DOI: 10.5301/ejo.5000441
Eur J Ophthalmol 2014; 24 ( 5 ): 712-717
ORIGINAL ARTICLE
Reasons for early ocular hypertension after uneventful cataract surgery Fan Fan, Yi Luo, Yi Lu, Xin Liu Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai - China
Purpose: To discuss the reasons for and measurements of early ocular hypertension after uneventful phacoemulsification and intraocular lens (IOL) implantation. Methods: This was a retrospective review of patients who had early ocular hypertension after cataract surgery from a single-surgeon practice that medications failed to control or required additional surgery from September 2011 to January 2013. Results: Of the 1270 eyes that had cataract surgery by one surgeon in our department in 16 months, 12 (9.4‰) eyes of 12 patients met the inclusion criteria. The mean postoperative intraocular pressure (IOP) peak was 41 (range 32-62) mm Hg. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had antiglaucoma surgery history. Ahmed valve implantation with mitomycin C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil needling revision with MMC. The IOP dropped in 3 eyes only in the case that the conventional topical corticosteroid agent was stopped, diagnosed as steroid responders. One eye of a patient with diabetes mellitus (DM) developed pseudophakic pupillary block angle-closure glaucoma due to the plasma glucose fluctuations. The IOP was controlled after Nd:YAG laser iridotomies. Residual cortex caused ocular hypertension in 2 eyes and surgical aspirations were performed. Following monitoring of IOP for 6 to 24 months, all eyes were within the normal range. Conclusions: Patients with history of glaucoma surgery; high myopia, especially in young age; and DM merit particular observation and treatment for possible IOP elevation following cataract surgery. Keywords: Cataract surgery, Diabetes, Ocular hypertension, Phacoemulsification, Steroid responders, Trabeculectomy Accepted: January 21, 2014
INTRODUCTION Many studies have reported early ocular hypertension after cataract surgery with a multifactorial pathogenesis, including inflammation (1), pigment dispersion (2), and retained viscoelastic material (3-5), lens or iris debris (6). With the maturation of phacoemulsification, parallel development in instrumentation and equipment, and antibiotic prophylaxis, postoperative ocular hypertension caused by iatrogenic bacterial endophthalmitis has been declining in recent years (7). Other risk factors that cause intraocular pressure (IOP) elevation, however, may threaten vision after cataract surgery. 712
We examined causes of ocular hypertension that required further treatment after common and uneventful cataract surgery in our department. Identifying these risk factors might forewarn ophthalmologists to use closer postoperative surveillance or alternative pharmacologic or surgical approaches (8).
METHODS Patients Patients who had ocular hypertension (IOP >21 mm Hg) that glaucoma medications failed to control or required
© 2014 Wichtig Publishing - ISSN 1120-6721
Fan et al
additional surgery in the first 3 months after uneventful cataract surgery from September 1, 2011, to January 31, 2013, were reviewed. Intraocular pressure was measured by Goldmann applanation tonometry. Preoperatively, all patients underwent a complete ophthalmologic examination. Intraocular pressure was lower than 21 mm Hg in all eyes. None of the patients was using any medications like steroids or antiglaucoma drugs preoperatively. Patients with previous traumatic history, uveitis, or penetrating keratoplasty and those with complicated cataract surgery were excluded.
Surgical technique Clear corneal phacoemulsification and foldable intraocular lens (IOL) implantation was performed by a single experienced surgeon (Y.L.). All procedures were performed with the patient under topical anesthesia. A 2.8-mm clear corneal upper incision was made. Viscoelastic was injected (DisCoVisc, Alcon, Inc., Fort Worth, Texas, USA), and a continuous curvilinear capsulorhexis and hydrodissection
of the nucleus was performed. Phacoemulsification of the nucleus was performed using the phaco-chop technique. A foldable IOL was implanted in the bag, viscoelastic was removed by irrigation/aspiration, and the corneal incision was left unsutured. One day postoperatively, prednisolone acetate and levofloxacin eyedrops were started 3 times every day and tapered 2 weeks. Pranoprofen eyedrops were prescribed at a dose of 3 times every day for 4 weeks.
