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MRIMS Journal of Health Sciences 2016;4(2)
http://www.mrimsjournal.com/
pISSN: 2321-7006, eISSN: 2321-7294
Original Article
Clinical study of lens induced glaucoma
Seetha Lakshmi DK1, Jayashree MP2
1
Assistant Professor, Department of Ophthalmology, Karnataka Institute of Medical Sciences, Hubli
2
Associate Professor, Department of Ophthalmology, Nijalingappa Medical College, Navanagar, Bagalkot, Karnataka
Corresponding Author:
Dr. Seetha Lakshmi DK
Email: [email protected]
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. 3 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
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
Page 118
Seetha Lakshmi DK et al. Clinical study of lens induced glaucoma
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
Right
Left
Both
Total
Number
Percentage
29
19
02
50
58
38
04
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
Immature cataract
Mature cataract
Hypermature
cataract
Traumatic cataract
Total
Number
08
17
22
Percentage
16
34
44
03
50
06
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%).
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
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Seetha Lakshmi DK et al. Clinical study of lens induced glaucoma
Table 3: Etiological diagnosis of lens induced glaucoma
Etiological diagnosis
Phacomorphic
glaucoma
Phacolytic glaucoma
Lens particle glaucoma
Dislocation of the lens
Total
Number
27
Percentage
54
15
03
05
50
30
06
10
100
Table 4: Distribution of dislocation cases of lens
Dislocatio
ns
05
10%
Traumatic
Anteri
Posteri
or
or
Spontaneous
Anteri
Posteri
or
or
01
02%
00
00
02
04%
02
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
inflammation
Mild
Moderate
Severe
of
Number
Percentage
24
16
10
48
32
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
Normal
Shallow
Deep
Variable
Total
Number
Percentage
00
27
20
03
50
00
54
40
06
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
Clear
Lens particulate matter
Number
27
03
07
09
01
03
14
18
02
06
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.
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.
Total
cases
studie
d
50
100%
Hypopyon
Aqueous flare and cells
Lens in the anterior chamber
Vitreous in the anterior
chamber
Total
Percentage
54
06
Table 8: Post operative improvement of vision in relation to
duration of glaucoma
Duration
in weeks
No. of
cases
One
week
Two
weeks
More
than two
weeks
Total
30
(60%)
12
(24%)
08
(16%)
Visual recovery
6/9 – 6/18 –
6/12
6/24
09
18
(30%) (60%)
00
08
(66.7%)
00
00
50
09
(100%) (18%)
X2 = 9.628, p = 0.0009628
26
(52%)
6/60 –
CF
03
(10%)
04
(33.3%)
06
(75%)
NoPL
13
(26%)
02
(04%)
00
00
02
(25%)
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
6/9 – 6/12
6/18 – 6/24
6/36 – 6/60
< 6/60
No PL
No.
cases
12
16
09
11
02
of
Percentage
Remarks
24
32
18
22
04
Good
Satisfactory
Useful
Poor
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
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
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Seetha Lakshmi DK et al. Clinical study of lens induced glaucoma
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.
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systematic approach, 7th ed. London: Elsevier; 2011. p.
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3) Gifford H. The causes of the glaucoma of
hypermature cataract. Arch Ophthalmol 1927;56:4579.
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.
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glaucoma in Nepal. Indian J Ophthalmol
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Cite this article as: Seetha Lakshmi DK, Jayashree
MP. Clinical study of lens induced glaucoma
MRIMS J Health Sciences 2016;4(2):118-121.
Source of Support: Nil. Conflict of Interest: None.
MRIMS Journal of Health Sciences, Vol. 4, No. 2, April-June 2016
Page 121