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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 58  |  Issue : 3  |  Page : 162-168

Clinical study of lens-induced glaucoma at community health center in India


Community Health Center, Bandikui, Dausa, Rajasthan, India

Date of Submission06-Apr-2020
Date of Decision21-Apr-2020
Date of Acceptance01-May-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Pawan N Jarwal
Community Health Center, Bandikui, Dausa, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_35_20

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  Abstract 


Background and Objective: It has long been recognized clinically that several forms of glaucoma may occur in association with the formation of cataracts, which are an important cause of secondary glaucoma in the developing world.- These lens-induced glaucomas are a common occurrence in India, hardly surprising in a situation where the incident of cataract cases far exceeds the total number of surgeries performed currently. In the developing world, like India, financial, cultural, and psychosocial barriers to accessing excellent surgical services still exist. There is an ever-increasing backlog of cataract due to the population explosion, increased life expectancy, and low productivity in terms of utilization of the available surgical services. The uptake of eye care services by the rural community has also been sub-optimal in countries like India, where lens-induced glaucomas (LIGs) are a common cause of ocular morbidity. The present study has endeavored to determine the characteristics, risk factors, and their consequences on postoperative visual outcome, intraocular pressure (IOP), including optic disc changes in LIGs. Materials and Methods: This study included 50 cases of different types of LIG, admitted in the wards of the Community Health Center, Bandikui, Dausa, Rajasthan, during the period January–September 2019. All consecutive patients diagnosed as LIG on the basis of clinical symptoms and signs were included. Clinical features included pain, loss of vision, redness of the eye, presence of an intumescent, mature, or hypermature cataract associated with raised IOP of >21 mm Hg. Results: In this study series, it is observed that the most frequent type of LIG was phacomorphic glaucoma (PMG) (64%) followed by PhacoLyticc Glaucoma (PLG) (28.00%). In this study, good visual acuity achieved by cases with phacolytic glaucoma (57.00%) was more than PMG (50.00%) optic disc, at last, follow-up in the affected eyes was normal in the majority (36.00%). There were six cases of cystoid macular edema, and the media was hazy in two cases. Glaucomatous disc damage was found in 52% of cases. Although clinically significant disc damage was found more in PMG (57.7%) than PLG (33.33%). Conclusion: Results have shown that the LIGs were more common in the age group of 60–69 years and in females, good visual acuity can be achieved in lens-induced glaucoma presenting within 2 weeks, with intraocular pressure of <35 mm Hg and with meticulous control of intraocular pressure and inflammation with medications preoperatively. Planned small incision cataract surgery with intraocular lens implantation, minimal tissue handling, a good follow-up with efficient management of attendant complications and inflammation, are the key factors in the management.

Keywords: Lens-induced glaucoma, phacolytic, phacomorpic


How to cite this article:
Jarwal PN. Clinical study of lens-induced glaucoma at community health center in India. TNOA J Ophthalmic Sci Res 2020;58:162-8

How to cite this URL:
Jarwal PN. Clinical study of lens-induced glaucoma at community health center in India. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Oct 23];58:162-8. Available from: https://www.tnoajosr.com/text.asp?2020/58/3/162/294986




  Introduction Top


Glaucomas in which the lens plays a role, either by size or by position or by causing inflammation have been classified as lens-induced glaucomas (LIGs).

Abnormalities of crystalline lens may incite elevation of intraocular pressure often accompanied by intraocular inflammation; these pathological conditions are known as phacogenic or LIG In the past, significant confusion existed about the terminology and mechanisms causing glaucoma.

These are heterogeneous group of uncommon maladies, which can develop through either open-angle or angle-closure mechanisms.[1] Phacolytic glaucoma and lens particle glaucoma are secondary open-angle glaucomas. The iridocorneal angle is open, and there is blockage of the trabecular meshwork by lens proteins.

Phacomorphic glaucoma (PMG) and lens displacement glaucoma are secondary angle-closure glaucoma. Phacoanaphylactic uveitis, now termed as lens-induced uveitis, is not truly an anaphylactic reaction but is a granulomatous reaction that can result in glaucoma with either open-angle, angle-closure or combined open-angle and angle-closure glaucoma.[2] The present study has endeavored to determine the characteristics, risk factors and their consequences on postoperative visual outcome, intraocular pressure (IOP), including optic disc changes in LIGs.

