Glaukoma Akibat Kelainan Lensa

a. Dislokasi Lensa

Lensa kristalina dapat mengalami dislokasi akibat trauma atau secara spontan, misalnya

pada sindrom Marfan. Dislokasi anterior dapat menimbulkan sumbatan pada apertura

pupil yang menyebabkan iris bombe dan penutupan sudut. Dislokasi posterior ke dalam

vitreus juga berkaitan dengan glaukoma meskipun mekanismenya belum jelas. Hal ini

mungkin disebabkan oleh kerusakan sudut pada waktu dislokasi traumatik.1

Pada dislokasi anterior, terapi definitifnya adalah ekstaksi lensa segera setelah tekanan

intraokular terkontrol secara medis. Pada dislokasi posterior, lensa biasaanya dibiarkan dan

glaukoma diobati sebagai glaukoma sudut terbuka primer.8

b. Intumesensi Lensa

Lensa dapat menyerap cukup banyak cairan sewaktu mengalami perubahan-

perubahan katarak sehingga ukurannya membesar secara bermakna. Lensa ini kemudian

dapat melanggar batas bilik depan, menimbulkan sumbatan pupil dan pendesakan sudut, serta

menyebabkan glaukoma sudut tertutup. Terapi berupa ekstraksi lensa, segera setelah tekanan

intraokular terkontrol secara medis.1

c. Glaukoma Fakolitik

Sebagian katarak stadium lanjut dapat mengalami kebocoran kapsul lensa anterior,

dan memungkinkan protein-protein lensa yang mencair masuk ke dalam bilik mata depan.

Terjadi reaksi peradangan di bilik mata depan, anyaman trabekular menjadi edema dan

tersumbat oleh protein-protein lensa, dan menimbulkan peningkatan tekanan intraokular akut.
Ekstraksi lensa merupakan terapi definitif, dilakukan segera setelah tekanan intraokular

terkontrol secara medis dan terapi steroid topikal telah mengurangi peradangan intraokular.1

Lens-induced-glaucoma is a distinct pathological entity, clinically recognisable, easily

preventable and often curable by cataract extraction.

At the beginning of the century Gifford described glaucoma associated with hypermature
cataract and suggested that it could be prevented and cured by timely cataract extraction.
Since then various authors Irvine and Irvine (1952), Flocks, Littman and Zimmerman (1954)
and Chandler (1958) have discussed varying types of such cases and under different names of
lens-induced-glaucoma, lens-induced uveitis and glaucoma, endophthalmtis-phaco-
anaphylactica, phaco-toxic glaucoma, phacogenetic and phacogenic glaucoma and finally
phacolytic glaucoma. The modern trend is to label them as phacolytic glaucoma. but as the
clinical picture can easily be uveitis and glaucoma or simply glaucoma (associated with a
mature or hypermature cataract) it is better to retain the term lens-induced-glaucoma. This is
noncomittal but suffers from the disadvantage of not excluding glaucoma associated with an
intumescent-cataract and or senile exfoliation of lens capsule etc.

Three outstanding features of this group of patients are (1) the sudden onset of glaucoma in
an eye with mature or hypermature cataract (2) the advanced age of the patient generally
above fifties and (3) the almost constant observation of good vision and normal tension in the
opposite eye which may be aphakic or otherwise. This clinical observation is further
strenghthened by the fact that removal of the cataractous lens with or without the prior and
concurrent use of diamox, leads to a lessening of the congestion in the eye and an uneventful
recovery with fairly good vision. It is true that the diagnosis is not complete without the
characteristic histological changes seen when such an eye is enucleated. As a matter of fact
similar pathological findings in all such enucleated eyes have been the prime-factor in the
recognition of this clinico-pathological entity.

In this study a clinical review of 46 cases of lens-induced-glaucoma is described. As the

diagnosis was satisfactory, in none of these eyes enucleation was suggested (even though a
few had no light perception) and hence, no pathological confirmation is available.

Age

Majority of the cases in this study - 19 out of 46 -- were of the age group 60 years and above
constituting 41.3%. the eldest being a man 75 years of age. 15 cases were in the age group of
50 to 59 years and 12 cases were below 50 years, the youngest being a lady of 40 years. The
age incidence rises shaply at 60 years -

Sex

There were 29 females and 19 males.

Presenting clinical features

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, When they came in with acute rise of tension and a congested eye, the visual acuity
was only light perception or at best hand-movement. Even this light perception was absent in
5 cases. They could easily be labelled as painful-blind-eyes from absolute glaucoma with no
hope for vision.

