VISUAL ACUITY AND INTRAOCULAR

PRESSURE AFTER CATARACT EXTRACTION

IN PHACOMORPHIC ANGLE CLOSURE: A
RETROSPECTIVE REVIEW

FRANCES ANDREA AÑOVER, MD

THIRD YEAR RESIDENT
DOH EYE CENTER
ADVISER: NILO VINCENT FLORCRUZ II, MD
INTRODUCTION

• A form of angle closure due to a thick, mature cataract

obstructing the normal pathway of aqueous humor out of
the eye, leading to an acute rise in intraocular pressure

• May result in irreversible optic nerve damage and visual

loss

• Phacomorphic angle closure accounts for 74.6% of all

lens-induced glaucoma cases seen1
INTRODUCTION

• Cataract extraction is the definitive mode of treatment2-5

• Delaying management for more than two weeks after

onset of symptoms portends a poorer visual outcome2,4-6
INTRODUCTION

• Despite timely removal of the cataract, there may still be

progression of glaucomatous optic nerve damage

• After cataract surgery, 19.5% still needed anti-glaucoma

medications, and 3.7% needed laser iridotomy or
glaucoma filtering surgery8
INTRODUCTION

• Limited reports in Asian countries like Nepal6,

Hong Kong2,3,5,7, Malaysia8, and India4

• No available local data

OBJECTIVE

• To investigate the visual acuity and intraocular

pressure outcomes of cataract extraction on
phacomorphic angle closure patients through a
five-year records review
METHODS

• Retrospective cohort study

• All medical records came from a single tertiary eye

care facility in a government hospital
METHODS
99 CASES OF PHACOMORPHIC
ANGLE CLOSURE IN THE
GLAUCOMA REGISTRY FROM
8 LOST TO FOLLOW-UP JANUARY 2014 TO AUGUST 2019
8 HAD MISSING DATA
4 HAD A CHANGE IN
DIAGNOSIS
7 TREATED ELSEWHERE 62 EYES INCLUDED IN DATA SET
PRIOR TO CONSULT
10 UNDERWENT DIODE
WITHOUT SURGERY

TABULATED BASED ON:

AGE
SEX
CHIEF COMPLAINT
DURATION OF SYMPTOMS
VISUAL ACUITY
MEAN INTRAOCULAR PRESSURE
INTERVENTION DONE
VERTICAL CUP DISC RATIO

STATISTICAL ANALYSIS
METHODS
• Visual acuity was measured using the Bailey-Lovie ETDRS
chart and subsequently converted to Logarithm of Minimal
Angle of Resolution (LogMAR) for statistical analysis

• For non-numeric visual acuities, the Freiburg Visual Acuity

Test (FrACT) was adapted

VISUAL ACUITY LogMAR Conversion

CF 1.7
HM 2.0
LPj 2.3
LP 2.6
NLP 3.0
METHODS

VISUAL ACUITY OUTCOMES

0.5 LogMAR or less

TREATMENT SUCCESS
(ETDRS 20/50 or better)

PARTIAL TREATMENT 0.6 - 1.0 LogMAR

SUCCESS (ETDRS 20/63 to 20/200)

1.7 - 3.0 LogMAR

TREATMENT FAILURE
(Worse than 20/200)
METHODS

VERTICAL CUP-DISC RATIO

NORMAL VCDR ≤ 0.5

MODERATELY SUSPICIOUS FOR

GLAUCOMATOUS NERVE VCDR 0.6 - 0.7
DAMAGE

HIGHLY SUSPICIOUS FOR

GLAUCOMATOUS NERVE VCDR ≥ 0.8
DAMAGE
RESULTS

MEAN AGE: 64.42 ± 10.93 YEARS

 RESULTS
CHIEF COMPL AINT

EYE PAIN

BLURRING OF VISION

EYE REDNESS

HEADACHE

0 12.5 25 37.5 50

FREQUENCY (N)
 RESULTS
D U R AT I O N O F S Y M P TO M S U N T I L
C O N S U LT

LESS THAN 1 WEEK

1-2 WEEKS

3-4 WEEKS

5-12 WEEKS

13-24 WEEKS

>24 WEEKS

0 7.5 15 22.5 30
FREQUENCY (N)
RESULTS
INITIAL VA 1 MONTH POST-OP VA MEAN CHANGE P-VALUE

2.06±1.01 0.89±1.01 1.16±1.01 p<0.0001

INITIAL IOP 1 MONTH POST-OP IOP MEAN CHANGE P-VALUE

52.74 ± 10.36 16.31 ± 7.80 36.4 ± 13.14 p<0.0001

RESULTS
VISUAL ACUITY OUTCOMES
RESULTS

Correlation between duration of

symptoms and post-operative
visual acuity:
p=0.044
RESULTS

Correlation between initial IOP and

VA at 1 month:
p=0.300

Correlation between IOP at one

month and VA at 1 month:
p=0.176
RESULTS
SURGICAL INTERVENTION DONE
RESULTS

9 out of 62 (14.52%) had an IOP

greater than 21mmHg even
after cataract extraction
 RESULTS
ADDITIONAL TREATMENT GIVEN

