European Journal of Cardiovascular Medicine

Among the Lens-induced glaucomas Phacomorphic (secondary angle-closure) and Phacolytic (open-angle glaucoma) glaucomas are the commonly observed types. The angle-closure can be caused by lens swelling (phacomorphic glaucoma) or lens dislocation (ectopia lentis). The open-angle glaucomas include glaucoma related to leakage of lens proteins through the capsule of a mature or hypermature cataract (phacolytic glaucoma), obstruction of the trabecular meshwork following cataract extraction, capsulotomy, or ocular trauma by liberated fragments of lens material (lens-particle glaucoma), and hypersensitivity to own lens protein following surgery or penetrating trauma (phacoantigenic glaucoma). Narrowing of the angle can occur slowly with formation of the cataract by pushing the iris forward or acutely precipitated by an intumescent cataractous lens leading to obstruction of aqueous flow between the border of the pupil and the anterior capsule of the lens (pupillary block). 1,2,3,4,5 Finally Epstein et al 6 provided evidence for the role of high-molecular-weight soluble lens protein in causing direct obstruction of aqueous outflow channels.

Regardless of the exact pathogenesis of phacolytic glaucoma, the condition occurs chiefly in the setting of a senile hypermature, or Morgagnian cataract with leakage of lenticular material through microscopic openings in an apparently intact lens capsule.7 In rare cases, the cataract may be immature, with liquefaction of the posterior cortex.On examination, the IOP is very high, accounting for the pain at presentation. The drainage angle is open, with no visible abnormality. Microcystic edema may be present in the cornea, and there may be scattered cells on the endothelium or endothelial precipitates. Often, an inflammatory reaction is present throughout the eye. Cellular reaction in the anterior chamber can vary from mild cells and flare to an intense reaction with pseudohypopyon.8 In phacolytic glaucoma, cells in the aqueous may be larger than the lymphocytes seen in other uveitic processes. These larger cells are thought to be swollen macrophages with engulfed lenticular material. Aggregates of macrophages may also be seen along the surface of the lens capsule.7 The definitive treatment for patients with presumed phacolytic glaucoma is cataract extraction.

The presentation of phacomorphic glaucoma is similar to acute angle-closure glaucoma. Patients may experience severe pain and headache secondary to elevated IOP, blurred vision, perception of halos around lights, nausea, vomiting, bradycardia, and sometimes diaphoresis.7 Clinical features may include corneal edema, conjunctival injection, and a mid-dilated pupil. The intumescent lens may be observed pushing the iris forward and reducing the anterior chamber depth. Anterior chamber cells and flare may also be present. Phacomorphic glaucoma is diagnosed clinically. Unlike the other types of lens-induced glaucoma, gonioscopy reveals a closed angle. Once IOP and inflammation are under control, definitive treatment with cataract extraction should proceed. As the intracapsular cataract extaraction has been the prefered mode of surgery for the lens induced glaucomas since long time, although there is a perceptible shift towards extracapsular cataract in the recent times with reports of safety with posterior chamber intraocular lens implantation aiming to the prognosis of good postoperative visual recovery.Thus this study was planned to study the visual outcome in Phacolytic and Phacomorphic glaucomas with posterior chamber intraocular lens implantation in our set up

The setting of the study was at department of Ophthalmology, Government Medical College, Machilipatnam. A one-year observational study was conducted during the period from December 2022 to November 2023. All the cases of Phacolytic and Phacomorphic glaucoma which were clinically diagnosed and as per the the standard case definitions admitted in the ward during the above period were included in the study after duly following the inclusion and exclusion criteria as indicated below. Inclusion criteria: 1. Symptoms and Signs suggestive of Phacolytic glaucoma and Phacomorphic glaucoma and confirmed by standard diagnostic test.2. Patients with clear cut indication for surgical intervention 3. Patients who were given consent after detailed explaination of procedure and purpose of the study. Exclusion criteria: 1. Patients who did not give consent 2. Lens induced glaucoma following trauma.

Objectives: 1. To know the socio-demographic profiles of the study subjects 2. To study the visual outcome and good control over IOP (<21mm Hg) in Phacolytic and Phacomorphic glaucomas following extracapsular cataract extraction with posterior chamber lens implantation and to identify the risk factors and their impact on postoperative visual acuity and IOP.

