|Year : 1972 | Volume
| Issue : 2 | Page : 88-93
Lens induced glaucoma. A clinical study
Medical College, Patna, India
J N Rohatgi
Medical College, Patna
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rohatgi J N. Lens induced glaucoma. A clinical study. Indian J Ophthalmol 1972;20:88-93
Lens-induced-glaucoma is a distinct pathological entity, clinically recognisable, easily preventable and often curable by cataract extraction.
At the beginning of the century Gifford described glaucoma associated with hypermature cataract and suggested that it could be prevented and cured by timely cataract extraction. Since then various authors Irvine and Irvine (1952), Flocks, Littman and Zimmerman (1954) and Chandler (1958) have discussed varying types of such cases and under different names of lens-induced-glaucoma, lens-induced uveitis and glaucoma, endophthalmtis-phacoanaphylactica, phaco-toxic glaucoma, phacogenetic and phacogenic glaucoma and finally phacolytic glaucoma. The modern trend is to label them as phacolytic glaucoma. but as the clinical picture can easily be uveitis and glaucoma or simply glaucoma (associated with a mature or hypermature cataract) it is better to retain the term lens-induced-glaucoma. This is noncomittal but suffers from the disadvantage of not excluding glaucoma associated with an intumescent-cataract and or senile exfoliation of lens capsule etc.
Three outstanding features of this group of patients are (1) the sudden onset of glaucoma in an eye with mature or hypermature cataract (2) the advanced age of the patient generally above fifties and (3) the almost constant observation of good vision and normal tension in the opposite eye which may be aphakic or otherwise. This clinical observation is further strenghthened by the fact that removal of the cataractous lens with or without the prior and concurrent use of diamox, leads to a lessening of the congestion in the eye and an uneventful recovery with fairly good vision. It is true that the diagnosis is not complete without the characteristic histological changes seen when such an eye is enucleated. As a matter of fact similar pathological findings in all such enucleated eyes have been the prime-factor in the recognition of this clinico-pathological entity.
In this study a clinical review of 46 cases of lens-induced-glaucoma is described. As the diagnosis was satisfactory, in none of these eyes enucleation was suggested (even though a few had no light perception) and hence, no pathological confirmation is available.
Majority of the cases in this study - 19 out of 46 -- were of the age group 60 years and above constituting 41.3%. the eldest being a man 75 years of age. 15 cases were in the age group of 50 to 59 years and 12 cases were below 50 years, the youngest being a lady of 40 years. The age incidence rises shaply at 60 years -
There were 29 females and 19 males.
Presenting clinical features
Since the onset of glaucoma in these cases is a complication of mature or hypermature cataract, all of them had poor vision from the first. There were 14 cases with varying degrees of hypermature cataract two of which had subluxated and 32 had mature or practically mature cataract, When they came in with acute rise of tension and a congested eye, the visual acuity was only light perception or at best hand-movement. Even this light perception was absent in 5 cases. They could easily be labelled as painful-blind-eyes from absolute glaucoma with no hope for vision.
The onset of glaucoma in all these cases was characterised by pain in and around the eyes, headache of varying intensity, nausea, vomiting and in some cases even prostration. Examination revealed oedematous swollen lids with marked congestion, corneal haziness and often dilated and fixed pupil. A group of five cases revealed the presence of uveitis, aqueous flare, irregular pupil from posterior synechia, and keratic precipitates (in 2 cases). They could easily be thought of as cases of uveitis with secondary glaucoma. The depth of the anterior chamber varied. It was shallow in nine cases (confirming the diagnosis of acute congestive glaucoma in a cataractous eye) on the other hand it was deeper in five cases, associated with hypermature cataract and was of normal depth in the other cases. The lens had become subluxated in 2 cases with hypermaturity.
The intra-ocular tension was invariably more than 30 mm of Hg Schiotz in these cases.
Clinical findings o f the other eye
Classically this was an aphakic eye with extra-capsular lens-extraction a few months to a few years back with no congestion or redness and with useful. vision. In the present series of cases this was the finding of 13 cases. These patients were elderly and in them the onset of glaucoma was almost violent.
The second-group of 8 cases had impaired vision in the opposite eye from incipient and immature cataract (4 cases) mature cataract-3 cases, (two with rise of tension in both eyes) and hypermature cataract one case. The tension in the that eye was normal.
