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Lens-related glaucoma

Phacomorphic glaucoma

Enlarging lens causes pupillary block with secondary angle closure
Clinical features
- Shallow AC with fixed mid-dilated pupil
- Swollen/intumescent cataractous lens
- Closed angle on gonioscopy
- Open contralateral angle with deep AC (cp with PACG)
Management: as for PACG with laser PI and early cataract extraction

Microscopic leak of soluble lens protein from the hypermature cataract that obstructs the TM
Clinical features
- Lens protein in AC (may form pseudohypopyon)
- Deep AC
- Open angle on gonioscopy with visible lens protein
- Macroscopically intact lens capsule
- No KPs
Tests: AC tap shows lens protein and foamy macrophages
Management as for open angle glaucoma with early cataract extraction

Inflammatory reaction to lens protein eg following traumatic rupture of the capsule (cp. with phacolytic) or postoperative retained lens fragment
Type IV hypersensitivity reaction: granulomatous inflammatory response
- A zone of PMLs surrounded by macrophages and giant cells
- Inflammation develops within 2 weeks of sensitisation to lens protein
Can cause sensitisation to lens protein leading to aggressive response after contralateral eye surgery
Clinical features
- Recent trauma/surgery
- AC activity +/- hypopyon (must exclude endophthalmitis)
- Synechiae
- Open angle (deep AC)
Management: topical treatment of inflammation and IOP
- Surgery: remove retained fragments
- Consider intracapsular cataract removal for fellow eye to reduced exposure to lens protein

Pupillary block caused by anterior lens subluxation or dislocation into the AC
Associated with
- Trauma
- Ocular disease
  - Aniridia
  - PXF
  - Axenfeld-reiger syndrome
  - Megalocornea
  - RP
- Systemic disease
  - Marfan’s syndrome
  - Homocystinuria
  - Ehlers-danlos
  - Sturge weber
  - Crouzon syndrome
Management: dilate and lie patient supine and then constrict to keep lens safely behind iris
- Early lens extraction via vitreoretinal approach