Common Cases: Lens and Glaucoma

1. Dr. Riyad BanayotDr. Riyad Banayot

3. Hypermature cataract. Note the wrinkling of the anterior capsule, the
lens has liquefied and leaks out of the capsule.

4. A morgagnian cataract. The cortex has turned into milky liquid and the
nucleus is displaced inferiorly.

5. A rosette cataract. This is seen in blunt trauma.
Look for other signs in the posterior segment such as choroidal tear or RD

6. A lamellar cataract. There are opacities at various levels of the fetal
nucleus. It is the most common type of congenital cataract.

7. A posterior subcapsular cataract.
Causes include: steroid use, DM, chronic uveitis, RP, atopic dermatitis.

8. A droplet cataract seen in a patient with galactosaemia.

9. In a young patient
With bilateral cataract. Look for:
 Atopic dermatitis (examine the face)
 Diabetic mellitus (examine fundus for DR)
 Retinitis pigmentosa (examine fundi for
pigmentary changes)
 Myotonic dystrophy (note the typical facies of
frontal balding, bilateral ptosis and delayed
muscle relaxation)
With unilateral cataract. Look for:
 Fuch's heterochromic uveitis
 Trauma
 Chronic uveitis
 Retinal detachment

10.  There is a significant shift in the fluid
content of the normal lens probably
related to the accumulation of sorbitol
inside the diabetic lens.
 The result is:
 Myopia or
 Rapid formation of subcapsular granular
cataract also called the snowstorm cataract.

11.  Nuclear sclerotic cataract.
 The increased density of the nucleus
increases the refractive index, and as a
result the patient develop myopia.
 As a result, patients who previously
needed plus lenses for reading, find that
they can now read without glasses.

12.  Phacomorphic glaucoma: Cataract can
increase the lens size causing shallowing of
the anterior chamber and angle closure
 Phacolytic glaucoma: Lens protein leaks
form the lens and elicits a macrophagic
response. The inflammatory material blocks
the flow of aqueous through the trabecular
meshwork
 Phacoantigenic uveitis: This is caused by
lens protein released through a ruptured
lens capsule causing a granulomatous
inflammation

13. A posterior chamber
lens showing
YAG capsulotomy
An anterior chamber
lens in an eye with
complicated cataract
operation showing
hazy cornea. This is
pseudophakic
bullous keratopathy
An iris clip lens (Binkhorst
lens). This lens is not
longer favored due to the
risk of iritis, lens
dislodgement and
corneal decompensation

14.  Capsulorrhexis provides a stronger edge
and allows phacoemulsification to be
carried out safely.
 The implant can be held more securely
and gives a better centration.

15.  Ideally, if the lens were to be placed in
the sulcus, the power of the lens (with
the same A constant) is reduced by 1/2 D
from that calculated pre-operatively.
 In this case, the focal point is moved
anteriorly, and the patient becomes
myopic.

16.  Cystoid macular edema = Irvine-Gass syndrome.
 Typically seen 4-8 weeks following the cataract
extraction.
 More common after
 intracapsular than extracapsular cataract extraction.
 vitreous loss
 presence of iris or vitreous incarceration.
 Treatment is controversial and the great majority
improves without treatment.
 Treatment options include:
 Topical steroid or non-steroidal anti-inflammatory medications.
 Acetazolamide is often given and is believed to reduce the macular
edema.
 Predisposing factors:
 Iris or vitreous incarceration
 Freeing the iris and vitrectomy can improve the edema.

17. • There is a circular
imprint of pigment
on the anterior
capsule from
the iris.
• This may result
from previous
posterior
synechiae or
trauma (Vossiu's
ring).
• It is of no visual
significance.

18. • Rosette cataract.
• This is typical of
traumatic cataract
resulting from blunt
injury.
• The cataract begins
in the subcapsular
region and with time
become buried in
the cortex.
• Vision is usually
reduced.

19. • There is a star
shaped opacity in
the anterior
subcapsular area.
• This is seen in
patient on
chlorpromazine for
more than 2 years.
• Vision may be
normal as this type
of cataract seldom
causes significant
visual impairment.

20. An aphakic eye with broad
iridectomy and peripheral
iridectomy.
An aphakic eye with
corneal edema as a
result of vitreous touch.

21.  The patient may be wearing thick lenses or
contact lenses.
 In intracapsular cataract extraction, there is
usually iridectomy and the presence of vitreous
in the anterior chamber (examine the cornea for
any decompensation due to vitreous touch).
 Some patients may have extracapsular cataract
extraction without implant (for example in clear
lens extraction for high myopia).
 In young children with aphakia, consider:
 Lens dislocation such as Marfan's syndrome
 Cataract extraction in juvenile chronic arthritis, look for
cells and flare in the anterior chamber and band
keratopathy.
 Direct ophthalmoscopy on a high myopic patient
with aphakia requires relatively low minus
(concave) power on the ophthalmoscope.

