Lecture: Lens Particle Glaucoma (1 Slide in 5 Minutes)

Dr. Kahook: Lens induced glaucoma can be subdivided into distinct categories that include: 1. Phacolytic Glaucoma, 2. Lens Particle Glaucoma and 3. Phacoantigenic Glaucoma. I will cover Lens Particle Glaucoma in this session of 1 Slide in 5 Minutes.

Lens Particle Glaucoma results from liberated cataract material after the lens capsule is compromised post cataract surgery or post trauma. This is in distinction to phacolytic glaucoma which occurs in the absence of visible openings in the lens capsule. The liberated lens material subsequently acts as a physical barrier to aqueous humor egress from the anterior chamber across the trabecular meshwork and into the distal outflow system. Disruption of aqueous outflow leads to elevation of intraocular pressure (IOP) in a manner that is congruous with the amount of lens material present. The rise in IOP may present weeks to years after the presence of lens material in the anterior chamber.

Examination:
The typical presentation involves complaint of a red eye and photophobia with or without altered visual acuity. On exam, microcystic corneal edema is often present with lens material observable in the angle. The lens material is often composed of fluffy cortical material with or without lens nucleus fragments. Moderate inflammatory reaction with cell and flare and synechiae formation are both common.

Differential Diagnosis:
Careful history and slit lamp examination will help direct the diagnosis and this is especially the case when past cataract surgery has been performed or ocular trauma has been reported with identifiable retained lens fragments. Phacolytic glaucoma, a form of secondary open angle glaucoma that is related to
leakage of high molecular weight proteins through microscopic openings in the capsule of a hypermature cataract, also results in elevated IOP but can easily be distinguished with history (lack of cataract surgery or trauma) and physical exam (presence of mature or hypermature cataract). Sending aqueous taps for analysis to identify polymorphonuclear cells could be done if there is confusion between lens particle glaucoma and phacoantigenic glaucoma, although the differences are academic since the treatment is essentially the same. Neovascular glaucoma and uveitic glaucoma may in part mimic the disease process of lens particle glaucoma but each can be ruled out with proper history and examination.

Treatment:
Fortunately, many of the patients who suffer from lens particle glaucoma do not actually manifest optic neuropathy if the disease is identified in early stages and prompt definitive treatment is instituted. Treatment is carried out with IOP lowering medications, mydriatics (to avoid or lessen formation of synechiae) and steroids until the lens material is resorbed or surgical intervention is completed to wash out the lens material. The surgical treatment involves anterior chamber washout with removal of all lens material from the anterior chamber. Every patient should undergo dilated fundus examination with optic nerve assessment at baseline. Visual field testing can set a baseline for presence or absence of optic neuropathy and extended follow up, when possible, should be instituted to ensure recovery and addressing any future needs of the patient.