|Year : 1959 | Volume
| Issue : 2 | Page : 52-56
Acute glaucoma requiring lens extraction
|Date of Web Publication||7-May-2008|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lowe R. Acute glaucoma requiring lens extraction. Indian J Ophthalmol 1959;7:52-6
The introduction of Acetazoleamide ( Diamox ) has removed most cases of acute glaucoma from the former position of surgical emergency ; but the dramatic fall in intraocular pressure mint not be permitted to encourage a false sense of security in the patient or the ophthalmologist. Now more than ever, is it known that every patient who has developed an attack of acute congestive primary glaucoma will need an early operation upon that eye and possibly upon both eyes. Acetazoleamide removes the acute emergency; but more important it permits the eye to return to a state where the underlying condition may be properly assessed. It is upon this careful and sometimes difficult assessment that the type of operation is determined, for it is by no means a routine decision.
Most cases are readily classified into one of the three big groups, namely(1) narrow angle, with angle closure due to the periphery of the iris forced against the cornea, ( 2 ) chronic simple glaucoma with decompensation, or ( 3 ) secondary glaucoma. However, examinations of quietened eyes allow the diagnosis of rarer conditions.
Instead of the operation being always limited to a selection between peripheral iridectomy and iridencliesis some cases require lens extraction. Under this heading may be grouped the following lens conditions which may cause acute glaucoma-(1) dislocation, (2) phacolysis, (3) intumescence, (4) malignant glaucoma.
| Dislocated Lens|| |
A dislocated lens has long been known to cause acute glaucoma. All acetazoleamide does is to unmask some dislocations that were hidden by the oedema and congestion of the acute phase. When the cornea clears and the dislocated lens is seen to be the cause of the acute glaucoma its removal becomes obligatory.
Case No. I. Mr. W.McB., age 6o years, reported on 12 December 1955 with the complaint that his right eye had been sore for two days. Examination showed severe right ciliary injection and corneal oedema, a shallow anterior chamber, a dilated and fixed pupil and a very high intraocular tension to palpation. His left eye was white, the optic disc showed no cupping and the vision with correction was 6/9.
He was given 500 milligrammes of acetazoleamide (Diamox) by mouth and admitted to hospital. The pupil constricted with repeated eserine drops, and with further acetazoleaniide the tension fell overnight to right 30,* left 18. After another day's treatment the right and left tensions were 16 and 17 respectively. By this time the right cornea had practically cleared so that a vitreous knuckle could be seen protruding through the pupil and a white lens was identified deep in the vitreous in the six o'clock position. Gonioscopy showed a very wide and open angle of the right anterior chamber.
Intraocular tensions are recorded as conversions to intraocular pressures expressed in millimetres of mercury . as measured with a Schiotz (weightless) X tonometer.
While awaiting the routine operating day the acetazoleamide was discontinued. Within two days the right eye became painful and the tension rose to 60. With further acetazoleamide administration the tension again subsided satisfactorily.
On the day tenth from the original onset, operation was performed under general anesthesia. Following a Graefe-knife incision and a full iridectomy above, with a sphincterotomy below, the large smooth white lens was delivered with a vectis with no definite vitreous loss. After the usual wound toilet and closure by the preplaced sutures air was injected into the anterior chamber.
Convalescence was uneventful. One month later the right tension was 25 and vision was less than 6/60 with a correcting lens. He continued to use his left eye for his usual activities but this eye began to develop nuclear sclerosis and lens opacities After six months the right tension was 35 and the vision in the right eye was only 6/36 with correction. At twelve months the right tension was 22 and vision had improved to 6/18 with correction but by eighteen months the tension appeared to be controlled normally and vision was 6/9 with correction. By this time his right eye was the better eye for reading because his left lens opacities were increasing. Three months later he was wearing his aphakic correction and his left eye was awaiting cataract extraction ( later performed successfully ).
