Phacolytic Glaucoma Research Articles

Vitreous Opacities in Phacolytic Glaucoma

To report five cases of vitreous opacification in phacolytic glaucoma (PG). The records of patients with PG were retrospectively reviewed. A total of 135 eyes with PG were studied to determine the presence of vitreous opacification. Five eyes with PG demonstrated opacification of the vitreous, which was first noted at surgery and confirmed postoperatively. All patients had had symptoms of PG for 7 days or more (mean +/- SD, 10.6 +/- 2.4 days) before they sought medical attention. Three eyes had a hypopyon on preoperative examination; two of these eyes showed refractile crystals in the anterior chamber. The opacities resolved spontaneously in all five eyes over a period of 12 weeks and interfered with visual activity only in the immediate postoperative period. Vitreous opacification in PG is a self-limited process that may not require surgical intervention unless more rapid visual rehabilitation is desired. The vitreous opacification probably results from an exaggeration of the process causing the anterior chamber reaction.

Endocapsular surgery and capsular bag fixation of intraocular lenses in phacolytic glaucoma

Performing endocapsular surgery can be more difficult in eyes with phacolytic glaucoma because the capsule is fragile and zonules are weak. In this study, I investigated the safety and efficacy of a technique for performing endocapsular surgery with and without posterior chamber intraocular lens (IOL) implantation in 19 eyes of 19 patients with phacolytic glaucoma. This technique involves aspiration of the fluid cortex from the capsular bag using a 26 gauge bent needle. After anterior capsulotomy with angled Vannas scissors, the nucleus is delivered using minimal pressure on the irrigating vectis. The remaining cortex is completely removed using minimal irrigating fluid. At the end of the procedure, a posterior chamber IOL is inserted in the bag as indicated. A V-shaped anterior capsulectomy is completed using Vannas scissors, without exerting traction on the zonules. Intraoperatively, internal structures can be clearly visualized and the entire procedure performed with minimal trauma to the fragile lens capsule and zonular apparatus. I encountered no major complications. Follow-up ranged from 12 to 36 months with satisfactory visual outcome and good intraocular pressure control without antiglaucoma medication in all patients.

Lens-induced Glaucoma 65 Years After Congenital Cataract Surgery

We observed an unusual case of lens-induced glaucoma that occurred 65 years after congenital cataract extraction. We successfully treated the patient by removing the residual lens material with pars plana vitrectomy. The intraocular specimen exhibited lens material, epithelial cells, and macrophages. It may have taken years for the residual lens material to denature and break into small pieces, which resulted in phacolytic and lens-particle glaucoma.

Extracapsular Cataract Extraction and Posterior Chamber Lens in the Management of Phacolytic Glaucoma

OBJECTIVE:To determine whether extracapsular cataract extraction (ECCE) with a posterior chamber intraocular lens (PC IOL) insertion poses any particular surgical problem in the management of phacolytic glaucoma. STUDY DESIGN: A prospective study of postoperative results of ECCE and PC IOL at 1 week, 1 month and long-term follow-up ranging from 10 to 38 months. SETTING: University Eye Clinic of Athens. PATIENTS: Six patients suffering from phacolytic glaucoma of some 24–72 hours duration. MAIN OUTCOME MEASURES: Operative complications, postoperative status including intraocular pressure and visual acuity. RESULTS: No operative complications occurred. No significant intraocular pressure problems were recorded. One case of postoperative macular oedema complicated an otherwise excellent visual result in all cases. In the postoperative period of observation no significant opacification of the posterior capsule was noted. CONCLUSIONS: There were no significant problems related to cataract and lens implant surgery with patients with phacolytic glaucoma. The preoperative situation of inflammation and raised intraocular pressure resolved rapidly after surgery. The visual outcome was very satisfactory.

Cytokines in human intraocular inflammation.

