UNUSUAL EARLY-ONSET PHACOLYTIC GLAUCOMA

Description of a rare case of phacolytic glaucoma occuring at a relatively young age of 63 years, emphasizing the clinical features, diagnostic and treatment challenges and favorable postoperative evolution after surgical management.

Ophthalmology Department, University Hospital - Cluj-Napoca, Romania

A 63-year-old woman presented with sudden-onset pain and redness in the right eye for three days, accompanied by progressively decreasing visual acuity. The ocular symptoms have been worsening and are associated with headache, nausea and vomiting. On examination, her visual acuity was light perception oculus dexter (OD) and 0,9 without correction oculus sinister (OS). On slit-lamp evaluation, OD showed mixed conjunctival hyperemia, diffuse corneal edema, white deposits in the anterior chamber, pseudohypopyon and brunescent corticonuclear lens opacities. OS had a multifocal intraocular lens (IOL), well positioned and centered. Intraocular pressure (IOP) measured 40 mmHg OD and 16 mmHg OS. Dilated fundus examination of the OD could not be performed. Fundus examination OS revealed a vital optic disc, well demarcated, without pathological cupping, macula with a blurred reflex and a slight increase in arteriolar reflex. B-scan ultrasonography showed a hyperechoic structure anteriorly with no vitreous or retinal pathology. The patient was diagnosed with phacolytic glaucoma and hypermature cataract OD and pseudophakia and hypertensive angiopathy OS, associated with essential hypertension.

The local treatment of the OD consisted of dorzolamide and Betabioptal. The systemic therapy included one tablet of acetazolamide twice daily and aspacardine administered the same way. The surgical approach was technically demanding due to the advanced stage of the cataract OD and consisted of aspiration of crystalline lens proteins from the anterior chamber combined with phacoemulsification and IOL implantation into the capsular bag.

2 weeks post-surgery OD: visual acuity was 0,2 without correction and 0,6 with correction, no conjunctival or perikeratic congestion, clear cornea, fine Descemet’s folds, IOL well positioned and centered, posterior capsular fibrosis. IOP was 19 mmHg. Fundus examination OD showed: slightly pale optic disc, well demarcated, macula with diminished reflex, 2 cotton-wool spots located superotemporal (ST) to the optic disc, flame-shaped hemorrhage located ST to the macula, mild increase in arteriolar reflex.
2 months postoperative Optical Coherence Tomography (OCT) for ganglion cell layer and retinal nerve fiber layer (RNFL) was performed and revealed a structural thinning of the retinal nerve fiber layer and ganglion cells.

Phacolytic glaucoma is a rare form of secondary glaucoma and represents an ophthalmic emergency, requiring prompt surgical treatment. In this case, the phacolytic glaucoma developed as a complication due to delayed surgery of the cataract, emphasizing the importance of early cataract management.