AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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• Introduction
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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Background

Lens-particle glaucoma, a subclassification of lens-induced glaucoma, is a type of secondary open-angle glaucoma involving intraocular retention of fragmented lens debris. Following surgery or injury, lens material may be sequestered within the capsular bag or dislocated into other areas of either the posterior eye or anterior eye. Characteristically, large lens pieces spontaneously fragment further into small (sometimes invisible) particles that eventually migrate into the anterior chamber and obstruct aqueous outflow. Lens-particle glaucoma is not associated with decentration or dislocation of an intact lens.

Pathophysiology

The mechanism involves the following 4 processes: (1) presence of a nonintact lens capsule, usually violated during trauma or intraocular surgery; (2) dislocation of lens fragments into the anterior or posterior segment, with subsequent release of lens particles into the anterior chamber; (3) obstruction of trabecular meshwork by lens debris and inflammatory components; and (4) reduction of the outflow facility of an open anterior chamber angle, resulting in elevation of intraocular pressure (IOP).

Frequency

United States

Incidence has not been reported.

Mortality/Morbidity

Mortality is not associated with this condition. Morbidity is rare.

Race

No known racial predilection exists.

Sex

No known gender predilection exists for the condition. Penetrating eye trauma, a risk factor for lens-particle glaucoma, has been reported to occur more commonly in young adult males. Alcohol abuse is a significant comorbidity in this population.

Age

All ages are affected, ranging from infancy (especially when involving congenital cataract surgery) to late adulthood. Penetrating eye injuries occur most frequently in young adults. However, lens-particle glaucoma probably occurs most commonly in elderly persons as a complication of cataract surgery.

CLINICAL

Section 3 of 11  

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• Differentials
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• Follow-up
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• Multimedia
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History

• Patients are often asymptomatic.
• Depending on the severity of IOP elevation and associated intraocular inflammation, symptoms of monocular eye pain, redness, and/or blurred vision may be present.
• Although spontaneous rupture of the lens capsule has been described, a recent or remote history of trauma or intraocular surgery, particularly cataract extraction, typically is present.
• The onset of lens-particle glaucoma has been reported to occur many years after cataract surgery.
• • The condition commonly is encountered in cases of phacoemulsification that were complicated by a posteriorly dislocated lens nucleus.
  • Obstruction of the trabecular meshwork by lens material may have a role in the mechanism of an early postoperative IOP spike after uncomplicated phacoemulsification.
  • Lens-particle glaucoma also may cause elevated IOP after laser capsulotomy. Obtain any history of YAG laser procedures in all pseudophakic patients under evaluation for glaucoma.
  • Dislocation of a posterior intraocular lens has been reported to cause late onset lens-particle glaucoma.

Physical

• Unilateral elevation of IOP is present.
• Variable degree of inflammation, including cell and flare, corneal edema, keratic precipitates, or hypopyon, is present.
• Lens debris, sometimes seen as a fluffy pseudohypopyon layered in the inferior anterior chamber or as small free-floating fragments of cortex that circulate in the aqueous, may be visible by slit lamp examination. Lens or cellular debris also may be deposited on the corneal endothelium.
• Anterior chamber angle is open by gonioscopy, although inflammatory anterior synechia may be observed later in more severe cases.
• Lens fragments may be visible on dilated slit lamp examination, adherent to the lens capsule.
• Elschnig pearls may be observed.
• Particles of cortex or nucleus that are dislocated into the vitreous usually are visualized readily by indirect ophthalmoscopy. In such cases, careful scleral depression can aid in identifying occult lens particles that are positioned over the anterior retina or ora serrata.
• In cases of glaucoma with severe associated phacoantigenic uveitis, other late findings may include posterior synechia, peripheral anterior synechia, vitreitis, and retinal detachment.