The presence of interleukin 6 (IL-6), interleukin 1 (IL-1), interleukin 2 (IL-2) and tumour necrosis factor (TNF) was investigated in vitreous and aqueous aspirates from eyes undergoing vitrectomy for the treatment of different inflammatory conditions. Cadaveric vitreous from 10 normal subjects were used as controls. IL-6 was observed in 5 specimens from eyes with idiopathic uveitis (range = 26-264 pg/ml), in 2 specimens from eyes with uveitis complicated with retinal detachment (28 and 279 pg/ml, respectively), in 6 samples from eyes with diabetic retinopathy (range = 5-480 pg/ml), in one sample from an eye with phacolytic glaucoma (1190 pg/ml) and in one specimen from an eye with Behçet's disease (366 pg/ml). Although IL-1 was detected in 80% of all the samples investigated, concentrations of this cytokine greater than 3 pg/ml were only observed in 2 specimens from eyes with uveitis (5 and 20 pg/ml, respectively) and 2 samples from eyes with diabetic retinopathy (3 and 31 pg/ml, respectively). TNF was present in 3 specimens from eyes with uveitis (range = 2-24 pg/ml) and 1 sample from eyes with diabetic retinopathy (4 pg/ml), but was not detected in the eyes with phacolytic glaucoma or Behçet's disease. IL-2 (less than 0.1 U/ml) was detected in one sample from an eye with uveitis, one specimen from an eye with uveitis complicated with retinal detachment and 2 samples from eyes with diabetic retinopathy. None of the cytokines measured were detected in any of the control vitreous. The present observations suggest that cytokines, particularly IL-6 and IL-1, may act as local amplification signals in pathological processes associated with chronic eye inflammation.

Lens-induced glaucoma.

The crystalline lens is implicated as a causative element in producing several forms of glaucoma. Etiologically they represent a diversity in the presentation of the glaucomatous process. These conditions include glaucoma related to: lens dislocation (ectopia lentis), lens swelling (intumescent cataract), classical pupillary block, aqueous misdirection--ciliary block, phacoanaphylaxis, lens particle, and phacolytic glaucoma. The management of elevated intraocular pressure often requires altering the intraocular relationship of anatomic structures surrounding the lens or lens removal. We will review the entities that produce these lens-induced glaucomatous conditions and suggest a rational approach to their diagnosis and treatment.

Comparison of Specular Microscopy and Examination of Aspirate in Phacolytic Glaucoma

Although phacolytic glaucoma is well known and the clinical picture is well recognized, the nature of the polychromatic hyperrefringent granules is less well understood. A series of five cases was examined by specular microscopy, and the anterior chamber aspirate obtained at operation was subsequently examined by direct microscopy of the wet aspirate. Direct microscopy showed that the macrophages identified histologically in the aspirate corresponded to regular round cells about three times the size of an erythrocyte seen in the relief mode of specular microscopy. This finding aided in the interpretation of cellular deposits seen on specular microscopy. One hyperrefringent granule was seen on the posterior endothelium on specular microscopy, and results of subsequent examination of the aspirate showed this and the crystals in another patient to be morphologically identical with cholesterol crystals. The findings confirm that cholesterol crystals are present in the exudate in phacolytic glaucoma and are responsible for hyperrefringent granules.

Treatment of Phacolytic Glaucoma with Extracapsular Cataract Extraction

The treatment of choice for phacolytic glaucoma has been intracapsular cataract extraction (ICCE). The current study was undertaken to determine the efficacy of extracapsular cataract extraction (ECCE) as a definitive treatment for phacolytic glaucoma. Five cases of phacolytic glaucoma that occurred between 1984 and 1986 were studied after a retrospective chart review; ECCE (with placement of a posterior chamber intraocular lens [PC IOL]) was performed without complication and was curative in all five eyes. All patients (100%) maintained intraocular pressures (IOPs) of less than 20 mmHg, without medical therapy. The best-corrected visual acuity for all cases was 20/50 or better (80%, ≥ 20/40) with 5 months to 3 years follow-up. These results suggest that ECCE is an effective alternative for the treatment of phacolytic glaucoma and allows surgeons the freedom to choose the procedure with which they are most comfortable. Additionally, implantation of a PC IOL is a safe and efficacious procedure in restoring visual function in these patients.

Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma.

Leakage of lens proteins from a hypermature cataract can result in a characteristic glaucoma that is associated with the invasion of the anterior chamber by monocytes. We hypothesized that the lens proteins themselves might account for the monocyte response. A sonicated lens induced concentration-dependent migration of monocytes in a Boyden chamber assay system. Checkerboard analysis indicated that the movement was directed rather than merely random. Relative to a control chemoattractant, N-formyl-methionyl-leucyl-phenylalanine, the lens induced monocyte migration more potently than neutrophil migration. The ability to induce migration was markedly reduced by incubating the lens with either trypsin or papain. Chemotactic activity was readily demonstrable in lenses from young donors without cataracts. Separation of lens proteins by gel filtration with high-performance liquid chromatography indicated that the chemotactic activity was most consistently associated with the gamma crystallin fraction. The chemotactic activity of lens proteins may contribute to the pathogenesis of phacolytic glaucoma or the uveitis resulting from retained cortical material after cataract extraction.

Acidic lens-protein-degrading activity in aqueous humour

Lens-protein-degrading activity in human aqueous humor was determined biochemically. Proteolytic activity was found in the pellet of aqueous humor from patients with Morgagnian cataract, traumatic cataract, after cataract, traumatic lens luxation, and phacolytic glaucoma. The activity was found at pH 3.8 and it was inhibited partly by pepstatin or leupeptin. Possibly, cathepsin D and lysosomal thiol proteinases in the macrophages play a major role in the degradation of escaping lens protein under pathologic conditions.

Immunoassay of serum alpha-1 antitrypsin level in uveitis.

The serum alpha-1 antitrypsin level was measured in 60 patients with endogenous uveitis, 27 patients with phacoallergic endophthalmitis, 12 patients with phacolytic glaucoma, and 58 healthy subjects. Thirty-four patients with endogenous uveitis were also followed up for 6 months after treatment, and the serum alpha-1 antitrypsin level was measured again. There was a significant rise in the serum alpha-1 antitrypsin level in cases of endogenous uveitis and phacoallergic endophthalmitis but no alteration in cases of phacolytic glaucoma. Among the patients with endogenous uveitis the level was significantly raised in cases of anterior uveitis, but there was no change in cases of posterior uveitis. A significant rise was seen only in cases of acute anterior uveitis but not in chronic anterior uveitis. The serum alpha-1 antitrypsin level was unaltered in endogenous uveitis despite clinical improvement.

Diagnosis and Management of Lens-induced Glaucoma

Lens-induced glaucoma may occur as either secondary angle-closure or open-angle glaucoma. Dislocation or swelling of the lens can cause papillary block and subsequent angle-closure glaucoma. Leakage of soluble lens proteins from a relatively intact cataractous lens can result in a severe secondary open-angle glaucoma (phacolytic glaucoma). Heavy molecular weight protein, believed to be of lens origin, has now been identified in 12 of 12 anterior chamber, specimens from such patients. This liberated lens protein can directly obstruct the trabecular outflow pathways. After extracapsular cataract surgery or after lens trauma, liberated fragments of lens material may mechanically impair the drainage of aqueous humor through the outflow channels (lens particle glaucoma). The diagnosis and management of these different lens-induced glaucomas are reviewed. With proper recognition; these glaucomas are promptly cured by the surgical removal of the lens (material).

Retinal Perivasculitis in Phacolytic Glaucoma

A 63-year-old man with a posteriorly dislocated lens developed phacolytic glaucoma. The lens was removed at vitrectomy and extensive retinal perivascular infiltrates were observed at the time of surgery. Two days later, his intraocular pressure was normal and the retinal perivascular changes had completely disappeared.

