|Year : 1997 | Volume
| Issue : 1 | Page : 53-59
An alternate way to manage patients with morgagnian cataracts and phacolytic glaucoma
VST Centre for Glaucoma Care, L.V. Prasad Eye Institute, Hyderabad, India
A K Mandal
VST Centre for Glaucoma Care, L.V. Prasad Eye Institute, Hyderabad
|How to cite this article:|
Mandal A K. An alternate way to manage patients with morgagnian cataracts and phacolytic glaucoma. Indian J Ophthalmol 1997;45:53-9
|How to cite this URL:|
Mandal A K. An alternate way to manage patients with morgagnian cataracts and phacolytic glaucoma. Indian J Ophthalmol [serial online] 1997 [cited 2013 May 24];45:53-9. Available from: http://www.ijo.in/text.asp?1997/45/1/53/15022
The term, morgagnian cataract, refers to a clinical form of cataract hypermaturity. A typical morgagnian cataract consists of a capsular sac containing a more or less transparent, free floating nucleus in the midst of a completely liquified milky cortex. [Figure - 1] It is not as rare as the scanty reports in the literature would imply. Morgagnian cataracts, the older literature would indicate, were a frequent occurrence and were frequently encountered by the older ophthalmologists. In the modern ophthalmic practice, morgagnian cataracts are much less often met with, although cataracts of varying degrees of hypermaturity are still frequently seen. It is not uncommon during surgery to observe cataracts which, as soon as the capsule is incised, allow escape of a milky fluid cortex, followed by a diminutive nucleus. Such cataracts can be looked on as differing only in degree from the fully developed morgagnian cataract, in which the disintegration of the cortex has not advanced to the extent of causing a dislocation of the lens nucleus.
The complications of morgagnian cataracts are those of hypermature cataracts in general in addition to those peculiar to this form alone. Such complications invariably manifest themselves in the form of a secondary glaucoma known as phacolytic glaucoma. [Figure - 2] If the onset happens to be acute and stormy, the patient seeks advice before serious damage to the eye has taken place. If, however, as often happens, the onset is insidious, a damaging pressure may be present for a long time, unnoticed, so that by the time the patient is seen, perception of light is entirely gone. A frequent occurrence ushering in the glaucoma in these cases seems to be the escape of lenticular contents into the anterior chamber with or without rupture of the lens capsule. It is well known that the lens substance may become absorbed through the intact capsule, as numerous reported instances of spontaneous absorption of cataract would indicate. The frequency with which a spontaneous cure of cataract is associated with glaucoma has been previously noticed "........unfortunately for Nature's statistics, I have to report that in three of my four cases the eye has been lost by glaucoma. (Gifford)"
Although the first clinical description was by Gifford in 1900, the term phacolytic glaucoma was coined by Flocks et al in 1955. Phacoloytic glaucoma represents a lens induced acute secondary open angle glaucoma associated with rapid onset of pain, redness and watering in the eye and the intraocular pressure (IOP) may become as high as 60 to 80mm Hg. Visual acuity is reduced to perception of light with sometimes inaccurate or doubtful projection of rays. The lens usually shows a hypermature morgagnian cataract or mature cataract, rarely an immature cataract. Flocks et al believed that the condition was attributable to obstruction of the intertrabecular spaces by macrophages distended with engulfed lens material and morgagnian fluid that had escaped from the lens. Goldberg popularized Millipore filter technique for identification of the diagnostic macrophages. Epstein et al have shown that direct obstruction of outflow pathways by leaking heavy-molecular-weight soluble proteins (molecular weight 150 x 10 daltons) may significantly affect the pathogenesis of human phacolytic glaucoma. Such clogging is more specific than macrophage response in phacolytic glaucoma.
The aim of this communication is to highlight an alternate way to manage patients with morgagnian cataracts and phacolytic glaucoma with a simple technique of endocapsular surgery and capsular bag fixation of intraocular lenses.
| Establishing the diagnosis|| |
The diagnosis of morgagnian cataracts is easy and straight forward. However, the diagnosis of phacolytic glaucoma at times is difficult. A clinician must be able to rule out other possibilities such as:
- 1) Acute angle closure glaucoma, with or without an intumescent cataract
- 2) Phacomorphic glaucoma
- 3) Traumatic angle-recession glaucoma with cataract
- 4) Traumatic cataract induced uveitis and glaucoma
- 5) Uveitis with secondary open angle glaucoma
- 6) Neovascular glaucoma
- 7) Endogenous endophathalmitis with cataract
Adequate history and a meticulous examination listed below will clinch the diagnosis:
- 1) Applanation tonometry
- 2) Slit-lamp biomicroscopy
- 3) Gonioscopy
- 4) Posterior segment examination by ultrasonography
In phacolytic glaucoma, corneal epithelial and stromal oedema are usually present and the angle remains open without any visible abnormality. The anterior chamber may show intense flare and circulating particulate matter in the aqueous. The lens is usually hypermature with white capsular patches on its anterior surface.
