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Year : 2016 | Volume : 4 | Issue : 2 | Page : 118 - 121  


Original Articles
Clinical study of lens induced glaucoma

Seetha Lakshmi DK1, Jayashree MP2

1Assistant Professor, Department of Ophthalmology, Karnataka Institute of Medical Sciences, Hubli

2Associate Professor, Department of Ophthalmology, Nijalingappa Medical College, Navanagar, Bagalkot, Karnataka

Corresponding Author:

Dr. Seetha Lakshmi DK

Email: sita_diddapur@rediffmail.com

 

Abstract:

Background: Lens induced glaucoma is a common occurrence. Secondary glaucoma has been found in 10% of senile cortical cataracts. Ruling out the coexisting primary glaucomas, lens induced glaucomas has been taken up for this interesting study. Objective: To analyze the different mechanisms and clinical features of lens induced gluacomas. Methods: This clinical study included 50 cases of different types of lens induced glaucomas in individuals whose age group varied from 12 to 90 years and both the sexes conducted on the in patients of Ophthalmology department. All the cases of secondary glaucomas suspected to be lens induced were admitted to the wards. Detailed history was ascertained. Previous history of extra-capsular lens extraction in the other eye was carefully noted. Results: Majority of the patients were in the age group of 50-75 years. The incidence of lens induced glaucoma was more among females (68%) than males (32%). Right eye was found to be more commonly affected (58%) than the left eye (38%) and both eyes were involved in 4% of cases.. The majority of the eyes affected had hypermature cataract (44%) followed by mature cataract (34%). Phacomorphic glaucoma caused by intumescent lens has been the major cause contributing to 54% of cases. 27 cases (54%) showed shallow anterior chamber. Conclusion: The incidence of lens induced glaucoma was more among females (68%) than males (32%). Right eye was found to be more commonly affected (58%) than the left eye (38%).Both eyes were involved in 4% of cases. The majority of the eyes affected had hypermature cataract (44%).

Key words: Incidence, Glaucoma, Lens

INTRODUCTION:

Lens plays an important role in pathological states of the eye. Cataract defined as the opacification of the crystalline lens of the eye is the commonest cause of curable blindness worldwide. In India, cataract alone is responsible for 85% of curable blindness i.e. for about 8 millions of blind people. 1  Glaucoma as a complication of cataract is a common occurrence. Secondary glaucoma has been found in 10% of senile cortical cataracts. Ruling out the coexisting primary glaucomas, lens induced glaucomas has been taken up for this interesting study. 2

Lens induced glaucomas can develop during various stages of development of cataract. An intumescent, swollen lens blocking the pupil and/or producing secondary angle closure accounts for phacomorphic glaucoma. In the hypermature stage of cataract the leaking lens proteins are engulfed by macrophages which block the trabecular meshwork causing a phacolytic glaucoma. Release of lens materials into the anterior chamber through a surgical or a traumatic opening in the lens capsule causes lens particle glaucoma in which insoluble lens particles obstruct the aqueous outflow pathways. Autoimmunity to lens antigens rarely causes phacoanaphylactic uveitis and glaucoma after a planned extra capsular cataract extraction or trauma. In developed countries, the availability of eye care services to those blind from cataract ensures that a large majority have their sight restored. In contrast, in developing countries like India in which majority of cataract blind are found, there has been an accumulation of unattended persons blind from cataract resulting in cataract backlog. This is due to insufficient number of ophthalmic surgeons as well as mal distribution of qualified personnel. This cataract backlog contributes to a significant number of lens induced glaucomas. Also some of our patients report very late for surgery after the attainment of hypermaturity due to illiteracy, ignorance and poverty or they neglect the cataract if they have a good vision in the other eye. This also contributes significantly to the incidence of lens induced glaucomas which we encounter.

Though the term lens induced glaucoma is a general term used for all the secondary glaucomas, where pathology of the lens is the sole factor, the mechanism of production of secondary glaucoma varies in each type and similarly the clinical features and treatment differ in each type. Hence present study has been taken up to analyze the different mechanisms and clinical features which they produce which will help in the management of the cases of lens induced gluacomas due to different mechanisms.

