Phacomorphic glaucoma can cause secondary angle-closure glaucoma due to increased lens thickness (advanced cataract, rapidly intumescent lens, or traumatic cataract) that narrows the iridoconeal angle via either a pupillary block or the forward displacement of the lens–iris diaphragm. Sudden rise in intraocular pressure can lead to irreversible visual loss in the affected eye.1,2 Femtosecond laser-assisted cataract surgery has been used effectively for routine cases3–5 and for traumatic cataracts.6 Herein we report the effective use of this technology for managing phacomorphic glaucoma with a mature lens.
An 89-year-old woman was referred to the Ophthalmology Department of Semmelweis University, Budapest, Hungary, from a regional hospital due to acute angle-closure glaucoma with high intraocular pressure (62 mm Hg) in January 2013 after administration of conservative antiglaucoma therapy (pilocarpin, timolol, and dorzolamide eye drops supplemented with systemic carbonic anhydrase inhibitor acetazolamide). She had felt pain in her right eye for 3 days.
Slit-lamp biomicroscopy, applanation tonometry, gonioscopy, optical biometry, Scheimpflug imaging, and B-scan ultrasound examinations were performed on admission. Visual acuity was hand motions in the right eye and 0.2 (Snellen 4/20) in the left eye. Slit-lamp examination of the anterior segment showed significantly injected conjunctiva, mycrocystic and stromal corneal edema, and extremely shallow anterior chamber. The pupil was miotic due to previously applied parasympathomymetic eye drops. The intraocular pressure was 40 mm Hg measured with Goldmann applanation tonometry. Closed anterior chamber angle was found in the superior and inferior quadrants with gonioscopy.
After Nd:YAG iridotomy and application of local antiglaucoma therapy, intraocular pressure decreased, ranging from 18 to 27 mm Hg, during the following days. The visual acuity increased to 0.4 (Snellen 4/10).
The extremely shallow anterior chamber and mature cataract supported the diagnosis of phacomorphic glaucoma previously suspected by Scheimpflug camera (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany) and optical biometry (Lenstar; Haag-Streit, Mason, OH) results (central corneal thickness: 703 μm, anterior chamber depth: 1.19 mm from endothelial layer to anterior lens surface) and lens thickness of 5.31 mm with an axial length of 20.33 mm (Figure 1A).
Figure 1. Scheimpflug-imaging. (A) Corneal edema, shallow anterior chamber, narrow chamber angle, and mature cataract preoperatively. (B) Deeper anterior chamber and wider chamber angle postoperatively.
Considering the anterior chamber anatomical characteristics and lens thickness, femtosecond-laser assisted cataract surgery was performed to ensure the creation of intact capsulorrhexis on a tensioned lens capsule of a mature cataract.
Clear corneal incisions were created and a Malyugin ring was implanted for mechanical pupil dilation after lens capsule staining (methylene blue). After implantation of the Malyugin ring, the viscoelastic material was removed and the anterior chamber was filled with balanced salt solution. The corneal tunnel was sutured before docking the patient interface of the femtosecond laser system. (Figure 2A).
Figure 2. Intraoperative and postoperative state. (A) Clear corneal incisions, stained lens capsule, implanted Malyugin ring, and sutured corneal tunnel can be observed. (B) Femtosecond laser pretreatment: capsulorrhexis and lens fragmentation. (C) At the end of the surgery. (D) Digital photography of the anterior segment 1 week after cataract surgery.
The anterior crystalline lens surface was identified with an integrated optical coherence tomography imaging system. A 4.8-mm diameter capsulotomy was performed by scanning a cylindrical pattern starting 300 μm below the anterior capsule and ending at 300 μm above the capsule. Capsulotomy was followed by lens fragmentation (Figure 2B).
After femtosecond laser pretreatment, the corneal suture was removed. The anterior chamber was filled with viscoelastic material using a soft-shell technique applying Viscoat and Provisc (Alcon Laboratories, Inc., Fort Worth, TX). The free-floating stained capsulotomy was removed with a rhexis forceps while prefragmented lens quadrants were removed with phacoemulsification using the Infiniti Vision System (Alcon Laboratories, Inc.). Total phacoemulsification time was 67.2 seconds and phacoemulsification energy was 25%.
An Acrysof MA60AC (Alcon Laboratories, Inc.) hydrophobic intraocular lens was injected into the capsular bag and the Malyugin ring and viscoelastic material were removed from the anterior and posterior chambers after intraocular lens implantation. At the end of the procedure, 0.1 mL carbachol was injected intracamerally. All incisions were left sutureless (Figure 2C).
Within the first 10 days, the patient received a combination of antibiotic and steroid eye drops (dexamethasone and tobramycin). No postoperative complications occurred and no further antiglaucoma therapy was needed.
One week after femtosecond laser-assisted cataract surgery, the corrected distance visual acuity was 0.4 (Snellen 4/10) as a result of postoperative corneal edema, which showed gradual improvement in the postoperative period. Intraocular pressure was 18 mm Hg without any concomitant antiglaucoma therapy. Deeper anterior chamber and wider chamber angle were measured using Scheimpflug imaging (Figures 1B, 2C, and 2D). The cornea was clear by 20 days postoperatively.
Phacoemulsification is associated with smaller incision and less risk of suprachoroidal hemorrhage compared to extracapsular cataract extraction and thus was beneficial for management of phacomorphic glaucoma when possible. The shallow anterior chamber, intumescent cataract, and liquefied lens contents make the continuous curvilinear capsulorrhexis technically challenging and the presence of any corneal edema makes the whole surgical procedure more difficult.1,2
Femtosecond laser-assisted cataract surgery offers the possibility of a well-centered complete capsulotomy even in the case of an extremely shallow anterior chamber and intumescent cataract. Prefragmentation of the cataractous lens decreases the energy of the phacoemulsification procedure, reducing postoperative corneal edema.3
Proper pupil dilation is essential before femtosecond laser treatment to avoid iris cut. Therefore, the use of mechanical intraocular pupil dilators is recommended in the case of small pupils. According to our experience, implantation of a Malyugin ring is a safe method but the corneal wound needs to be sutured before docking the patient interface of the femtosecond laser.
Our results indicate that a femtosecond laser can be used successfully in certain instances of phacomorphic glaucoma, even if mechanical pupil dilatation is needed.
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