Causes

• Penetrating eye trauma with perforation of the lens capsule
• Blunt trauma with rupture of the lens capsule or dislocation of the lens
• Uncomplicated cataract surgery
• Cataract surgery with incomplete removal of the lens cortex
• Cataract surgery complicated by posterior dislocation of nucleus or nuclear fragments
• Other intraocular surgery involving intentional or inadvertent compromise of the lens capsule's integrity

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Steroid-induced glaucoma
Epithelial ingrowth
Sympathetic ophthalmia
Uveitis-glaucoma-hyphema (UGH) syndrome
Endophthalmitis

WORKUP

Section 5 of 11  

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• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Lab Studies

• Consider anterior chamber tap and vitreous tap with smears for Gram and Giemsa stains and cultures with antimicrobial sensitivities.
• Culture media should include blood agar, Sabouraud media, chocolate agar, and thioglycolate broth.

Imaging Studies

• In cases of ocular trauma, 20-MHz ultrasound probe has been reported to help facilitate the visualization of posterior capsule integrity. The effective use of 50-MHz ultrasound biomicroscopy has been described in the assessment of occult zonular defects in traumatic cataracts.
• B-scan ultrasonography may be useful in localizing and measuring posteriorly displaced lens debris, particularly large nucleus fragments.

Procedures

• Anterior chamber tap and vitreous tap

Histologic Findings

If anterior chamber paracentesis is performed, histology may demonstrate foamy macrophages and lens particles.

Often, a coexisting phacoantigenic uveitis exists, and the lens histology may include the classic finding of zones of granulomatous and nongranulomatous inflammation that surround degenerating lens material.

Anterior chamber angle histologic examination of enucleated eyes may confirm the presence of macrophages in the trabecular meshwork, perhaps contributing to decreased outflow facility.

TREATMENT

Section 6 of 11  

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Medical Care

• The elevated IOP of lens-particle glaucoma often responds to medical management.
• 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.
• Prostaglandin analogues have not been tested, 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.
• In managing this condition, treat the associated uveitis. Initial therapy typically involves a topical corticosteroid agent in conjunction with a topical cycloplegic agent.

Surgical Care

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. 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.
• Management of posterior lens fragment dislocation varies depending on the anticipated risk of complications.
• For example, a total lens dislocation with an intact capsule may not require immediate surgical intervention because the risks of glaucomatous, inflammatory, or retinal complications are low in this setting.
• Similarly, small nuclear fragments have been tolerated without specific intervention. Both the lens-particle–induced glaucoma and the inflammatory response appear to be proportionate to the size of the fragment.
• Large nuclear fragments are tolerated poorly in the posterior segment, even over short periods.
• Because of significant risks of further complications, the primary cataract surgeon should not attempt to retrieve intravitreal lens fragments from an anterior approach. 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. Immediate pars plana vitrectomy at the same sitting for dislocated lens fragments during cataract surgery has been described.
• Posterior vitrectomy with lensectomy has been associated with postoperative improvement or resolution of lens-particle glaucoma. Good visual outcomes have been reported.

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 3 wk postoperatively) is associated with more favorable visual results.
• Also, consider retina consultation to assist in differentiating postoperative phacoantigenic uveitis from endophthalmitis or sympathetic ophthalmia.

MEDICATION

Section 7 of 11  

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The goal of therapy is IOP reduction. Medications often can be used short term and then discontinued. IOP should be monitored after stopping medications, and therapy should be reinstituted when necessary.

Bimatoprost (Lumigan), travoprost (Travatan), and unoprostone (Rescula) are new ophthalmic prostaglandin analogs recently approved in the United States. Bimatoprost is a prostamide analog with ocular hypotensive activity. It mimics the IOP-lowering activity of prostamides via the prostamide pathway. Travoprost and unoprostone are prostaglandin F2-alpha (ie, dinoprost) analogs similar to latanoprost. They are selective FP prostanoid receptor agonists believed to reduce IOP by increasing uveoscleral outflow. They are indicated for the lowering of IOP in patients with open-angle glaucoma or ocular hypertension who are intolerant of other IOP-lowering medications or insufficiently responsive (failed to achieve target IOP determined after multiple measurements over time) to another IOP-lowering medication.

Bimatoprost and travoprost are each administered once daily at bedtime (ie, 1 gtt in affected eye[s] hs); whereas, unoprostone must be administered bid. They have not been studied in pediatric patients.

These medications are contraindicated if hypersensitivity has been documented. No drug interactions have been reported. All are classified as pregnancy category C (ie, safety for use during pregnancy has not been established).

