Aphakic and Pseudophakic Glaucoma Treatment & Management

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 15, 2012
 

Medical Care

Management is dependent largely on the mechanism of the glaucoma. In both aphakic/pseudophakic pupillary block, the initial treatment is mydriasis. This is used to either break the block or enlarge the pupil beyond the edges of the AC IOL. Temporizing measures include aqueous suppressants and hyperosmotics. Miotics can help in the long-term management after the acute phase. Epinephrine is avoided because of the risk of macular edema. Ultimately, iridotomy usually is needed in both cases. In aphakia, the iridotomy must be placed over a pocket of aqueous behind the iris, and this may require multiple attempts. Other options include trabeculoplasty, cyclophotocoagulation, and pars plana vitrectomy.

Preoperatively, the use of external pressure reducers to maintain AC depth and to minimize potential complications (eg, vitreous loss, expulsive hemorrhage) may be considered. However, potential adverse effects of optic nerve atrophy or arterial occlusion must be considered. Careful use of epinephrine in local anesthetic may help to preserve perfusion to the optic nerve.

Judicious use of a viscoelastic substance may help to control a postoperative rise in IOP, whereas carbachol and acetylcholine have both been shown to decrease IOP postoperatively. Notably, carbachol was associated with decreased IOP at 24 hours, 2 days, and 3 days postoperatively. Further, the choice of IOL may influence the postoperative course.

Although dictated by the clinical scenario, one may remember the increased incidence of glaucoma with the early generation AC IOL and iris-fixation lens as compared to the PC IOL. Special attention must be devoted to patients with complicating factors (eg, corneal endothelial cell loss, fibrous endothelial metaplasia, angle cicatrization). A decrease in intraoperative trauma and complications would allow the surgeon increased flexibility in the choice of IOL.

Further, Bomer found a correlation between the surgeon's experience and the rise in postoperative IOP.[10] Increased IOP has been noted within 6-7 hours postoperatively and usually returns to normal in 1 week. A modest increase in the IOP poses minimal threat in the nonglaucomatous eye; but, if clinically warranted, beta-blockers, acetazolamide, and apraclonidine have been shown to be of benefit. Of these, apraclonidine is more effective if given 1 hour preoperatively. Further, pilocarpine gel also was shown to be effective, although attention must be paid to inflammation.

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Surgical Care

Both argon and Nd:YAG lasers can be used in pupillary block and help to distinguish it from aqueous misdirection. Argon laser trabeculoplasty benefit both pseudophakic and aphakic populations, and it may delay the need for surgical intervention by 18 months, although 36-month follow-up examinations were not encouraging.

Iridoplasty is used to alter the peripheral iris morphology when iridotomy cannot be performed. For instance, shrinking the peripheral iris deepens the AC in iridocorneal touch. The posterior capsule needs to be broken to establish communication between the retrocapsular space and the AC. This technique is helpful in retrocapsular pupillary block or anterior aqueous misdirection.

Posterior aqueous misdirection involves deposition of aqueous fluid in the vitreous cavity and is relieved with vitreolysis using Nd:YAG laser. Cyclodestructive therapy using laser (argon and Nd:YAG) or ultrasound has been described. Generally reserved for patients who have failed other therapies, cyclodestructive therapy is performed using transpupillary, endophotocoagulation, and transscleral approaches. Noureddin compared Nd:YAG cyclocoagulation to filtering procedures and showed that, although both reduced IOP significantly, fewer medications were needed postoperatively in the filtering procedure group.[11]

Incisional approaches include filtering procedures and drainage implant devices. Filtering procedures are divided into full-thickness and partial-thickness procedures. Although the full-thickness approach is theoretically superior, study data have ranged from no difference in IOP control to higher complication rates when compared to partial-thickness approaches even when using 5-FU. Shields, on the other hand, notes that trabeculectomy has been associated with increased efficacy and safety.[8, 12, 13] However, aphakic eyes are associated with an increased incidence of complications and lower efficacy than phakic eyes. Nonpenetrating trabeculectomy (viscocanalostomy) has gained popularity, but no data are available comparing aphakic/phakic/pseudophakic populations.

Artificial drainage implants are divided into valved and nonvalved types. These are especially useful when the likelihood of success from filtering procedures is low. Shields reports a 70% success rate with aphakic and pseudophakic populations with a decline to 50% over 5 years, which is consistent with other reported values.[8]

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Contributor Information and Disclosures
Author

Robert H Graham, MD  Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society

Disclosure: WebMD/eMedicine Salary Employment

Specialty Editor Board

Bradford Shingleton, MD  Assistant Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary

Bradford Shingleton, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Martin B Wax, MD  Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Society for Neuroscience

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors, Sai Gandham, MD, and DooHo Brian Kim, BA, to the development and writing of this article.

References

  1. Duke-Elder S. Disease of the lens and vitreous: glaucoma and hypotony. In: System of Ophthalmology. Vol 11. 1969:11.

  2. Cinotti AA, Jacobson JH. Complications following cataract extraction. Am J Ophthalmol. 1953;36:929.

  3. Stark WJ, Worthen DM, Holladay JT, et al. The FDA report on intraocular lenses. Ophthalmology. Apr 1983;90(4):311-17. [Medline].

  4. Hoskins HD Jr. Management of pseudophakic glaucoma. In: Greve EL, ed. Surgical Management of Coexisting Glaucoma and Cataract. 1987.

  5. Yildirim N, Gursoy H, Sahin A, Ozer A, Colak E. Glaucoma after penetrating keratoplasty: incidence, risk factors, and management. J Ophthalmol. 2011;2011:951294. [Medline]. [Full Text].

  6. Urban B, Bakunowicz-Lazarczyk A. Aphakic glaucoma after congenital cataract surgery with and without intraocular lens implantation. Klin Oczna. 2010;112(4-6):105-7. [Medline].

  7. Epstein DL, Allingham RR, Schuman JS. Chandler and Grant's Glaucoma. Baltimore, Md: Williams & Wilkins;1997.

  8. Shields MB. Textbook of Glaucoma. Baltimore, Md: Williams & Wilkins; 1998.

  9. Kirsch RE, Levine O, Singer JA. Ridge at internal edge of cataract incision. Arch Ophthalmol. Dec 1976;94(12):2098-2104. [Medline].

  10. Bömer TG, Lagreze WD, Funk J. Intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon's experience. Br J Ophthalmol. Sep 1995;79(9):809-13. [Medline].

  11. Noureddin BN, Wilson-Holt N, Lavin M, et al. Advanced uncontrolled glaucoma. Nd:YAG cyclophotocoagulation or tube surgery. Ophthalmology. Mar 1992;99(3):430-6; discussion 437. [Medline].

  12. Comer RM, Kim P, Cline R, Lyons CJ. Cataract surgery in the first year of life: aphakic glaucoma and visual outcomes. Can J Ophthalmol. Apr 2011;46(2):148-52. [Medline].

  13. Bothun ED, Guo Y, Christiansen SP, Summers CG, Anderson JS, Wright MM, et al. Outcome of angle surgery in children with aphakic glaucoma. J AAPOS. Jun 2010;14(3):235-9. [Medline].

  14. Altintas O, Yuksel N, Karabas VL, Demirci G. Cystoid macular edema associated with latanoprost after uncomplicated cataract surgery. Eur J Ophthalmol. Jan-Feb 2005;15(1):158-61. [Medline].

  15. Araie M, Ishi K. Effects of apraclonidine on intraocular pressure and blood-aqueous barrier permeability after phacoemulsification and intraocular lens implantation. Am J Ophthalmol. Jul 15 1993;116(1):67-71. [Medline].

  16. Arcieri ES, Santana A, Rocha FN, Guapo GL, Costa VP. Blood-aqueous barrier changes after the use of prostaglandin analogues in patients with pseudophakia and aphakia: a 6-month randomized trial. Arch Ophthalmol. Feb 2005;123(2):186-92. [Medline].

  17. Arvind H, George R, Raju P, et al. Glaucoma in aphakia and pseudophakia in the Chennai Glaucoma Study. Br J Ophthalmol. Jun 2005;89(6):699-703. [Medline].

  18. Barnes EA, Murdoch IE, Subramaniam S, Cahill A, Kehoe B, Behrend M. Neodymium:yttrium-aluminum-garnet capsulotomy and intraocular pressure in pseudophakic patients with glaucoma. Ophthalmology. Jul 2004;111(7):1393-7. [Medline].