RESULTS Of the 1270 eyes that underwent cataract surgery by one surgeon in our department in 16 months, 12 (9.4%) eyes of 12 patients met the inclusion criteria. The characteristics and treatment are listed in Table I. The average age was 55 years. All patients complained of ocular pain and decreased vision at the initial onset of the glaucoma secondary to phacoemulsification. The mean postoperative IOP peak was 41 mm Hg (range 32-62) with worse than 0.02
TABLE I - CHARACTERISTICS AND TREATMENT OF THE ENROLLED EYES Case
Sex/ IOP peak, Age, y mm Hg
Time of Relative initial disease onset, d history
Ocular surgery history
Interval Medication between treatment for ocular CS and hypertension Tb, mo
Course of Resolve medication measurement treatment, wk
1
F/69
37
1
PACG
Tb + MMC
96
Tim, Bri, Ace, Man
7
Ahmed
2
M/67
35
60
PACG
Tb + MMC
3
Tim, Bri, Ace
6
Ahmed
3
M/70
48
1
PACG
Tb + MMC
48
Tim, Bri, Ace, Man
7
Ahmed
4
M/61
54
1
PACG
Tb + MMC
6
Tim, Bri, Ace, Man
6
Ahmed
5
F/56
39
50
PACG
Tb + MMC
6
Tim, Bri, Ace, Man
4
5-FU needling
6
F/50
62
1
PACG
Tb + MMC
17
Tim, Bri, Lat, Ace, Man
3
5-FU needling
7
M/45
35
7
High myopia
No
/
Tim, Bri, Ace
5
Stop using steroids
8
M/40
37
30
High myopia
No
/
Tim, Bri, Ace, Man
4
Stop using steroids
9
F/50
35
5
High myopia
No
/
Tim, Bri, Lat, Ace
4
Stop using steroids
10
F/59
32
7
DM
No
/
Tim, Bri
1
Laser iridotomies
11
F/52
40
2
No
No
/
/
/
Surgical aspiration of retained cortex
12
M/65
39
1
No
No
/
/
/
Surgical aspiration of retained cortex
5-FU needling = 5-fluorouracil needling revision with mitomycin C; Ace = acetazolamide combined with potassium chloride sustained release tablets; Bri = brimonidine; CS = cataract surgery; DM = diabetes mellitus; Lat = latanoprost; Man = mannitol; MMC = mitomycin C; PACG = primary angle-closure glaucoma; Tb = trabeculectomy; Tim = timolol.
© 2014 Wichtig Publishing - ISSN 1120-6721
713
Early ocular hypertension after cataract surgery
decimal visual acuity. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had trabeculectomy for primary angle-closure glaucoma before cataract surgery. The mean age of the 6 patients was 60 years. The median time interval between the 2 surgeries was 11.5 months. We used timolol combined with brimonidine eyedrops 3 times daily or added oral acetazolamide (9, 10). Intravenous mannitol was administered for 3 days if IOP exceeded 35 mm Hg. The IOP could not be controlled after medications for an average of 5.5 weeks; as a result, Ahmed valve implantation with mitomycin-C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil (5-FU) needling revision with MMC. Intraocular pressures were in the normal range without drugs in the late follow-up period. Glaucoma medications did not work until the postoperative conventional topical corticosteroid agent was stopped in 3 eyes. Intraocular pressure was in the normal range when we stopped all the eyedrops at 4 or 5 weeks postoperatively. Thus, the 3 cases were diagnosed as steroid responders. Interestingly, 2 of the 3 eyes had high myopia with mean axial length of 26.1 mm. One patient had sudden ocular pain in the operated eye on the seventh postoperative day. The IOP was 32 mm Hg. Slit-lamp examination revealed cornea edema and fibrinous membrane covering the pupil. The patient had a diabetes mellitus (DM) history of at least 10 years. Fasting plasma glucose at the time was 12.6 mmol/L; it was 7.8 mmol/L in the preoperative blood test. Aside from 4 times daily prednisolone acetate 1%, cycloplegics and glaucoma medications (timolol combined with brimonidine) were added to the operated eye topically. The IOP was not reduced significantly after 1-week medication course. Then we performed Nd:YAG laser peripheral iridotomies, opening 2 laser holes at 4 and 8 o’clock. The IOP decreased to 16 mm Hg in 3 hours and remained in the normal range afterwards. Uncorrected decimal visual acuity improved from 0.01 to 0.5. Residual cortex caused ocular hypertension in the 2 remaining eyes and the surgical aspirations were performed.
DISCUSSION Although postoperative IOP peaks may occur in eyes with no history of glaucoma, the spikes are more prolonged and pronounced in patients with preexisting glaucoma (10-12). 714
In the present study, of all the cases with uncontrolled IOP after phacoemulsification, the majority of eyes had previous trabeculectomy for primary angle-closure glaucoma before cataract surgery. Some clinical studies found that phacoemulsification had an adverse effect on the maintenance of the filtering bleb, although the effect was smaller than that of extracapsular cataract extraction (ECCE) (13, 14). The cause of an adverse effect of phacoemulsification on IOP control, if any, is assumed to be surgery-induced inflammation that causes stimulation of subconjunctival scarring, which would result in the failure of bleb function. In this model, the interval between the initial trabeculectomy and subsequent phacoemulsification may be a critical factor in the failure of trabeculectomy. Likewise, Chen et al (15) found that an interval of fewer than 6 months between trabeculectomy and cataract extraction was a risk factor for the loss of IOP control. Moreover, a Cox proportional hazards analysis revealed that postoperative IOP in eyes with previous trabeculectomy might be affected by the IOP before trabeculectomy and phacoemulsification within 1 year after trabeculectomy (16). Another study analyzed the effect of phacoemulsification more than 2 years after trabeculectomy (21 eyes) and found that the IOP after