Lens Induced Glaucomas

2. Lens Induced Secondary Angle Closure Glaucomas Condition(s) related to the size of the lens -Intumescent cataract - Traumatic cataract Mechanism: - Pupillary block - Direct angle closure - Combination Phacomorphic Glaucoma [PMG]

3. Lens Induced Secondary Angle Closure Glaucomas Condition related to the site of the lens - Subluxated - Dislocated Mechanism: - Direct angle closure - Pupillary block

5. Lens Induced Secondary Open Angle Glaucomas Condition(s) related to soluble lens proteins Mechanism: - Heavy Molecular Weight protein [HMW] - Macrophagic response ?? Lens Protein Glaucoma [Phacolytic Glaucoma]

6. Lens Induced Secondary Open Angle Glaucomas Condition related to lens particles Mechanism: - Blockage of TM by lens particles e.g-retained lens matter -Post. YAG capsulotomy Lens Particle Glaucoma

7. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] More common in smaller eyes (hyperopic) Encountered more in developing countries Predisposed by rapidly developing intumescent cataract and traumatic cataract

8. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Mechanism: Swollen lens Pupillary block Angle closure Iris bomb�

10. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Stages of PMG: Pupillary Block Angle crowding Chronic angle closure

11. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Clinical Picture: Like PACG Mid-dilated fixed pupil Shallow A/c Closed angle Faulty light projection

12. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Diagnosis: Clinical picture Gonioscopy of both eyes Ultrasonography Paracentesis ?

13. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Management: Medical treatment to lower IOP Frequent topical steroid Pilocarpine Laser Iridotomy [?PLI] Cataract extraction + P/C IOL [ + trab. In long standing PMG] The other eye

14. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Advantages of Laser PI: Relieves acute attack Allows eye to quiet pre-op Allows evaluation of angle Allows safe pre-op medriusis

15. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Risk of Iridotomy: Bleeding Endothelial injury Rupture of lens capsule Failure/Inflammation

16. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intra-operative Difficulties: Difficult capsulotomy Shallow Alc; pos. pressure Constricted pupil Poor view [corneal edema] Descemet�s detachement Weak Zonules

17. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intraoperative Difficulties Poor View: Preoperative mannitol Topical preoperative glycerine ? Scrapping of epithelium

18. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Difficult Capsulotomy and (Shallow A/c): Deepening with viscoelastic mat. through paracentesis Puncture the lens at the center and aspirate liquefied cortex Cont�n next slide�

19. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Difficult Capsulotomy and (Shallow A/c + POS. pres.): Limited PPV (only cutter) Trypan blue Central circular capsul. Start at 12 o�clock (can opener tech.)

20. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Constricted Pupil: Mechanical Mydriasis - Visco elastic mat. - Pupil dilator - Pupil retractor - Small sphineteroctomies - Sector iridotomy

21. Lens Induced Secondary Angle Closure Glaucoma Phacomorphic Glaucoma [PMG] Intra-operative Difficulties Descemet�s Detachment: Avoid repeated A/c entry with sharp instrument Careful IOL insertion Viscoelastic mat.

22. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] A type of lens induced open angle glaucoma Described by Zeeman in 1943 Defined as phacolytic glaucoma by Flocks in 1955

23. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Lens Protein: 33% of total weight 85% soluble -Alpha crystallin � 15% - B Crystallin � 55% - ? Crystallin � 15% insoluble �albuminoid� 15%

24. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Heavy Molecular Weight Protein [HMW]: Increases with age & cataract formation Mainly in nuclear region Absent in infantile & juvenile lenses

25. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Experimental Studies: Perfusion of enucleated human eyes with HMWps 0.5mg severe obstruction Perfusion time obstruction Irrigation with BSS or alphachemotrypsin LMWps 1h no obstruction

26. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Engorged macrophages after cataract needling in children no phacolytic glaucoma Swollen rabbit macrophages failed to elevate IOP

27. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Studies: �Patients with phacolytic glaucoma� HMWps 35% of total protein (0.8mg) 0.8 mg is well in excess to cause obstruction No HMWps in normal subjects with immature & mature cataract

28. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Mehchanism: Simple obstruction of the TM by HMWps �MW>150x106 daltons� Macrophages ? Obstructors �normal scavenger response�

29. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Picture: Pain H/o poor vision [faulty L. projection] Conj. Hyperemia Corneal Edema Unilateral [other eye is aphakic or pseudophakic Cont�n next slide�

30. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Clinical Picture: Mature or hypermature cataract IOP Heavy flare White patches on the Capsule Open angle with deep A/c

31. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Differential Diagnosis: Acute Angle closure glaucoma (PMG) Neovascular glaucoma Ghost-cell glaucoma Angle recesion glaucoma Uveitic glaucoma

32. Lens Induced Secondary Open Angle Glaucoma Lens Protein Glaucoma [Phacolytic Glaucoma] Management: Medical Therapy Admission Anti-glaucoma therapy Hyperosmotic agents Topical steroids Surgical Cataract Extraction �Sufficient I/A�

34. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Usually Follows: Planned or unplanned extra cap. cataract extraction Penetrating lens injury Nd: YAG laser capsulotomy

35. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Mechanism: Obstruction of T.M. by: Free lens material ? Inflammatory response

36. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Management: Medical Therapy: - Anti-glaucoma therapy - Topical steroid Surgical: - A/c wash-out

37. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Is the most common complication Acute �within hours� Magnitude - 10mmHg above baseline reported in 59% - >40mmHg occurred in 38% - NLP have been reported

38. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Risk is greater in: Glaucoma patients Eyes without IOL More energy

39. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Management: Measure IOP 1h post laser capsulotomy Prophylactic anti-glaucoma therapy Topical steroids Cont�n next slide�

40. Lens Induced Secondary Open Angle Glaucoma Lens Particle Glaucoma Nd: YAG laser Post. Capsulotomy and IOP Elevation Management: Medical Therapy - Anti-glaucoma therapy (avoid meotics) - Hyperosmotic agents Surgical - Alc wash-out - Filtering procedure

41. Lens Induced Glaucomas