Aphakic or Pseudophakic

Glaucoma

Prima Maya Sari, MD

OPHTHALMOLOGY DEPARTMENT OF SRIWIJAYA UNIVERSITY

MOH. HOESIN HOSPITAL PALEMBANG
2018
INTRODUCTION
 Glaucoma

IOP soon after

surgery as well
Aphakic Pseudophakic as conditions
that occur
much later.

Glaucoma associated with aphakia, but

particularly pseudophakia, are important
considerations given the more than 1.25
million cataract surgeries performed each
year.
ETIOLOGY
 Etiology

Working
alone
Multiple
mechanisms
In synergy

Leading to glaucoma in patients with

aphakia or pseudophakia
EPIDEMIOLOGY
 Epidemiology
Duke-Elder
• Estimated 12% incidence of postoperative glaucoma in
1969.
Cinot
• Noted an increased incidence of glaucoma after
extracapsular cataract extraction (ECCE) (7.5%) as
compared to intracapsular cataract extraction (ICCE)
(5.7%)
Stark
• Noted that AC IOL (5.5-6.3%), iris-fixation (3.9-4.3%) lens
and posterior chamber (PC) IOL (1.6-3.5%).
Hoskins
• Observed 5.5% in AC IOL and 1.6% in PC IOL.
 Epidemiology
Other sources report the incidence between 5-41%

Aphakia, chronic glaucoma less prevalent at 3%

Pseudophakia, the incidence of IOP rise went down

with (ECCE) and (PCIOL) implantation 29-50%.
Chronic glaucoma prevalence in pseudophakic 2.1-4%
after the ECCE

Glaucoma was also found in 11.3% in ACIOL

Diagnosis
 Diagnosis

Glaucoma in aphakic/pseudophakic the

same as in phakic glaucoma

Collection of good patient history

Gonioscopy, Optical Coherence Tomography,

Ultrasound biomicroscopy (UBM), Humphrey, etc
 Diagnosis

• distortion of the anterior chamber angle

viscoelastics,
Dependen •
• Inflammation
t on the • Hemorrhage
• pigment dispersion
mechanis • ghost cell
m •
•
vitreous in the anterior chamber
pupillary block (pseudophakic/aphakic)
involved • malignant glaucoma
• posterior capsulotomy.
 Distortion of the anterior chamber angle

Kirsch showed

A white ridge resembling an inverted snowbank

Corneal stromal edema or tight corneoscleral

suture remains debated.

Structure was associated with peripheral anterior

synechiae, vitreous adhesion, and hyphema all of
which could cause elevated IOP
 Viscoelastics

Viscoelastic

• Protect the endothelial cells of the cornea

• Maintain anterior chamber
• The mechanism to be implicated in the
pressure elevation is a transient obstruction
of the trabecular meshwork.

Dispersive viscoelastic [Viscoat] have lower viscosity and

are harder to remove, and hence are more likely to
increase IOP than cohesive ones such as Provisc and
Healon.
 Inflammation and Hemorrhage

Consequences of surgery

Movement of the
IOL against the
iris causing the The clinical triad
Fibrosis and release of Retained cortical of uveitis,
anatomical inflammatory and material in the AC glaucoma, and
distortion of the red blood cell is another cause hyphema
COA debris that of inflammation described as UGH
obstruct the syndrome.
trabecular
meshwork.
Inflammation and Hemorrhage

UGH Syndrome
 Pigment Dispersion

Pigment granules from the iris epithelium to

be released during the cataract surgery
• lead to obstruction of the trabecular meshwork
• Posterior chamber lenses inserted in the sulcus are
most commonly associated with the increase of the eye
pressure
Pigment Dispersion