TOPICAL MEDS

LASER IRIDOTOMY

SURGICAL PI

TSCPC

TRABECULECTOMY

0 1.75 3.5 5.25 7

FREQUENCY (N)
 RESULTS
VERTICAL CUP-DISC RATIO

NORMAL VCDR
48%

HIGHLY SUSPICIOUS GLAUCOMATOUS NERVE DAMAGE

35%

MODERATELY SUSPICIOUS GLAUCOMATOUS NERVE DAMAGE

16%
RESULTS
Initial IOP and VCDR:
p=0.99

Duration of symptoms and VCDR:

p=0.016

VA at 1 month and VCDR:

p<0.0001
DISCUSSION

• Collected demographic data are

comparable to similar studies in
terms of age and sex2,4-5,7-8

• The most common complaint was

eye pain
DISCUSSION

• 48.38% sought consult more than

two weeks from onset of symptoms

• May be due to poverty, ignorance,

lack or awareness, no facilities, and
lack of prompt referral4
DISCUSSION

• Statistically significant mean

improvement in VA and mean
reduction in IOP

• Similar results with other studies4-7,9

DISCUSSION

• Statistically significant correlation

between duration of symptoms and
visual acuity at one month post-
surgery (p=0.044), comparable to
other reports4,5

• Possibly because of irreversible

ischemic nerve damage and axonal
flow disruption5
DISCUSSION

PHACOEMULSIFICATION ECCE

LESS ENDOTHELIAL DAMAGE2

SMALLER WOUND5

LESS SURGICAL RISK IN THE

LESS RISK OF EXPULSIVE
PRESENCE OF CORNEAL EDEMA
HEMORRHAGE5
AND LOOSE ZONULES2

DIFFICULT TO OBTAIN A
CONTINUOUS CURVILINEAR
CAPSULORRHEXIS5
DISCUSSION
• 6 cases (9.68%) underwent combined
cataract extraction with trabeculectomy

• A study by Senthil and colleagues

compared sole cataract surgery with
combined cataract extraction and
trabeculectomy: similar IOP control at six
months post-operatively10
DISCUSSION
• 14.52% had IOP greater than 21mmHg

• 19.35% given other treatment modalities

• Duration of trabecular-iris angle closure

may lead to the formation of peripheral
anterior synechiae3

• Prompt cataract removal for better

chances of open-angle configuration
post-surgery3
DISCUSSION
• More than half had cup-disc ratios suspicious for
glaucomatous nerve damage

• Significant relationship between visual acuity at

one month and vertical cup-disc ratio, and
between duration of symptoms and vertical cup-
disc ratio

• Secondary apoptosis of healthy neurons,

cytokines and free radicals lead to ganglion cell
damage2

• Monitor for progression for a minimum of 2 years5

LIMITATIONS AND RECOMMENDATIONS

• Longer follow-ups are needed

• Vertical cup-disc ratio is subjective

• Suggest optic nerve OCT and perimetry

for objective documentation of possible
glaucomatous damage

• Anatomical correlations (e.g. axial

length, UBM, anterior segment OCT)
CONCLUSION
• Cataract extraction is generally effective
in the management of phacomorphic
angle closure

• Duration of symptoms, not presenting

IOP, may affect post-operative visual
acuity and vertical cup-disc ratio

• More objective tests needed to assess

glaucomatous nerve damage
REFERENCES
1.FlorCruz, N., Joaquin-Quino, R., Silva, P., Khu, P. (2005). Profile of glaucoma cases seen at a tertiary referral hospital. Philipp J Ophthalmol, 30(4):
161-165.

2.Lee, J., Lai, J., Yick, D., Yuen, C. (2012). Prospective study on retinal nerve fiber layer changes after an acute episode of phacomorphic angle closure.
Int Ophthalmol, 32(6): 577-582.

3.Lee, J., Lai, J., Yick, D., Yuen, C. (2013). Prospective case series on trabecular-iris angle status after an acute episode of phacomorphic angle closure.
Int J Ophthalmol, 6(1): 67-70.

4.Sharanabasamma, M., Vaibhav, K. (2016). Management and visual outcome in patients of lens-induced glaucomas at a tertiary eye care hospital in
South India. J Curr Glaucoma Pract, (10)2: 68-75.

5.Lee, J., Lai, J., Yick, D., Tse, R. (2010). Retrospective case series on the long-term visual and intraocular pressure outcomes of phacomorphic glaucoma.
Eye (Lond), 24(11):1675-80.

6.Pradhan, D., Hennig, A., Kumar, J., Foster, A. (2001). A prospective study study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol,
49(2): 103-7.

7.Lee, J., Lai, J., Lam, R., Wong, B., Yick, D., Tse, R. (2011). Retrospective analysis of the risk factors for developing phacomorphic glaucoma. Indian J
Ophthalmol, 59(6): 471-474.

8.Papaconstantinou, D., Georgalas, I., Kourtis, N., Krassas, A., Diagourtas, A., Koutsandrea, C., Georgopoulos, G. (2009). Lens-induced glaucoma in the
elderly. Clin Interv Aging, 4: 331-336.

9.Yaakub, A., Abdullah, M., Siti Raihan, I., Ahmad Taiudin, LS. (2014). Lens-induced glaucoma in a tertiary centre in northeast of Malaysia. Malays Fam
Physician, 9(2): 48-52.

10.Senthil, S., Chinta, S., Rao, HL., Choudhari, NS., Pathak-Ray, V., Mandak, AK., Garudadri, CS., (2016). Comparision of cataract surgery alone versus
cataract surgery combined with trabeculectomy in the management of phacomorphic glaucoma. J Glaucoma, 25(3): e209-e213.
Thank you!