The third group had vision varying from finger counting to normal visual standard. In them the lens was clear, free from any opacity and not the cause of reduced vision. Further the intraocular tension was normal in all the cases except case No. 44, where the fellow right eye had also rise of tension with congestion of the eye and shallow anterior chamber and there was evidence of uveitis in the left eye with irregular pupil and a few posterior-synechia along with mature cataract. Even the light perception was doubtful. Gonioscopy was not feasible. Case No. 1 also in this group had his right aphakic eye enucleated a few years back following injury.
These 46 cases of clinically diagnosed lens-induced glaucoma with or without uveitis were varyingly diagnosed clinically as follows :
1. Acute congestive glaucoma with mature or hypermature cataract.
2. Absolute glaucoma with no light perception.
3. Mature or hyper-mature cataract with uveitis and secondary glaucoma due to uveitis.
4. Cases of chronic congestive glaucoma with acute exacerbation.
5 Cases of congestive glaucoma associated with subluxated lens.
The difficulty of diagnosis arose in three cases. In two of them, cases No. 8 and 38 the fellow eye had also rise of intra ocular tension along with mature cataract. In the third case No. 44 the fellow eye had features of congestive glaucoma. In such cases goniscopy is of help by deciding the nature of the angle of the anterior chamber whether it is narrow angle or wide-angle. But this may not be always feasible in an acutely congested eye. Another important point is that the fellow eye shows no rise of intraocular tension even on repeated examinations, a point in favour of this glaucoma being labelled as secondary and not primary idiopathic in etiology. To add to this diagnostic difficulty was the absence of even light-perception in the glaucomatous eye in 5 cases of the series labelled as cases of absolute- glaucoma with poor prognosis. As one would see while discussing the treatment, that even in these cases a proper diagnosis (as to the cause of glaucoma) was rewarding by saving the eye from unnecessary enucleation. But this of course deprived us from studying the histo-pathological changes in such cases.
The features of uveitis-aqueous flare and cells, keratic precipitate, irregular pupil with post-synechia led one to think that there was uveitis which caused secondary rise of tension.
In all these cases no mydriatic was given and in only few of them Eserine salicylas as drops was prescribed. In clear cut cases the routine was to use Diamox (acetazolamide) orally and usually combined with Cortucid ointment locally in the eye to lessen the congestion. In most of the cases in a couple of days, the intra-ocular tension did come down to a lower and safe figure from its previously high reading. Thereafter surgery was taken recourse to. In younger patients and those with highly apprehensive mood, intravenous anaesthesia was used for lens extraction. In the rest it was the routine local anaesthesia.
3 cases (3, 8, 36) had iridectomy by dialysis as the 1st stage operation for in them the intra-ocular tension was very high. Subsequently after a few weeks the cataractous lens was removed
Intra-capsular lens-extraction with no irrigation was followed in 24 cases and 17 cases had extracapsular removal with ant. chamber irrigation in 9 cases and no irrigation in 6 cases. In them the left over lenticular matter in the anterior chamber was very little in amount to justify irrigation. Of the remaining 2 cases, one refused operation and the other had only retro-bulbar injection of Novocaine and alcohohol as there was no P.L. even on repeated examination.
Along with removal of lens, intra or extra-capsular, iridectomy by dialysis was also combined in 10 cases, peripheral button-hole-iridectomy in 3 cases and broad-basal iridectomy in 13 cases. The latter two procedures signify variation in the surgical technique of cataract removal. Iridectomy by dialysis was done as a safeguard against any untoward complication on the table. As a matter of fact in these cases the first thing was iridectomy by dialysis and then the lens was removed. These were earlier cases of the series and in the succeeding patients this procedure was given up with no untoward effect on the success of the operation. This observation in itself is a great diagnostic point in favour of the diagnosis of lens-induced glaucoma, that is, remove the cause, the cataractous lens and the glaucoma gets cured.