After receiving the Ethical committee clearance from the institution the study was began and the required data was collected by using a pretested proforma pertaining to their socio-demographic profiles, assessing the visual outcome by comparing the IOP range befor and after correction with posterior chamber intraocular lens implantation and also by visual acuity and also assessing the impact of the risk factors on visual acuity postoperativrly etc; and all the cases (study subjects) of the study were managed and followed until discharge. Finally the collected data was analyzed by using appropriate statistical tools like percentages, proportions, measures of central tendency, measures of dispersion, standard error of mean , correlation coefficient and tests of significance etc. with the help of computer software. The study results were compared and discussed in the light of published material of various similar studies belongs to different authors and there by conclusions and recommendations were framed

Table 1: Age and Sex wise distribution among Phacolytic and Phacomorphic glaucomas of study subjects.

                                            Mean  ± 2 SD = 52.04± 24, 28 - 76,  P < 0.01            

• Among the total study subjects about 40% were males and 60% were females
• It was observed that the burden of the disease was more between 51-70 years of age group (71%) with the Mean age 52 years
• And also it was noticed that the disease burden was more among females when compared to males significantly

Table 2: Risk factors influencing the post operative visual acuity in the study group

• It was observed that the visual acuity was poor among the study subjects > 60 years of age and when compared to males’ visual acuity was improved better among females in this study after correction with surgery
• And also, it was noticed that visual acuity was improved significantly among the study subjects who have > 35 mm of IOP at the time of presentation and with reference to type of glaucoma there was no difference observed related to visual acuity between the two.
• Further it was found that the visual acuity was significantly improved among the study subjects who´s preoperative IOP was raised within 1 week when compared to > 1week of starting of symptoms.

Table no.3: Distribution of IOP range of study subjects at the time of admission

                                            Mean  ± 2 SD = 40± 14, 26 - 54,  P >0.05

• About 13.8% of study group have IOP of < 30 mm of Hg initially at the time admission followe by 20% have between 30 - 40 mm of Hg and remaining about 66.2% have > 40 mm of Hg.

Table 4: Distribution of IOP range of study subjects at the time of last follow-up visit

                                                Mean  ± 2 SD = 18.5± 6, 12.5 - 24.5,  P >0.05

• It was observed that about 10.8% of study subjects have IOP of < 10 mm Hg at the time of last follow up visit after surgical intervention followed by 53.8% between 10-15 mmHg, 32.3% between 15-21 mm of Hg,1.5% have > 21 mm of Hg and about 1.5% that was for one study subject it was not recorded and nearly all the study subject´s IOP was come to normal which was statistically highly significant (P<0.005) and also it was noticed that the improvement of IOP between these two groups of Phacolytic & Phacomorphic glaucoma was same (P>0.05).

Table 5: Distribution of final corrected visual acuity of study subjects between the two types of glaucoma

Significantly about nearly 60% of the study subjects final corrected visual acuity was lies between 6/6 - 6/18  and there was no significant difference between Phacolytic and Phacomorphic glaucoma regarding distribution of visual acuity after correction (P>o.o5). 

In the present study out of total 65 study subjects 40 % were males and 60 % were females which was correlated with the findings of the other studies like Nannaware SL et al9, Chandrashekharan S et al10, J W Lee J S et al11, R Kothari S et al12, A Yaakub N et al13, Ramakrishnan R et al14, Mohinder Singh et al15, Prajna N et al16 and Jain IS et al17 etc. And it was understood that in our study the distribution of the disease was more among females as it was observed in the above studies also. The females were affected more than males which could be due to the factors of hormonal imbalence (decreased levels of oestrogen & Progesteron) as age advances which intern causes increased secretion of ciliary body and there by accumulation of aqueous fluid leads to glaucoma and also not maintaining the balanced diet etc; This shows that there is a need for awareness in the population so that females also receive early cataract treatment if the problem identified early. The mean age of the study subjects in the present study was 52 years and majority of the study subjects were belonged to age group between 51-70 years (71%) which was also on a par with the figures of the above-mentioned studies and Peram V et al18 study also. By observing the above figures, it was understood that the problem was more distributed among above middle & older age people of both sex. And it was observed that the visual acuity was poor among the study subjects > 60 years of age and when compared to males’ visual acuity was improved better among females in this study. And also it was noticed that visual acuity was improved significantly among the study subjects who have > 35 mm of IOP at the time of presentation and with reference to type of glaucoma there was no difference observed related to visual acuity between the two types of glaucomas (Phacomorphic and Phacolytic). Interestingly the disease burden was more among female study subjects and after correction the visual acuity was also improved significantly among females when compared to males in this study.