phacoemulsification was not significantly higher than that before phacoemulsification at any time point (17). Taken together, these findings may indicate that a filtering bleb requires 1 to 2 years to stabilize against phacoemulsification (18). Younger age is another factor that predisposes to bleb failure, with one study reporting that patients younger than 50 years have a significantly increased risk (15). In the 6 eyes of our study, the median time interval between the 2 surgeries was 11.5 months. The mean age of the 6 patients was 60 years. After an average of 5.5 weeks medication course, IOP did not drop. In the end, we had to apply Ahmed valve implantation or 5-FU needling revision with MMC to keep IOP in the normal range without drugs. Accordingly, in order to minimize IOP rise in patients who had previous trabeculectomy after uneventful cataract surgery, prophylaxis may be adopted. All patients should be advised of the potential risk as part of the consent procedure (19). It is generally advisable to delay cataract surgery until 1 to 2 years after trabeculectomy if possible (19). Minimal conjunctival and iris manipulation is recommended (15). More aggressive anti-inflammatory treatment in the postoperative period may decrease the risk of bleb failure (20). Aside from patients with known glaucoma or hypertension history, there are other risk factors for high IOP after
© 2014 Wichtig Publishing - ISSN 1120-6721
Fan et al
phacoemulsification. Considering that topical corticosteroid agents are routinely prescribed after cataract surgery, large populations are exposed to the risk for a topical steroid response. Although the IOP rise is generally reversible and treatable and is usually well-tolerated, the elevations may be sufficiently high and prolonged to cause ocular morbidity. In our series, IOP dropped in 3 eyes only when the topical corticosteroid agent that postoperative conventionally used was stopped. Interestingly, the 3 patients were relatively young in the current study group, with mean age of 45 ± 5 years. Of note, 2 of them had high myopia, with mean axial length of 26.1 mm. Chang et al (21) reviewed 1642 patients who had uneventful cataract surgery; 39 were diagnosed as steroid responders, defined as an IOP increase greater than 25% while on topical prednisolone (minimum 28 mm Hg) followed by a decrease of more than 25% after topical prednisolone was discontinued. Comparing the age and axial length between steroid responders and nonresponders, the study concluded that younger patients with high myopia had a higher risk for postoperative steroid response after uneventful cataract surgery and may require more frequent IOP monitoring or alternative topical anti-inflammatory medications. The characteristics of the 3 steroid responders in our study were in accordance with the conclusions of Chang et al. This gives us several practical clinical implications. Although every patient being treated with ocular steroids should be monitored for a possible IOP elevation, younger patients with axial high myopia merit more frequent follow-up. Alternative pharmacologic therapy might also be considered for higher risk patients. Topical nonsteroidal anti-inflammatory drugs alone may be sufficient to suppress postoperative inflammation after uneventful cataract surgery in many eyes. Certain topical corticosteroid agents, such as loteprednol etabonate and fluorometholone, are less likely to induce an IOP response (22, 23). Finally, a shorter than usual course of topical corticosteroid treatment could be considered in higher risk patients. Since having changed our cataract operation technique from ECCE to phacoemulsification, we had the impression of less fibrinous membranes postoperatively. Fibrinous exudate pupillary membrane occlusion and secondary glaucoma are relatively rare complications after cataract surgery with modern techniques and instruments. So far, DM has been proposed as risk factor of pseudophakic pupillary block and angle-closure glaucoma (24, 25). Khor et al (26) reported fibrin pupillary-block glaucoma after phacoemulsi-
fication cataract surgery in 4 patients, 3 of whom had DM. One study on anterior segment complications after phacovitrectomy comparing diabetic and nondiabetic patients also concluded that the ratio of fibrinous uveitis was significantly higher in the diabetic group (27). Previous reports suggested that propensity to breakdown of the bloodaqueous barrier in diabetic patients was associated with fibrin formation after cataract surgery (25, 28). In particular, DM with uncontrolled plasma glucose tends to lead to serious noninfectious inflammation after cataract surgery. However, ophthalmologists are apt to overlook plasma glucose fluctuations in DM and unable to take precautions in advance. In the present pupillary membrane occlusion case, the patient had 10 years DM history with 12.6 mmol/L fasting plasma glucose at the onset of secondary glaucoma. The treatment of fibrin pupillary-block glaucoma has not been officially established. Ocular hypertension develops when an inflammatory fibrin membrane occludes the pupil, resulting in peripheral angle closure (26). When we met with the patient, topical cycloplegics and corticosteroids were first selected to dilate the secluded pupil and promote anti-inflammation, thus breaking the membranous occlusion and opening the physiologic aqueous fluid pathway. However, medications failed to release the pupil and reoperation to dissect the synechia would create a second