22.  Image magnification
 Spherical aberration
 A “jack-in-the-box”
ring scotoma
 Reduced visual field
 Physical inconvenience
 Cosmetic appearance
 30%
 Pin cushion effect
 Prismatic effect
 Weight of glasses
 Eyes appear large

23.  An phakic eye which is myopic with an
axial length of 31mm is equal to -21D.
 Clear lens extraction can fully correct a
myopic eye measuring -21D.

24. A subluxated lens in the
superior nasal direction.
(Marfan's syndrome)
Arachnodactyly (long
fingers) in a Marfan's
patient
High arch palate in a
Marfan's patient

25.  If the eye is not dilated:
 Iridodonesis (abnormal tremor of the iris)
 Phacodonesis (abnormal movement of the lens)
 Deep AC depth or vitreous herniation into AC.
 Signs of Marfan's syndrome
 Superior nasal subluxation of the lens; Arachnodactyly;
High arch palate; Arm span longer than height
 In homocystinuria:
 Downward subluxation of lens; Same features as
Marfan's syndrome; Patient tends to be mentally
subnormal and may have fair hair.
 In Weill-Marchesani's syndrome:
 Mental retardation; short stature; stubby fingers
 look for pseudoexfoliation syndrome
 look for signs of trauma which is the most
common cause of subluxated lens.

26.  Trauma
 Hypermature cataract
 Anirida
 High myopia
 Congenital glaucoma
 Ehler-Danlo's syndrome
 Hyperlysinaemia

27.  Optical problems including:
 Astigmatism
 Monocular diplopia
 Uveitis
 Pupillary block glaucoma

28. Marfan’s syndrome Homocystinuria
Cardiac arrhythmia Arterial thrombosis
Spontaneous pneumothorax

29. This is pseudoexfoliation syndrome.
Pupil dilatation is poor and there is risk of zonular dialysis.

30. The patient has hyper-extensibility of the joint. This is a sign of Ehler-Danlos's
syndrome.
The patient is at risk of lens subluxation.

31. This patient has physical signs of ankylosing
spondylitis (stiff back and kyphosis).
The problems encountered will include:
- Posturing of the patient during operation
- Poorly dilated pupil due to anterior synechiae

32. Right Eye
K1 = 42.75
K2 = 42.50
AL = 21.75 mm
Refraction = - 8.25 D
VA = 6/24
Left EYE
K1 = 42.25
K2 = 42.50
AL = 22.00 mm
Refraction = - 7.55 D
VA = 6/24
• This patient's biometry shows average keratometry readings and axial
lengths but high minus refraction.
• These changes are seen in patients with significant nuclear sclerosis. The
lenses are likely to be large and hard.
• A large lens will give a shallow anterior chamber making capsulorrhexis
difficult for the inexperienced surgeon.
• A hard nucleus increases the phaco time and in the hand of inexperienced
surgeon complications such as corneal edema is increased.
lens

34. Cystic bleb indicating a
functioning trabeculectomy
Adrenochrome pigments on the lower
lid tarsal conjunctiva seen with topical
adrenaline use

35.  Physical signs of the treatment the patient is
receiving
 Physical signs for possible causes (e.g. PDS,
PXF)
 Physical signs indicating the severity of the
condition
 Surgery (Traby, tube, iridectomy)
 Poor drainage is suggested by an absence of
bleb or a dome-shaped vascularized bleb caused
by subconjunctival fibrosis
 Constricted pupil (Pilocarpine)
 Heterochromia iridis (Latanoprost)
 Adrenochrome (adrenaline)

36. Most common cases of 2ry
OAG
with anterior physical signs are:
Pigment dispersion syndrome
Pseudoexfoliation syndrome
Iridocorneal endothelial (ICE) syndrome
Fuch's heterochromic cyclitis.

37. Advantages:
Reduced post-operative
leakage
Less trauma to the
cornea
Disadvantages:
Smaller bleb
Poorer scleral exposure
Higher chance of button
holes
Advantages:
Better exposure of limbus
More diffuse bleb due to
the lack of a posterior scar
line to limit the extension
of the bleb
Easier technique & less
time
Disadvantages:
Frequent wound leaks
Risk of corneal trauma

