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Phacomorphic Glaucoma: Case and Review: Joseph Sowka, O.D
Phacomorphic Glaucoma: Case and Review: Joseph Sowka, O.D
Abstract Phacomorphic glaucoma is a lens-induced secondary angle closure glaucoma that may occur
as a result of mature cataract formation. A patient with markedly asymmetric cataract and anterior
chamber depth was referred after the development of significant eye pain and elevated intraocular
pressure that did not respond to topical antiglaucoma medications. The presence of an asymmetric
mature lens, angle closure, and intraocular pressure elevation in the affected eye led to the diagnosis of
phacomorphic glaucoma. Because the patient was systemically ill, physically frail, and had poor vision
in the affected eye since birth, secondary to strabismic amblyopia, initial therapy was medically directed
toward pain management. Cycloplegia, corticosteroids, and aqueous suppressants successfully ameliorated the patients intraocular pressure and adequately controlled pain. However, progression to
phacolysis and subsequent failure of pain management necessitated referral for lens extraction. The
diagnosis and mechanism of phacomorphic glaucoma is discussed along with a review of current
treatment modalities.
Optometry 2006;77:586-589
Case report
A 48-year-old black woman with cerebral palsy, sickle cell
disease, and arthritis was referred urgently for a glaucoma
Corresponding author: Joseph Sowka, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328.
E-mail: jsowka@nova.edu
1529-1839/06/$ -see front matter 2006 American Optometric Association. All rights reserved.
doi:10.1016/j.optm.2006.08.013
Joseph Sowka
Issue Highlight
587
week but told to call immediately if her pain did not
improve or if it worsened within the next several days.
The patient returned as scheduled and reported good
medical compliance. Her visual acuity was unchanged in
each eye. She now reported that her ocular pain had greatly
diminished and was now only occasional. She had no ocular
pain at the time of the visit. Intraocular pressures were 19
mmHg O.D. and 40 mmHg O.S. Her left pupil was pharmacologically dilated. The patient was instructed to continue the medications prescribed at the last visit as well as to
resume brimonidine bid O.S. The patient was reappointed
for 3 months with the instructions to return immediately
should there be any increase in pain or other changes.
At the 3 month follow-up, the patient reported good
medical compliance and no further instances of ocular pain.
Intraocular pressures by Goldman applanation were 16
mmHg O.D. and 25 mmHg O.S. There were no changes in
her biomicroscopic evaluation. Because there was no potential for improved functional vision O.S., and her pain was
well managed medically, she was deemed not to be a good
candidate for lens extraction. She continued all medications.
The patient was successfully followed up medically for
the next 7 months. However, at her most recent progress
evaluation, she reported that she had developed significant
pain again in her left eye as well as general photophobia.
The visual acuity was unchanged in the right eye but had
decreased to no light perception in the left eye. Additionally, the left cataract was visibly whiter on gross inspection.
Her family members had also noticed that her pupil seemed
whiter than in the past month.
Biomicroscopic evaluation found a hypermature, lytic
cataract O.S. with a moderate anterior chamber reaction.
Intraocular pressures were 18 mmHg O.D. and 38 mmHg
O.S. It was determined that the phacomorphic lens had now
become phacolytic. As a result, it was felt that medical
control would no longer be appropriate to manage the
patients pain and that the patient would now benefit from
medically necessary cataract extraction. Ultrasonography,
planned to ascertain if an intraocular process may have
contributed to the asymmetric cataract formation, was abandoned in favor of a surgical consultation for cataract extraction. The consulting surgeon agreed that lens removal was
medically necessary despite poor visual potential. At the
time of this writing, the patient is scheduled for cataract
extraction O.S (see Figure 1).
Discussion
As the name implies, phacomorphic (phaco lens; morph
shape) glaucoma develops secondary to the shape of the
lens. Angle closureacute, subacute, or chronic can be
triggered by a mature or intumescent cataract and occurs in
eyes with previously open angles as well as in those with
narrow, occludable angles. This is encountered more often
in developing countries where health care is not easily
588
Figure 1
Joseph Sowka
Issue Highlight
cellular response, with the proteins being engulfed by macrophages, which congregate on the surface of the lens and
become trapped within the trabecular meshwork.19 When
the accumulation of macrophages and HMW-soluble proteins physically block and impede aqueous outflow through
the trabecular meshwork, a secondary pressure rise known
as phacolytic glaucoma is said to ensue.20
Conclusions
Although lens-induced glaucomas are not encountered commonly in populations that have ready access to cataract
surgery, they can easily occur in patients who allow cataracts to mature. Lens-induced glaucomas represent a significant percentage of secondary glaucomas.3 A mature cataract can induce angle closure and phacomorphic glaucoma,
whereas a hypermature cataract can induce phacolytic glaucoma. In some cases, such as the one presented here, more
than 1 lens-induced mechanism may occur in a patient.
Although cataract extraction typically is the definitive treatment for lens-induced glaucomas, there are steps that must
be taken in advance to address the acute nature of the
condition. Also, for a variety of reasons, some patients may
not be good surgical candidates, which may be the underlying reason that a cataract may not have been addressed
earlier and allowed to mature. Alternate chronic medical
therapies may then be more appropriate for that particular
patient situation.
The patient presented here was a poor surgical candidate
because of no potential visual improvement and frail health.
Because the pain was the most significant concern, medical
rather than surgical therapy was initially successfully instituted. However, the progression from phacomorphic to
phacolytic glaucoma with an inability to medically control
pain necessitated a change in therapeutic approach.
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