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Describe after-cataract and lens-induced glaucoma.

Ophthalmology · 3rd Professional

After-cataract

After-cataract is opacification of the retained posterior capsule and any residual lens matter after extracapsular cataract surgery.
It is the commonest late complication of cataract surgery, and is sometimes called secondary cataract or posterior capsular opacification.
Mechanism — the surgery necessarily leaves behind the lens epithelial cells of the anterior capsule and the equatorial germinative zone. These cells proliferate, migrate across the posterior capsule, and undergo fibrous metaplasia into myofibroblasts, which contract and wrinkle the capsule

Type	Description
Elschnig’S pearls	Clusters of swollen, vacuolated, translucent "bladder cells" — abortive attempts by the epithelial cells to form new lens fibres. They look like a cluster of soap bubbles or fish eggs on retroillumination, and are the commoner form
Soemmering’S ring	A doughnut-shaped ring of retained cortical matter trapped between the anterior and posterior capsule leaves at the periphery. Often visually insignificant because it lies outside the pupil
Fibrous type	A thin, wrinkled, fibrotic membrane from myofibroblastic metaplasia; less common but more difficult to treat

Lens-induced Glaucoma

Type	Mechanism and features
Phacomorphic glaucoma	An intumescent (swollen) cataract pushes the iris-lens diaphragm forward, producing pupil block and acute angle closure. Presents exactly as acute angle-closure glaucoma — severe pain, haloes, a hazy cornea, a mid-dilated fixed pupil and a rock-hard eye — but with a visible cataract and a normal fellow eye angle. Treated by controlling the pressure medically, then urgent cataract extraction.
Phacolytic glaucoma	In a hypermature or Morgagnian cataract, high-molecular-weight lens protein leaks out through an intact capsule. Macrophages engorged with protein then obstruct the trabecular meshwork. An open-angle glaucoma with a deep anterior chamber, intense flare with large floating white cells and a pseudohypopyon, but NO keratic precipitates and NO synechiae. Treated by pressure control and then lens extraction
Lens particle glaucoma	After capsule rupture from trauma or surgery, retained cortical particles directly obstruct the meshwork. Anterior chamber shows white fluffy cortical material. Treated by removing the retained matter
Phacoantigenic (phacoanaphylactic) uveitis	An immune granulomatous reaction to exposed lens protein after capsule rupture. Granulomatous uveitis with keratic precipitates and synechiae, often weeks after the injury. Treated with steroid and removal of all lens material
Glaucoma from a dislocated lens	By pupil block (anterior dislocation) or by direct angle obstruction

Applied Aspects

Explain that the cataract has not come back; patients with after-cataract believe the operation failed, and a clear explanation and a five-minute laser resolve both the vision and the anxiety
Check the pressure an hour after YAG capsulotomy, particularly in a glaucomatous eye; a transient spike is the commonest complication and is treatable
Do a primary posterior capsulotomy in every child; after-cataract is universal and rapid, and they cannot cooperate with a laser

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