Title: How Long is Too Long to Wait for Cataract Surgery? A Case of Phacomorphic Glaucoma in an Elderly Male

Author(s): Samuel Harrosh, O.D. (Resident, Department of Veterans Affairs New York Harbor Health Care System) Barbara Mendoza, O.D. (Resident, Department of Veterans Affairs New York Harbor Health Care System) Murray Fingeret, O.D., F.A.A.O (Program supervisor, Department of Veterans Affairs New York Harbor Health Care System)

Abstract: A 95 year old black male with previously diagnosed primary open angle glaucoma presents with sudden onset eye pain in his left eye and a dull headache. Through immediate intervention angle closure was prevented.

Outline

I. Case History

 Patient demographics: 95 year old black male  Chief complaint: Eye pain in the left eye and a dull headache especially when looking down to read.  Ocular History: o Primary open angle glaucoma OU o History of complicated cataract extraction OD that same year. Patient was found intra-operatively to have loose zonules and had zonular dehiscence 270° inferiorly before any substantial manipulation. Nucleus was retained in vitreous. Cataract extraction, peripheral iridectomy, and anterior vitrectomy were done, however due to lack of corneal clarity patient was left aphakic. Combined pars plana vitrectomy and pars plana lensectomy with anterior chamber intraocular lens implantation was done the following week. o Cataract OS  Medical History: o Non Insulin Dependent Diabetes Mellitus II x ~50 years o Hypertension x ~50 years o Chronic kidney disease o Monoclonal Gammopathy  Medications: o Brimonidine Tartrate 0.2%/Brinzolamide 1% BID OU o Latanoprost 0.005% QHS OU o Cilostazol 100mg tab o Glimepiride 2mg tab o Aspirin 81mg tab o Ferrous Sulfate 325mg tab

II. Pertinent Findings:

 Clinical o Corrected visual acuities: OD 20/30 PH NI, OS 20/60 PH NI o Pupils: Anisocoria OD>OS, surgical pupil OD, round, poorly reactive to light, (-)APD o Motilities: Full and smooth, no restrictions OU  Physical o Biomicroscopy: . Lids: ptosis OD, capped meibomian glands OU . Conjunctivae: white and quiet OD, grade 1 injection 360 OS . Corneas: 3 sutures superiorly OD, pigments on endothelium inferiorly OD, otherwise clear OU . Iris: Patent PI at 12, 1, and 3 o'clock, bowed iris approach OS, (-)NVI OU . Anterior chamber: deep and quiet OD, shallow OS . Anterior chamber angle: open 4x4 OD, closed OS . Lenses: ACIOL centered in place with haptics in proper position and no iris capture, Grade 2+ NS with ACC OS o Goldman applanation tonometry: OD 20mmHg, OS 30mmHg o Fundoscopic examination: Non-dilated with 90D lens . Optic disc: OD 0.85H/V, OS 0.65H/0.75V, OU borders pink and distinct, (-)drance hemes, (-)NVD . Macula: flat and clear OU, (-)CSME OU . Vessels: normal caliber OU, (-)hemes, (-)cotton wool spots o Auxiliary testing: . Gonioscopy: No structures seen OS with 4 mirror lens . B-scan ultrasound: No choroidals or masses OS

III. Differential Diagnosis:

 Primary/leading: o Secondary angle closure glaucoma/Phacomorphic glaucoma  Others: o Primary angle closure glaucoma o Intraorbital mass/tumor

IV. Diagnosis and Discussion:

 Elaborate on the condition o Phacomorphic glaucoma is a type of secondary angle closure caused by increased lens thickness, as in the case of an advanced cataract. It may either be due to anterior displacement of the lens-iris diaphragm or a pupillary block mechanism (1). o This type of angle closure occurs more frequently in countries where cataract surgery is not readily available. It has an equal sex and race predilection and may even occur in young patients but is more common the elderly (1). o Phacomorphic glaucoma occurs more frequently in smaller hyperopic eyes with larger lenses and shallower anterior chambers. Zonular weakness due to age, trauma, and pseudoexfoliation play a significant role in the development of phacomorphic glaucoma (1). o Angle closure can be brought about via pupillary dilation. During mid- dilation the peripheral iris relaxes and may bow forward and come into contact with the trabecular meshwork resulting in pupillary block (1). o Patients with this condition may present with sudden onset eye pain, decreased vision, halos around lights, headaches, nausea, and vomiting (1). o Clinical signs include increased intraocular pressure, mid-dilated and poorly reactive pupil, decreased anterior chamber depth, asymmetric cataracts, corneal haze, and conjunctival injection (1).  Expound on unique features o Given this patient’s history of zonular weakness OD, only a grade 2+ nuclear sclerotic cataract OS, and a diffusely shallow anterior chamber OS his condition may have been the result of phacodonesis with zonular instability and an anteriorly displaced crystalline lens.

V. Treatment and Management

 The patient was sent emergently to the Brooklyn campus to be evaluated by a glaucoma specialist.  A laser peripheral iridotomy was done OS that same day at the Brooklyn campus. His intraocular pressure went down to 20mmHg OS status post LPI.  A note was made to book the patient for cataract extraction within one month and to consider pars plana vitrectomy at that time should the patient be willing to undergo surgery.  The patient was followed closely over the course of the next month. Given the appearance of his anterior chamber depth (deep centrally) and adequate intraocular pressure control after the LPI, cataract surgery was no longer deemed necessary. A plan was made to dilate the patient at his next visit and discuss cataract extraction at that time.  One study suggests an immediate argon laser peripheral iridotomy provides greater safety, efficacy, and stability as the initial treatment of phacomorphic angle closure than topical or oral intraocular pressure lowering medications (2).  Some surgeons believe performing combined cataract surgery and trabeculectomy provides best long-term intraocular pressure control. One study compares the outcomes of combined cataract surgery and trabeculectomy with cataract surgery alone in these patients. Results indicate that both groups benefit from similar intraocular pressure control at six months with the cataract surgery alone group also enjoying a faster visual recovery (3).

VI. Conclusion

 It is important to differentiate phacomorphic angle closure from acute primary angle closure as the management of these patients differs.  An anterior segment optical coherence tomography may be helpful in differentiating these two. Using the Zhongshan Angle Assessment Program on the Visante optical coherence tomography one study concluded that greater lens vault, greater axial length, greater angle opening distance, and shallower anterior chamber depth are more indicative of phacomorphic angle closure (4).  Prompt referral for a laser peripheral iridotomy should be initiated immediately.  Cataract extraction is important in the management of these patients and should be considered in the quiet eye as a prophylactic treatment.

References

1. Shields MB. Textbook of Glaucoma. 1998.

2. Lee JW, Lai JS, Yick DW, Yuen CY. Argon laser peripheral iridoplasty versus systemic intraocular pressure-lowering medications as immediate management for acute phacomorphic angle closure. Clin Ophthalmol. 2013;7:63-9.

3. Senthil S, Chinta S, Rao HL, et al. Comparison of Cataract Surgery Alone Versus Cataract Surgery Combined With Trabeculectomy in the Management of Phacomorphic Glaucoma. J Glaucoma. 2016;25(3):e209-13.

4. Moghimi S, Ramezani F, He M, Coleman AL, Lin SC. Comparison of Anterior Segment-Optical Coherence Tomography Parameters in Phacomorphic Angle Closure and Acute Angle Closure Eyes. Invest Ophthalmol Vis Sci. 2015;56(13):7611-7.