Further it was found that the visual acuity was significantly improved among the study subjects who´s preoperative IOP was raised within 1 week of starting of symptoms when compared to > 1week which correlates with the figures of Venkataratnam P et al19 study, Chandrasekharan Set al10 study, Ramakrishnan R et al 14study and Mohinder Singh et al15 study etc; In our study the mean preoperative IOP was 40 mm Hg which was also correlated with the figures of other studies like Peram V et al18, Ramakrishnan R et al14, Nanneware SL et al9 and Venkataratnam P et al19 etc; and our study observation of high preoperative IOP was in correspondence with the studies of  S Senthil et al20, G Singh et al21, J Podhorecki et al22, Ramakrishnan R et al14, Mohinder Singh et al15, Prajna N et al16 and Jain IS et al17 etc; And in this study it was noticed that all the study subject´s IOP was come to almost normal  at the time of discharge, which was statistically highly significant (P<0.005) and was also in support of the all previously mentioned studies. And in addition to this, it was noticed that the improvement of IOP between these two groups of Phacolytic & Phacomorphic glaucoma was same (P>0.05). Significantly about nearly 60% of the study subject´s final corrected  visual acuity was lies between 6/6 - 6/18  and there was no significant difference between Phacolytic and Phacomorphic glaucoma regarding distribution of visual acuity after correction which was in correlation with the findings of Nanneware SL et al study 9(63.33%), Ramakrishna et al study 14(68%), Mohinder  et al study 15(61%) and Prajna et al study16 (57.1%) but the studies by Venkataratnam et al 19and Jain IS et al17 reported lesser figures.

LIMITATIONS

The study was a hospital based and conducted in a small group of patients.

As the distribution of the disease was observed more among the female study subjects and above middle & older age group population, it is very important to target our intervention and preventive strategies among these groups to control the incidence and prevalence of the lens induced glaucomas (Phacolytic & phacomorphic). The factors contributing high female preponderence like hormonal imbalence and not maintaining balanced diet should be addressed whenever the patient visits the health care facility for routine checkup. Further it is very important to conduct awareness programmes among the target population towards the need of screening and early identification of the problem which give oppurtunity to the ophthalmologist to initiate the treatment with medicines early and thereby to prevent the need of surgical intervention or development of complications. In addition to this in our study we observed that , among the total study subjects who´s IOP was raised within one week of starting of symptoms the visual acuity was improved significantly (P<0.05) when compared to >1 week of suffering with symptoms which shows that early intervention is more useful to the patients.

Finally this study concludes that the recovery of fair visual acuity in these cases poses a strong argument in favor of primary implantation of an IOL in posterior chamber.As the goal of National Program for Control of Blindness and Visual Impairment (NPCB and VI), made by Government of India is to reduce the prevalence of avoidable blindness will be at stake if there is a lack of incorporating strong advocacy towards the prevention of blindness due to glaucoma.23The advocacy for blindness prevention due to glaucoma can be focused on three important areas: first- early detection and treatment of glaucoma; second-generating an enabling environment for service delivery and third- resource mobilization for glaucoma service.24 The seven World Health Organization steps mentioned for successful advocacy are suggested while advocating a control program for the prevention of glaucoma blindness wherever appropriate.25

