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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 30
| Issue : 2 | Page : 51-55 |
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A Comparison of Clinical Profile and Treatment Outcomes of Phacomorphic and Phacolytic Glaucoma in a Tertiary Eye Care Hospital of India
Sardar Khan, Avik Kumar Roy, Aparna Rao
LV Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Patia, Bhubaneswar, Odisha, India
| Date of Submission | 06-Oct-2021 |
| Date of Decision | 29-Sep-2021 |
| Date of Acceptance | 01-Nov-2021 |
| Date of Web Publication | 06-Jul-2022 |
Correspondence Address:
Dr. Avik Kumar Roy
LV Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Patia, Bhubaneswar, Odisha 751024
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njo.njo_36_21
Objective: To compare the clinical features, and treatment outcomes of phacomorphic glaucoma (PMG) versus phacolytic glaucoma (PLG) in a tertiary care eye hospital in India. Methods: A retrospective review of electronic medical record data of all patients operated for phacolytic and PMGs, between March 2013 and March 2020, was performed. Patients with a history of trauma pre-existing glaucoma or who were blind at presentation were excluded. Patients’ demographic data, clinical features, visual and surgical outcomes were analyzed. Results: There were 78 and 86 eyes with a mean age of 69.0 and 70.3 years for PMG and PLG, respectively. Time from onset of symptoms to presentation in the clinic was longer in PMG group of patients (30.7 ± 53.2 days) compared to the PLG group (15 ± 17.5 days). Visual acuities and/or intraocular pressures (IOPs) at presentation were comparable in the two groups. Corneal decompensation or scarring was 3.8% in PMG versus 2.8% in PLG. About 24.4% patients in PMG group were initially misdiagnosed and treated as either primary open angle or closed angle glaucoma, whereas there was no misdiagnosis in the PLG group. Small incisional cataract surgery (SICS) with posterior chamber intraocular lens implantation was performed in 65.4% of phacomorphic and 68.6% of phacolytic groups. Combined cataract and trabeculectomy were carried out in 8.9% of phacomorphic and 4.6% of phacolytic. Vitrectomy was required in 17.9% in phacomorphic and 12.8% in PLG, statistically significant improvement in overall mean logMAR visual acuity improved from 1.5 to 1.4, and IOP reduced by 53% by postoperative 1 week. Conclusion: Both PMG and PLG respond favorably to standard SICS, irrespective of their duration of symptoms. The final visual acuity gain and control of IOPs were comparable in the two groups.
Keywords: Lens-induced glaucoma, phacolytic glaucoma, phacomorphic glaucoma
How to cite this article:
Khan S, Roy AK, Rao A. A Comparison of Clinical Profile and Treatment Outcomes of Phacomorphic and Phacolytic Glaucoma in a Tertiary Eye Care Hospital of India. Niger J Ophthalmol 2022;30:51-5 |
| Introduction | |  |
Lens-induced glaucoma (LIG) refers to a heterogeneous group of secondary glaucoma, caused by abnormality of the crystalline lens inside the eye.[1] The various subtypes include open-angle forms such as phacolytic glaucoma (PLG) and lens-particle glaucoma and closed-angle forms such as phacomorphic glaucoma (PMG) and phacotopic glaucoma.[2] The etiology of these forms of LIG are diverse.[2],[3],[4],[5] Cases of PLG have been reported in literature since 1960s.[6],[7],[8],[9],[10],[11],[12] In spite of the advancement and wide-spread availability of cataract surgery, incidence of PLG is still not infrequent.[13],[14],[15] By far, PMG is reported to be the commonest form of LIG.[16] Both the subtypes namely PMG and PLG usually reveal history of slowly progressive diminution of vision because of cataract before the sudden onset of the symptoms from raised IOP. The two entities differ markedly in their clinical signs.[19] PMG presents with shallow anterior chamber (AC), mostly mid-dilated and vertically oval pupil, and a white intumescent cataract. On the other hand, PLG presents with hypermature or morgagnian cataract, leaked lens matter, cells and flare in AC, and open angle. In addition to ageing,[18] an axial length shorter than 23.7 mm,[18] shallow AC,[23] and female gender[19],[20] are regarded as a risk factor for developing PMG. Eyes with primary angle closure disease are also susceptible to develop phacomorphic attack.[21],[22] Investigations such as AC ocular coherence tomography[24] and ultrasound biomicroscopy[25],[26] tools are reported to be effective in predicting eyes developing into PMG. There are some studies in the literature, reported from Nepal[16] or Malaysia[17] detailing on demographics, clinical features, and treatment outcomes of the two common clinical forms of LIG. But long-term comparative detailed analysis has not yet been reported from India, which is why we are describing our experience in managing the two most common type of LIG, reported over a 7-year period in a tertiary eye care center in India.