trauma to the inflamed eye. Therefore, we performed iridotomy using Nd:YAG laser to open the aqueous fluid pathway and got immediate good results. In one case series of 6 diabetic patients who developed pseudophakic pupillary block with angle-closure glaucoma after undergoing ECCE, laser iridotomies were performed in 4 eyes and decreased the IOP in 3. Thus the author recommended that a peripheral iridectomy should be performed in pseudophakic eyes of patients with DM at the time of the cataract surgery (24). In another case series of fibrin pupillary-block glaucoma after phacoemulsification cataract surgery, all patients were successfully treated by Nd:YAG laser peripheral iridotomy (26). Nevertheless, iridotomy is not the only way to handle the condition and it has the potential risk of damaging the corneal endothelium when there is severe corneal edema or iridocorneal contact (29). Geller and Xu (30) reported a successful result using Nd:YAG laser technique to dissect and move the dense pupillary membrane away in one case with rheumatoid arthritis who had severe induced iritis with dense fibrinous pupillary membrane occlusion and high IOP following cataract surgery. Yoshino et al (29) first reported fibrin pupillary-block glaucoma after cataract
© 2014 Wichtig Publishing - ISSN 1120-6721
715
Early ocular hypertension after cataract surgery
surgery successfully treated with intracameral tissue plasminogen activator (tPA). But tPA intraocular injection had initial severe complications like intraocular bleeding and recurrence of fibrin accumulation (31). In summary, eyes with history of glaucoma or glaucoma surgery, relatively young patients with high myopia, and patients with DM were at higher risk of ocular hypertension after phacoemulsification. These risk factors may forewarn ophthalmologists to merit closer observation and take preventive measures in particular individuals. We recommend that these eyes should be monitored closely and frequently, especially 6 hours after surgery, the next day, and at 1, 2, and 4 weeks. It is generally advisable to delay cataract surgery for 1 to 2 years in previous trabeculectomy patients. Alternative postoperative pharmacologic therapy should be adopted in the high-risk eye, including choosing loteprednol etabonate or equivalent rather than prednisolone acetate and shortening the topical steroid course. With regard to patients with DM, keep-
REFERENCES
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ACKNOWLEDGMENT The authors thank Dr. Jianhui Zhuang from the School of Medicine of Tongji University for comments and suggestions. Financial Support: Supported by grants from the National Natural Science Foundation of China (Grant No. 81371002). Conflict of Interest Statement: None of the authors has conflict of interest with this submission. Address for correspondence: Yi Luo 83 Fenyang Road Shanghai 200031 China [email protected]
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Hirneiss C, Neubauer AS, Kampik A, Schönfeld CL. Comparison of prednisolone 1%, rimexolone 1% and ketorolac tromethamine 0.5% after cataract extraction: a prospective, randomized, double-masked study. Graefes Arch Clin Exp Ophthalmol 2005;243:768-73. 2. Almond MC, Wu MC, Chen PP. Pigment dispersion and chronic intraocular pressure elevation after sulcus placement of 3-piece acrylic intraocular lens. J Cataract Refract Surg 2009;35:2164-6. 3. Moser CL, Martin-Baranera M, Garat M, de Miguel PV, Rubio M. Corneal edema and intraocular pressure after cataract surgery: randomized comparison of Healon5 and Amvisc Plus. J Cataract Refract Surg 2004;30:2359-65. 4. Rainer G, Menapace R, Schmid KE, et al. Natural course of intraocular pressure after cataract surgery with sodium chondroitin sulfate 4%-sodium hyaluronate 3% (Viscoat). Ophthalmology 2005;112:1714-8. 5. Feys J, Fajnkuchen F, Salvanet-Bouccara A. [Factors influencing early post surgical ocular hypertension after phacoemulsification.] J Fr Ophtalmol 2000;23:884-7. 6. Schaal S, Barr CC. Management of retained lens fragments after cataract surgery with and without pars plana vitrectomy. J Cataract Refract Surg 2009;35:863-7.
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Yao K, Zhu Y, Zhu Z, et al. The incidence of postoperative endophthalmitis after cataract surgery in China: a multicenter investigation of 2006-2011. Br J Ophthalmol 2013;97: 1312-7. Zamvar U, Dhillon B. Postoperative IOP prophylaxis practice following uncomplicated cataract surgery: a UK-wide consultant survey. BMC Ophthalmol 2005;5:24. Moisseiev E, Kurtz S, Lazar M, Shemesh G. Intraocular pressure reduction using a fixed combination of timolol maleate 0.5% and brimonidine tartrate 0.2% administered three times daily. Clin Ophthalmol 2013;7:1269-73. Fogagnolo P, Centofanti M, Figus M, et al. Short-term changes in intraocular pressure after phacoemulsification in glaucoma patients. Ophthalmologica 2012;228:154-8. Yasutani H, Hayashi K, Hayashi H, Hayashi F. Intraocular pressure rise after phacoemulsification surgery in glaucoma patients. J Cataract Refract Surg 2004;30:1219-24. Levkovitch-Verbin H, Habot-Wilner Z, Burla N, et al. Intraocular pressure elevation within the first 24 hours after cataract surgery in patients with glaucoma or exfoliation syndrome. Ophthalmology 2008;115:104-8. Wang X, Zhang H, Li S, Wang N. The effects of phacoemulsification on intraocular pressure and ultrasound biomicroscopic image of filtering bleb in eyes with cataract and functioning filtering blebs. Eye 2009;23:112-6.
