What is the management of lens-induced glaucoma?

Management of Lens-Induced Glaucoma

Lens-induced glaucoma requires urgent cataract extraction as definitive treatment, with preoperative medical IOP control using aqueous suppressants (topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors, or oral acetazolamide) to reduce inflammation and corneal edema before surgery. 1, 2, 3

Immediate Medical Management

Initial IOP Control

• Start aggressive aqueous suppression immediately to lower IOP below 30 mmHg before surgery 1, 2
• Topical beta-blockers (timolol 0.5% twice daily) as first-line aqueous suppressant 4, 5
• Add topical carbonic anhydrase inhibitors (dorzolamide or brinzolamide) for additional 15-20% IOP reduction 4, 5
• Add topical alpha-2 agonists (brimonidine) if needed for further suppression 4, 5
• Oral acetazolamide 250-500mg is FDA-approved for preoperative IOP reduction in acute angle-closure glaucoma and should be used when IOP exceeds 40 mmHg (present in 64.2% of lens-induced glaucoma cases) 6, 1

Adjunctive Therapy

• Topical corticosteroids to reduce inflammation and improve surgical outcomes 5
• Cycloplegics (atropine 1% or homatropine 2%) to stabilize blood-aqueous barrier and reduce pain 5
• Avoid miotics (pilocarpine) as they worsen pupillary block in phacomorphic glaucoma 2

Definitive Surgical Treatment

Timing and Approach

• Cataract extraction is the only curative treatment and should be performed urgently once IOP is controlled and corneal clarity permits adequate visualization 1, 2, 3
• All patients (100%) in recent series underwent cataract surgery with excellent IOP control (mean postoperative IOP 13.9 mmHg) 1
• Extracapsular cataract extraction or phacoemulsification removes the inciting lens material 2, 3

Surgical Considerations

• Clear corneal edema preoperatively with medical therapy to optimize surgical visualization 1, 5
• Remove all lens material completely, as retained fragments perpetuate lens particle glaucoma 2
• Consider anterior chamber washout if significant lens protein or particles are present 2

Type-Specific Management

Phacomorphic Glaucoma (71.7% of cases)

• Results from intumescent lens causing pupillary block and angle closure 1, 2
• Requires cycloplegia to relieve pupillary block component 5
• Laser peripheral iridotomy is not definitive treatment but may temporize if surgery must be delayed 7, 2

Phacolytic Glaucoma (28.3% of cases)

• Caused by high molecular weight lens proteins obstructing trabecular meshwork 1, 2
• Presents with open angles on gonioscopy with white particles in anterior chamber 2
• Requires more aggressive aqueous suppression as outflow is directly impaired 2

Lens Particle Glaucoma

• Occurs after trauma or previous cataract surgery with retained lens fragments 2
• May require pars plana vitrectomy if fragments are posteriorly located 2

Expected Outcomes

Visual Recovery

• 30.2% achieve visual acuity >6/18 postoperatively 1
• 42% have final vision 6/60 or worse due to delayed presentation and optic nerve damage 3
• Better outcomes correlate with earlier presentation and lower presenting IOP 1, 3

IOP Control

• 100% of patients achieve IOP control after lens removal 1, 2
• Mean postoperative IOP drops from >40 mmHg to 13.9 mmHg 1
• Glaucoma medications can typically be discontinued after surgery 2

Critical Pitfalls to Avoid

• Never delay cataract surgery once medically stabilized - prolonged elevated IOP causes irreversible optic nerve damage 1, 3
• Do not perform laser peripheral iridotomy as definitive treatment for phacomorphic glaucoma; it only temporizes 2
• Avoid operating through hazy cornea - preoperative medical therapy must clear edema first 1, 5
• Do not use prostaglandin analogs preoperatively as they increase inflammation 4
• Recognize that late presentation (100% presenting with vision <3/60) indicates poor public awareness requiring education efforts 1, 3

Postoperative Management

• Continue topical corticosteroids for 4-6 weeks to control postoperative inflammation 5
• Monitor IOP at 1 day, 1 week, and 1 month postoperatively 1
• Assess optic nerve for permanent glaucomatous damage requiring long-term monitoring 8
• Most patients will not require long-term glaucoma medications after successful lens removal 2