Glaucoma secondary to aphakic and intraocular lens

Introduction to glaucoma secondary to aphakic and intraocular lens The incidence of secondary glaucoma after cataract surgery varies greatly with the changes in the age of surgery, and is related to the improvement of microsurgery techniques. In general, the increase in intraocular pressure and glaucoma after cataract surgery is less in phacoemulsification than in extracapsular surgery. Extracapsular surgery is less than intracapsular enucleation. Intraocular lens implantation is better than intraocular lens implantation. The ciliary sulcus is implanted less, and the posterior chamber intraocular lens is less than the anterior chamber and iris type intraocular lens. basic knowledge The proportion of illness: 0.0005% Susceptible people: no special people Mode of infection: non-infectious Complications: vitreous

The cause of glaucoma secondary to aphakic and intraocular lens

Cause:

It is related to the state of the lens surgery and the intraocular lens.

Pathogenesis

Increased intraocular pressure and glaucoma after cataract and intraocular lens surgery may be temporary or persistent, and may occur in a variety of mechanisms, ranging from open-angle and closed-angle, or both. Yes, most believe that the original intraocular pressure level of the surgical eye and the previously existing glaucoma have nothing to do with the increase in intraocular pressure after cataract surgery and the control of glaucoma.

1. Temporary increase in intraocular pressure occurs in the early postoperative period, mostly reversible, and self-limited intraocular pressure rise, the reasons may be related to the following factors:

(1) iris corneal angle distortion: due to the corneal scleral incision over-tightening of deep corneal substantial edema, a white sputum can be seen under the keratomileus keratoplasty, the inner edge of the corneal scleral incision protrudes into the anterior chamber, covering the corner, near the trabecular meshwork Distortion, affecting the outflow of aqueous humor and causing elevated intraocular pressure, this condition is common in extracapsular or intracapsular cataract extraction surgery with a large incision of the limbus.

(2) Dissolution of the lens suspensory ligament: also known as enzymatic glaucoma, which occurs after intracapsular cataract extraction with a 1:5000 to 1:10000 alpha chymotrypsin solution, which is characterized by selective dissolution of the lens suspensory ligament. The fiber is decomposed into small fragments of uniform size and length of about 100 nm, which block the barrier of aqueous humor discharge caused by the trabecular mesh gap. It is also believed that the enzyme destroys the blood-aqueous barrier or the direct toxicity of the enzyme to the trabecular meshwork and ciliary body. Caused.

(3) Surgical inflammation and/or viscoelastic residue: Surgical trauma can cause edema of trabecular tissue. Different degrees of inflammation can occur after operation. Iris pigment may fall off and spread. The viscoelastic application used in surgery cannot be pumped. Absorbed and left in the anterior chamber. In the above conditions, inflammatory cells, fibrin, pigment particles or residual viscoelastic substances can block the trabecular meshwork extensively, causing temporary increase in intraocular pressure, which is temporary early after cataract surgery. The most common cause of elevated intraocular pressure.

(4) Residual lens material: After extracapsular enucleation or phacoemulsification or even lensectomy, the lens cortex, capsule and other fragments that have not been completely removed can block the trabecular mesh space, causing an increase in intraocular pressure, especially Glaucoma is more likely to occur when the lens material remains in the vitreous. In addition, Nd:YAG laser incision can also block the trabecular mesh space due to the release of posterior capsule fragments, causing an increase in acute intraocular pressure.

(5) The vitreous is detached into the anterior chamber: especially the formed vitreous body is detached into the anterior chamber, which can block the trabecular meshwork and cause an increase in acute intraocular pressure.

2. Sustained increase in intraocular pressure The above-mentioned temporary increase in intraocular pressure can be converted into a sustained increase in intraocular pressure if it cannot be released in time, but it is more common for the following reasons.