The features to be noted abut this case are : (1 ) an acute attack of glaucoma was caused by a dislocated lens ; (2) the angle of the anterior chamber was wide and open ; ( 3 ) lens extraction cured the glaucoma, but,(4) the intraocular tension took some months to become stable and normal, and, (5) the vision remained poor for a very long time but became almost normal with correction after eighteen months.
| Phacolytic Glaucoma|| |
Hypermature cataract as a cause of acute glaucoma has been recognised for over fifty years and many papers have been written to show that this type of glaucoma can be cured by removal of the lens. Nevertheless, from the files of the Armed Forces Institute of Pathology, Flocks, Littwin and Zimmerman ( 1955) were able to provide a clinico-pathologic study of one hundred and thirty-eight eyes that had been enucleated to relieve this painful syndrome. Probably more than half of these eyes could have been saved. They gave the name " Phacolytic Glaucoma " to denote the basic pathologic process.
Case No. 2. Mrs. A. C. knew that for many years she had a left cataract because when she was aged eighty-two years she had been told that a cataract was present but her vision would last her life-time.
She was seen on 13 January 1958 with complaint that two days previously her left eye had begun to ache ; later the aching became very severe and was accompanied by vomiting. Her health was said to be good.
Examination showed only mild left ciliary injection but marked left corneal oedema, a deep anterior chamber and a hypermature left cataract. The left intraocular tension felt high but not hard. After the oral administration of two tablets of acetazoleamide ( Diamox ) she was admitted to hospital where the left intraocular tension was recorded as 45. With continued acetazoleamide tablets and eserine eye drops the left intraocular tension fell overnight to 15. Slit lamp examination then showed a moderate flare but no cells in the aqueous and a hypermature cataract containing iridescent spots. Gonioscopy showed wile angles of the anterior chambers. Due to senile lens sclerosis the vision in her other eye was reduced to counting fingers at three feet.
After considerable protestation about her age she was persuaded to have an operation. On the day eighth after the onset, under local anesthesia after a Graefe-knife cataract incision followed by two peripheral iridotomies the lens appeared positioned well forwards.
The capsule was grasped at six o'clock by Castroviejo forceps and the lens was removed through the round pupil, mainly by expression. As the lens was lifted it became evident that a Morgagnian cataract was present and as the lens was removed in its capsule a milky fluid leaked into the anterior chamber. The eye was irrigated and the wound was closed by the preplaced sutures.
On admission to hospital she had given her age as 91 years but after the operation she confided in the nursing sister that it was really 96 and that she had put her age back in order not to appear so old.
During convalescence some lens flakes were seen over the anterior vitreous face but these quickly absorbed. Vision slowly improved and after four months had reached 6/9 and the ability to read J 3 with appropriate correcting lenses. She then firmly requested the glasses and had not reported since that time.
The features to be noted in this case are : (1) an attack of acute glaucoma was caused by lens material from a Morgagnian cataract, (2) the angle of the anterior chamber was wide, and, (3) lens extraction cured the glaucoma and restored good vision.
| Intumescence of the Lens|| |
A rapid swelling of the lens as a cause of acute glaucoma was first recognised by von Graefe in 1869. The generally accepted theory is that the swollen lens pushes the root of the iris into contact with the cornea to occlude the filtration angle. The following case shows that other mechanisms may be involved in causing the rise in pressure.
Case No. 3. Miss M., aged 87 years, had left amblyopia exanopsia. She had been examined in 1952 when her right vision was 6/12 with correction. She reattended on 8 January 1958 with the complaint of blurred right vision. Her history was very vague and she appeared to be very unintelligent. She stated that some two or three weeks previously her right vision suddenly became very misty. A friend said that she had suffered very severe pain at the onset.
Examination of the right eye showed no redness, the cornea was clear except that there were some folds in Descemet's Membrane, the anterior chamber was extremely shallow, the pupil was slightly dilated but reacted to light and the vitreous contained numerous opacities. The retina could not be seen but vision was reduced to 2/60.
