Year : 2001 | Volume
: 49 | Issue : 2 | Page : 103--107
A prospective study of 413 cases of lens-induced glaucoma in Nepal
Damodar Pradhan1, Albrecht Hennig1, Jitendra Kumar1, Allen Foster2,
1 Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
2 London School of Hygiene & Tropical Medicine London, United Kingdom
Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
Purpose: To determine the frequency and types of lens-induced glaucoma (LIG), reasons for late presentation and outcome of current management.
Methods: Prospective case series of 413 patients/eyes with LIG over a 12-month period in 1998; 311 of these patients underwent cataract surgery. Visual acuity and intraocular pressure (IOP) were pre-and postoperatively assessed.
Results: Four hundred and thirteen (1.5%) of 27,073 senile cataracts seen in the outpatient department of Sagarmatha Choudhary Eye Hospital, Lahan, Nepal presented with LIG. There were 298 (72%) phacomorphic cases and 115 (28%) phacolytic glaucoma. Pain for more than 10 days was reported by 293 (71%) patients. The majority, 258 (62.4%), travelled a distance of more than 100 kms to the hospital. The major reasons for late presentation were «DQ»no escort«DQ» in 143 (34.6%) and «DQ»lack of money«DQ» in 128 (31.0%) cases. At presentation the IOP was more than 30 mm Hg in 327 (79%) eyes. Following cataract surgery, 251 (80.7%) had 21 mm Hg or less at discharge. The visual acuity was hand-movement or less before surgery in all eyes; at discharge 120 of 311 operated eyes (38.6%) achieved 6/60 or better, 97 (31.2%) less than 6/60, and 94 (30.2%) less than 3/60. The main causes for poor outcome in 94 cases were optic atrophy in 32 (34%) eyes, uveitis in 25 (26.6%)eyes and corneal oedema in 24 (25.5%) eyes.
Conclusion: The results highlight the importance of early diagnosis and treatment of visually disabling cataract. There is a need to educate both the patient and the cataract surgeon of the dangers of lens-induced glaucoma and of the poor outcome if treatment is delayed.
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Pradhan D, Hennig A, Kumar J, Foster A. A prospective study of 413 cases of lens-induced glaucoma in Nepal.Indian J Ophthalmol 2001;49:103-107
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Pradhan D, Hennig A, Kumar J, Foster A. A prospective study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol [serial online] 2001 [cited 2022 May 17 ];49:103-107
Available from: https://www.ijo.in/text.asp?2001/49/2/103/22643
Sagarmatha Choudhary Eye Hospital, Lahan is situated in Southeast Nepal. It has 300 beds and provides services to more than 80,000 ophthalmic out patients and performs more than 20,000 eye operations annually. More than 75% of the patients come from the northern Indian state of Bihar. There is no waiting list for cataract surgery at Sagarmatha Choudhary Eye Hospital.
A significant proportion of cataract patients still present with advanced cataract leading to complications. Lens-induced glaucoma (LIG) may be due to:
(a) secondary angle closure from swelling of the lens due to absorption of fluid producing an intumescent cataract (phacomorphic glaucoma);
(b) occlusion of an open anterior chamber angle by macrophages that has phagocytosed lens protein. The lens protein leaks out of the lens capsule of the hypermature cataract (phacolytic glaucoma);
(c) obstruction of the outflow channels of the anterior chamber angle by inflammatory cells and debris, produced secondary to an immune hypersensitivity reaction to lens protein (phacoanaphylactic glaucoma).
Despite the availability of modern medical and surgical management, the visual outcome in many cases is poor. This prospective study investigated the frequency and type of LIG, the reasons for late presentation and studied the outcome of current management.
Materials and Methods
A prospective study was undertaken over a 12-month period in 1998. All consecutive patients diagnosed as LIG on the basis of clinical symptoms and signs were included. Clinical features included pain, loss of vision, redness of the eye, presence of an intumescent, mature or hypermature cataract associated with raised intraocular pressure (IOP) of more than 21 mm Hg except in those who had already received prior antiglaucoma treatment.
A total of 413 patients/eyes were included. Patients completed a specially designed form, providing their address, distance travelled to the hospital, duration of pain and the reasons for delay in presenting.
A detailed clinical examination of both eyes included the status of the lens, depth of the anterior chamber by slitlamp biomicroscopy, applanation tonometry and gonioscopy. Based on the slitlamp examination the type of LIG was determined. Phacomorphic glaucoma was diagnosed when patients presented with red eye, acute pain and reduction of vision of certain duration. On clinical examination the eye showed circumcorneal congestion, corneal oedema, shallow anterior chamber, dilated and fixed pupil, intumescent cataract and in untreated cases IOP >
21 mm Hg. Likewise the patients were diagnosed with phacolytic glaucoma when they complained of acute pain and redness in the eye with longstanding poor vision. On examination the eye showed marked diminution of vision, corneal oedema, normal or deep anterior chamber containing floating lens particles and/or pseudohypopyon in severe cases and hypermature morgagnian cataractous lens in some cases. Dense flare was seen with extensive keratic precipitates.
