GRAND WARD ROUND

PREMAALOSHINEE
 Chief complaint

• Mr c, 74 years old/ chinese / man

• underlying hypertension and congestive cardiac failure
• No history of allergic
• Presented with right eye pain 4 /7
• Right eye redness for 4 /7 days
a/w blurring of vision and headache +
He had history of right eye progressively blurring of vision for
the past 3 years , but did not seek any medical attention
• Otherwise
• No history trauma/ procedure / operation done to right eye
• No itchiness
• No discharge
• No scotoma
• No metamorphosia
• No diplopia
• No nausea
• No family history of glaucoma / sudden blindness
• No history of steroid/ traditional medication
• Past ocular history
history of left eye cataract operation 10 years
ago
Social history
 Upon examination 10/01/2023
RE LE
Clean, not swollen Lid clean
reverse rapd positive RAPD
fulll eom full
pl on all 4 quadrant visual acquity 6/18
generalised injected , no chemosis Conj White, no chemosis
hazy ,whitish patch central ? lens material at Cornea nasal pterygium
endothelium ,level of pseudohyopyon at inferior,
cornea bedewing

unable to see iris detail pupil reactive and round

Deep, unable to appreciate cells AC Deep/q
catractous Lens stable iol with pco

60 mmHg IOP 13
no view Fundus 0.3, pink , macula and retina flat

b scan : Retina flat, vitreous clear, no obvious

abnormality of posterior segment seen
 Progression

• Impression:
1.RE phacolytic glaucoma with secondary high
iop
2. left eye pseudophakia
• Plans:
- admit ward 1 a
iv diamox 500mg stat than T. diamox 250mg qid
Start G. Maxidex STAT AND 2H RE
G. Timolast STAT AND OM RE
G. Xalatan ON RE
G. Trusopt stat and TDS RE
G. Alphagan stat and TDS RE
G. vigamox 4 hourly RE
T. SLow k 1/1 OD
G. hypertonic saline TDS re
to refer glaucoma team in ward
 seen by glaucoma team on
10/01/2023
• review iop upon patient reaching ward 1 a
• re IOP: 40 left eye :10

• increase g. maxidex hourly over the right eye

• add g. atropine od RE
 Upon examination 12/01/2023
RE LE
Clean, not swollen Lid clean
reverse rapd positive RAPD
fulll eom full
pl on all 4 quadrant visual acquity 6/18
generalised injected , no chemosis Conj White, no chemosis
hazy ,whitish patch central ? lens material at Cornea nasal pterygium
endothelium

unable to see iris detail pupil reactive and round

Deep, level of pseudohyopyon at inferior, ac AC Deep/q
filled with whitish material
unable to visualize Lens stable iol with pco

24 mmHg IOP 10
no view Fundus 0.3, pink , macula and retina flat
 progression
T. diamox 250mg qid
G. Maxidex H RE
G. Timolast STAT AND OM RE
G. Xalatan ON RE
G. Trusopt stat and TDS RE
G. Alphagan stat and TDS RE
G. vigamox 4 hourly RE
T. SLow k 1/1 OD
G. hypertonic saline TDS re
G. atropine od re
T. Prednisolone 40mg od ( started after rule out any on going infection )
biometry( to order iol + ctr and iris hook )
prop up patient 45 degree
 Upon examination 16/01/2023
RE LE
Clean, not swollen Lid clean
reverse rapd positive RAPD
fulll eom full
pl on all 4 quadrant visual 6/18
acqui
ty
generalised injected , Conj White, no chemosis
no chemosis
hazy, but periphery Corne nasal pterygium
clearing up, difuse pee a

periphery able to see pupil reactive and round

iris, round
Deep, level of AC Deep/q
pseudohyopyon at
inferior, ac filled with
whitish material
unable to visualize Lens stable iol with pco

25 mmHg IOP 13
no view Fund 0.3, pink , macula and
us retina flat
 progression
T. diamox 250mg qid
G. Maxidex H RE
G. Timolast STAT AND OM RE
G. Xalatan ON RE
G. Trusopt stat and TDS RE
G. Alphagan stat and TDS RE
G. vigamox 4 hourly RE
T. SLow k 1/1 OD
G. hypertonic saline TDS re
G. atropine od re
T. Prednisolone 40mg od
prop up patient 45 degree
aim for op on 18/01/2023
Lens-Induced Glaucoma: Diagnosis and
Management
• Lens-induced glaucoma is a secondary glaucoma in
which the crystalline lens is involved in the
mechanism of intraocular pressure (IOP) increase.
• The glaucoma may occur in open-angle or angle-
closure forms, and there are 4 distinct variants:
a)phacolytic
b) lens-particle
c)phacoantigenic
d) phacomorphic
 Phacolytic glaucoma