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14. Inal A, Bayraktar S, Inal B, Bayraktar Z, Yilmaz OF. Intraocular pressure control after clear corneal phacoemulsification in eyes with previous trabeculectomy: a controlled study. Acta Ophthalmol Scand 2005;83:554-60. 15. Chen PP, Weaver YK, Budenz DL, Feuer WJ, Parrish RK II. Trabeculectomy function after cataract extraction. Ophthalmology 1998;105:1928-35. 16. Awai-Kasaoka N, Inoue T, Takihara Y, et al. Impact of phacoemulsification on failure of trabeculectomy with mitomycinC. J Cataract Refract Surg 2012;38:419-24. 17. Manoj B, Chako D, Khan MY. Effect of extracapsular cataract extraction and phacoemulsification performed after trabeculectomy on intraocular pressure. J Cataract Refract Surg 2000;26:75-8. 18. Husain R, Liang S, Foster PJ, et al. Cataract surgery after trabeculectomy: the effect on trabeculectomy function. Arch Ophthalmol 2012;130:165-70. 19. Patel HY, Danesh-Meyer HV. Incidence and management of cataract after glaucoma surgery. Curr Opin Ophthalmol 2013;24:15-20. 20. Siriwardena D, Kotecha A, Minassian D, Dart JK, Khaw PT. Anterior chamber flare after trabeculectomy and after phacoemulsification. Br J Ophthalmol 2000;84: 1056-7. 21. Chang DF, Tan JJ, Tripodis Y. Risk factors for steroid response among cataract patients. J Cataract Refract Surg 2011;37:675-81. 22. Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate 1.0% for the treatment of inflammation after cataract surgery. J Cataract Refract Surg 2013;39: 168-73.
23. Mataftsi A, Narang A, Moore W, Nischal KK. Do reducing regimens of fluorometholone for paediatric ocular surface disease cause glaucoma? Br J Ophthalmol 2011;95:1531-3. 24. Weinreb RN, Wasserstrom JP, Forman JS, Ritch R. Pseudophakic pupillary block with angle-closure glaucoma in diabetic patients. Am J Ophthalmol 1986;102:325-8. 25. Miyake K, Maekubo K, Miyake Y, Nishi O. Pupillary fibrin membrane. A frequent early complication after posterior chamber lens implantation in Japan. Ophthalmology 1989;96: 1228-33. 26. Khor WB, Perera S, Jap A, Ho CL, Hoh ST. Anterior segment imaging in the management of postoperative fibrin pupillaryblock glaucoma. J Cataract Refract Surg 2009;35:1307-12. 27. Pinarci EY, Bayar SA, Sizmaz S, Yesilirmak N, Akkoyun I, Yilmaz G. Anterior segment complications after phacovitrectomy in diabetic and nondiabetic patients. Eur J Ophthalmol 2013;23:223-9. 28. Liu Y, Luo L, He M, Liu X. Disorders of the blood-aqueous barrier after phacoemulsification in diabetic patients. Eye 2004;18:900-4. 29. Yoshino H, Seki M, Ueda J, Yoshino T, Fukuchi T, Abe H. Fibrin membrane pupillary-block glaucoma after uneventful cataract surgery treated with intracameral tissue plasminogen activator: a case report. BMC Ophthalmol 2012;12:3. 30. Geller SL, Xu L. Treatment of fibrinous pupillary membrane occlusion following cataract surgery with microruptor laser. Ophthalmic Surg Lasers 1999;30:310-2. 31. Dabbs CK, Aaberg TM, Aguilar HE, Sternberg P Jr, Meredith TA, Ward AR. Complications of tissue plasminogen activator therapy after vitrectomy for diabetes. Am J Ophthalmol 1990;110:354-60.
© 2014 Wichtig Publishing - ISSN 1120-6721
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Eur J Ophthalmol 2014; 24 ( 5 ): 712-717
ORIGINAL ARTICLE
Reasons for early ocular hypertension after uneventful cataract surgery Fan Fan, Yi Luo, Yi Lu, Xin Liu Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai - China
Purpose: To discuss the reasons for and measurements of early ocular hypertension after uneventful phacoemulsification and intraocular lens (IOL) implantation. Methods: This was a retrospective review of patients who had early ocular hypertension after cataract surgery from a single-surgeon practice that medications failed to control or required additional surgery from September 2011 to January 2013. Results: Of the 1270 eyes that had cataract surgery by one surgeon in our department in 16 months, 12 (9.4‰) eyes of 12 patients met the inclusion criteria. The mean postoperative intraocular pressure (IOP) peak was 41 (range 32-62) mm Hg. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had antiglaucoma surgery history. Ahmed valve implantation with mitomycin C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil needling revision with MMC. The IOP dropped in 3 eyes only in the case that the conventional topical corticosteroid agent was stopped, diagnosed as steroid responders. One eye of a patient with diabetes mellitus (DM) developed pseudophakic pupillary block angle-closure glaucoma due to the plasma glucose fluctuations. The IOP was controlled after Nd:YAG laser iridotomies. Residual cortex caused ocular hypertension in 2 eyes and surgical aspirations were performed. Following monitoring of IOP for 6 to 24 months, all eyes were within the normal range. Conclusions: Patients with history of glaucoma surgery; high myopia, especially in young age; and DM merit particular observation and treatment for possible IOP elevation following cataract surgery. Keywords: Cataract surgery, Diabetes, Ocular hypertension, Phacoemulsification, Steroid responders, Trabeculectomy Accepted: January 21, 2014
INTRODUCTION Many studies have reported early ocular hypertension after cataract surgery with a multifactorial pathogenesis, including inflammation (1), pigment dispersion (2), and retained viscoelastic material (3-5), lens or iris debris (6). With the maturation of phacoemulsification, parallel development in instrumentation and equipment, and antibiotic prophylaxis, postoperative ocular hypertension caused by iatrogenic bacterial endophthalmitis has been declining in recent years (7). Other risk factors that cause intraocular pressure (IOP) elevation, however, may threaten vision after cataract surgery. 712
We examined causes of ocular hypertension that required further treatment after common and uneventful cataract surgery in our department. Identifying these risk factors might forewarn ophthalmologists to use closer postoperative surveillance or alternative pharmacologic or surgical approaches (8).