In phacomorphic LIG, preoperative treatment to reduce IOP included topical timolol, oral acetazolamide and intravenous mannitol just before the surgery in refractory cases. In phacolytic glaucoma topical betamethasone every two hours, and atropine twice a day were also used. In patients with perception of light (or better), cataract extraction was offered under guarded prognosis.
Scleral tunnel sutureless cataract extraction was performed under peribulbar anaesthesia. A frown incision was made 2 mm away from the limbus. The length of the incision varied from 6 mm to 8 mm depending on the size of the nucleus. The tunnel was dissected to at least 1 mm of clear cornea. The anterior chamber was entered and a linear capsulotomy performed. Hydrodissection was undertaken with an irrigating cannula. The nucleus with epinucleus was mobilised and either expressed by the hydrodissection cannula or extracted by a nucleus hook designed by us. The remaining cortical matter was aspirated with a Simcoe cannula. Viscoelastics were used to deepen the anterior chamber when required. A +21 posterior chamber intraocular lens (IOL) was implanted where the fellow eye was pseudophakic or had early lens changes. The reasons for not implanting an IOL were: patient refusal; presence of a subluxated lens; posterior capsule rupture; vitreous problems during surgery; aphakia in the fellow eye; severe pre-operative inflammation; and doubtful visual recovery after surgery. A subconjuctival injection of dexamethasone (1 mg) and gentamycin (20 mg) was given at the end of the procedure. Aphakic patients received +11.0D spectacles correction.
The postoperative stay varied from 2 to 5 days depending on complications. Betamethasone, neomycin and a short-acting cycloplegic were used postoperatively. Systemic and/or subconjunctival steroids were given to patients with a severe exudative reaction. At discharge a detailed examination including uncorrected visual acuity, IOP, slitlamp biomicroscopy and fundoscopy with 90 D lens was performed. The cause of blindness (visual acuity <
3/60) was recorded. Patients were discharged with instruction to use a topical antibiotic steroid combination four times a day and to return for follow-up after one month. During follow-up all examinations were repeated.
Magnitude and classification
Out of 27,073 senile cataracts seen in our outpatient department in 1998, 413 (1.5%) presented with LIG. Phacomorphic glaucoma was present in 296 patients (72%) and phacolytic glaucoma in 115 (28%). No case was diagnosed as phacoanaphylactic glaucoma.
Age and gender
The age range in both types of LIG was 40 to 80 years, with 145 (35%) cases occurring in patients aged under 60 years of age. The female to male ratio was 1.7:1.[Table:1]
Pain of more than 10 days' duration in the affected eye was the chief presentation in 293 of 413 (71%) patients. Patients came from within 50 km of the hospital, and 258 (62.4%) from more than a 100 km distance. The major reasons for late presentation were "no escort" in 143 (34.6%) and "lack of money" in 128 (31.0%) cases. Other reasons were "lack of time" in 29 (7.0%), "no desire for surgery" in 27 (6.5%), "uncertainty about where to go" in 25 (6.1%), "feeling of adequate vision" in 22 (5.3%), "no mature cataract" in 19 (4.6%), "fear
' in 18 (4.4%) and "uncontrolled systemic diseases" - (diabetes mellitus and hypertension) in 2 (0.5%) patients.
Visual acuity in affected eye
None of the 413 affected eyes had vision better than hand movement (HM) at presentation. At discharge, 120 of 311 operated eyes (38.6%) had 6/60 or better, 97 (31.2%) less than 6/60, and 94 (30.2%) had less than 3/60.
Of the 413 fellow eyes 152 (36.8%) had a visual acuity less than <
3/60 and a further 70 (17.0%) less than 6/60. Only 60 (14.5%) had vision of 6/6 to 6/18[Table:2]. Examination of the fellow eyes revealed that 270 (65.4%) were phakic, 123 (29.8%) aphakic, 16 (3.8%) pseudophakic and 4 (1.0%) were one-eyed. Out of 152 fellow eyes having visual acuity less than 3/60, 126 (82.9%) were phakic, 22 (14.5%) aphakic and 4 (2.6%) one-eyed. Of 126 phakic eyes, 120 (95.2%) had cataract reducing the vision to less than 3/60; 4 (3.2%) had a previous attack of LIG; and 2 (1.6%) had corneal opacities. Of 22 blind aphakic eyes, 10 (45.5%) were blind due to anterior segment surgical complications, 6 (27.3%) had old total retinal detachment, and 6 (27.3%) had secondary glaucoma with optic atrophy.
IOP at presentation ranged from 14 to 81 mm Hg. 327 (79.2%) of 413 eyes had an IOP of more than 30 mm Hg at presentation[Table:3] whereas 59 (14.3%) eyes had an IOP less than 22 mm Hg as they had already received medical antiglaucoma treatment elsewhere. After the administration of anti-glaucoma medication in 311 eyes selected for cataract surgery, 206 (66.2%) had an IOP of 21 mm Hg or less, and 301 (96.8%) had an IOP less than 30 mm Hg. Following surgery, 251 of 311 eyes (80.7%) had an IOP of 21 mm Hg or less at discharge.
