Phacolytic glaucoma is an inflammatory glaucoma caused by the leakage of lens protein through the capsule of a mature or hypermature cataract (Fig 4-10). As the lens ages, its protein composition becomes altered, with an increased concentration of high-molecular-weight lens protein. In a mature or hypermature cataract, these proteins are released through microscopic openings in the lens capsule. The proteins precipitate a secondary glaucoma as these lens proteins, phagocytizing macrophages, and other inflammatory debris obstruct the trabecular meshwork.
The clinical picture usually involves an elderly patient with a history of poor vision who has sudden onset of pain, conjunctival hyperemia, and worsening vision. Examination reveals a markedly elevated IOP, microcystic corneal edema, prominent cell and flare reaction without keratic precipitates (KP), and an open anterior chamber angle (Fig 4-11). The lack of KP helps distinguish phacolytic glaucoma from phacoantigenic glaucoma. Cellular debris may be seen layering in the anterior chamber angle, and a pseudohypopyon may be present. Large white particles (clumps of lens protein) may also be seen in the anterior chamber. A mature or hypermature (morgagnian) cataract is present, often with wrinkling of the anterior lens capsule representing loss of volume and the release of lens material (see Fig 4-10). Although medications to control the IOP should be used immediately, definitive therapy requires cataract extraction.