38. Low IOPLow IOP
Wound leakage
 Patching.
 Re-suturing is needed if
leakage fails to stop after
24-48 hours
Excessive drainage
 No leakage
 Patching may be useful.
Choroidal effusion
 Persistent marked
shallowing of AC with
hypotony
 If it persists for 10-14
days post-op, surgical
drainage is needed plus
AC reformation.
High IOPHigh IOP
Angle closure glaucoma
 Non-patent iridectomy
 YAG iridotomy is needed.
Aqueous misdirection
 Patent iridectomy
 Most cases respond to
medical Rx (cycloplegic,
B-blockers and systemic
Acetazolamide.
 failure to Med Rx:
Nd:YAG laser to disrupt
the posterior or anterior
hyaloid if the eye is
phakic or aphakic.
 Alternatively, par plana
vitrectomy is useful.
 In phakic eye, pars plana
vitrectomy and
lensectomy

39.  Age of patient: young more than old
 Race of patient: black more than other
races
 Type of glaucoma: traumatic, uveitic &
neovascular are more likely to fail
 Previous failed surgery
 Use of certain topical medication such as
topical adrenaline

40. • The iris and the lens
show dandruff-like flakes.
• The flakes on the lens are
arranged in a bull-eye
fashion with an
intermediate clear zone.
• The corneal endothelium
shows pigment
deposition.
• Retroillumination shows
peripupillary iris
transillumination.
• Look for:
• Traby, OD cupping,
phacodenesis, lens
sublaxation
Pseudoexfoliation syndrome

41.  The exact source is unknown.
 It may be produced by the epithelium of
the lens and other tissues because the
material is not confined to the eyes.
 The condition is thought to be a
generalized disorder of the basement
membrane.
 Bio-chemically, the material is made up of
proteoglycan materials and has features of
basement membrane.
 Cataract operation does not stop its
production.

42.  About 60% of patients with
pseudoexfoliation syndrome develop
secondary open angle glaucoma.
 Compared with primary open angle
glaucoma, this type is less responsive to
medical therapy.
 Argon laser trabeculoplasty is useful
initially to control the pressure but this is
eventually lost (sometimes abruptly).
 Trabeculectomy is useful and has the
same success rate as POAG.

43. Sampaolesis' line
A line of pigment
deposition anterior
to Schwalbe's line

44.  Poor pupillary dilatation.
 Weak zonules predisposes to zonular
dehiscence. This risk is increased with
vigorous hydrodissection or excessive nucleus
manipulation during Phacoemulsification.
 Increased risk of posterior capsular
rupture.

45. Glaucoflecken
Opacities behind anterior
lens capsule resulting from
anterior epithelium necrosis
Laser peripheral
iridotomy usually
situated peripherally &
superiorly
Surgical iridectomy
Eye with previous acute
glaucoma (irregular pupil)
The AC is usually shallow but may be normal in pseudophakia.
The lens contains white opacities anteriorly.
The iris may show atrophy from ischemic changes with irregular pupil which
may react poorly to light.
Peripheral iridotomy is usually present. Assess patency.

46.  Not all cases of acute glaucoma are
treated with laser iridotomies.
 You may have patients who had had
surgical iridectomies. With a casual
examination, this may be mistaken for
trabeculectomy without a functioning
bleb. The clue to this is the absence of a
scleral flap, glaucoflecken and iris
changes
 Examine the opposite eye for
prophylactic treatment whether laser or
surgical.

47.  Primary angle closure glaucoma:
 The mechanism is due to pupillary block.
 The AC is shallow both centrally and peripherally.
 Plateau iris syndrome:
 The main mechanism is caused by occlusion of the
trabecular meshwork by the anteriorly positioned
peripheral iris.
 Patients are younger (fourth or fifth decade of life).
 The AC is deep centrally.
 Patients with plateau iris syndrome may not respond to
laser iridotomy like primary angle closure glaucoma.
 Laser peripheral iridoplasty or miotic therapy may be
needed.

48.  Shallow anterior chamber
 Hypermetropia
 Small corneal diameter
 Short axial length of globe
 Large crystalline lens

49.  Patients with narrow angle may develop
AACG when the pupil is dilated due to
pupillary block.
 Provocative tests may be used to identify
the latent cases; the result is positive if
there is 8 mmHg pressure rise in the first
hour.
 The provocative test may be:
 Physiological: for example the dark room test
in which the pressure of the test is checked
when the pupil becomes dilated in the dark or
 Pharmacological with 10% phenylephrine
(which is reversible with thymoxamine)

50. Radial transillumination of the iris in
the midperiphery region. This is seen
with retroillumination. Each area
represents area devoid of pigment
epithelium
Krukenberg's
spindle with diffuse
illumination
Krukenberg's
spindle with
retroillumination
The corneal endothelium contains
vertically orientated deposition of
pigments (Krukenberg's spindle).
The pigment may also be seen on the
iris, lens and the trabecular meshwork

51.  Pigment in the trabecular meshwork by
performing gonioscopy
 Any peripheral iridoctomies which may be
performed in an attempt to reduce the
production of pigment
 look at the patient's glasses, most of this
patients has myopia
 Examine the optic disc for cupping
 What percentage of patients with PDS
develop glaucoma ? 30%30%

52.  Patients with PDS typically shows wide
fluctuation of the intraocular pressures.
 The pressure may be normal in the clinic
but can rise quickly following exercise or
pupillary dilatation in the dark.