METHODS Patients Patients who had ocular hypertension (IOP >21 mm Hg) that glaucoma medications failed to control or required
© 2014 Wichtig Publishing - ISSN 1120-6721
Fan et al
additional surgery in the first 3 months after uneventful cataract surgery from September 1, 2011, to January 31, 2013, were reviewed. Intraocular pressure was measured by Goldmann applanation tonometry. Preoperatively, all patients underwent a complete ophthalmologic examination. Intraocular pressure was lower than 21 mm Hg in all eyes. None of the patients was using any medications like steroids or antiglaucoma drugs preoperatively. Patients with previous traumatic history, uveitis, or penetrating keratoplasty and those with complicated cataract surgery were excluded.
Surgical technique Clear corneal phacoemulsification and foldable intraocular lens (IOL) implantation was performed by a single experienced surgeon (Y.L.). All procedures were performed with the patient under topical anesthesia. A 2.8-mm clear corneal upper incision was made. Viscoelastic was injected (DisCoVisc, Alcon, Inc., Fort Worth, Texas, USA), and a continuous curvilinear capsulorhexis and hydrodissection
of the nucleus was performed. Phacoemulsification of the nucleus was performed using the phaco-chop technique. A foldable IOL was implanted in the bag, viscoelastic was removed by irrigation/aspiration, and the corneal incision was left unsutured. One day postoperatively, prednisolone acetate and levofloxacin eyedrops were started 3 times every day and tapered 2 weeks. Pranoprofen eyedrops were prescribed at a dose of 3 times every day for 4 weeks.
RESULTS Of the 1270 eyes that underwent cataract surgery by one surgeon in our department in 16 months, 12 (9.4%) eyes of 12 patients met the inclusion criteria. The characteristics and treatment are listed in Table I. The average age was 55 years. All patients complained of ocular pain and decreased vision at the initial onset of the glaucoma secondary to phacoemulsification. The mean postoperative IOP peak was 41 mm Hg (range 32-62) with worse than 0.02
TABLE I - CHARACTERISTICS AND TREATMENT OF THE ENROLLED EYES Case
Sex/ IOP peak, Age, y mm Hg
Time of Relative initial disease onset, d history
Ocular surgery history
Interval Medication between treatment for ocular CS and hypertension Tb, mo
Course of Resolve medication measurement treatment, wk
1
F/69
37
1
PACG
Tb + MMC
96
Tim, Bri, Ace, Man
7
Ahmed
2
M/67
35
60
PACG
Tb + MMC
3
Tim, Bri, Ace
6
Ahmed
3
M/70
48
1
PACG
Tb + MMC
48
Tim, Bri, Ace, Man
7
Ahmed
4
M/61
54
1
PACG
Tb + MMC
6
Tim, Bri, Ace, Man
6
Ahmed
5
F/56
39
50
PACG
Tb + MMC
6
Tim, Bri, Ace, Man
4
5-FU needling
6
F/50
62
1
PACG
Tb + MMC
17
Tim, Bri, Lat, Ace, Man
3
5-FU needling
7
M/45
35
7
High myopia
No
/
Tim, Bri, Ace
5
Stop using steroids
8
M/40
37
30
High myopia
No
/
Tim, Bri, Ace, Man
4
Stop using steroids
9
F/50
35
5
High myopia
No
/
Tim, Bri, Lat, Ace
4
Stop using steroids
10
F/59
32
7
DM
No
/
Tim, Bri
1
Laser iridotomies
11
F/52
40
2
No
No
/
/
/
Surgical aspiration of retained cortex
12
M/65
39
1
No
No
/
/
/
Surgical aspiration of retained cortex
5-FU needling = 5-fluorouracil needling revision with mitomycin C; Ace = acetazolamide combined with potassium chloride sustained release tablets; Bri = brimonidine; CS = cataract surgery; DM = diabetes mellitus; Lat = latanoprost; Man = mannitol; MMC = mitomycin C; PACG = primary angle-closure glaucoma; Tb = trabeculectomy; Tim = timolol.