MATERIAL AND METHODS

This clinical study included 50 cases of different types of lens induced glaucomas in individuals whose age group varied from 12 to 90 years and both the sexes. This study was conducted on the in patients of Ophthalmology department, Vijayanagara Institute of Medical Sciences, Bellary. All the cases of secondary glaucomas suspected to be lens induced were admitted to the wards. Detailed history was ascertained. The details included the duration and progression of diminution of vision, the onset of pain, watering, redness and photophobia in the affected eye and headache and vomiting were taken.The time interval between the onset of pain,redness and photophobia to the presentation in the hospital was noted. Previous history of extra-capsular lens extraction in the other eye was carefully noted.

All these patients were thoroughly examined for their general condition. Ocular examination consisted of a detailed examination of the globe, adnexa including the lacrimal apparatus. All the cases were studied clinically in detail, in order to establish the glaucoma being due to the lens. Particular attention was paid to the corneal condition. The details about the anterior chamber were noted with regards to its depth, cells, flare and the presence of lens particulate matter. Next the condition of the iris for any evidence of iritis, posterior synechiae (atrophic patches) and iridodonesis were carefully noted. The lens, its size, condition of the capsule and the stage of cataract were noted. Particular attention was paid for the detection of the mark of wound of entry in the cornea was noted. In cases of blunt injury presence of subluxation or dislocation was carefully noted. Apart from trauma the other causes of spontaneous dislocation was also determined. In the affected eye the retinal function was determined by assessing the perception and projection of light. The pupil was studied with regards to its size, shape, margin and reaction to light both direct and indirect. The intra-ocular tension was recorded using Schioltz tonometer.

The other eye was also examined in detail giving main importance to the status of the lens, the angle of the anterior chamber, the fundus and the intraocular pressure.  The management of these cases consisted of relief from pain and reduction of elevated intra ocular pressure to near normal levels by medical management before taking the patient for surgery. Relief from pain was by the systemic administration of non steroidal anti inflammatory drugs. The medical management of glaucoma consisted of oral administration of acetazolamide tablets 500 mg stratum followed by 250 mg, 6 hourly after food. This was supplemented wherever necessary by oral glycerin two ounces three times a day.

In all cases where there was no contra indication, 300 cc of IV mannitol 20% was given at the rate of 6 drops per minute. Along with the above systemic medication topical timolol maleate or 0.5% twice daily was used.  and to control inflammation topical  betnesol was used.

Having brought the intra ocular pressure to within normal limits  by medical means surgery was resorted to. Surgical management consisted of proper pre operative preparation. Care being taken while doing ocular massage following peribulbar anesthesia in cases of hypermature and subluxated lenses. Planned extra capsular cataract extraction with peripheral iridectomy was done in majority of the cases. In few cases, lens extraction was combined with anti glaucoma surgery; particularly in cases where we thought shallow anterior chamber has lasted long enough for the development of peripheral anterior synechiae and obstructive glaucoma.

In three cases of retained lens material following extra capsular cataract extraction causing glaucoma the lens material in the anterior chamber was removed by irrigation and aspiration method. Complications during surgery such as vitreous loss and subluxation of the lens were noted and dealt accordingly. Routine post operative dressing was done and the in the follow up attention was paid to the subsidence of the inflammatory signs, corneal haziness and reduction of IOP  at the time of discharge along with routine recording of vision and IOP. After the discharge of the patients from the hospital they were reviewed weekly for a period of six weeks.

 

RESULTS

The youngest patient was 11 years old and the eldest was 90 years old. Majority of the patients were in the age group of 50-75 years. The incidence of lens induced glaucoma was more among females (68%) than males (32%).

Table 1: Distribution of study subjects as per the side of eye affected

Side of the eye affected

Number

Percentage

Right

29

58

Left

19

38

Both

02

04

Total

50

100

 

Right eye was found to be more commonly affected (58%) than the left eye (38%).

Table 2: State of the lens

State of the lens

Number

Percentage

Immature cataract

08

16

Mature cataract

17

34

Hypermature cataract

22

44

Traumatic cataract

03

06

Total

50

100

 

In the affected eye with glaucoma, the state of the lens ranged from immature, mature to hypermature cataract and traumatic cataract. The majority of the eyes affected had hypermature cataract (44%) followed by mature cataract (34%).