Acute phacolytic glaucoma with primary intraocular lens implantation after intracapsular cataract extraction

A case of acute phacolytic glaucoma was treated with intracapsular cataract extraction and primary implantation of an iris fixation intraocular lens. The glaucoma resolved and visual acuity of 20120 was obtained. Indications for and against this management approach are discussed.

Calcium Oxalate Crystals in the Aqueous

We found octohedral crystals in the aqueous of a patient with phacolytic glaucoma. They were identified as calcium oxalate by their physical and chemical characteristics.

Total White Hypopyon: an Unusual Presentation of Phacolytic Glaucoma

Phacolytic glaucoma normally presents with clinical features of eye pain and redness, anterior chamber inflammation, and increased intraocular pressure. This report is of a patient with phacolytic glaucoma, which presented as a total white hypopyon in a non-inflamed eye. Other possible causes of pseudohypopyon in this age group such as endogenous endophthalmitis or Masquerade syndrome were excluded before the patient underwent extracapsular cataract extraction with secondary posterior chamber intraocular lens implantation. She achieved satisfactory visual acuity postoperatively.

Cytology of human lens aspirate. Its relationship to phacolytic glaucoma and phacoanaphylactic endophthalmitis.

Following needling and aspiration of cataract, the anterior chamber aspirate from 28 eyes of 23 patients was analyzed cytologically. The almost purely macrophagic cellular response was directly related to the time elapsed between needling and aspiration. The type of cell was identical to but much fewer in number than cells seen with phacolytic glaucoma. The escaping lens protein of senile hypermature cataracts is probably altered and more noxious than the normal lens substance found in the anterior chamber following needling of soft cataracts. No difference in cellular response was noted between those eyes from 15 patients who had had no previous surgical manipulation of the lens in the fellow eye and 13 who had experienced such surgery. Phacoanaphylactic endophthalmitis must involve factors (such as the genetic makeup of the individual) other than simply the presence of altered lens protein within the eye following disruption of the lens capsule.

Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous.

Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous.

Contusive angle recession in phacolytic glaucoma.

Phacolytic glaucoma is a distinct entity than can be recognized clinically and pathologically. It is manifested clinically by the acute onset of glaucoma in an eye with a hypermature cataract. Cells and flare are present in a deep anterior chamber, and typically there is a lack of synechias as well as a lack of keratic precipitates. Appropriate treatment consists of prompt cataract extraction with irrigation of the anterior chamber. One of the clinical features of phacolytic glaucoma that has been emphasized is its occurrence in elderly patients with senile cataracts who present no evidence of any other intraocular disease. In the clinicopathologic study of Flocks et al, 1 the majority of the 138 patients were over 70 years of age, and the fellow eye was aphakic. In only eight cases were the cataracts considered of traumatic origin. These eight cases were included in a group of patients with monocular cataract

PHACOLYTIC GLAUCOMA AGGRAVATED BY HYPHEMA THAT FOLLOWED IRIDECTOMY.

The purpose of this report is to present an unusual case of acute open-angle secondary glaucoma. The phacolytic origin of the glaucoma was unrecognized, and the condition was treated by iridectomy. Postoperative hemorrhage aggravated the glaucoma, and this unfortunate combination of events led to enucleation. Report of a Case Clinical History. —The completely blind right eye of a 62-year-old Caucasian woman was enucleated 18 days after the onset of acute congestive glaucoma. When first examined, the day the glaucomatous attack began, the eye was thought to have a shallow chamber and a mature cataract. A diagnosis of acute angle-closure glaucoma was made, and an iridectomy was performed immediately. After this surgical intervention there was bleeding into the anterior chamber and the tension became too high to measure. Lens extraction had been performed on the left eye many years before; the patient's corrected visual acuity was 20/40, and the intraocular pressure