| Discussion|| |
After extra-capsular cataract extraction or after trauma to the lens capsule, lens matter is freely exposed to the intra-ocular fluid. In majority of cases such residual lens matter or lens cortex gets absorbed without the occurrence of any undue inflammatory reaction. Also in hypermature cataracts, the lensmatter may eventually be absorbed without causing any inflammatory response in the eye. But in occasional cases presence of disorganised lens matter in the anterior chamber bathed by aqueous evokes an inflammatory response of great severity, so prolonged that the eye may 'eventually be lost if the residual lens matter is not removed. Verhoeff and Lemoine in 1922, drew attention to such lens-induced uveitis calling them endophthalmitis-phaco-anaphylactica. The presumption is that such cases are allergic in nature, (the allergen being lens protein), on the basis of the finding that those persons who suffered the violent type of ocular symptom when tested intra-dermally displayed a positive skin test to lenticular-pretein and when given a desensitising course of intra muscular injection of lens protein rapidly showed an amelioration of their symptom. Whether this whole concept is allergic or can also be explained on the basis of a toxic reaction has been raised by Gifford, Knapp and Heath and Irvine. This is specially true when one is dealing with such cases in an eye with hyper-mature cataract where the uveitis can be explained as a toxic reaction to Morgagnian fluid. This is the phacotoxic type of lens-induced uveitis and glaucoma.
In endophthalmitis-phaco-anaphylactica, the inflammation primarily in the iris and around the lens matter is predominantly polymorphonuclear and giant-cell reaction. In phacotoxic the reaction in the iris and more around mature or hyper-mature lens matter is mainly plasma-cell and macrophage-cells which engulf the latter with a few polymorphs and gaint-cells.
The terms phacogenic and phacogenetic glaucoma are not correct for they may mislead. They do not tell us how the glaucoma is produced due to lens and hence, glaucoma associated with exfoliation of senile lens-capsule, intumsecent cataract, and even with sub-luxated and dislocated lens may be thought of with these terms The same difficulty arises with the term lens-induced-glaucoma or lens induced-uveitis and glaucoma. With this term, however, ophthalmic surgeons have understood the above categories of endophthalmitis phaco-anaphylactica and the phacotoxic glaucoma. In these conditions uveitis is clear-cut and there is a rise of intra-ocular tension to a moderate degree and sometimes not. The rise of intraocular tension may be due to anterior or posterior synechia or to obstruction of the chamber-angle by inflammatory exudates.
The 3rd category of lens-induced glaucoma is the case seen again associated with a mature or hypermature cataract (where the other eye is generally aphakic and quiet) more with the hypermature type where the lens matter is engulfed by macrophages. And these swollen eosinophil-stained-macrophages are seen (on histological examination) blocking the trabecular mesh work and lying on the back of cornea and ant. surface of iris etc. This is a mechanical blockage-glaucoma and Flocks, and Littwin and Zimmerman (1955) have rightly labelled this as phacoly tic-glaucoma, for it is associated with lysis of lens matter. It has been observed that in such cases the element of uveitis namely keraticprecipitates, aqueous-flare and posterior synechia are minimal and at times absent altogether and also such cases may not show much congestion. As against this, the type phacotoxic and endcphthalmitis-phaco-anaphylactica have more of uveal reation and marked congestion of the eye but only moderate rise of tension. So one can clinically label in which category to put a particular case of lens-induced-uveitis and glaucoma. But all the same, since the basic mechanism in both groups of cases is that the lens or lens-matter is at fault. it has to be removed. Vorhoeff dictum that it is better to remove the offending lens or residual lens matter than to remove the eye has been amply justified by the present series of cases where, but for clinical diagnosis of lens-induced-uveitis and glaucoma many such eyes would have been enucleated.
| References|| |
Chandler Paul, A.: Problems in diagnosis and treatment of lens induced uveitis and glaucoma. Archives of Ophthal. 60:828, 1958.
Courtney, R.H.: Endopthalmitis with secondary glaucoma accompanying absorption of the crystalline lens. TransAmerican Ophth. Soc. 40, 355, 1942.
Flocks, Littwin and Zimmerman.: Phacolytic Glaucoma. (Chicago) Archives of Ophthal. 54, 37, 1955.
Gifford: (1900) Amer J. Ophth. 17, 73.
Irvine S.R. and Irvine; A.R.Jr.: Lens induced uveitis and Glaucoma Am. J. of Ophth. 35: 177, 370 & 489, 1952.
Law F.: Ocular reactions to lens - Proteins. British J. of Ophthal. 37: 157, 1953.
Leigh, A.G. Lens induced Uveitis. Trans-Ophthal. Soc. U.K. 65: 51, 1955.
Rohatgi, J.N.: Post-operative Uveitis. Proceedings of the All India Ophthalmological Society, 19, 1961.