Table 3: Etiological diagnosis of lens induced glaucoma

Etiological diagnosis

Number

Percentage

Phacomorphic glaucoma

27

54

Phacolytic glaucoma

15

30

Lens particle glaucoma

03

06

Dislocation of the lens

05

10

Total

50

100

 

Phacomorphic glaucoma caused by intumescent lens has been the major cause contributing to 54% of cases followed by phacolytic glaucoma in 30% due to leakage of lens proteins from hypermature cataract.

Table 4: Distribution of dislocation cases of lens

Total cases studied

Dislocations

Traumatic

Spontaneous

Anterior

Posterior

Anterior

Posterior

50

05

01

02

00

02

100%

10%

02%

04%

00

04%

 

Out of 50 cases of lens induced glaucoma 5 belonged to the category of dislocation of the lens causing secondary glaucoma of these, one anterior and two posterior. Both the cases of spontaneous dislocation were posterior.

Table 5: Degree of inflammatory signs

Degree of inflammation

Number

Percentage

Mild

24

48

Moderate

16

32

Severe

10

20

 

Mild inflammation was present in majority of the cases (48%) followed by moderate inflammation (32%).

Table 6: Depth of anterior chamber

Depth of anterior chamber

Number

Percentage

Normal

00

00

Shallow

27

54

Deep

20

40

Variable

03

06

Total

50

100

 

27 cases (54%) showed shallow anterior chamber and 20 (40%) cases showed deep anterior chamber.

Table 7: Status of anterior chamber

Status of anterior chamber

Number

Percentage

Clear

27

54

Lens particulate matter

03

06

Hypopyon

07

14

Aqueous flare and cells

09

18

Lens in the anterior chamber

01

02

Vitreous in the anterior chamber

03

06

Total

50

100

 

Anterior chamber was clear in 27 (54%) of cases, contained lens particulate matter in three cases, hypopyon in 7 cases and aqueous flare and cells in 9 cases.

Table 8: Post operative improvement of vision in relation to duration of glaucoma

Duration in weeks

No. of cases

Visual recovery

6/9 – 6/12

6/18 – 6/24

6/60 – CF

NoPL

One week

30 (60%)

09 (30%)

18 (60%)

03 (10%)

00

Two weeks

12 (24%)

00

08 (66.7%)

04 (33.3%)

00

More than two weeks

08 (16%)

00

00

06 (75%)

02 (25%)

Total

50 (100%)

09 (18%)

26 (52%)

13 (26%)

02 (04%)

X2 = 9.628, p = 0.0009628

Table 8 shows the post operative improvement of vision in relation to duration of glaucoma. It was found that the good improvement of vision was seen in those patients who approached for treatment earlier. Thus the recovery rate was 86% (27 out of 30) among patients who approached within a week compared to 66.7% (8 out of 12) among patients who visited in the second week. It was zero percent recovery for patients who approached after two weeks. This trend was found to be statistically significant.

Table 9: Best corrected visual acuity post operatively

Visual acuity

No. of cases

Percentage

Remarks

6/9 – 6/12

12

24

Good

6/18 – 6/24

16

32

Satisfactory

6/36 – 6/60

09

18

Useful

< 6/60

11

22

Poor

No PL

02

04

Very poor

 

From the above table, it is evident that 56% had satisfactory visual improvement and 18% had useful vision and 22% some vision and only 4% did not show any visual recovery and these two patients who did not show visual recovery had reported after two weeks of onset of symptoms.

