PHACOMORPHIC GLAUCOMA

Signs and Symptoms

Patients with phacomorphic glaucoma are typically elderly, female, and often of small stature. Frequently, they are hyperopic with a nanophthalmic eye. By definition an advanced, intumescent cataract will be present in the affected eye. Visual acuity is poor, often well below 20/400. There will be a shallow anterior chamber. In eyes with markedly asymmetric cataract formation, anterior chamber depth may be accordingly disparate. Often, patients will present with acute onset of ocular redness and pain with an edematous cornea and elevated IOP. Gonioscopically, during the acute attack, there will be corneal edema, and no anterior chamber angle structures will be visible. Occasionally, there may be a precipitating incident such as pharmacological pupil dilation.1-3

Pathophysiology

Phacomorphic glaucoma is a patho-logic rise in IOP precipitated by the shape of the lens. That is, the lens becomes intumescent and thickened through the process of cataractogenesis. This can cause a relative pupil block with secondary angle closure with all of the attendant signs and symptoms of an acute angle closure attack. Further, the swelling of the lens may press upon the iris and ciliary body, forcing them anteriorly and shallowing the anterior chamber. Thus, there can be an acute angle closure attack that may not respond to laser peripheral iridotomy (LPI).

Management

Medical therapy is used to reverse the process and acutely lower the IOP. Beta-blockers, alpha-2 adrenergic agonists, topical corticosteroids, topical or oral carbonic anhydrase inhibitors, and oral hyperosmotics may all be systematically employed. Superior IOP control and shortening the duration of the attack preoperatively is essential in improving the final visual outcome.4

In cases where pupil block precipitates an angle closure, LPI is indicated following medical treatment to attempt to relieve the resultant aqueous congestion and IOP rise.5 This is especially true when relative pupil block is the main pathogenesis. In cases in which pupil block only partially contributes to the angle closure, argon laser peripheral iridoplasty can reverse the apposition and alleviate the condition.

Cataract extraction will ultimately relieve the condition. Extracapsular cataract extraction, either with or without secondary lens implantation, remains the most common procedure to correct phacomorphic glaucoma.6-8 There often is a poor visual outcome secondary to both surgical complications as well as the lens induced glaucoma.9 This is especially true for patients over 60 years and those in whom the glaucoma has persisted beyond five days.6

Clinical Pearls

  • While acute primary angle closure is typically symmetrical, phacomorphic glaucoma is not. Be aware of a possibility of a narrow angle and shallow chamber in patients with advanced, unilateral cataract.
  • Long-term miotic usage in patients with mature cataracts may predispose the patient to phacomorphic glaucoma.
  • Patients with POAG may develop angle closure and phacomorphic glaucoma with continued cataract development. Perform gonioscopy at least annually on all glaucoma patients.

 

  1. Abramson DH, Franzen LA, Coleman DJ. Pilocarpine in the presbyope: Demonstartion of an effect on the anterior chamber and lens thickness. Arch Ophthalmol 1973;89:100-2.
  2. Gorin G. Angle closure glaucoma induced by miotics. Am J Ophthalmol 1966;62:1063-6.
  3. Gayton JL, Ledford JK. Angle closure glaucoma following a combined blepharoplasty and ectropion repair. Ophthal Plast Reconstr Surg. 1992;8(3):176-7.
  4. Das JC, Chaudhuri Z, Bhomaj S, et al. Combined extracapsular cataract extraction with Ahmed glaucoma valve implantation in phacomorphic glaucoma. Indian J Ophthalmol. 2002;50(1):25-8.
  5. Tomey KF, al-Rajhi AA. Neodymium:YAG laser iridotomy in the initial management of phacomorphic glaucoma. Ophthalmology. 1992;99(5):660-5.
  6. Prajna NV, Ramakrishnan R, Krishnadas R, et al. Lens induced glaucomas--visual results and risk factors for final visual acuity. Indian J Ophthalmol. 1996;44(3):149-55.
  7. McKibbin M, Gupta A, Atkins AD. Cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma. J Cataract Refract Surg. 1996;22(5):633-6.
  8. Rao SK, Padmanabhan P. Capsulorhexis in eyes with phacomorphic glaucoma. J Cataract Refract Surg. 1998;24(7):882-4.
  9. Lim TH, Tan DT, Fu ER. Advanced cataract in Singapore--its prognosis and complications. Ann Acad Med Singapore. 1993;22(6):891-4.

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