53.  The iris is bowed posteriorly, causing it to
rub against the lens zonules.
 This results in the loss of the pigment
epithelium resulting in transillumination
and the endothelium deposition of
pigment.
 The vertical orientation of the pigment is
due to conventional current.

54.  It equalizes the pressures between the
posterior and anterior chamber and
therefore corrects the posterior bowing of
the iris.
 This reduces the rubbing and thus
decreased pigment loss.

56. A tube which enters the anterior chamber through the limbus region. This is a seton
used for glaucoma operation. Molteno's tube is the most commonly used

57.  Previous trabeculectomy
 Presence of signs indicating the
underlying condition:
 Rubeosis iridis
 ICE syndrome

58. It is used for refractory glaucoma
 Neovascular glaucoma
 Previous multiple failed filtration procedures
 Conjunctival scarring from previous failed
filtration (making the development of a filtration bleb
impossible)
 Childhood glaucoma in which primary
procedures have failed

59.  All setons contain a tube and a plate.
 The tube is inserted into the anterior
chamber to drain the aqueous and is
made up of either silicone or silastic.
 The plate forms the reservoir for the
drained aqueous and is made up of
plastic or silicone.
 The main difference between different
setons is in the design of plates.

60.  Excessive drainage leading to hypotony.
 Modification through valve insertion has
been made to the tube and plate to make
the seton pressure-dependent.

61. There is iris atrophy with corectopia and polycoria
Iridocorneal endothelial syndrome (ICE)

62.  The eye may have previous glaucoma
operation
 The cornea may show signs of
decompensation with corneal edema.
 The endothelium shows guttate-like
changes
 A tube in the anterior chamber
 Signs of glaucoma in posterior segment

63.  The main abnormality is in the corneal
endothelium appears like the epithelium.
 The endothelium becomes several layer
thick and spreading over the TM and iris
causing:
 Glaucoma
 Iris distortion
 The cause is unknown.

64.  Essential iris atrophy: There is progressive
angle closure by:
 peripheral anterior synechiae
 Corectopia, polycoria and iris atrophy. T
 he changes are the results of pulling by the
endothelium.
 Iris naevus syndrome (Cogan-Reese):
 Angle changes are as above
 Diffuse naevus covering the anterior iris.
 Iris nodules may or may not be present. The
nodules are the results of iris stroma protruding
through the abnormal endothelium growing over the
iris.
 Chandler's syndrome falls between the above
two entities.

65. The iris contains irregularly arranged blood vessels

66.  Seton tube in the anterior chamber which
may be used to treat this condition
 Examine the posterior segment;
 Central retinal vein occlusion
 Diabetic retinopathy

67.  This is neovascular glaucoma secondary
to ischaemic central retinal vein
occlusion.

68.  Most common causes:
 Central retinal vein occlusion
 Diabetic retinopathy
 Retinal artery occlusion
 Chronic retinal detachment
 Sickle cell retinopathy
 Radiation retinopathy
 Carotid artery occlusive disease
 Chronic uveitis

69. Small keratic precipitates scattered throughout the corneal endothelium (stellate
keratic precipitates). Fuch's heterochromic cyclitis

70.  The iris may show:
 Hhypochromia (best seen in the day light)
 Iris transillumination due to iris atrophy
 There may be irregular fine vessels on the iris
 The patient may have posterior subcaspular
cataract
 The anterior chamber may have flare or cells
 The conjunctiva is white
 NO Posterior synechiae
 The iris may contain abnormal iris vessels
 Check for the presence of trabeculectomy

71.  Uveitis:
 This tends to be chronic and not responsive to
steroid.
 Steroid may increase the risk of glaucoma and
cataract
 Glaucoma:
 May respond initially to medical treatment
 Trabeculectomy is usually needed.
 Bleb failure is common. Antimetabolites is
recommended
 Cataract:
 Extraction and heparin surface-modified IOL is
usually successful.

72.  Pre-operatively:
 the pupil may not dilate well due to iris
atrophy
 Peri-operatively
 Hyphema from the abnormal iris vessels is
common (Amsler's sign)

73. The abnormal eye may be:
 Hypochromic:
 Idiopathic
 Congenital Horner's syndrome
 Chronic uveitis
 Post-cataract operation
 Pigment dispersion syndrome
 Waardenburg's syndrome
 Post-herpes zoster iritis
 Hyperchromic:
 Melanosis
 Iris naevus syndrome
 Rubeosis iridis
 Siderosis