Out of 413 patients with LIG 311 (75.3%) underwent cataract surgery, 20 (4.8%) left against medical advice and 82 (19.9%) had no perception of light and were deemed unsuitable for surgery. All the 311 cases underwent scleral tunnel sutureless cataract surgery; 191 (61.4%) had ECCE without PCIOL and 102 (32.8%) received a +21D PCIOL. An ICCE was done in 17 (5.5%) patients; one of these patients (0.3%) received an ACIOL.
Cause of poor outcome
The causes of blindness at discharge in 94 eyes are shown in[Table:4] The major causes were optic atrophy in 32 eyes (34.0%), uveitis in 25 eyes (26.6%) and corneal oedema in 24 eyes (25.5%).
In spite of motivating the operated patients and offering monetary incentives, the follow-up rate was low. Only 105 patients (33.8%) reported for follow-up 4 - 12 weeks after surgery. With best correction, 33 eyes (31.4%) achieved 6/18 or better and 22 (21.0%) less than 3/60[Table:2]. The causes of blindness in these 22 eyes were optic atrophy in 15 eyes (68.2%) and uveitis and corneal oedema in 3 eyes (13.6%) each. At follow-up 89 (84.8%) eyes had an IOP below 22 mm Hg.
Risk factors for poor outcome at discharge
In 82 phacolytic cases 54 (65.9%) had a poor outcome, compared with 137 out of 229 (59.8%) in the phacomorphic group (Z=0.99, p=0.16-not significant). In the phacomorphic group the distance from the hospital, duration of pain, and high level of IOP at presentation were all associated with poor visual outcome. In the phacolytic group, only the long distance from hospital could be demonstrated to be significantly associated with poor outcome[Table:5].
This prospective study was undertaken to investigate the reasons for late presentation of LIG and to assess outcome after surgery.
Of the nearly 27,000 cases of senile cataract seen in the outpatient department of Sagarmatha Choudhary Eye Hospital, in 1998, 413 (1.5%) presented with LIG.
In this series phacomorphic glaucoma was more common (298 eyes; 72%) than phacolytic glaucoma (115 eyes; 28%). Lim reported a ratio of 12:1 for phacomorphic to phacolytic glaucoma, and Prajna et al found more or less equal numbers in their series.
The age range for both types of LIG in this series was 40-80 years with 145 (35.1%) of the cases occurring in patients under the age of 60. LIG was more common in females, with a ratio of 1.7:1. It is possible that socio-economic and cultural constraints play a role leading to neglect and late presentation of cataract in this region.
Two-thirds of the patients had pain in the eye for more than 10 days and 4 in five came from a distance of more than 50 kms from the hospital. Poor transportation and bad roads make travelling difficult in this part of Nepal and North India. One in three patients reported that they had no escort to the hospital and a similar proportion stated that they could not afford surgery. Some patients in this part of Nepal and North India with cataract will wait for free eye camp surgery in the vicinity of their homes rather than visit a distant hospital for treatment. Snellingen et al  reported similar reasons for late presentation.
The majority of 413 fellow eyes had poor vision, with only 60 (14.5%) having an acuity of 6/18 or better. One in three patients had had cataract surgery in their fellow eye.
Results of surgery
Out of 413 patients with LIG, 311 (75%) were admitted for cataract operation. Sub-luxation of the lens and postoperative inflammation were more severe in phacolytic glaucoma. This may be due to leakage of lens protein into the anterior chamber and vitreous cavity.
At discharge 120 (38.6%) of 311 operated cases achieved 6/60 or better. Of 105 cases reporting for follow up between 4 and 12 weeks, 33 (31.4%) eyes achieved 6/18 or better with best correction, and 22 (21.0%) were blind (less than 3/60 vision) mainly due to optic atrophy in 15 (68.2%) out of 22 eyes. The IOP was below 22 mm Hg in 89 (84.8%) of 105 eyes at follow up. The final visual outcome is worse in our series than in other studies.[1, This is probably because the majority of the patients reported later than ten days after the onset of pain.
In the phacomorphic group poor outcome was associated with delay in presentation (duration of pain and distance from hospital) as well as the level of IOP. Although the same factors could not be demonstrated in the phacolytic group this is likely to be due to the smaller sample size.
These results highlight the importance of early diagnosis and treatment of mature cataract. There is a need to educate both the patient and the cataract surgeon of the dangers of LIG and of the poor outcome if treatment is delayed.
|1||Lim T, Tan D, Fu E. Advanced cataract in Singapore. Its prognosis and complications. Ana Acad of Med, 1993; vol. 22, No.6:891-94.|
|2||Prajna N, Ramakrishnan R, Krishnadas R, Manoharan N, et al. Lens induced glaucoma - Visual results and risk factors for final visual acuity. Indian J Ophthalmol 1996;44:14-155.|
|3||Snellingen T, Shrestha BR, Gharti MP, Shrestha JK, Upadhyay MP, Pokhrel RP, et al: Socioeconomic barriers to cataract surgery in Nepal: the South Asian cataract management study. Br J Ophthalmol 1998;82:1424-28.|