The onset of glaucoma in all these cases was characterised by pain in and around the eyes,
headache of varying intensity, nausea, vomiting and in some cases even prostration.
Examination revealed oedematous swollen lids with marked congestion, corneal haziness and
often dilated and fixed pupil. A group of five cases revealed the presence of uveitis, aqueous
flare, irregular pupil from posterior synechia, and keratic precipitates (in 2 cases). They could
easily be thought of as cases of uveitis with secondary glaucoma. The depth of the anterior
chamber varied. It was shallow in nine cases (confirming the diagnosis of acute congestive
glaucoma in a cataractous eye) on the other hand it was deeper in five cases, associated with
hypermature cataract and was of normal depth in the other cases. The lens had become
subluxated in 2 cases with hypermaturity.

The intra-ocular tension was invariably more than 30 mm of Hg Schiotz in these cases.

Clinical findings o f the other eye

Classically this was an aphakic eye with extra-capsular lens-extraction a few months to a few
years back with no congestion or redness and with useful. vision. In the present series of
cases this was the finding of 13 cases. These patients were elderly and in them the onset of
glaucoma was almost violent.

The second-group of 8 cases had impaired vision in the opposite eye from incipient and
immature cataract (4 cases) mature cataract-3 cases, (two with rise of tension in both eyes)
and hypermature cataract one case. The tension in the that eye was normal.

The third group had vision varying from finger counting to normal visual standard. In them
the lens was clear, free from any opacity and not the cause of reduced vision. Further the
intraocular tension was normal in all the cases except case No. 44, where the fellow right eye
had also rise of tension with congestion of the eye and shallow anterior chamber and there
was evidence of uveitis in the left eye with irregular pupil and a few posterior-synechia along
with mature cataract. Even the light perception was doubtful. Gonioscopy was not feasible.
Case No. 1 also in this group had his right aphakic eye enucleated a few years back following
injury.

Differential diagnosis

These 46 cases of clinically diagnosed lens-induced glaucoma with or without uveitis were
varyingly diagnosed clinically as follows :

1. Acute congestive glaucoma with mature or hypermature cataract.

2. Absolute glaucoma with no light perception.

3. Mature or hyper-mature cataract with uveitis and secondary glaucoma due to uveitis.
4. Cases of chronic congestive glaucoma with acute exacerbation.

5 Cases of congestive glaucoma associated with subluxated lens.

The difficulty of diagnosis arose in three cases. In two of them, cases No. 8 and 38 the fellow
eye had also rise of intra ocular tension along with mature cataract. In the third case No. 44
the fellow eye had features of congestive glaucoma. In such cases goniscopy is of help by
deciding the nature of the angle of the anterior chamber whether it is narrow angle or wide-
angle. But this may not be always feasible in an acutely congested eye. Another important
point is that the fellow eye shows no rise of intraocular tension even on repeated examina-
tions, a point in favour of this glaucoma being labelled as secondary and not primary
idiopathic in etiology. To add to this diagnostic difficulty was the absence of even light-
perception in the glaucomatous eye in 5 cases of the series labelled as cases of absolute- glau-
coma with poor prognosis. As one would see while discussing the treatment, that even in
these cases a proper diagnosis (as to the cause of glaucoma) was rewarding by saving the eye
from unnecessary enucleation. But this of course deprived us from studying the histo-
pathological changes in such cases.

The features of uveitis-aqueous flare and cells, keratic precipitate, irregular pupil with post-
synechia led one to think that there was uveitis which caused secondary rise of tension.

Treatment

In all these cases no mydriatic was given and in only few of them Eserine salicylas as drops
was prescribed. In clear cut cases the routine was to use Diamox (acetazolamide) orally and
usually combined with Cortucid ointment locally in the eye to lessen the congestion. In most
of the cases in a couple of days, the intra-ocular tension did come down to a lower and safe
figure from its previously high reading. Thereafter surgery was taken recourse to. In younger
patients and those with highly apprehensive mood, intravenous anaesthesia was used for lens
extraction. In the rest it was the routine local anaesthesia.

3 cases (3, 8, 36) had iridectomy by dialysis as the 1st stage operation for in them the intra-
ocular tension was very high. Subsequently after a few weeks the cataractous lens was
removed

Intra-capsular lens-extraction with no irrigation was followed in 24 cases and 17 cases had
extracapsular removal with ant. chamber irrigation in 9 cases and no irrigation in 6 cases. In
them the left over lenticular matter in the anterior chamber was very little in amount to justify
irrigation. Of the remaining 2 cases, one refused operation and the other had only retro-bulbar
injection of Novocaine and alcohohol as there was no P.L. even on repeated examination.