Aims and objective

The aim of this study is to evaluate the characteristics, risk factors, and their consequences in LIGs on postoperative:

  1. Visual outcome
  2. IOP
  3. Optic disc change.



  Materials and Methods Top


This study included 50 cases of different types of LIG, admitted in the ward of the Community Health Center, Bandikui, Dausa, Rajasthan, during the period January 2019–September 2019.

Inclusion criteria

LIG patients were identified by the following criteria:

  • Cataract associated with an acute rise in intraocular pressure to cause clinical signs and symptoms
  • Slit-lamp examination to diagnose phacomorphic, phacolytic, lens particle and lens displacement.


Exclusion criteria

  • Patients with co-incident cataract and glaucoma
  • Other secondary glaucomas (such as due to trauma inflammation, neovascular glaucoma)
  • Abnormal material deposition in the anterior chamber (mainly pigment dispersion, pseudoexfoliation) complicated cataract
  • Patients unfit for surgery due to very poor general condition.


All consecutive patients diagnosed as LIG on the basis of clinical symptoms and signs were included. Clinical features included pain, loss of vision, redness of the eye, presence of an intumescent, mature or hypermature cataract associated with aised IOP of >21 mm Hg.

A detailed clinical examination of both eyes included the status of the lens, depth of the anterior chamber by slit-lamp biomicroscopy, and Schiotz tonometry.

Based on the slit-lamp examination, the type of LIG was determined.[38] The clinical features were noted in the study-defined pro forma, after patients signed the written 45 and informed consent. At presentation visual acuity, IOP, inflammation, including corneal changes were recorded, which were repeated after the institution of the medical line of treatment. None of the cases had a fundal glow at presentation. PMG was diagnosed when patients presented with red-eye, acute pain, and reduction of vision of a certain duration. On clinical examination, the eye showed circumcorneal congestion, corneal edema, shallow anterior chamber, dilated and fixed or sluggish pupil, intumescent cataract, and IOP more than 21 mm Hg. Phacolytic glaucoma was diagnosed when patients presented with acute pain in the eye with long-standing poor vision. On examination, the eye showed marked diminution of vision, corneal edema, normal or deep anterior chamber containing floating lens particles and or pseudohypopyon in severe cases and hypermature Morgagnian cataractous lens in some cases. The dense flare was seen with extensive keratic precipitates.[38]

Lens particle glaucoma was diagnosed when patients presented usually within weeks or even months to years later, of the initial surgery or trauma. Clinical findings include free cortical material in the anterior chamber, elevated IOP, moderate anterior chamber reaction, microcystic corneal edema, and with time the development of posterior and peripheral anterior synechiae.

Phacoanaphylaxis is diagnosed if patients presented with a moderate anterior chamber reaction, keratic precipitates on both corneal endothelium and anterior lens surface, low-grade vitritis, synechial formation and residual lens material in the anterior chamber. Glaucoma, while it may occur, is not common in eyes with phacoanaphylaxis.[39] Patients with ectopia lentis have symptoms of decreased visual acuity, although minimally subluxed lenses may be asymptomatic. On examination, phacodonesis and iridodonesis can be seen. In addition to the inflammatory signs mentioned above, signs of either phacolytic process or pupillary block is made out.[1] The management of these 50 cases consisted, with the aim of preserving useful vision, relief from pain, and reduction of the elevated ocular tension to almost normal levels, achieved by both medical and surgical methods. Relief from pain was by bringing down the IOP and by systemic administration of analgesics. Antiemetics were given in cases of severe vomiting.

Preoperative medical line of treatment

In all cases, preoperative medication to reduce IOP included topical timolol 0.5% twice a day, oral acetazolamide 500 mg twice a day and intravenous mannitol 20% stratum, and also just before the surgery in refractory cases. Topical mydriatics, phenylephrine 10%, and cycloplegics were started just before surgery, for the good capsulotomy. Local antibiotics such as ciprofloxacin, chloramphenicol, polymyxin, ofloxacin, gatifloxacin were used in different combinations to make the conjunctival sac sterile. Systemic, oral ciprofloxacin (500 mg) twelve hourly was given as prophylaxis to prevent postoperative infection.

Surgical line of management

In all patients, cataract extraction with intraocular lens (IOL) implantation was offered under guarded prognosis, written consent was taken for all the patients who underwent surgery. Irrespective of the level of fall of tension, all the patients were taken for surgery either on the same day or on the following days depending on patients' condition. Postoperatively in the ward, all the patients received the topical antibiotic-steroid combination, six times a day and mydriatic-cycloplegic, twice a day. If severe uveal inflammation was present, then short course of systemic steroids was given. If the tension appeared to be on the higher side, topical timolol 0.5% daily, were instilled and in severe cases, oral acetazolamide or IV mannitol 20% stratum was given depending on the severity.

