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Phacolytic glaucoma is caused by a cataract maturing to the point where it blocks the eye’s drainage network. This increases intraocular pressure, causing pain and discharge from the eye. (Learn More)
Phacolytic Glaucoma & Cataracts
Phacolytic glaucoma is a form of glaucoma, which is caused by the lens protein leaking through the capsule of a mature, or a hypermature, cataract.
A mature cataract is one where the lens of the eye is totally opaque, causing the greatest degree of vision loss that can be experienced because of a cataract. A cataract that is not opaque is known as an “immature” cataract, while a hypermature cataract is one that has become liquified.
As the eye’s lens ages, its natural composition of proteins changes. There is an increase in the concentration of proteins that have a high molecular weight. When a patient has a mature or a hypermature cataract, the proteins pass through microscopic apertures in the lens capsule, heralding a secondary glaucoma because they obstruct the structure of tiny openings and vents around the eye.
Clinical Settings & Treatment
In a clinical setting, this typically looks like an elderly patient who has had recurring vision problems for a considerable length of time but has now experienced a sudden onset of pain, increase in the degree of vision loss, marked sensitivity to light, and inflammation and discharge from the affected eye. They will have a very high level of intraocular pressure as well as other disorders of the eye that will strongly implicate a phacolytic cataract. An ophthalmologist will likely notice cellular debris and clumps of the lens protein, which will look like large white particles. Patients with phacolytic glaucoma will usually have a mature or hypermature cataract.
Medications are available to reduce the swelling inside the eye, but the most comprehensive treatment for phacolytic glaucoma will be to remove the lens of the eye and replace it with an artificial lens, one on which cataracts cannot grow.
In the United States today, phacolytic glaucoma is relatively rare, to the point where the American Academy of Optometry refers to it as a “complication” of cataracts. Phacolytic glaucoma is most typically found in areas where there are barriers to health care and/or among elderly patients who have not had their cataracts already removed.
Gonioscopy & Differential Diagnosis
In treating phacolytic glaucoma, ophthalmologists should ask their patients when they first noticed the onset of pain and loss of vision. A patient who waits for more than five days since the onset will likely have a greater degree of vision loss and a more advanced stage of the glaucoma.
The American Academy of Ophthalmology notes that some patients who present with phagocytic glaucoma will have a medical history of deciding against the removal of an advanced cataract, possibly because of the barriers to health care. This (possibly forced) decision is what leads the cataracts to develop into their mature and hypermature forms, and ultimately what leads to phacolytic glaucoma.
To address the problem, patients will need a complete ophthalmologic exam. The eye will likely be inflamed, and the cornea will be swollen, so the examination should be as comprehensive as possible.
One component of the exam will be a gonioscopy, a painless exam that checks the drainage angle of the eye. This refers to an area at the front of the eye, located between the iris and the cornea. It is through the drainage angle that the aqueous humor naturally drains out of the eye.
The gonioscopy will determine the degree to which the draining process is impaired because of phacolytic glaucoma. Siphoning the aqueous humor out of the eye is essential for the maintenance of proper intraocular pressure, and the lack of siphoning is a major factor in the development of glaucoma.
Another procedure that helps an ophthalmologist treat phacolytic glaucoma is a differential diagnosis, where the doctor discerns between two or more possible causes behind the patient’s pain and their loss of vision. This is because those characteristics can be the result of other problems, such as infectious endophthalmitis, intraocular tumor, and many other forms of glaucoma. Performing a differential diagnosis is key to eliminate the other possible causes of the patient’s discomfort and to confirm that the treatment for phagocytic glaucoma is the right option.
Medications & Trabeculectomy
Medications are typically used to temporarily control the effects of glaucoma and inflammation. An ophthalmologist may prescribe anti-inflammatory drugs and aqueous suppressants for this purpose.
Surgery offers the most definitive form of treating phacolytic glaucoma. This is achieved through the removal of the lens and, with it, the mature or hypermature cataracts, allowing the intraocular pressure in the eye to recede.
Some ophthalmologists might wait to place a new intraocular lens until after the inflammation in the eye subsides. Others might prefer to make the replacement immediately. There is not a significant difference in vision to the patient with either option.
If the patient presents with phacolytic glaucoma that has been present for over a week (which counts as a long duration of onset), an ophthalmologist will likely elect for trabeculectomy to prevent recurring spikes of intraocular pressure after the surgery.
With trabeculectomy, the surgeon will open a drainage channel in the top of the eye and leave the site open for up to an hour, allowing for maximum drainage. After the procedure, the eye will be patched and shielded, and the stitches will be left in the eye for two weeks.
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Treating Phacolytic Glaucoma. (July/August 2004). American Academy of Ophthalmology.
Lens-induced Glaucoma in the Elderly. (August 2009). Clinical Interventions in Aging.
The Role of Trabeculectomy in Enhancing Glaucoma Patient's Quality of Life. (Sept-Dec 2017). Oman Journal of Ophthalmology.