Like latanoprost, all demonstrate the unusual adverse effect of permanent increase in pigment of the iris (ie, increases brown pigment) and eyelid, and they may increase eyelash growth. Bacterial keratitis may occur. Use is cautioned in uveitis or macular edema. They should not be used if inflammation is present.

Drug Category: Beta-blockers

Topical beta-adrenergic receptor antagonists decrease aqueous humor production by the ciliary body. Adverse effects are due to systemic absorption of the drug, resulting in decreased cardiac output and bronchoconstriction. In susceptible patients, this may cause bronchospasm, bradycardia, heart block, or hypotension. Monitor the patient's pulse rate and blood pressure. Patients may be instructed to perform punctal occlusion after administering the drops. Depression or anxiety may be experienced in some patients, and sexual dysfunction may be initiated or exacerbated.

Drug Category: Adrenergic agonists

Topical adrenergic agonists (sympathomimetics) decrease aqueous production and reduce resistance to aqueous outflow. Adverse effects include dry mouth and allergenicity.

Drug Category: Carbonic anhydrase inhibitors

Reduce secretion of aqueous humor by inhibiting carbonic anhydrase (CA) in the ciliary body. These drugs are less effective, and their duration of action is shorter than many other classes of drugs. Adverse effects are relatively rare but include superficial punctate keratitis, acidosis, paresthesias, nausea, depression, and lassitude. Corneal decompensation has been reported when this class of drugs is used in patients with corneal endothelial dysfunction.

Drug Category: Cycloplegic agents

Cholinergic antagonists commonly are used in the management of anterior intraocular inflammation, and, occasionally, they may be used in eyes with lens-particle glaucoma that have an active phacoantigenic uveitis. These topical drugs exert mydriatic and cycloplegic effects on the iris and ciliary body and reduce the permeability of the blood-aqueous barrier.

Drug Category: Corticosteroids

Corticosteroid agents commonly are used in combination with topical cycloplegics in the management of anterior uveitis. In cases of lens-particle glaucoma, the use of steroids is limited to eyes that have coexisting intraocular inflammation.

FOLLOW-UP

Section 8 of 11  

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• Introduction
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• Differentials
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• Medication
• Follow-up
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• Multimedia
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Further Inpatient Care

• Patients with lens-particle glaucoma rarely require hospital admission. Consider admission in the following situations:
• • IOP is elevated severely.
  • Intravenous mannitol is needed to control IOP.
  • Immediate plans for further surgical intervention exist.

Further Outpatient Care

• Any patient who develops acute glaucoma following cataract surgery, Nd:YAG capsulotomy, or trauma requires careful follow-up to monitor IOP control and medical management and/or surgery to remove residual lens particles.
• • Depending on the degree of IOP control and the presence of other coexisting complications, patients may require daily to weekly follow-up care early in the postoperative period.
  • Treat and monitor intraocular inflammation.

In/Out Patient Meds

• See Medication.

Complications

• Complications of retained intraocular lens particles include corneal decompensation, chronic uveitis, and cystoid macular edema.
• Pars plana vitrectomy for displaced nuclear fragments can be associated with complications of persistent glaucoma, uveitis, corneal edema, cystoid macular edema, vitreous hemorrhage, and retinal detachment.

Prognosis

• Prognosis is generally good with appropriately timed medical and surgical intervention.
• • Recent studies have reported final visual acuities of 20/40 or better in approximately two thirds of cases of dropped nuclei requiring vitrectomy.
  • Elevated IOP improves significantly in response to surgical removal of intraocular lens material.
  • A nonsurgical approach may be equally successful in cases of small retained lens fragments, if inflammation and IOP can be controlled acceptably, cellular processes in the trabecular meshwork are clearing the lens material.
  • Chronic open-angle glaucoma occurs in some patients following an episode of lens-particle glaucoma when lens particles have been reabsorbed.
  • The transient presence of lens debris in the anterior chamber angle has been theorized to possibly cause long-lasting trabecular dysfunction.

