with organic changes in the angle of the anterior chamber with a better improve­ment in the outflow facility and duration of the attack.

We could achieve normalisation of IOP in only 75% of cases of cataract surgery whereas Jain et a1 [4] had reported 90% success.

There is a better overall improvement in visual acuity outcome in ICCE + trabeculectomy group. This is not in agreement with the observations of Jain et a1 [4]s. We agree with Angra et a1 [3] that as the duration of the attack increases, the chance of regaining visual acuity worsens. We have found that the initial faulty light projection does not necessarily mean a poor outcome. The final visual acuity was related more to the duration of attack than to the type of surgery. But the operative complications and pre-ex­isting conditions like senile macular degeneration and glaucomatous optic atrophy had a role to play in the visual prognosis.

We noticed that the effect of cataract extraction alone seemed to have accounted for a greater percentage of endothelial cell loss than that of the combined trabeculectomy procedure, viz. 26.8% vs 16.1%. It was highly significant statistically (t=4.078);

p = 0.001). One of the reasons could be that in the combined procedure, the section is more scleral and hence larger, with a minimal chance of the swollen lens rubbing against the back of the cornea, The better control of LOP being another factor for a lesser endothelial cell loss in these cases.

SUMMARY

Evaluation of the two types of surgical moda;ities in relation to control of LOP, complications and visual prognosis was done. The combined ICCE with trabeculectomy procedure seemed superior in con­trolling the I.O.P. In eyes with a longer duration of attack, cataract extraction alone does not seem to control I.O.P. The post operative complications also did not appear to be more than those in the cataract extraction groups. The final visual prognosis was directly proportional to the duration of attack rather than to the type of cataract and modality of surgery.

Corneal endothelial cell loss appeared significantly less in the combined ICCE + trabeculectomy group.

 
  References Top

1.
Lowe R.F.: Arch. Ophthalmol, 1: 80-83, 1973.  Back to cited text no. 1
    
2.
Awasthi P. Raizada, Bhatia R.P & Srivastava S.K.: Proc. XXI Int. Cong. Ophthalmol, Mexico, 1124-1127, 1970.  Back to cited text no. 2
    
3.
Angra S.K., Singh A, Mohan M. & Bhatia I.M, X Trans Asia Pac. Acad. Ophthalmol. 10:342, 1985.  Back to cited text no. 3
    
4.
Jain S. Gupta A, Dogra M.R., Gangawar D.N., Dhir S. P: Ind. J. Ophthalmol. 31:648, 1983.  Back to cited text no. 4
    
5.
Verma BMD, Srivastava S.K. & Rekha. Proc. Ac. Ind. Ophthalmol Soc. 39:316, 1980.  Back to cited text no. 5
    
6.
Panda A, Mohan M, Choudhary S, Angra S.K. & Garg S.P: Trans Asia Pac, Acad. Ophthalmol 10:273, 1985.  Back to cited text no. 6
    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]


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