History

• 41-year-old female with history of decreased vision and pain in the right eye for one day

Exam Findings

• LLL: WNL OU
• S/C: 2+ injection OD, quiet OS
• Cornea: 1+ edema OD, clear OS
• AC: shallow with trace flare OD, deep/quiet OS
• Iris: anterior bowing OD, flat OS
• Lens: dense white cataract OD, 1+NSC OS
• AV: no view OD, quiet OS

• Gonioscopy
• OD closed in all four quadrants
• OS open to SS/TM in all four quadrants
• Fundus Exam
• OD no view
• OS CDR 0.3, macula flat, vessels WNL, mild NPDR
• B scan OD
• Retina and macula flat

Differential Diagnosis

• Phacomorphic glaucoma
• Acute angle closure glaucoma
• Neovascular glaucoma
• Phacolytic glaucoma
• Lens particle glaucoma
• Phacoantigenic glaucoma
• Lens subluxation

Diagnosis

• Phacomorphic glaucoma

Pathophysiology

• Acquired mass effect of mature cataract causes pathologic angle narrowing
• Can occur rapidly with lens intumescence
• Must be distinguished from primary angle closure glaucoma

Treatment

• Cosopt, Alphagan, IV Diamox administered with no improvement in IOP
• Laser peripheral iridotomy performed with patency noted and gush of fluid; IOP decreased to 65
• IV Mannitol given; IOP decreased to 52
• Patient scheduled for cataract surgery with phacoemulsification (iris hooks + cortex aspiration with 25g needle)
• POM#1 visual acuity was 20/50, IOP 14 without any anti-glaucoma medications

Prognosis and Future Directions

• Typically good visual acuity but may be dependent on presenting IOP as well as duration of symptoms (depending on study final VA range from 20/20 to 20/50 in majority of patients)
• RNFL thickness is reduced in superior and inferior quadrants after phacomorphic glaucoma
• Combined cataract surgery with trabeculectomy may be indicated in patients with long-standing symptoms given concern for persistent angle closure due to synechiae, although combined surgery does not appear to have better IOP control or better visual outcomes compared with cataract surgery alone

References

• Ramakrishnan R et al. Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthal.2010 Jul-Aug;58(4):303-6.
• Tham CCY et al. Immediate argon laser peripheral iridoplasty (ALPI) as initial treatment for acute phacomorphic angle-closure (phacomorphic glaucoma) before cataract extraction: a preliminary study. Eye (Lond). 2005 Jul. 19(7):778-783.
• Lee JWY et al. Retrospective case series on the long-term visual and intraocular pressure outcomes of phacomorphic glaucoma. Eye. 2010. 24:1675-1680.
• Lee JW et al. Retrospective analysis of the risk factors for developing phacomorphic glaucoma. Indian J Ophthal. 2011 Nov-Dec;59(6):471-4.
• Angra SK, Pradhan R, Garg SP. Cataract induced glaucoma-an insight into management. Indian J Ophthal. 1991 Jul-Sep;39:97-101.
• Jain IS, Gupta A, Dogra MR, Gangwar DN, Dhir SP. Phacomorphic glaucoma-management and visual prognosis. Indian J Ophthal.1983;31:648-53.
• Lee JWY et al. Argon laser peripheral iridoplasty versus systemic intraocular pressure-lowering medications as immediate management for acute phacomorphic angle closure. Clin Ophthalmol. 2013 Jan;7:63-69.

Contact

• Sahar Bedrood, MD, PhD, Assistant Professor of Clinical Ophthalmology, sahar.bedrood@med.usc.edu
• Brandon Wong, MD, PGY-2 Ophthalmology Resident, brandon.wong@med.usc.edu

Section Editors

• Vivek Patel, MD, Associate Professor of Clinical Ophthalmology, Program Director, vivek.patel@med.usc.edu
• Jesse Berry, MD, Assistant Professor of Clinical Ophthalmology, Associate Program Director, jesse.berry@med.usc.edu

 

Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel