Secondary glaucoma associated

with crystalline lens subluxation

Masaru Inatani, MD, Hidenobu Tanihara, MD, Megumi Honjo, MD,
Noriaki Kido, MD, Yoshihito Honda, MD

ABSTRACT
Purpose: To elucidate the clinical characteristics of secondary glaucoma associated with
subluxation of the crystalline lens.

Setting: Department of Ophthalmology and Visual Sciences, Kyoto University Graduate

School of Medicine, Kyoto, and Department of Ophthalmology, Tenri Hospital, Nara,
Japan.

Methods: This retrospective study comprised 14 eyes of 13 patients with uncontrolled

intraocular pressure (IOP) and lens subluxation. The subluxated lens was extracted
through surgery.

Results: Angle closure caused by the subluxated lens was complicated in 3 eyes. In the
remaining 11 eyes, uncontrolled IOP elevation was found despite the presence of deep
anterior chambers and wide open angles. A mean of 14.1 months 13.7 (SD) after
cataract surgery, IOP was well controlled (lower than 21 mm Hg) in all 14 eyes. Mean
IOP was 15.4 2.2 mm Hg at the final examination. Complications included transient
vitreous hemorrhage in 5 eyes, choroidal detachment in 2 eyes, and retinal tears in 1
eye.

Conclusion: Lens extraction surgery was effective in controlling IOP in eyes with second-
ary glaucoma associated with lens subluxation. J Cataract Refract Surg 2000; 26:
15331536 2000 ASCRS and ESCRS

cause the onset of glaucoma.1,2 These include pupil-

S ubluxation of the crystalline lens is associated with
several clinical conditions such as trauma,1,2 genetic
disorders (Marfans syndrome,3 homocystinuria,3
and Weill-Marchesani syndrome4), and pseudoexfo-
liation syndrome.5 In some eyes with a subluxated
lens, a variety of mechanisms have been reported to
Accepted for publication April 14, 2000.
From the Department of Ophthalmology and Visual Sciences, Kyoto
University Graduate School of Medicine, Kyoto (Inatani, M. Honjo,
Kido, Y. Honda), and the Department of Ophthalmology, Tenri Hospi-
tal, Nara (Tanihara), Japan.
Reprint requests to Hidenobu Tanihara, MD, Department of Ophthal-
mology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, Japan. E-
mail: tanihara@pearl.ocn.ne.jp.
2000 ASCRS and ESCRS
Published by Elsevier Science Inc.
lary block, formation of peripheral anterior synechias,
phacolytic glaucomas, postcontusion deformity of the
chamber angle, irritation of the ciliary body by the
displaced lens, and the presence of vitreous in the
anterior chamber. This study shows that in eyes with
secondary glaucoma associated with subluxated
lenses, extraction of the lens controls intraocular pres-
sure (IOP) levels without the use of pressure-lowering
procedures.
Patients and Methods
Included in this study were 14 eyes of 13 patients
(7 men and 6 women). All patients were recruited at
0886-3350/00/$see front matter
PII S0886-3350(00)00471-5
 LENS SUBLUXATION AND SECONDARY GLAUCOMA

the Department of Ophthalmology and Visual Sci-
ences, Kyoto University Graduate School of Medi-
cine, Kyoto, and the Department of Ophthalmology,
Tenri Hospital, Nara, Japan. Mean patient age was
64.2 years 11.0 (SD). Preoperative IOP in all pa-
tients was higher than 21 mm Hg with antiglaucoma
medication. Mean preoperative IOP was 38.9
15.7 mm Hg on a mean of 0.9 1.0 antiglaucoma
medications. Mean follow-up was 14.1 14.0
months (range 3 to 53 months).
Phakodonesis was observed by preoperative slitlamp
examinations in all 14 eyes. In 3 eyes (21%), a flat (or
shallow) anterior chamber and closed angle structures
were found by slitlamp and gonioscopic examinations
before surgical (or laser) treatments. Mean IOP in the
3 eyes with secondary angle-closure glaucoma was
48.0 24.6 mm Hg. In the other 11 eyes with IOP
elevation, deep anterior chambers and wide open angles
were observed preoperatively. Mean IOP in the 11 eyes
with secondary open-angle glaucoma was 36.4
12.1 mm Hg.
The subluxated lenses were caused by trauma in
4 eyes, pseudoexfoliation syndrome in 2 eyes, and un-
known etiologies in 8 eyes (Table 1). In 1 eye with a
history of trauma, the presence of pseudoexfoliative
material was observed on the pupillary region in the
iris. At preoperative slitlamp examination, herniated
vitreous into the anterior chamber was found in 4 eyes.
In 4 eyes, laser iridotomy (or surgical iridectomy) was
performed to rule out the possibility of a pupillary block
mechanism.
Surgical modalities for lens extraction were intra-
capsular cataract extraction in 10 eyes, phacoemulsifica-
tion and aspiration in 2 eyes, and pars plana lensectomy
in 2 eyes. In 11 eyes (79%), an intraocular lens (IOL)
was implanted using scleral fixation. In 11 eyes (79%),
an anterior vitrectomy was done to remove the vitreous
from the anterior chamber.
Results
In all 14 eyes, lens extraction (with IOL implanta-
tion in 11 eyes) was performed for the subluxated lenses
without additional glaucoma surgery such as trabeculec-
tomy or trabeculotomy. Immediately after lens extrac-
tion, IOP was lower than preoperatively in all 14 eyes.
Two weeks postoperatively, mean IOP was 17.9
5.8 mm Hg on a mean of 0.6 1.0 antiglaucoma med-
ications (Table 2). At the final examination, IOP was
well controlled (lower than 21 mm Hg) in all 14 eyes
with or without antiglaucoma medication (Tables 2 and
3). In 9 eyes (64%), IOP was well controlled without