All the patients were followed up regularly at 2, 4, and 6 weeks interval. At every visit, patients were evaluated for visual acuity with Snellen's chart, IOP by schiotz tonometer, slit-lamp examination of the anterior segment and posterior pole examination with a direct ophthalmoscope and 90D lens.


  Results Top


[Table 1] during the study period between January 19 and September 19, 2672 cases of cataract, attended outpatient department of CHC Hospital Bandikui. The number of LIG cases among these cataract cases in our study were 50, giving a prevalence of 1.87%.
Table 1: Magnitude of lens induced glaucoma

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In this study, the age range was 35–77 years with a mean of 61.57 ± 7.96 years [Table 2].
Table 2: Age and gender distribution of 50 patients with lens induced glaucoma

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Female 49 to male ratio was 2.3:1, with a mean age of 60.60 ± 6.98 years in females and 58.53 ± 9.56 years in males. The most frequent age group among both males and females was 60–69 years.

PMG was the most common LIG with 32 cases (64%), followed by phacolytic glaucoma with 14 cases (28.00%). None of the cases, in this study presented with phacoanaphylactic reaction [Table 3].
Table 3: Distribution of lens induced glaucoma subgroups

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In this study, it was observed that none of the cases at presentation had visual acuity better than hand movements, and only 06 cases (12%) had defective perception of ray (PR). At the last follow up, a majority of 24 (48%) cases gained good visual acuity of 6/12 or better [Table 4].
Table 4: Visual acuity at presentation and at last follow up

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In this study, the total mean IOP, at presentation was 44.18 ± 11.61 mm Hg (range 22–60 mm Hg), after medication, it was 28.71 ± 9.06 mm Hg and at last, follow-up it was 16.44 ± 6.54 mm Hg [Table 5].
Table 5: Intra ocular pressure at presentation, after medication, and at last follow-up

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The pupillary reaction at presentation was abnormal in 49 cases (98.00%) normal in none. There was a statistically significant change from the abnormal pupillary reaction at presentation to normal, on discharge in 24 (48.00%) cases and at last follow-up in 32 (64.00%) cases) [Table 6].
Table 6: Pupillary reaction at presentation, on discharge and at last follow up

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In this study, the affected eye in 28 cases (56.00%) most commonly had mature cataracts and in 18 cases (36.00%) most commonly had hypermature cataract and 02 cases (04.00%) each of immature and dislocated lens [Table 7].
Table 7: Lens status of the affected eye in lens induced glaucoma patients

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In this study, a majority of 48 cases (96.00%) underwent extracapsular cataract extraction with posterior chamber intraocular lens implantation and lens extraction with peripheral iridectomy in 2 cases (4.00%) [Table 8].
Table 8: Surgical procedure done in 50 cases of lens induced glaucoma

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In this study, uveitis was the most common complication in 15 cases (30.00%), cystoid macular edema in 6 cases (12.00%), bullous keratopathy in 3 cases (6.00%), there were 02 cases (4.00%) 0f vitreous loss, hyphaema, posterior capsular opacity and one case (2.00%) of papillary capture of IOL [Table 9].
Table 9: Postoperative complications

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Best corrected visual acuity (BCVA) of 6/12 or better, at last follow up was achieved in 16 (50.00%) cases of PMG and 08 (57.14%) cases of phacolytic glaucoma. Poor visual outcomes of <6/60 in both the subgroups were almost same with 07 (21.88%) cases in PMG and 03 (21.48%) cases in phacolytic glaucoma [Table 10].
Table 10: Optic disc changes at last follow up

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The optic disc changes at the end of last follow-up were normal in 10 cases (38.50%) and 06 cases (60%) in phacomorphic and phacolytic glaucoma respectively. Mild-to-moderate glaucomatous disc damage (GDD) was seen in 12 cases (46.13%) of phacomorphic and in only 04 cases (22.22%) of phacolytic glaucoma whereas severe damage was seen in 03 cases (11.53%) and 02 cases (11.11%), respectively. The difference in the optic disc appearance among subgroups was statistically not significant [Table 11].[31]
Table 11: Optic disc changes by lens induced glaucoma subgroups