Patient Education

• For excellent patient education resources visit eMedicine's Glaucoma Center. Also, see eMedicine's patient education articles Lens-Particle Glaucoma, Glaucoma FAQs, and Understanding Glaucoma Medications.

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Poor visual outcome following cataract surgery or trauma management is associated with increased risk of medicolegal claims. Indemnity payment resulting from such claims frequently depends upon the following:
• • The initial management of the case: Inadvertent retention of nuclear or epinuclear fragments in the anterior chamber following lensectomy requires prompt intervention to avoid potential corneal decompensation.
  • The timeliness of lens particle removal: Vitreoretinal referral should not be delayed when intravitreal lens particles are present.
• Anterior segment surgeons who are inexperienced in vitreoretinal surgical management should not attempt deep vitrectomy and removal of posterior vitreous lens fragments. The use of hooks, cannulas, spatulas, or forceps to retrieve a dislocated lens is not only hazardous but also ill advised.
• Even if immediate posterior vitrectomy is not anticipated, prompt consultation with a retina specialist regarding intravitreal lens debris is prudent for risk management.
• Document consultation to prevent subsequent allegations that delayed management caused an adverse patient outcome.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
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• Multimedia
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Media file 1:  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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Media type:  Photo

Media file 2:  Ruptured lens capsule with elevated intraocular pressure following trauma. Courtesy of KS Kooner, MD.
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Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
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• Differentials
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• Follow-up
• Miscellaneous
• Multimedia
• References

• Aaberg TM, Rubsamen PE, Flynn HW. Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol. Aug 1997;124(2):222-6. [Medline].
• Arbisser LB. Managing intraoperative complications in cataract surgery. Curr Opin Ophthalmol. 2004;15(1):33-9. [Medline].
• Barnhorst D, Meyers SM, Myers T. Lens-induced glaucoma 65 years after congenital cataract surgery. Am J Ophthalmol. Dec 15 1994;118(6):807-8. [Medline].
• Brick DC. Risk management lessons from a review of 168 cataract surgery claims. Surv Ophthalmol. Jan-Feb 1999;43(4):356-60. [Medline].
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• Epstein DL. Diagnosis and management of lens-induced glaucoma. Ophthalmology. Mar 1982;89(3):227-30. [Medline].
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• McWhae JA, Crichton AC, Rinke M. Ultrasound biomicroscopy for the assessment of zonules after ocular trauma. Ophthalmology. 2003;110(7):1340-3. [Medline].
• Monshizadeh R, Samiy N, Haimovici R. Management of retained intravitreal lens fragments after cataract surgery. Surv Ophthalmol. Mar-Apr 1999;43(5):397-404. [Medline].
• Nguyen TN, Mansour M, Deschenes J. Visualization of posterior lens capsule integrity by 20-MHz ultrasound probe in ocular trauma. Am J Ophthalmol. 2003;136(4):754-5. [Medline].
• Richter CU, Arzeno G, Pappas HR, et al. Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy. Ophthalmology. May 1985;92(5):636-40. [Medline].
• Richter CU. Lens-induced open-angle glaucoma. In: Ritch R, Shields MB, Krupin T, eds. The Glaucomas. Vol 2. 2nd ed. St. Louis, Mo;1996:1026-31.
• Rosenbaum JT, Samples JR, Seymour B, et al. Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma. Arch Ophthalmol. Nov 1987;105(11):1582-4. [Medline].
• Serle JB. Nontraumatic lens-induced glaucoma. Management of Difficult Glaucoma. Higginbotham ET, Lee DA, eds. Boston, Mass:. 1994;263-73.
• Smith D, Wrenn K, Stack LB. The epidemiology and diagnosis of penetrating eye injuries. Acad Emerg Med. 2002;9(3):209-13.
• Stefaniotou M, Aspiotis M, Pappa C. Timing of dislocated nuclear fragment management after cataract surgery. J Cataract Refract Surg. 2003;29(10):1985-8. [Medline].
• Terasaki H, Miyake Y, Miyake K. Visual outcome after management of a posteriorly dislocated lens nucleus during phacoemulsification. J Cataract Refract Surg. Nov 1997;23(9):1399-403. [Medline].

Article Last Updated: Aug 16, 2006