Table 1. Patient data.

Age Herniated Vitreous Surgical

Patient (Years) Sex Etiology Angle in Anterior Chamber History

1 82 M Trauma/pseudoexfoliation Closed N
2 46 M Trauma Open P
3 55 M Trauma Open P
4 59 F Trauma Open N
5 64 F Pseudoexfoliation Open N
6 81 F Pseudoexfoliation Open N LI
7 77 F Unknown Closed N PI
8 64 M Unknown Closed N PI
9 65 M Unknown Open P
10 58 M Unknown Open P
11 57 F Unknown Open N LI
12 54 M Unknown Open N
13(RE) 72 F Unknown Open N
13 (LE) Unknown Open N
RE right eye; LE left eye; N negative; P positive; PI peripheral iridectomy; LI laser iridotomy

1534 J CATARACT REFRACT SURGVOL 26, OCTOBER 2000

 LENS SUBLUXATION AND SECONDARY GLAUCOMA

Table 2. Mean preoperative and postoperative IOP and mean

glaucoma medications used.

Mean SD
Number IOP Number of
Exam of Eyes (mm Hg) Medications

Preoperative 14 38.9 15.7 0.9 1.0

Postoperative
2 weeks 14 17.9 5.8 0.6 1.0
1 month 14 14.8 3.2 0.4 0.8
3 months 14 15.4 3.0 0.5 0.9
6 months 10 16.0 2.7 0.5 0.8
1 year 7 17.0 2.3 0.8 0.9
2 years 2 16.0 0.5
3 years 1 14.0 0
4 years 1 19.0 0
Figure 1. (Inatani) Scattergram of visual acuity before (x-axis) and
Last 14 15.4 2.2 0.5 0.8
after (y-axis) lens extraction.

antiglaucoma medication. Mean IOP at the final exam-
ination was 15.4 2.2 mm Hg on a mean of 0.5 0.8
medications. The anterior chambers were deeply formed
in all eyes after lens extraction.
Postoperative complications included vitreous hemor-
rhage in 5 eyes (36%), choroidal detachment in 2 eyes
(14%), and retinal tears in 1 eye (7%) (Table 3). In
eyes with vitreous hemorrhage and choroidal detachment,
the identified complications resolved spontaneously
without additional surgical treatment. Because the reti-
nal tears were found after the lens extraction, laser pho-
tocoagulation was done to block the formed retinal
breaks.
At final examination, postoperative visual acuity
improved by more than 2 lines in 8 eyes (57%), re-
mained within 2 lines in 5 eyes (36%), and deteriorated

Table 3. Surgical results after lens extraction.

Surgical Pre IOP Final IOP Follow-up

Patient Mode A-vit (mm Hg) (mm Hg) (Months) Surgical Complications

1 ICCE 30 20 31
2 PPL IOL 52 16 53
3 PEA IOL 38 13 3 Choroidal detachment/vitreous hemorrhage
4 ICCE 24 19 16 Vitreous hemorrhage
5 ICCE IOL 58 16 12
6 PEA IOL 36 17 11 Vitreous hemorrhage
7 ICCE IOL 38 16 13 Choroidal detachment
8 PPL IOL 76 14 4 Retinal tears
9 ICCE IOL 22 14 16 Vitreous hemorrhage
10 ICCE IOL 30 16 7
11 ICCE IOL 50 19 19
12 ICCE 33 15 6 Vitreous hemorrhage
13(RE) ICCE IOL 25 11 3
13 (LE) ICCE IOL 32 10 3
RE right eye; LE left eye; ICCE intracapsular cataract extraction; PPL pars plana lensectomy; PEA phacoemulsification and aspiration;
IOL IOL implantation; A-vit anterior vitrectomy; Pre IOP preoperative intraocular pressure