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Fundus changes at last follow-up, was normal in 10 cases (58.82%) of those presented with IOP <35 mm Hg, and in 14 cases (42.43%) of those presented with IOP >35 mm Hg. There was severe GDD in 02 cases (11.76%) and 06 cases (18.18%) of those presented with IOP <35 mm Hg and more than 35 mm Hg, respectively. The correlation between the severity of disc damage and the height of IOP was statistically not significant [Table 12].
Table 12: Optic disc changes by intra ocular pressure

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  Discussion Top


LIGs are a common occurrence in India, hardly surprising in a situation where the incident of cataract cases far exceeds the total number of surgeries performed currently. Though these are clinically distinct entities, they have certain common factors in that they are lens-induced, they compromise the function of the optic nerve due to the rise of intraocular pressure, cataract surgery is curative in these cases, and finally, they uniformly share a guarded prognosis.[5]

This clinical study was undertaken to outline the different characteristics of glaucomas, to determine the risk factors and their consequences on postoperative visual acuity, IOP, and fundus changes following planned extracapsular cataract extraction. In this study, the magnitude of LIG was 1.87% during the study period as against 1.5% in Lahan study.[38]

In this study, the age range was 37–75 years with a mean age of 61.57 ± 7.96 years. The highest number of cases occurred in the age group 60–69 years (52.00%), Lahan study has found the occurrence of LIG in the age range of 40–80 years and highest in the 60–69 years (43.1%) age group, indicating that the lens-induced glaucomas are a condition of old age.[38]

In this study, females seemed to have an increased risk of having LIG compared to males with a ratio of 2.3:1. A study done at Madurai in 1994, found marginally significant increased risk of having these glaucomas in females (P = 0.05).[5] Lahan study has reported female-to-male ratio of 1.7:1. Although it is possible that these entities are more common in females because of socioeconomic constraints, we also have to consider the fact that the prevalence of LIG is more common in females than males. This finding was consistent with data from the Punjab study in India and from the Matlab study in Bangladesh.[38] In this study series, it is observed that the most frequent type of LIG was PMG (64%) followed by PhacoLyticc Glaucoma (PLG) (28.00%), the similar occurrence was noted by Madurai study (52.68%) 5 and Lahan study (72%).[38] Occurrences of various lens-induced glaucomas in the above studies show variations. Nevertheless, PMG has been the most frequent and most ommon among all the studies, including the present one, which is peculiar to the developing countries. In this study, none of PMG occurred <50 years of age, showing that PMG is a disease of old age with preponderance in 50–60 years age group, and the finding was consistent with the 1991 Delhi study.[39] This is perhaps because of insidious onset, lack of medical awareness, and limited resources in developing countries. On the other hand, phacolytic glaucoma represents lens-induced acute secondary open-angle glaucoma associated with rapid onset of pain, redness, and watering in the eye and acute rise in IOP causes the patient to seek medical advice earlier than PMG.

Visual outcome

In this study, none of the cases had vision better than hand movement at presentation. In this study, BCVA of 6/18 or better is slightly higher (32.00%) than the Lahan study series (31.40%). There was a significant proportion of cases that had blindness, with visual acuity <3/60 (08.00%) slightly more than Lahan's study (21.0%). Thus, in this study, a higher percentage of cases has achieved good visual recovery and slightly lower percentage of cases have poor visual outcomes when compared to Lahan study series.[38] The cause for poor vision in 12 cases (24.00%) was due to severe postoperative inflammation, bullous keratopathy, and cystoid macular edema. BCVA in this study, of 6/12 or better, was low (42.00%) and poor vision of <6/60 higher (16.00%) compared to Madurai study, with 59.13% and 11.82%, respectively.[5]

Analysis of risk factors

Final visual outcome by subgroups BCVA of 6/12 or better was taken as good visual acuity and <6/60 as the poor visual outcome.

In this study, good visual acuity achieved by cases with phacolytic glaucoma (57.00%) was more than PMG (50.00%) this difference was clinically significant but statistically not significant (P > 0.05). Poor outcome of less 68 than 6/60 showed no significant difference between PLG (21.47%) and PMG (21.88%). 1994, Madurai study series found no statistical difference between the two groups on the final postoperative visual recovery (P = 0.68).[5]

Duration of symptoms The Lahan study of 1998, found that duration of pain and high level of IOP at presentation in PMG was associated with poor visual outcome at discharge, while in phacolytic group no such association were made out. 38 Clinically, significant proportion of cases with IOP at presentation <35 mm Hg (58.80%) achieved good visual acuity than cases with IOP more than 35 mm Hg (33.34%), whereas no significant difference was found for poor outcome. The correlation between the height of IOP and the visual outcome was clinically significant but statistically not significant (P > 0.05). Madurai study also had found no statistically significant association between the level of preoperative IOP and final visual acuity.[5] The significant reduction in IOP after treatment was found in 60.00% and at last follow-up IOP reduction to baseline was achieved in 92.00% to be clinically and statistically significant. It is found that the reduction in mean IOP is greater after medication for glaucoma. Nevertheless, surgical removal of the lens is the definite treatment for lens-induced glaucoma, response to medications is very good in LIG.

