Medical Care
The elevated IOP of lens-particle glaucoma often responds to medical management. [26] Once infectious processes are excluded from the differential diagnoses, the most important approach to treating lens-particle glaucoma includes steroid use, cycloplegics, and ophthalmic drops to decrease intraocular pressure.
Topical beta-adrenergic antagonists are typical first-line agents.
Topical alpha-adrenergic agonists and carbonic anhydrase inhibitors are considered adjunctive agents. Be especially cautious when choosing a topical carbonic anhydrase inhibitor in cases involving compromised corneal endothelial function; irreversible corneal decompensation has been described in such scenarios.
In managing this condition, treat the associated inflammation. Initial therapy typically involves a topical corticosteroid agent in conjunction with a topical cycloplegic agent.
Therapies involving prostaglandin analogues have not been sufficiently reported, but exercise caution when using such agents in the postoperative period. Theoretical risks of increased inflammation and/or cystoid macular edema exist.
Likewise, miotic agents may exacerbate anterior segment inflammation.
In emergency management of severe acute lens-particle glaucoma, hyperosmotic agents have a useful role in controlling IOP.
Surgical Care
Fragments in Anterior Chamber
Consider surgical intervention in cases that involve large amounts of unabsorbed lens material, posteriorly dislocated lens or nuclear fragment, or uncontrolled IOP with conventional medical management. Surgical removal of lens material often leads to a substantial reduction of intraocular pressure, and further glaucoma surgery is usually not necessary. [10] Nucleus fragments in the anterior chamber should be removed surgically because of the risk of corneal decompensation. In contrast, cortical fragments in the anterior chamber often can be observed for breakdown and resorption, with appropriate medical management.
Removal of cortical debris from the posterior chamber usually requires irrigation and aspiration of lens material adherent to the lens capsule or ciliary sulcus. Intraocular lens repositioning or exchange may be necessary. Capsulectomy with anterior vitrectomy also may be indicated if the posterior capsule and/or zonules are not intact. Anterior chamber washout, achieved by irrigation and aspiration of balanced salt solution, is recommended to maximally remove the lens debris from the angle.
Fragments in Posterior Chamber
Management of posterior dislocation of lens material varies depending on the anticipated risk of complications. Large nuclear fragments are tolerated poorly in the posterior segment, even over short periods. Prompt vitreoretinal surgery is usually indicated. [27]
However, a total lens dislocation with an intact capsule may not require immediate surgical intervention because the risks of glaucomatous, inflammatory, or retinal complications are lower in this setting.
Similarly, very small intravitreal nuclear fragments may be tolerated without specific intervention. Both the lens-particle–induced glaucoma and the inflammatory response often may appear to be proportionate to the size of the fragment. However, some data suggest that final visual outcomes may not be correlated to nucleus fragment size. [28]
Because of significant risks of further complications, the primary cataract surgeon should not attempt to retrieve intravitreal lens fragments from an anterior approach. [29, 30, 31, 32] Immediate consultation with a vitreoretinal surgeon is recommended.
Pars plana vitrectomy (with removal of lens fragments by aspiration with a fragmatome in the midanterior vitreous cavity) has become the indicated management for large intravitreal nucleus fragments. [31, 32, 33, 34, 35, 36, 37, 28] Immediate pars plana vitrectomy at the same sitting for dislocated lens fragments during cataract surgery has been described. [5, 38, 39] One study has suggested that conservative medical management may be initially undertaken in some patients without detrimental outcomes due to a delay in surgery, [40] but other data have shown major advantages to early vitrectomy within the first week. [41]
Posterior vitreolensectomy has been associated with postoperative improvement or resolution of lens-particle glaucoma. Good visual outcomes have been reported, [32, 33, 34, 36, 37, 28] particularly with prompt intervention. [41]
Consultations
Immediately obtain a vitreoretinal consultation in the event of posterior lens dislocation as a complication of cataract surgery. Several studies have indicated that early vitrectomy (within 1-3 weeks postoperatively) is associated with more favorable visual results. [38, 39, 41, 42]
Also, consider a retinal consultation to assist in differentiating postoperative phacoantigenic uveitis from endophthalmitis or sympathetic ophthalmia.
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Lens nucleus dislocated into the inferior vitreous during cataract surgery. Reprinted from Survey of Ophthalmology, Vol 43. Monshizadeh R, Nasrollah S, Haimovici R: Management of retained intravitreal lens fragments after cataract surgery. 397-403. Copyright 1999, with permission from Elsevier Science.
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Ruptured lens capsule with elevated intraocular pressure following trauma. Courtesy of KS Kooner, MD.