J CATARACT REFRACT SURGVOL 26, OCTOBER 2000 1535

 LENS SUBLUXATION AND SECONDARY GLAUCOMA
in 1 eye (7%). In the eye with decreased visual acuity,
IOL tilt caused visual disturbance (Figure 1).
Discussion
Lens subluxation leads to secondary glaucoma
through a variety mechanisms.1,2 If the lens is sublux-
ated or tilted forward against the iris, the lens may block
aqueous flow through the pupil. In our retrospective
study, angle-closure (flat anterior chamber-induced)
glaucoma occurred in only 3 (21%) of 14 eyes. In the
other 11 eyes (79%), uncontrolled high IOP was found
despite the presence of deep anterior chambers and
wide open angles. Our study suggests that the major
form of the secondary glaucoma associated with lens
subluxation may be of the open-angle type.
Jensen and coauthors4 report 2 eyes with Weill-
Marchesani syndrome with normally positioned lenses
and glaucoma. Possible explanations for the onset of
secondary open-angle glaucoma in eyes with the sublux-
ated lenses include (1) dysfunction in trabecular aque-
ous outflow route caused by intermittent closure of the
angle, trauma, genetic backgrounds, and pseudoexfolia-
tion syndrome; (2) occult phacolytic glaucoma; (3) irri-
tation of the ciliary body by the displaced lens and
subsequent inflammatory reaction; (4) obstruction of
the trabecular tissues in the anterior chamber caused by
the presence of vitreous in the anterior chamber. Al-
though our retrospective study could not identify the
exact mechanisms related to the onset of the secondary
open-angle glaucoma, our results emphasize that in
most cases, secondary glaucoma caused by lens subluxa-
tion occurs even when there is no pupillary block.
In our study, lens extraction effectively lowered IOP
in eyes with secondary glaucoma associated with lens
subluxation. Important are the safety and usefulness of
lens extraction in controlling IOP without performing
pressure-lowering procedures including filtering surger-
ies. Because most cases of secondary glaucoma in our
study occurred in eyes with no pupillary block, relief of
the pupillary block cannot explain the effectiveness.
In 1967, Jarrett2 reported that in 18 (56%) of 32 glau-
comatous eyes with a dislocated lens, IOP was controlled
by lens extraction. However, 8 eyes (25%) lost vision and 6
(19%) required further surgical procedures (cyclodialysis or
cyclodiathermy) to control glaucoma. Jarretts results
indicate that surgical treatments to manage secondary
glaucoma associated with lens subluxation are risky.
1536 J CATARACT REFRACT SURGVOL 26, OCTOBER 2000
Recent advances in cataract and vitreous surgeries
and scleral fixation of IOLs enabled us to safely remove
the subluxated lenses. This is supported by the success of
recently reported procedures of lens extraction in glau-
comatous eyes with dislocated lenses.6 8 However,
these studies also indicate that the usefulness of recent
lens extraction surgeries in eyes with secondary open-
angle glaucoma associated with lens subluxation were far
from satisfactory.
In our study, lens extraction in eyes with glaucoma
associated with lens subluxation seemed useful in im-
proving visual acuity and lowering IOP. No patient lost
vision during the follow-up. Although our surgical tech-
niques included 3 kinds of lens extraction, all 3 mo-
dalities seemed similarly effective in managing
secondary glaucoma in eyes with subluxated lenses,
suggesting the presence of lens itself is involved in the
IOP elevation.
In conclusion, our study showed that secondary
open-angle glaucoma occurs in cases of a subluxated lens
and that lens extraction alone can help manage this kind
of secondary glaucoma. We recommend lens extraction
alone as the safe, useful first surgical treatment for sec-
ondary glaucoma associated with lens subluxation.
References
1. Chandler PA. Choice of treatment in dislocation of the
lens. Arch Ophthalmol 1964; 71:765786
2. Jarrett WH II. Dislocation of the lens; a study of 166
hospitalized cases. Arch Ophthalmol 1967; 78:289 296
3. Cross HE, Jensen AD. Ocular manifestations in the
Marfan syndrome and homocystinuria. Am J Ophthalmol
1973; 75:405 420
4. Jensen AD, Cross HE, Paton D. Ocular complications in
the Weill-Marchesani syndrome. Am J Ophthalmol 1974;
77:261269
5. Futa R, Furuyoshi N. Phakodonesis in capsular glaucoma:
a clinical and electron microscopic study. Jpn J Ophthal-
mol 1989; 33:311317
6. Schlote T, Volker M, Thanos S, Thiel H-J. Glaukom bei
Marfan-Syndrom: Lageabhangige Druckmessung als diag-
nostisches Kriterium. Klin Monatsbl Augenheilkd 1995;
207:386 388
7. Netland KE, Martinez J, LaCour OJ III, Netland PA.
Traumatic anterior lens dislocation: a case report. J Emerg
Med 1999; 17:637 639
8. Chaudhry NA, Belfort A, Flynn HW Jr, et al. Combined
lensectomy, vitrectomy and scleral fixation of intraocular
lens implant after closed-globe injury. Ophthalmic Surg
Lasers 1999; 30:375381