The diagnosis was difficult. A vitreous haemorrhage was considered but in view of the severe pain at the onset of the blurred vision, the very shallow anterior chamber and the folds in Descemet's Membrane it was thought that probably she had suffered an attack of acute angle-closure glaucoma due to intumescence of the lens and that the attack had subsided spontaneously. It was decided to wait and watch if the vitreous cleared but as a precaution she was ordered eye drops of two per cent pilocarpine to use four times daily.
What a precaution it was ! In two days she returned with severe pain watering and photophobia in the right eye, bright ciliary injection, a steamy cornea and a tension of 90. She was admitted in the hospital and placed on a regime of acetazoleamide tablets and eserine eye drops. The tension subsided only gradually and hovered between 30 and 35 even after ten days. During this time she was found to be epileptic and permission for operation was given only after considerable persuasion.
On the twelfth day under general anesthesia the tension was 16 and lens extraction was performed. On attempting the application of Castroviejo forceps the lens sank and vitreous- presented. The lens was removed with a vectis with the loss of a little vitreous, so a full iridectomy was completed. Convalescence was uneventful but the upper part of the cornea remained oedematous due to vitreous contact. Vision was poor with a correcting lens and the best that could be recorded was 3/36. The patient was unhelpful and the state of the vitreous or retina could not be determined. The tension was 17 in each eye and the right eye gave no discomfort.
The features to be noted in this case are : (1) an attack of acute glaucoma was caused by intumescence of the lens, (2) the first acute attack resolved spontaneously but after the use of pilocarpine was again precipitated presumably due to a pupil block from the miosis, and, (3) lens extraction cured the glaucoma.
In retrospect, the use of sympatheticomimetic mydriatics (neo-synephrine) probably would have been better than eserine.
| Malignant Glaucoma|| |
The term " Malignant Glaucoma " was used by von Graefe to describe a grave condition that followed some glaucoma operations and resulted in blindness. The following extract from von Graefe's paper was presented by Chandler (1951)-" One sees bad cases in which if the anterior chamber is flat there is a rise in tension during the immediate post-operative period. The iris and lens are in contact with the cornea. The eye begins to tear, there is circumcorneal injection ... the patient is aware of great tenderness in the ciliary region and complains of more or less ciliary pain. Visual acuity falls in an alarming fashion...through operation a new glaucomatous process is brought about which is unusual only in the continued failure of the anterior chamber to reform." The underlying feature of malignant glaucoma is the forward displacement of iris-lens diaphragm completely closing the angle and blocking the wound. The condition is particularly likely to occur when the cornea is small and before operation the anterior chamber is shallow and the tension high.
Attempts to prevent its occurrence should be made by intensive preoperative medical treatment or preliminary surgery (posterior sclerotomy or cyclodiathermy ). Chandler insists that lens extraction should be considered the treatment of election and that it should be performed before the ocular disturbance becomes too severe.
| Discussion and Conclusions|| |
Despite acetazoleamide acute primary glaucoma necessitates surgical control. The value of acetazoleamide lies in permitting accurate diagnosis of the underlying condition which then must be treated properly. The dangers of acetazoleamide lie in procrastination. Removal of the severe pain brings protests about operations but it is the duty of ophthalmologists to emphasise the necessity for correct surgery. The choice of the appropriate operation requires meticulous examinations to elucidate the cause or mechanism of the acute attack.
| Summary|| |
Acute glaucoma may be caused by the following lens conditions-- (1) dislocation, (2) phacolysis, (3) intumescence, (4) malignant glaucoma. Lens extraction is required to cure the acute attack.
| References|| |
Chandler, P. (1951) Am. J. Ophth., 34 : 993.
Chandler, P. (1957) A.M.A. Arch. of Ophth.57-639.
Flocks, M., Littwin, C. S. and Zimmerman, L. E. (1955) Arch. Ophth. (Chicago), 54-37.
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