41-year-old female with history of decreased vision and pain in the right eye for one day
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
OD closed in all four quadrants
OS open to SS/TM in all four quadrants
OD no view
OS CDR 0.3, macula flat, vessels WNL, mild NPDR
B scan OD
Retina and macula flat
Acute angle closure glaucoma
Lens particle glaucoma
Acquired mass effect of mature cataract causes pathologic angle narrowing
Can occur rapidly with lens intumescence
Must be distinguished from primary angle closure glaucoma
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
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.