Year : 1994 | Volume
: 42 | Issue : 3 | Page : 145--147
Phacolytic glaucoma-its treatment by planned extracapsular cataract extraction with posterior chamber intraocular lens implantation
Gurdeep Singh1, Jagmeet Kaur2, Sanjay Mall1,
1 Gandhi Medical College, Bhopal, India
2 Indian Council of Medical Research, Bhopal, India
E-1/100, Arera Colony, Bhopal 462 016
Phacolytic glaucoma has traditionally been treated with intracapsular lens extraction to avoid any anaphylaxis. Various mechanisms have been described for the rise of intraocular pressure in these cases. The present study was undertaken to evaluate the response of extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens implantation (PC IOL) in five cases of phacolytic glaucoma that occurred between March 1989 and August 1990. A planned extracapsular cataract extraction with can-opener capsulectomy was done in all the cases with placement of a sulcus-fixated modified J-loop Sinskey design intraocular lens. With a mean follow-up period of two years, all patients (100%) maintained a normal postoperative intraocular pressure of less than 20 mm Hg without any additional medical therapy. The final best-corrected visual acuity in 4 cases (80%) was 6/12 or better, while in one case it was 6/24 due to a senile maculopathy. These results show that ECCE with PC IOL implantation is a safe and efficacious method of visual rehabilitation in cases of phacolytic glaucoma
|How to cite this article:|
Singh G, Kaur J, Mall S. Phacolytic glaucoma-its treatment by planned extracapsular cataract extraction with posterior chamber intraocular lens implantation.Indian J Ophthalmol 1994;42:145-147
|How to cite this URL:|
Singh G, Kaur J, Mall S. Phacolytic glaucoma-its treatment by planned extracapsular cataract extraction with posterior chamber intraocular lens implantation. Indian J Ophthalmol [serial online] 1994 [cited 2021 Jun 13 ];42:145-147
Available from: https://www.ijo.in/text.asp?1994/42/3/145/25571
Phacolytic glaucoma was first described by Gifford in 1900 but it was Flocks et al in 1955 who for the first time showed that it is associated with a leaking hypermature cataractous lens.  Various other authors later described the reason for the rise of intraocular pressure (IOP) and demonstrated blockage of the drainage channels by macrophages that had engulfed lens proteins as well as blockage by the cortical fluid that had escaped from the ruptured lens capsule. , More recently, Epstein et all have shown that high molecular weight proteins are the causative element of trabecular block in this disease entity. Initially intracapsular lens extraction was the established surgical treatment for phacolytic glaucoma as it was thought that since the capsular and zonular system is weak in these cases, doing an extracapsular cataract extraction (ECCE) could be harmful and could lead to a severe anaphylactic type of uveitis.
Since the introduction of modern microsurgical extracapsular cataract extraction with posterior chamber intraocular lens (PC IOL) implant surgery, various investigators have shown beneficial results of this surgical procedure even in cases of phacolytic glaucoma.  Lane et al in a recent study treated 5 cases of phacolytic glaucoma with ECCE with placement of PC IOL and found excellent postoperative visual results. 
This study was undertaken to evaluate the results of conventional ECCE with PC IOL implantation in a series of 5 cases of phacolytic glaucoma.
MATERIALS AND METHODS
Five cases of phacolytic glaucoma aged between 64 and 70 years were subjected to a conventional ECCE extraction with a sulcus-fixated PC IOL implantation. Only those cases with minimum lenticular changes and good visual status in the fellow eye were included in the study to avoid problems of unilaterial aphakia [Table 1].
All the cases were operated by the same surgeon (G.S.) after control of uveal inflammation and intraocular pressure by appropriate medical therapy. This included administration of systemic acetazolamide 250 mg three times a day and local treatment with 0.5% timolol twice daily and dexamethesone 0.1% eye drops 4 times a day. One percent atropine eye ointment was put only once at the time of admission.
The period between diagnosis and surgery varied between three to six days depending on the control of uveitis and glaucoma.
On the day of surgery intravenous 20% mannitol 350 ml was given and the pupil was dilated with a combination of 1% tropicamide and 5% phenylepinephrine. Also, 1% flurbiprofen eye drops with 0.3% ciprofloxacin eye drops were instilled four times, each one hour before surgery. Flurbiprofen eye drops was used to prevent intraoperative miosis and ciprofloxacin eye drops was used as a prophylactic antibiotic.
The surgery included a fornix-based conjunctival flap. A can-opener capsulectomy was performed under 2% methylcellulose using a bent tip of a 26gauge needle. After enlarging the corneoscleral section, manual removal of the nucleus was done. Cortical clean up was done using a Simcoe bi-way cannula. Extra care was taken to do a good clean up to avoid any excessive postoperative uveal reaction. The posterior capsule was then pushed back with another bolus of 2% methylcellulose and an appropriately powered modified J-loop Sinskey design IOL was then dialled to position. A small peripheral iridectomy was done and the wound was closed with 10-0 nylon continuous shoe lace suture. At the close of surgery, a sub-Tenon injection of 20 mg gentamicin with 1 mg decadron was given in the lower fornix.
All the cases were subjected to a daily slit-lamp examination and the intraocular pressure was also measured daily for the first postoperative week. Systemic antibiotic (chloremphenicol 500 mg 3 times a day), acetazolamide 125 mg twice a day, anti-inflammatory drugs (ibuprofen 400 mg thrice a day), and supportive B complex were given for the first five postoperative days. Along with this, local dexamethasone, flurbiprofen and ciprofloxacin eye drops, 4 times a day was prescribed for 2 weeks. Later, this combination of 3 individual drops was tapered gradually over the next 6 weeks.
The final results were evaluation at completion of 8 weeks. This was in relation to visual recovery, control of intraocular pressure, uveal reaction, and other complications if any. The mean follow-up period was 2 years in this study.
Postoperatively, the uveal reaction was relatively more during the first week compared to normal eyes. This cleared completely within two weeks in all the cases. Intraocular pressure, on the other hand, showed a dramatic decline in all the cases after surgery and stabilised by the first week without any antiglaucoma medication.
Visual acuity improved to 6/12 or better in 4 of the 5 cases and was 6/24 in one case due to a senile maculopathy.
All the cases have since been operated for more than two years and in only one case posterior capsule thickening was seen which required a YAG capsulectomy. No other complication was encountered in this series.
The clinical presentation of phacolytic glaucoma was first described by Giffords. It was not until 1955 that Flocks et al [l] named it as 'phacolytic glaucoma' and suggested that it is associated with a leaking hypermature lens. During the last few decades various investigators have suggested various mechanisms for its pathogenesis. Zeeman described the macrophagic response to leaking lens material and attributed this to the cause of raised intraocular pressure in these cases. Later, Goldberg described the millipore filtration procedure to identify the causative macrophages in these cases.In his opinion glaucoma was due to trabecular blockage by macrophages as well as proteinaceous material. Epstein et all in their study suggested that the macrophages actually work as scavengers in an attempt to clear the anterior chainber and the outflow system. This concept was later supported by Yanoff and Scheie. 
Historically, there has been almost unanimous agreement that intracapsular lens extraction should be done in cases of phacolytic glaucoma because the posterior lens capsule is fragile and has microscopic defects. This in turn can, lead to a phacoanaphylactic reaction postoperatively.
Extracapsular surgery was first advocated by Irvine in 1957. He believed that this technique helps in the prevention of the forward movement of the vitreous and hence vitreous loss. More recently, Gross and Pearce used current microscopic extracapsular technique and reported excellent results in their cases of phacolytic glaucoma.
Lane et all also reported similar results in 1988. They did not find any weak capsular or zonular support in any of their patients who underwent an ECCE with PC IOL implantation. All the cases had controlled intraocular pressure with excellent visual results.
In this study with a mean follow-up period of two years all patients maintained a normal postoperative pressure of less than 20 mm Hg without any additional medical therapy. The best-corrected visual acuity in 80% of the cases was 6/12 or better which was comparable with the results of other investigators mentioned previously.
Results of this small series are encouraging and the excellent postoperative visual acuity with controlled IOP in all cases suggest that planned ECCE with PC IOL is a safe and effective method of visual rehabilitation in these cases of phacolytic glaucoma.
|1||Flocks M, Littwin CS, Zimmerman LE. Phacolytic glaucoma: A clinicopathological study of one hundred and thirty eight cases associated with hypermature cataract. Arch Opthalmol. 54:37-45, 1955.|
|2||Irvine SR, Irvine AR Jr. Lens-induced uveitis and glaucoma. Part III. "Photogenetic glaucoma": Lensinduced glaucoma; mature or hypermature cataract; open iridocorneal angle. Am J Ophthalmol. 35:489-499, 1952.|
|3||Goldberg MF. Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous. Br J Ophthalmol. 51:847-853, 1967.|
|4||Epstein DL, Jedziniak JA, Grant WM. Identification of heavy molecular weight soluble proteins in aqueous humourin 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||Gifford H. The dangers of spontaneous cure of senile cataract. Am J'Ophthalmol. 17:2892-93, 1900.|
|8||Zeeman WPC, Zwei Falle Von. Glaucoma phacogeneticum mit automischem befund. Ophthalmololgica. 106:136-142, 1943.|
|9||Yanoff M, Scheie HG. Cytology of human lens aspirate: its relationship to phacolytic glaucoma and phacoanaphylactic endophthalmits. Arch Ophthalmol. 80:166-170, 1968.|
|10||Irvine SR. Lens-induced uveitis and glaucoma. Symposium on Disease and Surgery of Lens. Transactions of the New Orleans Academy of Ophthalmology. St. Louis, CV Mosby Co. 186-199, 1957.|