(1) Intraocular inflammation: severe inflammation or prolonged inflammation after surgery, which has a certain relationship with the surgeon's microsurgical technique and experience. The vitreous prolapse is improperly treated in intracapsular or extracapsular cataract extraction; when extracapsular cataract is removed The lens cortex is not cleaned, and the large lens cortex remains; the phacoemulsification operation is too long and the energy is too large; when the intraocular lens is implanted, the intraocular lens is not in the capsular bag or the ciliary sulcus, but behind the surrounding iris. The situation can cause obvious and sustained inflammatory reaction and blockage of trabecular mesh space by particulate matter, resulting in sustained increase of intraocular pressure. Clinically, secondary glaucoma after phacoemulsification, there are often a large number of lenses after iris. Cortical residue, uveal inflammatory response is obvious, the common feature is that the phacoemulsification operation time is short, and the cortex is not fully absorbed.

(2) intraocular blood accumulation: a large amount of anterior chamber blood can increase the volume of the eye and block the outflow channel of the aqueous humor, causing the intraocular pressure to rise; repeated intraocular hemorrhage not only causes damage and degeneration of the trabecular tissue, but also causes the surrounding Pre-iris adhesion leads to progressive closure of the anterior chamber, intraocular hemorrhage occurring months or years after cataract intraocular lens surgery, or Swan syndrome (angiogenesis at the cataract incision), or long-term friction of the iris with intraocular lens and (or According to the ciliary body, in the aphakic or intraocular lens of the posterior capsule rupture, the longer-term vitreous hemorrhage can cause hemophagocytic glaucoma and hemosiderin glaucoma.

(3) pupillary block: cataract surgery after pupillary block caused by closed angle of the anterior chamber is the most common cause of glaucoma in the aphakic eye, its occurrence is related to the following factors: 1 severe inflammatory reaction after surgery can produce the pupillary margin Adhesion, resulting in pupillary block, 2 intraocular lens block pupils can be seen in various types of intraocular lens, especially iris fixation and anterior chamber type, posterior chamber intraocular lens is easy to move forward when the posterior capsule or suspensory ligament is relaxed The pupils are attached, causing pupillary blockage. This can also occur in the posterior capsule of the aphakic body. The posterior capsule directly adheres to the iris to block the pupil, allowing aqueous humor to accumulate between the posterior capsule and the vitreous anterior interface, forming a Petit. "cavity", the iris-posterior capsule is pushed forward, blocking the angle of the anterior chamber, 3 direct contact between the anterior interface of the vitreous and the iris, early osmotic, medium-term adhesion with the pupil sphincter, and later adhesion to the entire iris posterior surface, This type of pupillary block is more common in cataract surgery with a circular pupil. It can also occur after Nd:YAG laser posterior capsulotomy with vitreous hemorrhoids, within 4 eyes. Filling surgery, cataract surgery, air blister in the anterior or posterior chamber of the eye, especially the large volume of inflatable gas filled in the aphakic retinal surgery, can push the iris forward and the cornea, the silicone oil in the vitreous cavity or The pupil can often be blocked due to too much or due to improper position.

(4) Peripheral anterior adhesion: In addition to the closed angle adhesion caused by the above pupillary block, most cases of secondary angle-closure glaucoma in cataract intraocular lens surgery are caused by postoperative wound leakage. Due to the anterior chamber, it is generally believed that the peripheral anterior chamber of the 5 days or more after surgery will eventually form a pre-irisal adhesion. The surgical techniques and techniques are poor. If the incision is improperly closed or the incision is split after surgery, a progressive angle can occur. Adhesion is closed, in addition, prolonged inflammation in the eye after surgery; or the implanted intraocular lens is not in the capsular bag or in the ciliary sulcus, the dome is behind the surrounding iris, and the anterior chamber intraocular lens directly stimulates the trabecular tissue; or After the operation, the posterior capsule rupture has the vitreous prolapse and the treatment is not ideal. It can cause or aggravate the peripheral pre-iris adhesion. In a few cases, the corneal endothelial cells can be transformed into fibroblasts by pathological stimulation, destroying the corner structure and producing the surrounding area. Adhesion before the iris.