| Methods | | |
A retrospective medical record audit of the hospital database was performed to identify patients presenting with the diagnosis of LIG from March 2013 to March 2020. This included 78 cases of PMG and 86 cases of PLG. Patients with history of trauma, having pre-existing glaucoma, or nil visual prognosis at presentation were excluded. The diagnosis of glaucoma was made according to standard American Academy of Ophthalmology guidelines. PMG was defined as a variety of LIG with classical symptoms and signs such as pain and redness, shallow AC, cornea edema, and raised IOP with intumescent mature cataract. On the other hand, PLG was defined clinically based on the presence of the hypermature/morgagnian cataract with intact capsule, presence of leaked lens matter in AC. Details retrieved from the database for these patients included demographics such as age, gender, duration of symptoms, visual acuity (recorded in equivalent logMAR units from Snellen or ETDRS charts) and slit lamp examination, intraocular pressure (IOP; measured by Goldman Applanation Tonometry) on presentation and at follow-up visits. Glaucoma diagnostic data such as gonioscopy, fundus examination, and visual field tests were unavailable for most of the patients and hence not analyzed. The treatment details in term of isolated cataract surgery or additional glaucoma filtering surgery, if any and that of any intraoperative complications were obtained. The primary outcome measures were the improvement in logMAR acuity and decrease in IOP − both values taken from the recordings obtained from 1-week postoperative visits, as a significant number of patients were lost to follow-up.
Statistics methods
Statistical analysis was performed using SPSS version 22 (SPSS 22.0, Chicago, IL, USA). Descriptive analysis was performed for both groups in which categorical data were presented as frequencies and percentages and continuous variables were presented as mean ± standard deviation. Visual acuity was converted to logarithm of the minimum angle of resolution for statistical analysis. Between-group comparison was performed by using the t test for continuous variables and the Chi-squared test for categorical variables. A P-value <0.05 was considered statistically significant.
| Results | | |
The number of PMG and PLG cases were 78 and 86, respectively. The demographic data and clinical profiles are given in [Table 1].
The mean age of the entire cohort was 69.7 years − phacolytic cohort was little older in age. Significantly more female was affected with the PMG in our study. The duration of symptoms before presenting to our institute was more variable in PMG (range being 2 days to 1 year) than PLG (range being 2–90 days). The mean visual acuities at presentation in both the cohorts were as poor as logMAR 2.3–amounting to perception of light present. The baseline IOP values in the two groups were similar − the overall mean IOP being 37.2 mmHg. More patients with PMG than PLG were initially diagnosed and treated as other forms of primary glaucoma (24.4% vs. 0%, respectively). In addition, pseudoexfoliation (PXF) was more associated with PMG than PLG (20.5% vs. 5.8%, respectively).
The management details in terms of surgeries carried out, their complications, and postoperative outcomes are highlighted in [Table 2]. | Table 2 Surgical management of the eyes, intraoperative complications, and postoperative outcome
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 | Table 3 Comparison of the surgical outcome of present study with previous published reports
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The commonest (91.1% in PMG group and 95.4% in PLG group) surgery performed was that of cataract removal with or without implantation of intraocular lens (IOL). Additional glaucoma filtering surgery − namely trabeculectomy − was not needed in the majority. Only 7 out of 78 eyes in PMG (8.9%) and 4 out of 86 (4.6%) in PLG eyes received combined cataract-glaucoma procedures. Intraoperative complications such as posterior capsular rent, zonular dialysis, vitreous loss, or nuclear drop were more numerous in PMG group (17.9%) than PLG group (12.8%) − which was not statistically significantly different (P = 0.8). The postoperative improvement in visual acuity was significant in the two groups − equivalent to 10 more lines in Snellen chart − though statistically not different in between the groups (P = 0.8). The logMAR improvement is more vivid in the PMG group (1.5 ± 0.7) than the PLG group (1.4 ± 0.7). The two groups also revealed significant IOP lowering − more in the PMG group. Mean IOP lowering were 20.3 mm in PMG and 18.8 mm in PLG. There was no difference in the improvement in visual acuity or IOP in the two groups which presented earlier or later.