1. Doc Ophthalmol. 1992;81(3):317-38.
2. Epstein DL. Diagnosis and management of lens-induced glaucoma. Ophthalmology. 1982 Mar;89(3):227-30.
3. Richter C, Epstein DL. Lens-induced open-angle glaucoma In: Ritch R, Shields MB, Krupin T, eds. The Glaucomas. 2nd ed. St Louis: Mosby; 1996.
4. Kanski J, Brad Bowling. Lens-related glaucoma. In: kanski J, Brad Bowling, eds. Clinical Ophthalmology: A systematic approach. 7th ed. Elsevier Saunders; 2011.
5. Sowka J. Phacomorphic glaucoma: case and review. Optometry. 2006 Dec;77(12):586-9.
6. Flocks M et al. Arch Ophthalmol. 1955;54(1):37-47.
7. Papaconstantinou D et al. Clin Interv Aging. 2009; 4:331-336.
8. Conner IP et al. Lens-induced glaucoma. In: Kahook M et al, eds. Chandler and Grant’s Glaucoma, 5th ed. Thorofare, N.J.; Slack; 2013:441-447.
9. Nannaware SL, Singasandra SM, Mallaiah D, Venkataswamy SB, Management and visual outcome in patients of Phacolytic glaucoma in a tertiary eye care hospital. Ip Int J Ocul Oncol Oculoplasy 2021; 7(4) 372 - 377.
10. Chandrashekharan S, Chakrabarty S, Tanwar M, Madhuvarasu B, Uduman MS,Ramakrishnan R. Outcomes and favourable prognostic factors in patients of phacomorphic and phacolytic glaucoma managed by manual small-incision cataract surgery: A retrospective study. Indian J Ophthalmol. 2022 Apr;70(4):1216-1221.doi: 10.4103/ijo.IJO_2371_21. PMID: 35326019; PMCID: PMC9240532.
11. J W Lee J S Lai D W Yick R K Tse Retrospective case series on the long-term visual and intraocular pressure outcomes of phacomorphic glaucomaEye (Lond)20102411167580
12. R Kothari S Tathe P Gogri A Bhandari Lensinduced Glaucoma: The Need to Spread Awareness about Early Management of Cataract among Rural PopulationISRN Ophthalmol201358172710.1155/2013/581727
13. A Yaakub N Abdullah Siti Raihan I, Ahmad Tajudin LS Lens-induced glaucoma in a tertiary centre in northeast of MalaysiaMalaysian Family Physician2014924852
14. Ramakrishnan R, Maheshwari D, Abdul Kader M, Singh R, Pawar N, Bharathi MJ. Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthalmol. 2010 Jul-Aug; 58(4): 303–306.
15. Mohinder Singh, Hassan Al-Arrayyed, Revathy Krishnan, Intraocular Lens Implantation in Phacomorphic Glaucoma. Bahrain Medical Bulletin, Vol.24, No.3, September 2002;24(3):88-90.
16. Prajna N, Ramakrishnan R, Krishnadas R, Manoharan N, et al. Lens induced glaucoma - Visual results and risk factors for final visual acuity. Indian J Ophthalmol 1996; 44:149-155.
17. Jain IS, Gupta A, Dogra MR, Gangwar DN, Dhir SP. Phacomorphic glaucoma Management and visual prognosis. Ind J Ophthalmol 31:648-653, 1983
18. Peram, V., Atti, S., & Mahendra, S. (2017). Phacolytic glaucoma: visual outcome. International Journal of Research in Medical Sciences, 5(6), 2636–2640. https://doi.org/10.18203/2320-6012.ijrms20172461
19. Venkataratnam P, Srihari Atti, S Mahendra. A study of visual outcome of phacomorphic glaucoma. MRIMS J Health Sciences 2018;6(1):20-24.
20. S Senthil S Chinta H L Rao N S Choudhari V Pathak-Ray A K Mandal Comparison of Cataract Surgery Alone Versus Cataract Surgery Combined With Trabeculectomy in the Management of Phacomorphic GlaucomaJ Glaucoma2016253e2091310.1097/IJG.0000000000000229
21. G Singh J Kaur S Mall Phacolytic glaucoma - Its treatment by planned extracapsular cataract extraction with posterior chamber intra ocular lens implantationIndian J Ophthalmol19944231457
22. J Podhorecki A Munir Result of operations for hypermature cataract complicated with phacolytic glaucomaKlin Oczana20021045-63503
23. Ramasamy D, Ravilla T. Advocacy for eye care. Indian J Ophthalmol. 2012;60:376–9. [PMC free article] [PubMed] [Google Scholar
24. National Health Policy, 2017. Ministry of Health and Family Welfare, Government of India. [Last accessed on 2019 Dec]. Available from: http://164.100.158.44/showfile.php
25. World Health Organization. A practical guide to successful advocacy. [Last accessed on 2019 Feb]. vailable from: http://wwwwhoint/chp/advocacy/chpmanualEN-webfinalpdf