(5) Corticosteroid reaction: Long-term application of corticosteroid eye drops after surgery, especially in individuals with high positive reaction to corticosteroids such as myopia, and family history of primary open angle glaucoma.

(6) Neovascularization: In diabetic patients, especially those with proliferative diabetic retinopathy in the eye, anterior segmental neovascularization is prone to occur after cataract surgery. Intracapsular cataract extraction is better than extracapsular cataract extraction. The complete operation of the capsule is more likely to promote the formation of iris neovascularization, which is damaged by the mechanical barrier of the lens vitreous, and the neovascular growth factor released by the retinal lesion is easily related to the anterior segment of the eye.

(7) Epithelial implantation or fibrous membrane ingrowth: improper operation of cataract surgery, poor incision closure, epithelial cells of the corneal conjunctiva from the wound into the eye, can cause the epithelial membrane to directly cover the trabecular meshwork, or cause peripheral anterior iris adhesion, or The formation of epithelial membrane blocks the pupil, glaucoma occurs, if the surgical incision is poorly coupled and accompanied by intraocular tissue or foreign body embedding, iris, vitreous, lens capsule or cortical fragments, cotton fiber, etc., can be induced The proliferation and growth of the fibrous membrane and the involvement of tissues such as the angle of the eye eventually lead to glaucoma.

Glaucoma prevention secondary to aphakic and intraocular lens

All cataracts should be carefully examined before surgery for any complications associated with glaucoma, especially in patients with glaucoma. Do not use adrenaline together with the anesthetic after the ball to avoid affecting the blood supply to the optic nerve. Use a variety of different eye compression methods to reduce the pressure on the eye to reduce the volume of the vitreous and reduce the risk of intraoperative fulminant hemorrhage, but the choice of antihypertensive method should be appropriate, excessive pressure or excessive time will cause optic atrophy or retinal blood vessels Embolization, implantation of intraocular lens should be moderately sized. The case of abnormal glaucoma or iris corneal angle is a relative contraindication for anterior chamber intraocular lens implantation. Studies have shown that open anterior chamber intraocular lens is suitable for posterior capsule with vitreous prolapse. Patients with rupture that cannot be implanted in the posterior chamber intraocular lens have relatively few complications.

Minimize tissue damage during surgery, help reduce complications caused by hemorrhage and inflammation, and secondary glaucoma associated with it, use viscoelastic substances and chymotrypsin with caution, especially for those with glaucoma, artificial lens The application of miotic drugs such as acetylcholine after implantation can not only reduce the sputum but also reduce the intraocular pressure of 3-6 hours after surgery.

Glaucoma complications secondary to aphakic and intraocular lenses Complications

Corneal conjunctival epithelial implantation, vitreous hernia, pupillary clamping syndrome, peripheral anterior iris adhesion.

Symptoms of glaucoma secondary to aphakic and intraocular lens common symptoms rainbow eye pressure increased uveitis ligament rupture without lens lens pupil fixed tremor lens shift

Symptom

After cataract intraocular lens surgery, the eye has more eye pain when the intraocular pressure is elevated. The visual acuity is blurred or the visual acuity that is obviously improved after the operation is decreased. If the corneal edema occurs, it can also be accompanied by the phenomenon of rainbow vision. These symptoms are often obscured by the performance of the surgical injury response, and may not be noticed and valued by the doctor. When some symptoms persist or gradually increase, it is found that the intraocular pressure is elevated, and the chronic intraocular pressure rises after the operation. Usually there are no obvious symptoms, and some only show blurred vision or decreased vision. Some doctors in the clinic are used to check only the anterior segment of the eye. Because of the posterior dysfunction, the intraocular pressure and fundus examination are neglected. Most of them have obvious optic nerve and visual field damage.

