Background

Glaucoma associated with aphakia, but particularly pseudophakia, are important considerations given the more than 1.25 million cataract surgeries performed each year.

Glaucoma in this article refers to conditions that cause increased intraocular pressure (IOP) soon after surgery as well as to those conditions that occur much later. Examples include viscoelastic-associated pressure rise measured in hours to ghost cell glaucoma occurring weeks after surgery.

Pathophysiology

The pathophysiology is dependent on the mechanism involved and includes the following: distortion of the anterior chamber angle, viscoelastics, inflammation, hemorrhage, pigment dispersion, ghost cell, vitreous in the anterior chamber (AC), pupillary block (pseudophakic/aphakic), malignant glaucoma, and posterior capsulotomy.

Frequency

United States

Duke-Elder estimated a 12% incidence of postoperative glaucoma in 1969.^[1]However, the landscape of postcataract complications has been altered by the advent of the intraocular lens (IOL) and fine wound-closure techniques. In the modern era, the incidence of glaucoma is dependent on both the methodology and the type of IOL used.

For instance, Cinotti has noted an increased incidence of glaucoma after extracapsular cataract extraction (ECCE) (7.5%) as compared to intracapsular cataract extraction (ICCE) (5.7%).^[2]

Further, Stark has noted that AC IOL (5.5-6.3%) has been associated with an increased incidence of postoperative IOP elevation over iris-fixation (3.9-4.3%) lens and posterior chamber (PC) IOL (1.6-3.5%).^[3]These figures are consistent with those reported by Hoskins, in which he observed 5.5% in AC IOL and 1.6% in PC IOL.^[4]However, congenital cataract surgeries are associated with a higher incidence of glaucoma, and data range from 6.1-24%.

Mortality/Morbidity

Without good IOP control, glaucoma may result in blindness.

Age

This condition may occur at any age after cataract surgery; however, cataracts are most commonly found in the elderly population.

Prognosis

The prognosis is dependent on the ability to control the IOP.

Patient Education

For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education articles Glaucoma Overview, Glaucoma FAQs, and Glaucoma Medications.

