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Intricate clinical evaluation and management strategies in vision-threatening phacomorphic glaucoma

 Department of Cataract, Cornea, Trauma, Ocular Surface, External Diseases and Refractive Surgery; Department of Cataract, Pediatric Ophthalmology and Strabismus Services Aravind, Eye Hospital, Postgraduate Institute of Ophthalmology, Puducherry, India

Date of Submission11-Apr-2022
Date of Acceptance27-Jun-2022
Date of Web Publication02-Aug-2022

Correspondence Address:
Bharat Gurnani,
Aravind Eye Hospital, Postgraduate Institute of Ophthalmology, Puducherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2211-5056.353131

How to cite this URL:
Gurnani B, Kaur K. Intricate clinical evaluation and management strategies in vision-threatening phacomorphic glaucoma. Taiwan J Ophthalmol [Epub ahead of print] [cited 2023 Mar 23]. Available from: https://www.e-tjo.org/preprintarticle.asp?id=353131

Dear Editor,

As we all know, intumescent cataract is a surgical challenge for all cataract surgeons, and the definitive treatment is cataract extraction. If left untreated, it can result in phacomorphic glaucoma, posing management challenges.[1] These patients present with very high uncontrolled intraocular pressure (IOP) and a shallow anterior chamber. Intraoperatively, there is an increased risk of zonular dialysis (ZD), posterior capsular rent (PCR), whole bag removal, vitreous loss, and expulsive choroidal hemorrhage.[2] Prompt diagnosis and meticulous management are warranted to safeguard vision in these cases. We read an interesting article by Gupta et al.[3] on “Survival analysis of phacomorphic glaucoma at a tertiary hospital in North India,” and we must congratulate the authors for bringing out a large-scale analysis. However, we have a few important observations and suggestions to make that we believe will benefit all ophthalmologists and readers globally.

First, the title is labeled as “survival analysis.” The authors have thought differently by adding survival analysis as survival is generally linked with life and death. In this article, survival can be linked to anatomical and functional outcomes of phacomorphic glaucoma. Alternative terminology could have been clinical outcomes or long-term outcomes of phacomorphic glaucoma.

Second, the authors have taken phacomorphic glaucoma cases as mentioned in the analysis. It would have been great if strict inclusion and exclusion criteria had been defined, which are missing. The inclusion criteria should be patients with a diagnosis of phacomorphic glaucoma with an age above 40 years. The exclusion criteria would be all pediatric patients, all patients with a diagnosis other than phacomorphic glaucoma, incomplete case records, patients not willing for surgical intervention, patients systemically unfit for surgery, and patients lost to follow-up.

Third, in the demographics and clinical examination on the day of presentation, the presence or absence of relative afferent pupillary defect (RAPD), pseudohypopyon, and presence of light perception (PL) with the accurate projection of rays are critical prognostic indicators in each case. Delayed presentation, presence of RAPD and absence of PL are linked with glaucomatous optic neuropathy and poor prognosis. Hence, these findings should be documented in each case. It would be perfect for authors to describe more clearly about some important clinical findings in each case.

Considering the management of phacomorphic glaucoma cases, the authors have employed phacoemulsification as a management modality that should be avoided in these cases due to crowded anterior segments and high risk of complications such as corneal decompensation ZD, PCR, nucleus drop, vitreous loss, and aphakia. We at our center consider only manual small incision cataract surgery (MSICS) for these cases and have found excellent results. The authors have used intravenous (IV) mannitol for only >35 mmHg IOP cases. We at our center use IV mannitol for all these cases irrespective of IOP level to shrink the vitreous and reduce intraoperative positive pressure. Ramakrishanan et al.[4] employed MSICS for 74 phacomorphic glaucoma cases and found excellent results. In their analysis, none required antiglaucoma medications, no significant complications were noted intraoperatively, and nearly 70% had visual acuity of 20/40 or better.

Another strategy I usually follow for these cases is an intraoperative vitreous tap before starting the surgery. A vitreous tap reduces the IOP, deepens the anterior chamber, and facilitates surgical manipulation in the anterior chamber. Did the authors perform vitreous tap in any of these cases?

The authors have mentioned that 30 patients were excluded or not operated on. It would be good to know the reason for not operating on these patients? If not operated on time, these cases can rapidly progress to corneal decompensation and optic atrophy.

Finally, the authors have also used iris-claw IOL, sulcus fixated IOL, and anterior chamber IOL in a few cases. Because these cases have a high incidence of anterior chamber inflammation, fibrinous uveitis, and corneal edema, we usually avoid secondary IOL implantation in the primary setting in these cases. We typically place secondary IOL as a staged procedure in these cases. Once again, we want to congratulate the authors for this detailed analysis.


We acknowledge Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry.

Financial support and sponsorship


Conflicts of interest

The authors declare that there are no conflicts of interest of this paper.

  References Top

Ling JD, Bell NP. Role of cataract surgery in the management of glaucoma. Int Ophthalmol Clin 2018;58:87-100.  Back to cited text no. 1
Sowka J. Phacomorphic glaucoma: Case and review. Optometry 2006;77:586-9.  Back to cited text no. 2
Gupta R, Agrawal S, Chauhan L. Survival analysis of phacomorphic glaucoma at a tertiary hospital in North India. Taiwan J Ophthalmol 2022;12:61-7.  Back to cited text no. 3
  [Full text]  
Ramakrishanan R, Maheshwari D, Kader MA, Singh R, Pawar N, Bharathi MJ. Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthalmol 2010;58:303-6.  Back to cited text no. 4
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