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General Information ⬇

Definition

Leakage of lens material through an intact lens capsule leads to outflow obstruction (typically in presence of a hypermature cataract).

Symptoms ⬆ ⬇

Unilateral pain, decreased vision (despite poor vision from cataract, increased blurring may be noticeable), tearing, injection, and photophobia.

Signs ⬆ ⬇

Critical

Markedly increased IOP, accompanied by iridescent particles and white material in the anterior chamber or on anterior surface of lens capsule. A hypermature (liquefied, Morgagnian) or mature cataract is typical. May occur less commonly in presence of an immature cataract with liquefaction of the posterior cortex. Pain is usually severe.

Other

Microcystic corneal edema, anterior chamber cell and flare (cells may be larger than typical uveitic white blood cells), pseudohypopyon, and severe conjunctival injection. Gonioscopy reveals an open anterior chamber angle. Clumps of macrophages may be seen in the inferior angle.

Differential Diagnosis ⬆ ⬇

All of the following can produce an acute increase in IOP to high levels, but none display iridescent particles in the anterior chamber:

Work Up ⬆ ⬇

Workup

  1. History: Longstanding poor vision (chronic/mature cataract)? Recent trauma or ocular surgery? Recurrent episodes? Prior uveitis?
  2. Slit lamp examination: Look for iridescent or white particles as well as cell and flare in the anterior chamber. Check IOP. Evaluate for cataract and corneal edema. Look for signs of trauma. Note, the lens capsule is intact in this diagnosis.
  3. Gonioscopy of the anterior chamber angles of both eyes: Topical glycerin may be placed on the cornea, after topical anesthesia, to temporarily clear any edema.
  4. Retinal and optic disc examination if possible. Otherwise, B-scan US before cataract extraction to rule out intraocular tumor or retinal detachment.
  5. If the diagnosis is in doubt, an anterior chamber paracentesis can be performed to detect macrophages bloated with lens material on microscopic examination (see Appendix 13, ANTERIOR CHAMBER PARACENTESIS).

Treatment ⬆ ⬇

The immediate goal of therapy is to reduce the IOP and inflammation. The cataract should be removed promptly (within several days).

  • Medical therapy options include:
    • Topical β-blocker (e.g., timolol 0.5% daily or b.i.d.), α2 agonist (e.g., brimonidine 0.1% to 0.2% b.i.d. to t.i.d.), and/or topical CAI (e.g., dorzolamide 2% t.i.d.).
    • Systemic CAI (e.g., acetazolamide 500 mg sequel p.o. b.i.d.). Benefit of maintaining topical CAI in addition to a systemic agent is controversial.
    • Topical cycloplegic (e.g., cyclopentolate 1% t.i.d.).
    • Topical steroid (e.g., prednisolone acetate 1% every 15 minutes for four doses then q1h).
    • Hyperosmotic agent if necessary and no contraindications are present (e.g., mannitol, 1 to 2 g/kg i.v. over 45 minutes).
  • The IOP usually does not respond adequately to medical therapy. In cases where IOP cannot be managed medically, cataract removal is usually performed within 24 to 48 hours. In patients who have noticed a sudden decrease in vision, the urgency of cataract surgery is increased, especially in those whose vision has progressed to NLP over a few hours. In such cases, lowering the IOP immediately with an anterior chamber paracentesis is necessary prior to cataract extraction (see Appendix 13, ANTERIOR CHAMBER PARACENTESIS). Glaucoma surgery is usually not necessary at the same time as cataract surgery.

Follow Up ⬆

  1. If patients are not hospitalized, they should be reexamined the day after surgery. Patients may be hospitalized for 24 hours after cataract surgery for IOP monitoring.
  2. If the IOP returns to normal, the patient should be rechecked within 1 week.