DISCUSSION:

The youngest patient was 11 years old and the eldest was 90 years old. Majority of the patients were in the age group of 50-75 years. The incidence of lens induced glaucoma was more among females (68%) than males (32%). Right eye was found to be more commonly affected (58%) than the left eye (38%). In the affected eye with glaucoma, the state of the lens ranged from immature, mature to hypermature cataract and traumatic cataract. The majority of the eyes affected had hypermature cataract (44%) followed by mature cataract (34%). Phacomorphic glaucoma caused by intumescent lens has been the major cause contributing to 54% of cases followed by phacolytic glaucoma in 30% due to leakage of lens proteins from hypermature cataract. Out of 50 cases of lens induced glaucoma 5 belonged to the category of dislocation of the lens causing secondary glaucoma of these, one anterior and two posterior. Both the cases of spontaneous dislocation were posterior. Mild inflammation was present in majority of the cases (48%) followed by moderate inflammation (32%). 27 cases (54%) showed shallow anterior chamber and 20 (40%) cases showed deep anterior chamber. Anterior chamber was clear in 27 (54%) of cases, contained lens particulate matter in three cases, hypopyon in 7 cases and aqueous flare and cells without hypopyon in 9 cases. Dhar GL et al 4 in their study of 214 cases recorded over 6 years contributed about 3.4% of all cases of senile cataract admitted for cataract extraction during this period. The youngest patient in this series was aged 51 years and the oldest patient aged 83 years, with the mean average age being 65.5 years. The majority of the patients in the whole lot were in the 6th decade of their life. Females were in preponderance (121 cases) compared to males (93 cases) and in a ratio roughly 4:3 which is similar to the present study findings. Hypermature cataracts were seen in only 83 (39.0%) cases, -mature intumescent cataract in 126 (58.5%) cases and immature cataracts in 5 (2.5%) cases. Mean intraocular pressure in the affected eye was 36.6 mm Hg ± 7.4 mm Hg schiotz. The highest recorded tension was 60.3. mmHg Schiotz and lowest was 26.6 mm Hg Schiotz.

Rohatgi JN 5 in their study reported that majority of the cases were of the age group 60 years and above con­stituting 41.3%. There were 29 females and 19 males.
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.

Pradhan D et al 6 observed that 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 km to the hospital. The major reasons for late presentation were "no escort" in 143 (34.6%) and "lack of money" 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 edema in 24 (25.5%) eyes. Prajna NV et al 7 found that forty four percent had a posterior chamber intraocular lens implantation following surgery. Fifty seven percent eyes with phacomorphic glaucoma and 61% with phacolytic glaucoma recovered visual acuity of 6/12 or better. There was no significant difference in the final visual acuity between those patients who had an intraocular lens implanted and those who did not (P=0.18). Univariate analysis was performed for selected risk factors such as age, sex and duration of glaucomatous process as predictors of final visual acuity and odds ratios with 95% confidence intervals were calculated. Patients with age more than 60 years (OR=2.7, 95% CI=1.04 - 6.93) and in whom the glaucoma was present for more than 5 days (OR=3.1, 95% CI=1.21 - 8.13) had a significantly higher risk of poor visual outcome post-operatively.

CONCLUSION:

The incidence of lens induced glaucoma was more among females (68%) than males (32%). Right eye was found to be more commonly affected (58%) than the left eye (38%). The majority of the eyes affected had hypermature cataract (44%).The visual recovery is poorer in patients who presented  in the second week after the onset of pain and redness(due to raised IOP) than in patients who presented in the first week after the onset of symptoms.

REFERENCES:

  1. Ritch R, Shields BM, Krupin T, editors. The Glaucomas, 2nd The University of Michigan: Mosby; 1996.
  2. Nischal K, Pearson A. Glaucoma. In: Kanski JK, Bowling B, editors. Clinical Ophthalmology: A systematic approach, 7th London: Elsevier; 2011. p. 311.
  3. Gifford H. The causes of the glaucoma of hypermature cataract. Arch Ophthalmol 1927;56:457-9.
  4. Dhar GL, Bagotra S, Bhalla A. Lens induced glaucoma: A clinical study. Indian J Ophthalmol 1984;32(5):456-9.
  5. Rohatgi JN. Lens induced glaucoma: A clinical study. Indian J Ophthalmol 1972;20(2):88-93.
  6. 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(2):103-7.
  7. Prajna VN, Ramakrishnan R, Krishnadas R, Manoharan N. Lens induced glaucomas – visual results and risk factors for final visual acuity. Indian J Ophthalmol 1996;44(3):149-55.




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