2. Signs

Obvious elevated intraocular pressure can cause corneal edema and opacity. Long-term elevated intraocular pressure can cause obvious glaucomatous optic nerve damage. Clinical diagnosis mainly depends on the depth of anterior chamber, anterior chamber reaction, corneal or scleral incision, and iris morphology. , pupillary adhesions, intraocular lens, vitreous, angle of the room and other conditions, and for glaucoma examination of intraocular pressure, fundus and vision.

(1) anterior chamber depth: the anterior chamber of the aphakic or intraocular lens is usually deeper than that of the lens. If the anterior chamber is significantly shallower than the center, especially if there is adhesion after the pupil or iris bulging, the height suggests There is a pupil block. If the anterior chamber is generally shallow, it may be caused by incision leakage or choroidal detachment. It may also be caused by pupillary block of various causes. If the anterior chamber is unevenly shallow, it is an intraocular lens. The position is not correct or there is a rupture of the lens ligament, the presence of vitreous hemorrhoids, the anterior chamber completely disappears, and the possibility of malignant glaucoma is greater.

(2) anterior chamber reaction: the general response after cataract surgery is very light, especially the skilled doctor and mature phacoemulsification technology, if there is a more obvious anterior chamber reaction after surgery, in addition to vigilant infection, pay attention to observe the eye Pressure, secondary glaucoma-related changes in aqueous humor may have inflammatory or pigmented KP, cell floating and Tyndall phenomenon, cellulose exudation, hemorrhage or red blood cells, khaki-colored blood cells, gray-white lens cortical particles, etc. In many eyes with glaucoma after cataract intraocular lens surgery, during the glaucoma surgery, a large amount of residual lenticular cortical material spilled from the back of the iris was seen during the anterior chamber water outflow, which was after cataract surgery. Continue the root cause of uveal inflammatory response. In addition, it should be noted that the viscoelastic agent used in the cleansing operation at the end of the operation is more uniform and gel-like, but it can also aggravate the anterior chamber in the anterior chamber. The inflammatory response.

(3) cataract incision: mainly incision closure of the cornea or sclera, dislocation, distortion or splitting, suture loose or too tight, too shallow or too deep, can be expressed as wound leakage, low intraocular pressure, intraocular Tissue embedding, etc., long-term cases can occur progressive peripheral anterior adhesions, and even keratoconjunctival epithelium or fibrous tissue into the eye, it has been reported that after cataract extraction, histologically confirmed the incidence of epithelial ingrowth 0.09% ~0.11%, instruments with epithelial debris or fibrous sponges and suture channels left in the eye can cause the epithelium to grow into the anterior chamber, slit lamp examination: epithelial ingrowth from the wound, forward along the cornea The growth is a translucent or transparent gray film with a frosted glass-like shape and a thickened edge that grows to the back and expands to the iris surface, making the iris flattened, which is much wider than the one that grows behind the cornea. Many, but difficult to see, sometimes the epithelium can be extended back to the ciliary body flat and the glass membrane, the edge has holes, sometimes oval pores, which can be separated from the posterior elastic membrane of the cornea and the inflammatory membrane Identification, on The membrane itself has no blood vessel formation and can be differentiated from the neovascular membrane.

(4) iris morphology and pupillary adhesion: after cataract intraocular lens surgery, the iris is flat or even regressed, and iris tremor can be seen in the aphakic eye. If the iris is seen and accompanied by the full adhesion of the pupillary margin, it is for surgery. Pathological pupillary block caused by post-inflammation, early intraocular pressure is still normal, glaucoma is inevitable for a long time, and another manifestation of pathological pupillary block caused by inflammation after surgery is that the iris is trapped. This situation is not only There is a posterior adhesion of the pupillary margin, and the entire iris is completely adhered to the intraocular lens or the posterior capsule of the lens, or even the vitreous anterior membrane. A limited iris bulging is seen, which may be followed by vitreous or intraocular lens. The position is not correct, it can also be the residual of more local lens cortex, viscoelastic or air bubble residue. In addition to causing local peripheral anterior iris adhesion, these conditions will eventually lead to the formation of post-pupil adhesions due to inflammatory reaction. In the case of cataract incision leakage, the iris incarceration adhesion and the displacement of the pupil are often formed at the corresponding places, and a wide range of eyes may cause Pressure.