Along with removal of lens, intra or extra-capsular, iridectomy by dialysis was also combined
in 10 cases, peripheral button-hole-iridectomy in 3 cases and broad-basal iridectomy in 13
cases. The latter two procedures signify variation in the surgical technique of cataract
removal. Iridectomy by dialysis was done as a safeguard against any untoward complication
on the table. As a matter of fact in these cases the first thing was iridectomy by dialysis and
then the lens was removed. These were earlier cases of the series and in the succeeding
patients this procedure was given up with no untoward effect on the success of the operation.
This observation in itself is a great diagnostic point in favour of the diagnosis of lens-induced
glaucoma, that is, remove the cause, the cataractous lens and the glaucoma gets cured.

Discussion

After extra-capsular cataract extraction or after trauma to the lens capsule, lens matter is

freely exposed to the intra-ocular fluid. In majority of cases such residual lens matter or lens

cortex gets absorbed without the occurrence of any undue inflammatory reaction. Also in

hypermature cataracts, the lensmatter may eventually be absorbed without causing any

inflammatory response in the eye. But in occasional cases presence of disorganised lens

matter in the anterior chamber bathed by aqueous evokes an inflammatory response of great

severity, so prolonged that the eye may 'eventually be lost if the residual lens matter is not

removed. Verhoeff and Lemoine in 1922, drew attention to such lens-induced uveitis calling

them endophthalmitis-phaco-anaphylactica. The presumption is that such cases are allergic in

nature, (the allergen being lens protein), on the basis of the finding that those persons who

suffered the violent type of ocular symptom when tested intra-dermally displayed a positive

skin test to lenticular-pretein and when given a desensitising course of intra muscular

injection of lens protein rapidly showed an amelioration of their symptom. Whether this

whole concept is allergic or can also be explained on the basis of a toxic reaction has been

raised by Gifford, Knapp and Heath and Irvine. This is specially true when one is dealing

with such cases in an eye with hyper-mature cataract where the uveitis can be explained as a

toxic reaction to Morgagnian fluid. This is the phacotoxic type of lens-induced uveitis and

glaucoma.

In endophthalmitis-phaco-anaphylactica, the inflammation primarily in the iris and around

the lens matter is predominantly polymorphonuclear and giant-cell reaction. In phacotoxic the

reaction in the iris and more around mature or hyper-mature lens matter is mainly plasma-cell

and macrophage-cells which engulf the latter with a few polymorphs and gaint-cells.
The terms phacogenic and phacogenetic glaucoma are not correct for they may mislead. They

do not tell us how the glaucoma is produced due to lens and hence, glaucoma associated with

exfoliation of senile lens-capsule, intumsecent cataract, and even with sub-luxated and

dislocated lens may be thought of with these terms The same difficulty arises with the term

lens-induced-glaucoma or lens induced-uveitis and glaucoma. With this term, however,

ophthalmic surgeons have understood the above categories of endophthalmitis phaco-

anaphylactica and the phacotoxic glaucoma. In these conditions uveitis is clear-cut and there

is a rise of intra-ocular tension to a moderate degree and sometimes not. The rise of intra-

ocular tension may be due to anterior or posterior synechia or to obstruction of the chamber-

angle by inflammatory exudates.

The 3rd category of lens-induced glaucoma is the case seen again associated with a mature or

hypermature cataract (where the other eye is generally aphakic and quiet) more with the

hypermature type where the lens matter is engulfed by macrophages. And these swollen

eosinophil-stained-macrophages are seen (on histological examination) blocking the

trabecular mesh work and lying on the back of cornea and ant. surface of iris etc. This is a

mechanical blockage-glaucoma and Flocks, and Littwin and Zimmerman (1955) have rightly

labelled this as phacoly tic-glaucoma, for it is associated with lysis of lens matter. It has been

observed that in such cases the element of uveitis namely keraticprecipitates, aqueous-flare

and posterior synechia are minimal and at times absent altogether and also such cases may

not show much congestion. As against this, the type phacotoxic and endcphthalmitis-phaco-

anaphylactica have more of uveal reation and marked congestion of the eye but only

moderate rise of tension. So one can clinically label in which category to put a particular case

of lens-induced-uveitis and glaucoma. But all the same, since the basic mechanism in both
groups of cases is that the lens or lens-matter is at fault. it has to be removed. Vorhoeff dictum

that it is better to remove the offending lens or residual lens matter than to remove the eye has

been amply justified by the present series of cases where, but for clinical diagnosis of lens-

induced-uveitis and glaucoma many such eyes would have been enucleated[8].