  19. Berson FG, Patterson MM, Epstein DL. Obstruction of aqueous outflow by sodium hyaluronate in enucleated human eyes. Am J Ophthalmol. May 1983;95(5):668-72. [Medline].

  20. Brown DN. Long-term success of argon laser trabeculoplasty in aphakic and pseudophakic eyes. Invest Ophthalmol Vis Sci. 1992;33:1159.

  21. Carter BC, Plager DA, Neely DE, Sprunger DT, Sondhi N, Roberts GJ. Endoscopic diode laser cyclophotocoagulation in the management of aphakic and pseudophakic glaucoma in children. J AAPOS. Feb 2007;11(1):34-40. [Medline].

  22. Ellingson FT. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant. J Am Intraocul Implant Soc. Apr 1978;4(2):50-3. [Medline].

  23. Fontana H, Nouri-Mahdavi K, Caprioli J. Trabeculectomy with mitomycin C in pseudophakic patients with open-angle glaucoma: outcomes and risk factors for failure. Am J Ophthalmol. Apr 2006;141(4):652-9. [Medline].

  24. Harrison SE, Soll DB, Shayegan M, Clinch T. A new and effective protective agent for intraocular lens insertion. Ophthalmology. Nov 1982;89(11):1254-60. [Medline].

  25. Lee LC, Pasquale LR. Surgical management of glaucoma in pseudophakic patients. Semin Ophthalmol. Sep-Dec 2002;17(3-4):131-7. [Medline].

  26. Lima FE, Magacho L, Carvalho DM, Susanna R Jr, Avila MP. A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma. J Glaucoma. Jun 2004;13(3):233-7. [Medline].

  27. Michael I, Walton DS, Levenberg S. Infantile Aphakic Glaucoma: A Proposed Etiologic Role of IL-4 and VEGF. J Pediatr Ophthalmol Strabismus. Mar-Apr 2011;48(2):98-107. [Medline].

  28. Minckler DS, Heuer DK, Hasty B, Baerveldt G, Cutting RC, Barlow WE. Clinical experience with the single-plate Molteno implant in complicated glaucomas. Ophthalmology. Sep 1988;95(9):1181-8. [Medline].

  29. Rockwood EJ, Parrish RK 2nd, Heuer DK, et al. Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology. Sep 1987;94(9):1071-8. [Medline].

  30. Ruiz RS, Rhem MN, Prager TC. Effects of carbachol and acetylcholine on intraocular pressure after cataract extraction. Am J Ophthalmol. Jan 15 1989;107(1):7-10. [Medline].

  31. Ruiz RS, Wilson CA, Musgrove KH, Prager TC. Management of increased intraocular pressure after cataract extraction. Am J Ophthalmol. Apr 15 1987;103(4):487-91. [Medline].

  32. Shingleton BJ, Alfano C, O'Donoghue MW, Rivera J. Efficacy of glaucoma filtration surgery in pseudophakic patients with or without conjunctival scarring. J Cataract Refract Surg. Dec 2004;30(12):2504-9. [Medline].

  33. Simon JW, O'Malley MR, Gandham SB, Ghaiy R, Zobal-Ratner J, Simmons ST. Central corneal thickness and glaucoma in aphakic and pseudophakic children. J AAPOS. Aug 2005;9(4):326-9. [Medline].

  34. Simon JW, O'Malley MR, Gandham SB, Ghaiy R, Zobal-Ratner J, Simmons ST. Central corneal thickness and glaucoma in aphakic and pseudophakic children. J AAPOS. Aug 2005;9(4):326-9. [Medline].

  35. Simsek T, Mutluay AH, Elgin U, Gursel R, Batman A. Glaucoma and increased central corneal thickness in aphakic and pseudophakic patients after congenital cataract surgery. Br J Ophthalmol. Sep 2006;90(9):1103-6. [Medline].

  36. Valmaggia C, de Smet M. Endoscopic laser coagulation of the ciliary processes in patients with severe chronic glaucoma. Klin Monatsbl Augenheilkd. May 2004;221(5):343-6. [Medline].

 
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