Pigmentary
Glaucoma
Vitreous Filling the Anterior Chamber

Vitreous can protrude into the AC and

block the trabecular meshwork

This condition usually occurs weeks to

months postoperatively resulting in an
acute angle closure glaucoma

Spontaneous resolution usually occurs

in several months
Vitreous Filling the Anterior Chamber

Vitreus Filling
 Pupillary Block

Aphakic Pupillary block does not commonly present

Adherence between the vitreous humour and the

iris
• inhibits the flow of aqueous humour

The other mechanism may depend on the presence of

an intact anterior hyaloid
 Pupillary Block
The mechanisms underlying glaucoma include:

Pupillary
Bulging of Pupillary
capture of
block and
the iris posterior
inflammation
chamber

Pseudophakic pupillary block glaucoma can be seen

with anterior chamber
 Pupillary Block

Pseudophakic Pupillary Block

 Peripheral Anterior Synechiae and/or
Trabecular Damage

contribute chronic
Flat
to the angle
anterior
formation closure
chamber
of the PAS glaucoma

• or • in pseudophakic
inflammation and aphakic
glaucoma.
Peripheral Anterior Synechiae

Peripheral Anterior Synechiae

 Lens-Particle Glaucoma

nuclear or
cortical block the
pieces lens outflow

too large increase

to go the
through pressure
trabecular
meshwork
Lens-Particle Glaucoma

Lens Particle Glaucoma

 Ghost Cell Glaucoma

Released as a result of the chronic vitreous hemorrhage

in the patients with aphakic eyes

The ghost cells are present in the anterior chamber and

the vitreous humor

Could settle and obstruct the outflow through the

trabecular meshwork
Ghost Cell Glaucoma

Ghost Cell Glaucoma

 Neodymium: YAG Laser posterior capsulotomy

High eye
pressure Majority of
before the
surgery
cases present
with open
angle and
inflammation

Laser risk Absence of

posterior

factors
energy chamber
lens

The increase in
IOP is usually
transient, but in
some cases
becomes a long-
Myopia
term problem.
Differential Diagnosis
 Differential Diagnosis
• Pre-existing open angle glaucoma, Retained viscoelastic, Trabecular
edema or angle distortion, Surgical hyphema, Pigment Dispersion,
Inflammation, Pupillary Block, Aqueous Misdirection, Choroidal
At 1-7 days hemorrhage or effusion.

• Pre-existing open angle glaucoma, Vitreous in the anterior chamber,

Steroid-induced glaucoma, Ghost cell glaucoma, Lens particle
At 1-7 glaucoma, Neovascular glaucoma.
weeks

• Pre-existing open angle glaucoma, Ghost cell glaucoma, Lens particle

glaucoma, Uveitis-Glaucoma-Hyphema syndrome, Pigment Dispersion,
After 2 Chronic uveitis, Epithelial downgrowth , Pupillary block
months
Treatment & Management
 Treatment & Management
Medical care
Management is dependent largely on the mechanism of the glaucoma

Midriatic- pupillary block

Aqueous humor
Aqueous humor production
production
Inhibition of inflow Aqueous suppressants and hyperosmotic
reduction
reduction

Miotics agent -after the acute phase

The goals
The goals of
of pharmacotherapy
pharmacotherapy are
are to
to reduce
reduce morbidity
morbidity and
and to
to
prevent complications
prevent complications
 Treatment & Management

Surgical Care
Both argon and
Drainage
Filtering
implant Nd:YAG lasers can be
procedures used in pupillary block
devices

Iridoplasty
Trabeculectomy
Argon laser
/Iridotomy trabeculoplasty has been
associated with
increased efficacy
and safety
 Treatment & Management
Artificial drainage implants

Non
Valved valved

Shields reports a 70% success rate with aphakic

and pseudophakic populations with a decline to
50% over 5 years
Conclusion
 Conclusion

Aphakic and pseudophakic

glaucoma is not uncommon

Timely diagnosis and treatment could provide

the best outcome to preserve vision and function

Patients with glaucoma who are untreated or

poorly treated  experience loss of visual acuity
and visual fields, which may result in total visual loss
THANK YOU