(5) Intraocular lens: The early iris-fixed or pupil-fixed intraocular lens, the posterior chamber intraocular lens with no angle between the iliac crest and the optic can easily cause pupillary block glaucoma, and the anterior chamber intraocular lens can damage the anterior chamber tissue. In particular, the intraocular lens has a wide range of damage when displaced, which can lead to the occurrence of glaucoma. The posterior chamber intraocular lens can cause pupil block in the occurrence of iris incision syndrome, pupillary clamping syndrome, and capsular block syndrome. Adhesion to the peripheral iris, secondary glaucoma, improper placement of the intraocular lens, the sacral or optic can damage the ciliary body, the iris, cause inflammation, bleeding and pigmentation, especially intraocular lens suspension surgery, may Followed by glaucoma.

(6) Corner: For the classification of glaucoma that reveals aphakic or intraocular lens, pathogenesis and etiological diagnosis are necessary. In addition to the pathological angle change of the peripheral pre-irisal adhesion, some cases of elevated intraocular pressure can be found. Special performance: A large amount of melanin deposition in trabecular meshwork indicates that the iris is more obvious during operation. After surgery, the surface of the artificial lens or the rubbing of the iris repeatedly causes the pigment to fall off. The trabecular mesh changes yellow, suggesting that hemorrhage and hemolysis have occurred after the operation. Possible; if covered by shadow-like cell deposits, suggesting vitreous glaucoma caused by vitreous hemorrhage; such as loss of trabecular mesh morphological structure, suggesting cataract surgical incision or suture injury, wound epithelial membrane or fibrous membrane ingrowth Possibly; neovascular membranes are seen in the anterior chamber, especially after cataract surgery in patients with poorly controlled diabetes.

3. Intraocular pressure measurement The intraocular pressure measurement after cataract surgery is a necessary means to detect elevated intraocular pressure in time. Because of the influence of surgery, doctors and patients often have concerns about intraocular pressure measurement in the short term after surgery. It should be said that As long as there is no obvious eye irritation in the surgical eye, any method of intraocular pressure measurement can be performed on the first day after the operation. The intraocular pressure can usually be measured on the third day after the operation. The intraocular pressure measurement method can select the non-contact intraocular pressure. (NCT), the advantage is that no local anesthetic is used, avoiding possible cross infection and ocular surface damage, and easy to operate; the disadvantage is that it is susceptible to irregular ocular surface, corneal edema and corneal plaque, etc. Intraocular pressure (Goldmann tonometer) measurement is recognized as the least interfered method. Although the operation technology is relatively high and the operation process is complicated, at least in the clear diagnosis of glaucoma should be advocated for universal application, indentation type intraocular pressure ( Schiötz tonometer is sensitive to eye wall hardness, but it is especially suitable for corneal edema or leukoplakia, leukoplakia compared with non-contact tonometer. the amount.

Examination of glaucoma secondary to aphakic and intraocular lenses

Aqueous cytology to understand the number of cells in the aqueous humor and its types, especially in patients with inflammatory reactions in the anterior chamber.

B-ultrasound or UBM visit to measure the depth of the anterior chamber, to understand the position of the intraocular lens and the relationship between the intraocular lens and the ciliary body, the pupillary margin under dynamic conditions; the angle of the angle to understand the open state of the angle of the corner, visual field examination to understand the visual field defect Happening.

Diagnosis and diagnosis of glaucoma secondary to aphakic and intraocular lens

Diagnosis can be based on medical history and the necessary multiple auxiliary examinations.

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