Clinical Presentation

Duke-Elder S. Disease of the lens and vitreous: glaucoma and hypotony. System of Ophthalmology. 1969. Vol 11: 11.
Cinotti AA, Jacobson JH. Complications following cataract extraction. Am J Ophthalmol. 1953. 36:929.
Stark WJ, Worthen DM, Holladay JT, et al. The FDA report on intraocular lenses. Ophthalmology. 1983 Apr. 90(4):311-17. [QxMD MEDLINE Link].
Hoskins HD Jr. Management of pseudophakic glaucoma. Greve EL, ed. Surgical Management of Coexisting Glaucoma and Cataract. 1987.
Yildirim N, Gursoy H, Sahin A, Ozer A, Colak E. Glaucoma after penetrating keratoplasty: incidence, risk factors, and management. J Ophthalmol. 2011. 2011:951294. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Epstein DL, Allingham RR, Schuman JS. Chandler and Grant's Glaucoma. Baltimore, Md: Williams & Wilkins. 1997.
Shields MB. Textbook of Glaucoma. Baltimore, Md: Williams & Wilkins; 1998.
Kirsch RE, Levine O, Singer JA. Ridge at internal edge of cataract incision. Arch Ophthalmol. 1976 Dec. 94(12):2098-2104. [QxMD MEDLINE Link].
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. 1995 Sep. 79(9):809-13. [QxMD MEDLINE Link].
Noureddin BN, Wilson-Holt N, Lavin M, et al. Advanced uncontrolled glaucoma. Nd:YAG cyclophotocoagulation or tube surgery. Ophthalmology. 1992 Mar. 99(3):430-6; discussion 437. [QxMD MEDLINE Link].
Rękas M, Krix-Jachym K, Żarnowski T. Evaluation of the Effectiveness of Surgical Treatment of Malignant Glaucoma in Pseudophakic Eyes through Partial PPV with Establishment of Communication between the Anterior Chamber and the Vitreous Cavity. J Ophthalmol. 2015. 2015:873124. [QxMD MEDLINE Link].
Madgula IM, Anand N. Long-term follow-up of zonulo-hyaloido-vitrectomy for pseudophakic malignant glaucoma. Indian J Ophthalmol. 2014 Dec. 62 (12):1115-20. [QxMD MEDLINE Link].
Comer RM, Kim P, Cline R, Lyons CJ. Cataract surgery in the first year of life: aphakic glaucoma and visual outcomes. Can J Ophthalmol. 2011 Apr. 46(2):148-52. [QxMD MEDLINE Link].
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. 2010 Jun. 14(3):235-9. [QxMD MEDLINE Link].
Takihara Y, Inatani M, Ogata-Iwao M, Kawai M, Inoue T, Iwao K, et al. Trabeculectomy for open-angle glaucoma in phakic eyes vs in pseudophakic eyes after phacoemulsification: a prospective clinical cohort study. JAMA Ophthalmol. 2014 Jan. 132 (1):69-76. [QxMD MEDLINE Link].
Dao JB, Sarkisian SR Jr, Freedman SF. Illuminated Microcatheter-facilitated 360-Degree Trabeculotomy for Refractory Aphakic and Juvenile Open-angle Glaucoma. J Glaucoma. 2014 Sep. 23(7):449-54. [QxMD MEDLINE Link].
Eslami Y, Mohammadi M, Fakhraie G, Zarei R, Moghimi S. Ahmed glaucoma valve implantation with tube insertion through the ciliary sulcus in pseudophakic/aphakic eyes. J Glaucoma. 2014 Feb. 23(2):115-8. [QxMD MEDLINE Link].
Rabkin-Mainer Z, Wolf A, Mathalone N, Malamud A, Buckman G, Edmunds B, et al. Ex-PRESS Miniature Glaucoma Shunt versus Ahmed Glaucoma Valve in the Surgical Treatment of Glaucoma in Pseudophakic Patients. J Glaucoma. 2018 Aug 14. [QxMD MEDLINE Link].
FDA. UPDATE: Potential Eye Damage from Alcon CyPass Micro-Stent Used to Treat Open-Angle Glaucoma: FDA Safety Communication. fda.gov. Available at https://www.fda.gov/medical-devices/safety-communications/update-potential-eye-damage-alcon-cypass-micro-stent-used-treat-open-angle-glaucoma-fda-safety. October 24, 2018; Accessed: July 27, 2020.
Ahmed IIK, Fea A, Au L, Ang RE, Harasymowycz P, Jampel HD, et al. A Prospective Randomized Trial Comparing Hydrus and iStent Microinvasive Glaucoma Surgery Implants for Standalone Treatment of Open-Angle Glaucoma: The COMPARE Study. Ophthalmology. 2020 Jan. 127 (1):52-61. [QxMD MEDLINE Link].
Altintas O, Yuksel N, Karabas VL, Demirci G. Cystoid macular edema associated with latanoprost after uncomplicated cataract surgery. Eur J Ophthalmol. 2005 Jan-Feb. 15(1):158-61. [QxMD MEDLINE Link].
Araie M, Ishi K. Effects of apraclonidine on intraocular pressure and blood-aqueous barrier permeability after phacoemulsification and intraocular lens implantation. Am J Ophthalmol. 1993 Jul 15. 116(1):67-71. [QxMD MEDLINE Link].
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. 2005 Feb. 123(2):186-92. [QxMD MEDLINE Link].
Arvind H, George R, Raju P, et al. Glaucoma in aphakia and pseudophakia in the Chennai Glaucoma Study. Br J Ophthalmol. 2005 Jun. 89(6):699-703. [QxMD MEDLINE Link].
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. 2004 Jul. 111(7):1393-7. [QxMD MEDLINE Link].
Berson FG, Patterson MM, Epstein DL. Obstruction of aqueous outflow by sodium hyaluronate in enucleated human eyes. Am J Ophthalmol. 1983 May. 95(5):668-72. [QxMD MEDLINE Link].
Brown DN. Long-term success of argon laser trabeculoplasty in aphakic and pseudophakic eyes. Invest Ophthalmol Vis Sci. 1992. 33:1159.
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. 2007 Feb. 11(1):34-40. [QxMD MEDLINE Link].
Ellingson FT. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant. J Am Intraocul Implant Soc. 1978 Apr. 4(2):50-3. [QxMD MEDLINE Link].
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. 2006 Apr. 141(4):652-9. [QxMD MEDLINE Link].
Harrison SE, Soll DB, Shayegan M, Clinch T. A new and effective protective agent for intraocular lens insertion. Ophthalmology. 1982 Nov. 89(11):1254-60. [QxMD MEDLINE Link].
Lee LC, Pasquale LR. Surgical management of glaucoma in pseudophakic patients. Semin Ophthalmol. 2002 Sep-Dec. 17(3-4):131-7. [QxMD MEDLINE Link].
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. 2004 Jun. 13(3):233-7. [QxMD MEDLINE Link].
Michael I, Walton DS, Levenberg S. Infantile Aphakic Glaucoma: A Proposed Etiologic Role of IL-4 and VEGF. J Pediatr Ophthalmol Strabismus. 2011 Mar-Apr. 48(2):98-107. [QxMD MEDLINE Link].
Minckler DS, Heuer DK, Hasty B, Baerveldt G, Cutting RC, Barlow WE. Clinical experience with the single-plate Molteno implant in complicated glaucomas. Ophthalmology. 1988 Sep. 95(9):1181-8. [QxMD MEDLINE Link].
Rockwood EJ, Parrish RK 2nd, Heuer DK, et al. Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology. 1987 Sep. 94(9):1071-8. [QxMD MEDLINE Link].
Ruiz RS, Rhem MN, Prager TC. Effects of carbachol and acetylcholine on intraocular pressure after cataract extraction. Am J Ophthalmol. 1989 Jan 15. 107(1):7-10. [QxMD MEDLINE Link].
Ruiz RS, Wilson CA, Musgrove KH, Prager TC. Management of increased intraocular pressure after cataract extraction. Am J Ophthalmol. 1987 Apr 15. 103(4):487-91. [QxMD MEDLINE Link].
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. 2004 Dec. 30(12):2504-9. [QxMD MEDLINE Link].
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. 2005 Aug. 9(4):326-9. [QxMD MEDLINE Link].
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. 2006 Sep. 90(9):1103-6. [QxMD MEDLINE Link].
Valmaggia C, de Smet M. Endoscopic laser coagulation of the ciliary processes in patients with severe chronic glaucoma. Klin Monatsbl Augenheilkd. 2004 May. 221(5):343-6. [QxMD MEDLINE Link].