• is the sudden onset of open-angle glaucoma

caused by a leaking mature or hypermature
(rarely immature) cataract.
• for the role of high-molecular-weight soluble
lens protein in causing direct obstruction of
aqueous outflow channels.
• Clinical features. 
Present with
 pain
 a red eye
 blurry vision, with a history of a gradual
decrease in vision over the preceding months
or years.
An acute reduction in vision ---> corneal
edema associated with the glaucoma
• On examination: the IOP is very high
• The drainage angle is open, with no visible abnormality.
• Microcystic edema may be present in the cornea
• scattered cells on the endothelium or endothelial precipitates.
• Cellular reaction ---> anterior chamber can vary from mild cells
and flare to an intense reaction with pseudohypopyon.
•  In phacolytic glaucoma---> cells in the aqueous may be larger
than the lymphocytes seen in other uveitic processes.
• Diagnosis. 
 clinical diagnosis
 microscopic examination of aspirated
anterior chamber fluid can aid in suspected
cases.
• Biochemical studies --> high-molecular-weight
lens proteins that have leaked out of the
cataract
•  Phacolytic glaucoma is typically handled as an
emergency.
• Every effort is made to reduce the
inflammation and IOP medically
• definitive treatment for patients with
presumed phacolytic glaucoma is cataract
extraction.
 Lens particle glaucoma
• In lens particle glaucoma, IOP elevation is caused
by obstruction of aqueous outflow by lens
particles.
• this is a secondary open-angle glaucoma;
• lens-particle glaucoma is associated with a grossly
disrupted lens capsule and liberated fragments of
lens material in the anterior chamber
• It may occur after cataract surgery, trauma to the
lens, or YAG posterior capsulotomy.
• Clinical features. 
• similar as phacolytic glaucoma
• lens-particle glaucoma has a greater
inflammatory component, associated with
anterior and posterior synechiae and pupillary
membranes.
• The diagnosis
history of recent intraocular surgery or trauma,
along with the presence of gross lens material in
the anterior chamber.
 Phacoantigenic Glaucoma

• Pathogenesis.
•  Phacoantigenic glaucoma is a granulomatous inflammatory
reaction directed against own lens antigens after surgery or
penetrating trauma
• this leads to obstruction of the trabecular meshwork and
increased intraocular pressure.
• It is important to mention that phacoanaphylaxis is not the
correct name of this condition since it is not an allergy.
• The mechanism causing the reaction seems to be an Arthus-
type immune complex reaction mediated by IgG and the
complement system
• Clinical features. The clinical signs of phacoantigenic
glaucoma include
• eyelid edema
• conjunctival injection
• corneal edema
• an intense anterior chamber reaction
• posterior synechiae
• mutton-fat keratic precipitates
• Anterior vitritis may also be present.4
• Diagnosis. Definitive diagnosis requires the
presence of polymorphonuclear leukocytes in
the aqueous or vitreous specimen, as well as
circulating lens proteins within the aqueous
humor.
• Treatment. Treatment often begins with
topical steroid therapy and antiglaucoma
medications.
• surgical intervention to remove the remaining
lens material is often necessary.
 Phacomorphic Glaucoma

• Pathogenesis. A senile cataractous lens can become intumescent,

increase in thickness, and cause pupillary block.
• iridolenticular apposition disrupts the flow of aqueous humor from the
posterior chamber ---> anterior chamber.
• accumulation of aqueous in the posterior chamber, pushing the iris root
forward, which may ultimately contact the trabecular meshwork and
lead to angle closure.
• Risk factors predisposing to phacomorphic glaucoma include hyperopia,
which is associated with a smaller anterior chamber.
• Clinical features. The presentation of phacomorphic
glaucoma is similar to acute angle-closure glaucoma.
• severe pain and headache secondary to elevated IOP,
blurred vision, perception of halos around lights,
nausea, vomiting
• 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.
• Diagnosis. Phacomorphic glaucoma is
diagnosed clinically.
• Unlike the other types of lens-induced
glaucoma, gonioscopy reveals a closed angle.