Keratic precipates are usually not seen. Posterior or peripheral anterior synechia are characteristically absent. The anterior chamber fluid usually reveals engorged macrophages on microscopic examination. Biochemical studies have identified heavy-molecular-weight soluble lens protein in all cases.
| Management strategy|| |
The surgical technique of extra capsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation are the same in morgagnian cataracts as well as in phacolytic glaucoma and will be discussed later. In case of phacolytic glaucoma, the presurgical management should be done as described below:
A) Immediate management of high IOP
An immediate attempt should be made to lower the IOP with systemic hyperosmotics (intravenous mannitol, or oral glycerol), topical beta blockers and topical or systemic carbonic anhydrase inhibitors. Parasympathomimetic group of drugs (eg. pilocarpine) should preferably be avoided. When the IOP is lowered, the corneal oedema decreases and enables better evaluation of the anterior segment.
B) Management of anterior chamber inflammation
Patient should be started with intensive topical steroids (every 2 hours) topical cycloplegics (cyclopentolate) and systemic steroids if the inflammation is very severe.
C) Timing of surgical intervention
It is always preferable to wait for atleast 2 to 3 days before surgical intervention so that the IOP is lowered and the anterior chamber reaction is reduced. In the waiting period, patients must be on antiglaucoma medications, anti-inflammatory drops and under close supervision.
D) Surgical intervention:
Although there has been an unanimous agreement that cataract extractions is the definitive treatment of phacolytic glaucoma, controversy exists regarding the following:
- 1) ICCE vs ECCE
- 2) IOL implantation: to do or not to do
- 3) IOL implantation: primary vs secondary
- 4) IOL implantation: ideal position-in-the-bag vs sulcus fixation
- 5) Whether or not to add trabeculectomy to cataract extraction in phacolytic glaucoma.
Traditionally, ICCE has been the treatment of choice for phacolytic glaucoma to avoid the "dire consequences" of ECCE including phacoanaphylaxis. However, such possible consequences of ECCE have not I been adequately supported by clinical observations. Recently, there have been several reports stating that planned ECCE with PC IOL implantation is safe and curative in patients with phacolytic glaucoma.
| Surgical management|| |
A) Preoperative procedure
The pupil should be well dilated preoperatively with cyclopentolate hydrochloride 1%, alternating with phenylepherine hydrochloride 10% at 15 minutes interval in 4 sets, one hour preoperatively and another drop of each on the patient's arrival in the operation theatre. I prefer to operate on a very soft eye and therefore, in preparing my patients with phacolytic glaucoma preoperatively, I routinely give them mannitol 20% solution intravenously 1 gm/kg body weight to a maximum of 500 ml, of course, unless contraindicated for any other health reason.
B) Anaesthesia and preparation of the eye
A modified technique of anterior peribulbar anaesthesia is used without a conventional VII nerve block. No sedatives need to be used and this technique does not result in any discomfort.
Anaesthetic solution is prepared by dissolving one ampoule of hyaluronidase (1500 IU), and 0.3 ml of adrenalin in a 30 ml bottle of 2% lidocaine. Three millilitres of this solution along with 2 ml of 0.5% bupivacaine is drawn in a 5 ml syringe, to which a disposable half-inch 26 guage insulin needle is attached. The patient is requested to look up to make the orbital septum taut. The needle is inserted in the lower eyelid just above the inferior orbital margin approximately 5mm medial to the laternal canthus. It is advanced backwards and slightly medially parallel to the orbital floor, till the hub indents the skin and lateral part of the lower lid margin showed slight ectropion. Maintaining constant backward pressure with the hub, the solution is slowly deposited in the peripheral space. This is followed by application of a "Super-Pinki" for 30 minutes. No separate injection is given for lid akinesia. The effect of peribulbar anaesthesia is evaluated after 30 minutes. Topical anaesthetic drops are not used.
One drop of betadine solution is placed in the lower conjunctival cul-de-sac before the patient is shifted to the operating room. In the operating room the patient is positioned on a comfortable operating table and oxygen is given through the nasal catheter placed in the anterior nares. This has been found to be one of the most important aspects of local anaesthesia without sedation. The eye is scrubbed with povidone-iodine solution and then painted with Betadine solution followed by distilled water successively.