© 2014 Wichtig Publishing - ISSN 1120-6721
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Early ocular hypertension after cataract surgery
decimal visual acuity. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had trabeculectomy for primary angle-closure glaucoma before cataract surgery. The mean age of the 6 patients was 60 years. The median time interval between the 2 surgeries was 11.5 months. We used timolol combined with brimonidine eyedrops 3 times daily or added oral acetazolamide (9, 10). Intravenous mannitol was administered for 3 days if IOP exceeded 35 mm Hg. The IOP could not be controlled after medications for an average of 5.5 weeks; as a result, Ahmed valve implantation with mitomycin-C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil (5-FU) needling revision with MMC. Intraocular pressures were in the normal range without drugs in the late follow-up period. Glaucoma medications did not work until the postoperative conventional topical corticosteroid agent was stopped in 3 eyes. Intraocular pressure was in the normal range when we stopped all the eyedrops at 4 or 5 weeks postoperatively. Thus, the 3 cases were diagnosed as steroid responders. Interestingly, 2 of the 3 eyes had high myopia with mean axial length of 26.1 mm. One patient had sudden ocular pain in the operated eye on the seventh postoperative day. The IOP was 32 mm Hg. Slit-lamp examination revealed cornea edema and fibrinous membrane covering the pupil. The patient had a diabetes mellitus (DM) history of at least 10 years. Fasting plasma glucose at the time was 12.6 mmol/L; it was 7.8 mmol/L in the preoperative blood test. Aside from 4 times daily prednisolone acetate 1%, cycloplegics and glaucoma medications (timolol combined with brimonidine) were added to the operated eye topically. The IOP was not reduced significantly after 1-week medication course. Then we performed Nd:YAG laser peripheral iridotomies, opening 2 laser holes at 4 and 8 o’clock. The IOP decreased to 16 mm Hg in 3 hours and remained in the normal range afterwards. Uncorrected decimal visual acuity improved from 0.01 to 0.5. Residual cortex caused ocular hypertension in the 2 remaining eyes and the surgical aspirations were performed.
DISCUSSION Although postoperative IOP peaks may occur in eyes with no history of glaucoma, the spikes are more prolonged and pronounced in patients with preexisting glaucoma (10-12). 714
In the present study, of all the cases with uncontrolled IOP after phacoemulsification, the majority of eyes had previous trabeculectomy for primary angle-closure glaucoma before cataract surgery. Some clinical studies found that phacoemulsification had an adverse effect on the maintenance of the filtering bleb, although the effect was smaller than that of extracapsular cataract extraction (ECCE) (13, 14). The cause of an adverse effect of phacoemulsification on IOP control, if any, is assumed to be surgery-induced inflammation that causes stimulation of subconjunctival scarring, which would result in the failure of bleb function. In this model, the interval between the initial trabeculectomy and subsequent phacoemulsification may be a critical factor in the failure of trabeculectomy. Likewise, Chen et al (15) found that an interval of fewer than 6 months between trabeculectomy and cataract extraction was a risk factor for the loss of IOP control. Moreover, a Cox proportional hazards analysis revealed that postoperative IOP in eyes with previous trabeculectomy might be affected by the IOP before trabeculectomy and phacoemulsification within 1 year after trabeculectomy (16). Another study analyzed the effect of phacoemulsification more than 2 years after trabeculectomy (21 eyes) and found that the IOP after phacoemulsification was not significantly higher than that before phacoemulsification at any time point (17). Taken together, these findings may indicate that a filtering bleb requires 1 to 2 years to stabilize against phacoemulsification (18). Younger age is another factor that predisposes to bleb failure, with one study reporting that patients younger than 50 years have a significantly increased risk (15). In the 6 eyes of our study, the median time interval between the 2 surgeries was 11.5 months. The mean age of the 6 patients was 60 years. After an average of 5.5 weeks medication course, IOP did not drop. In the end, we had to apply Ahmed valve implantation or 5-FU needling revision with MMC to keep IOP in the normal range without drugs. Accordingly, in order to minimize IOP rise in patients who had previous trabeculectomy after uneventful cataract surgery, prophylaxis may be adopted. All patients should be advised of the potential risk as part of the consent procedure (19). It is generally advisable to delay cataract surgery until 1 to 2 years after trabeculectomy if possible (19). Minimal conjunctival and iris manipulation is recommended (15). More aggressive anti-inflammatory treatment in the postoperative period may decrease the risk of bleb failure (20). Aside from patients with known glaucoma or hypertension history, there are other risk factors for high IOP after
© 2014 Wichtig Publishing - ISSN 1120-6721
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phacoemulsification. Considering that topical corticosteroid agents are routinely prescribed after cataract surgery, large populations are exposed to the risk for a topical steroid response. Although the IOP rise is generally reversible and treatable and is usually well-tolerated, the elevations may be sufficiently high and prolonged to cause ocular morbidity. In our series, IOP dropped in 3 eyes only when the topical corticosteroid agent that postoperative conventionally used was stopped. Interestingly, the 3 patients were relatively young in the current study group, with mean age of 45 ± 5 years. Of note, 2 of them had high myopia, with mean axial length of 26.1 mm. Chang et al (21) reviewed 1642 patients who had uneventful cataract surgery; 39 were diagnosed as steroid responders, defined as an IOP increase greater than 25% while on topical prednisolone (minimum 28 