| Discussion | | |
The LIG developing from neglected hypermature cataracts is an important cause of secondary glaucoma in the developing world.[18] As elaborated in the results section, clinical parameters such as poor visual acuity or raised IOPs were not significantly different in the two subtypes. But in our studies, the PMG group had a higher number of missed diagnosis (of primary open angle or primary angle closure glaucoma) and also more associated with PXF material on iris or lens surface. As far as the treatment of LIG is concerned, it remains exclusively surgical − after a brief period of medical management of ocular inflammation using steroids and antiglaucoma medications. Preoperatively though, there is a scope of doing a peripheral iridoplasty[27],[28] and peripheral iridotomy[29] in PMG variant that are supposed to relieve the pupillary block and would pose as a first-line management. However, as a protocol, these were not followed in our institute. There are strong evidences in the literature that a standard cataract surgery alone is safe and effective in PMG.[20],[21],[30],[31],[32],[33],[34],[35] The need for removal of the offending cataractous lens is beyond doubt. IOL implantations have been achieved whenever there is good capsular support available. Both the groups in our study had remarkable (more than 10 lines in the Snellen chart) improvement in visual acuity postoperatively. This is more likely due to a combination of cataract removal and clearing of cornea edema from lowered IOP. Only 3.8% and 2.3% of the eyes in the two groups [Table 1] had corneal decompensation at presentation. But there are a lot of controversies regarding the addition of filtering surgery into it. Jain et al.[20] in 1980s strongly advocated against filtering surgery in PLG. For the first time in 1990s, Angra et al.[21] had proposed a guideline of doing only cataract or combined surgery, when the duration of presentation being <7 and >7 days, respectively. But following this, there has been a paucity of literature for almost one decade. Das et al.[35] in 2002, reported a series of 15 cases of PMG with combined extracapsular cataract extraction and Ahmed glaucoma valve implantation. Sachdev et al.[36] in 2017, went on to describe an addition of limited core vitrectomy before proceeding to perform phacoemulsification in PMG. The debate of performing an additional glaucoma filtering surgery in PMG was most aptly resolved by Senthil et al.[37] in 2016 who showed the results of better and faster visual recovery and a similar IOP control by cataract surgery alone in a cohort of PMG who presented within 4 weeks of onset of symptoms, in comparison with combined cataract and glaucoma surgery. As far as the management of PLG is concerned, cataract removal with or without IOL implantation has been known to be the standard procedure since long.[38],[39],[40],[41] Braganza et al.[42] described the addition of trabeculectomy if the duration of symptoms were longer than 1 week − but the visual acuity and IOP levels were comparable at 6 months follow-up. As far as direct comparison of the two most common types of LIG, namely phacomorphic and PLG, is concerned, there has been only a single comparative study − way back in 1996 by Prajna et al.,[43] where they performed extracapsular cataract extraction with or without IOL implantation. Our study has the advantage of utilizing the modern and probably safer, surgical options in the management of LIG and comparing the outcomes thereof. The direct head-to-head comparison of small incisional cataract surgery in these two disease types has not been described in the literature so far.
The major drawbacks of the study are its retrospective nature. The diagnosis of the cases was entirely clinical. In addition, we could not provide data on gonioscopy, fundus evaluation, and visual field examination − simply because these tests were deferred in the existing situations of patients having symptoms or significant media opacity. There was no documentation of modern investigations such as ocular coherence tomography (OCT) or ultrasound biomicroscopy (UBM). We do not believe the investigations will add to any significant value to the management of the disease in a developing country like ours. In addition, we lack in having any long-term data on the visual acuity and IOP levels − as most of the patients were lost to follow-up after first week.
To conclude, standard cataract surgery remains a useful treatment options for the two most common types LIG, namely PMG and PLG. Postoperatively, the improvement in vision and IOP control in these two disease scenarios are comparable.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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