C) Surgical technique
The key steps of surgical technique has been outlined in [Table - 1] and the details of the technique is described below:
* Superior rectus traction suture is applied with a 4-0 braided black silk
* A peritomy incision is made in the conjunctiva at the limbus from 9.30 to 2.30 o' clock position, i.e, almost 150 degrees of limbal circumference and "wing-cut" is given on the conjunctiva at the ends of the incision. Conjunctivo-Tenon's layer is then undermined and retracted to expose the upper limbus.
* Hemostasis is meticulously achieved by coagulating the larger limbal scleral blood vessels with the help of bipolar under water cautery.
* I then make a half-thickness incision in the sclero-limbal junction at the superior limbus extending about 120 degrees. A small stab incision is then made at 12 O'clock with a No.11 Bard-Parker blade. The posterior lip of the wound at 12 O'clock position is depressed to drain the aqueous and then the anterior chamber is irrigated with balanced salt solutions to remove the particulate matter and turbid aqueous, which is then replaced with sterile 2% methylcellulose solution.
* A 26-gauge 1/2 inch needle mounted on a 2 ml glass syringe filled with balanced salt solution is taken and the needle is bent almost 4 mm from the tip on the bevelled surface. I use this needle to aspirate the white milky fluid cortex from the capsular sac.
* The bent needle is introduced into the anterior chamber through the stab wound made at 12 O'clock position. The needle is then introduced through the anterior capsule into the capsular sac [Figure - 3] and the milky fluid cortex is aspirated as much as possible till the underlying nucleus becomes clearly visible. [Figure - 4] The needle is then withdrawn from the wound and the contents of the syringe are inspected for the aspirate. [Figure - 5]
* Sterile methylcellulose is then injected into the capsular sac through the puncture made in the anterior capsule by the needle and a small amount of it is injected into the anterior chamber too.
* On either side, the corneoscleral section is enlarged with scissors [Figure - 6] to its full extent (120°) from 10 to 2 O'clock position
* V-shaped anterior capsulotomy is done with angled Vannas scissors [Figure - 7] introduced through the punctured wound in the anterior capsule to avoid any traction on the zonules.
* A small amount of sterile methylcellulose is then injected under the capsular operculum and also under the lens nucleus to float the nucleus thereby severing the adhesions which are at times present between the nucleus and the posterior capsule.
* Nucleus delivery is accomplished by pressure on the sclera with the help of irrigating vectis until the nucleus tips up at 12 O'clock position aided with gentle pressure with the forceps at 6 O'clock position. [Figure - 8] However, this manoeuvre may not be required as the continuous flow of the irrigating solution may itself float the nucleus enabling its easy delivery.
* Subsequently, irrigation and aspiration of the residual cortex is carried out with the classical Simcoe cannula
* Since major part of the milky fluid cortex sequestered within the sac had been aspirated prior to capsulotomy, copious cortical clean up can be achieved by use of minimal amount of irrigating solution. I call this technique as the "dry technique" of ECCE in morgagnian cataracts.
* Sterile methylcellulose is injected into the capsular bag and in the anterior chamber too. A posterior chamber intraocular lens is implanted in the capsular bag and is dialed for proper centration. [Figure - 9]
* A V-shaped anterior capsulectomy is performed by using angled Vannas scissors which obviates the need for traction on the capsule or on the zonules. Alternatively, an oblique incision is made in the capsule from the right free margin of the capsular operculum and anterior capsulectomy is completed by partial capsulorhexis. However, in view of weak zonules associated with hypermature cataracts in phacolytic glaucoma, I prefer performing a V-shaped anterior capsulectomy.
* Corneoscleral incision is then closed with interrupted 10-0 monofilament nylon and before placing the final suture, the anterior chamber contents are exchanged with balanced salt solution.
* Conjunctival flap is repositioned and a drop of antibiotic steroid preparation along with a drop of timolol maleate (0.5%) is instilled into the conjunctival sac, and a patch and shield are applied to the eye.
D) Postoperative care
In the immediate postoperative period, the treatment regimen consists of dexamethasone 0.1% one drop six times a day, topical cyclopentolate 1% 3 times a day. In patients with phacoytic glaucoma and patients of morgagnian cataracts who had high IOP on the first postoperative day are treated with topical timolol maleate 0.5% drops two times a day with oral acetazolamide 250mg three times a day if required. Patients are routinely examined at day 1, 1,3 and 6 weeks, and every 3 months postoperatively. Most patients require monitoring with greater frequency. At each visit, the following parameters are assessed: visual acuity, corneal status, anterior chamber, IOL, IOP and fundus. Antiglaucoma medications are discontinued after the first postoperative week, if IOP is adequately controlled. Topical dexamethasole is gradually tapered off over 6 weeks.
| Results|| |
During the last five years I have had the opportunity of managing 37 eyes with phacolytic glaucoma who underwent extracapsular cataract extraction with or without primary posterior chamber IOL. [Figure - 10]-[Figure:13].