mm Hg) followed by a decrease of more than 25% after topical prednisolone was discontinued. Comparing the age and axial length between steroid responders and nonresponders, the study concluded that younger patients with high myopia had a higher risk for postoperative steroid response after uneventful cataract surgery and may require more frequent IOP monitoring or alternative topical anti-inflammatory medications. The characteristics of the 3 steroid responders in our study were in accordance with the conclusions of Chang et al. This gives us several practical clinical implications. Although every patient being treated with ocular steroids should be monitored for a possible IOP elevation, younger patients with axial high myopia merit more frequent follow-up. Alternative pharmacologic therapy might also be considered for higher risk patients. Topical nonsteroidal anti-inflammatory drugs alone may be sufficient to suppress postoperative inflammation after uneventful cataract surgery in many eyes. Certain topical corticosteroid agents, such as loteprednol etabonate and fluorometholone, are less likely to induce an IOP response (22, 23). Finally, a shorter than usual course of topical corticosteroid treatment could be considered in higher risk patients. Since having changed our cataract operation technique from ECCE to phacoemulsification, we had the impression of less fibrinous membranes postoperatively. Fibrinous exudate pupillary membrane occlusion and secondary glaucoma are relatively rare complications after cataract surgery with modern techniques and instruments. So far, DM has been proposed as risk factor of pseudophakic pupillary block and angle-closure glaucoma (24, 25). Khor et al (26) reported fibrin pupillary-block glaucoma after phacoemulsi-
fication cataract surgery in 4 patients, 3 of whom had DM. One study on anterior segment complications after phacovitrectomy comparing diabetic and nondiabetic patients also concluded that the ratio of fibrinous uveitis was significantly higher in the diabetic group (27). Previous reports suggested that propensity to breakdown of the bloodaqueous barrier in diabetic patients was associated with fibrin formation after cataract surgery (25, 28). In particular, DM with uncontrolled plasma glucose tends to lead to serious noninfectious inflammation after cataract surgery. However, ophthalmologists are apt to overlook plasma glucose fluctuations in DM and unable to take precautions in advance. In the present pupillary membrane occlusion case, the patient had 10 years DM history with 12.6 mmol/L fasting plasma glucose at the onset of secondary glaucoma. The treatment of fibrin pupillary-block glaucoma has not been officially established. Ocular hypertension develops when an inflammatory fibrin membrane occludes the pupil, resulting in peripheral angle closure (26). When we met with the patient, topical cycloplegics and corticosteroids were first selected to dilate the secluded pupil and promote anti-inflammation, thus breaking the membranous occlusion and opening the physiologic aqueous fluid pathway. However, medications failed to release the pupil and reoperation to dissect the synechia would create a second trauma to the inflamed eye. Therefore, we performed iridotomy using Nd:YAG laser to open the aqueous fluid pathway and got immediate good results. In one case series of 6 diabetic patients who developed pseudophakic pupillary block with angle-closure glaucoma after undergoing ECCE, laser iridotomies were performed in 4 eyes and decreased the IOP in 3. Thus the author recommended that a peripheral iridectomy should be performed in pseudophakic eyes of patients with DM at the time of the cataract surgery (24). In another case series of fibrin pupillary-block glaucoma after phacoemulsification cataract surgery, all patients were successfully treated by Nd:YAG laser peripheral iridotomy (26). Nevertheless, iridotomy is not the only way to handle the condition and it has the potential risk of damaging the corneal endothelium when there is severe corneal edema or iridocorneal contact (29). Geller and Xu (30) reported a successful result using Nd:YAG laser technique to dissect and move the dense pupillary membrane away in one case with rheumatoid arthritis who had severe induced iritis with dense fibrinous pupillary membrane occlusion and high IOP following cataract surgery. Yoshino et al (29) first reported fibrin pupillary-block glaucoma after cataract
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surgery successfully treated with intracameral tissue plasminogen activator (tPA). But tPA intraocular injection had initial severe complications like intraocular bleeding and recurrence of fibrin accumulation (31). In summary, eyes with history of glaucoma or glaucoma surgery, relatively young patients with high myopia, and patients with DM were at higher risk of ocular hypertension after phacoemulsification. These risk factors may forewarn ophthalmologists to merit closer observation and take preventive measures in particular individuals. We recommend that these eyes should be monitored closely and frequently, especially 6 hours after surgery, the next day, and at 1, 2, and 4 weeks. It is generally advisable to delay cataract surgery for 1 to 2 years in previous trabeculectomy patients. Alternative postoperative pharmacologic therapy should be adopted in the high-risk eye, including choosing loteprednol etabonate or equivalent rather than prednisolone acetate and shortening the topical steroid course. With regard to patients with DM, keep-
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ACKNOWLEDGMENT The authors thank Dr. Jianhui Zhuang from the School of Medicine of Tongji University for comments and suggestions. Financial Support: Supported by grants from the National Natural Science Foundation of China (Grant No. 81371002). Conflict of Interest Statement: None of the authors has conflict of interest with this submission. Address for correspondence: Yi Luo 83 Fenyang Road Shanghai 200031 China [email protected]
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