The IOP at last follow-up was reduced to normal limits (16.44 ± 6.54 mm Hg). This indicates that in LIGs IOP should be reduced by the medical line of treatment preoperatively to as normal as possible to achieve stable IOP postoperatively with no further antiglaucoma medications. There was no significant difference in IOP among LIG subgroups, both clinically and statistically.[39]

In the Lahan study of 1998, IOP at presentation ranged from 14 to 81 mm Hg. 79.2% eyes had an IOP of >30 mm Hg and 14.3% <22 mm Hg as they had already received medical antiglaucoma treatment elsewhere. After medication for glaucoma, 66.2% had an IOP <21 mm Hg, and 96.8% had an IOP <30 mm Hg. Following surgery, 80.7% had an IOP of 21 mm Hg or less at discharge. Lahan study has achieved slightly better IOP control than our study, especially after antiglaucoma medication.[38]

Madurai study reported IOP range of 22–70 mm Hg with marginally higher for phacomorphic than for phacolytic glaucomas. After hypotensive medications, 60% had an IOP of <30 mm Hg. The IOP was controlled in 95% of patients (<21 mm Hg) without the need for any antiglaucoma medication. Their study results are similar to the present study findings.[5] The 1991 Delhi study on PMG s was not able to control IOP in 37.5% of eyes.[37] The 1990 Vellore study on phacolytic glaucoma has found no significant correlation between duration of symptoms and the presenting IOP, as in the present study. A weak positive correlation was found between the duration of symptoms and the best controlled preoperative IOP, similar to the present study.[39]

Optic disc changes

Optic disc at last follow-up in the affected eyes was normal in majority (36.00%). There were 6 cases of cystoid macular edema and media was hazy in 2 cases. GDD was found in 52% cases. Though clinically significant disc damage was found more in PMG (57.7%) than PLG (33.33%), the difference was statistically not significant, (P > 0.05).

BCVA at last follow-up, correlated with fundus changes, has shown that the good visual acuity achieved in normal fundus was significantly high than cases with GDD. And poor visual acuity in cases with GDD was definitely high (52.00%) as none of the cases with normal fundus had poor visual acuity. These differences were clinically and statistically significant (P = 0.000).

In Madurai study, five patients (10.2%) with PMG s and 6 patients (13.6%) with phacolytic glaucomas had visual acuity <6/60. All these five patients with PMGs and 4 of the 6 patients with phacolytic glaucomas had compromised optic nerves due to the glaucomatous process itself, showing close association with our study inference. 5 In the Lahan study series, the percentage of optic atrophy cases (34.0%) is comparatively high from our study (15.56%).[38]


  Conclusion Top


Results have shown that the LIGs were more common in the age group of 60-69 years and in females, good visual acuity can be achieved in lens-induced glaucoma presenting within 2 weeks, with intraocular pressure of <35 mm Hg and with meticulous control of intraocular pressure and inflammation with medications preoperatively. Planned small incision cataract surgery with IOL implantation, minimal tissue handling, a good follow-up with efficient management of attendant complications and inflammation, are the key factors in the management. In other words, a delay in presentation of >2 weeks, and intraocular pressure of more than 35 mm Hg would result in severe inflammation affecting the optic nerve, the cause for poor vision in 12 cases (24.00%) were due to severe postoperative inflammation, bullous keratopathy and cystoid macular edema. Which would ultimately jeopardize vision, in these potentially blinding LIGs. It is to be stressed upon, imparting health education and creating awareness regarding cataracts and its implications among the rural community, ophthalmic assistants, and peripheral health workers.

This study has highlighted the characteristics, risk factors and their consequences in LIGs, and also the importance of early diagnosis, and efficient medical management to control IOP and inflammation, with meticulous surgery and IOL implantation and also proficient postoperative management and follow-up would probably achieve an excellent visual prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
39.
The Foundation of the American Academy of Ophthalmology. Basic and Clinical Science Course, Section: 10, 11. San Francisco: The Foundation of the American Academy of Ophthalmology; 2003-2004.  Back to cited text no. 39
    



 
 
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