A visual acuity of 6/12 or better was achieved in 66.7% and 84.6% in ECCE and ECCE + PC IOL group respectively. Intraocular pressure was well controlled in all patients without any antiglaucoma medication till the last followup. [Table - 2] The intraocular pressure remained controlled without antiglaucoma medication even in the group (n=5) where the desired visual recovery was not obtained. The poor visual recovery was attributable to glaucomatous disc damage. The duration and elevation of IOP did not cause any clinically detectable damage in the outflow pathway even when associated with significant glaucomatous disc damage. Hence, I feel, addition of trabeculectomy to cataract extraction seems superfluous in the control of IOP in patients with phacolytic glaucoma operated within 2 to 3 weeks onset of symptoms.
| Conclusion|| |
The described technique is superior as it offers the following advantages:
- 1) Ensures a soft globe
- 2) Chances of expulsive haemorrhage and choroidal effusion are minimized
- 3) Offers clear intraoperative visibility
- 4) Anterior capsulotomy can be performed without any undue manipulation on the lens capsule and zonular apparatus
- 5) Safe nucleus delivery
- 6) Minimal use of irrigating fluid for copious aspiration of residual cortex ("dry technique")
- 7) Good centration of IOL as it is implanted in-the-bag
- 8) After IOL implantation, anterior capsulectomy can be completed without exerting traction on the zonules
- 9) Sulcus fixated PC IOL implantation possible in case of posterior capsule rupture precluding the need for an anterior chamber IOL
- 10) Elevated IOP immediately after surgery from outflow obstruction by soluble lens protein is minimized.
The technique offers a safe, simple, quick, effective, and inexpensive way to perform ECCE with in-the-bag posterior chamber IOL implantation in phacolytic glaucoma and morgagnian cataracts. I perfected this technique in approximately 200 cases of morgagnian cataracts before employing it in phacolytic glaucoma. I offer this technique to the already existing surgical armamentarium in the management of phacolytic glaucoma and morgagnian cataracts.
The technique of extracapsular cataract extraction with posterior chamber intraocular lens implantation is now widely practised. The advantages of ECCE over ICCE are well documented in the literature. With a growing body of surgeons experienced in performing ECCE and PC IOL implantation, I believe that the time has come for a change from conventional ICCE to planned ECCE and in-the-bag IOL implantation in managing phacolytic glaucoma.
| References|| |
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|2.||Flocks M, Littwin CS. Zimmerman LE. Phacolytic glaucoma: a clinicopathologic study of one hundred thirty-eight cases of glaucoma associated with hypermature cataract. Arch Ophthalmol. 54:37-45, 1955. |
|3.||Goldberg MF. Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous. Br J Opthalmol. 51:847-853, 1967. |
|4.||Epstein DL. Jedzniak JA,Grant WM. Identification of heavy molecular weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci. 17:398-402, 1978. |
|5.||Gross KA, Pearce JL. Phacolytic glaucoma with ECCE and primary IOL implantation. Cataract. 2:22-23, 1984. |
|6.||Lane SS, Kopietz LA, Lindquist TD, Leavenworth N. Treatment of phacolytic glaucoma with extracapsular cataract extraction. Ophthalmology. 95:749-753, 1988. |
|7.||Moschos M, Brouzas D, Papantonis F. Extracapsular cataract extraction and posterior chamber lens in the management of phacolytic glaucoma. Eur J Implant and Refract Surg. 5:145-147, 1993. |
|8.||Singh G, Kaur J, Mall S. Phacolytic glaucoma - Its treatment by planned extracapsular cataract extraction with posterior chamber intraocular lens implanation. Ind J Ophthalmol. 42:145-147, 1994. |
|9.||Mandal AK. Endocapsular surgery and capsular bag fixation of intraocular lenses in phacolytic glaucoma. J Cataract Refract Surg. 22:288-293, 1996. |
|10.||Kishore K, Agarwal HC, Sood NN, Mandal AK. A modified technique of anterior peribulbar anaesthesia. Ind J Ophthalmol. 39:166-167, 1991. |
|11.||Mandal AK. How to diagnose and treat phacolytic glaucoma. Review of Ophthalmology 1996; Vol III, No. 8:106-108 |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12]
[Table - 1], [Table - 2]