The Clinical Outcomes of Cataract Extraction by Phacoemulsification in Eyes With Primary Angle-Closure Glaucoma (PACG) and Co-Existing Cataract

Phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle-closure glaucoma without cataract

OBJECTIVE

To compare phacoemulsification versus trabeculectomy with adjunctive mitomycin C in medically uncontrolled chronic angle-closure glaucoma (CACG) without cataract.

DESIGN

Prospective, randomized clinical trial.

PARTICIPANTS

Fifty medically uncontrolled CACG eyes without cataract of 50 patients.

INTERVENTION

Patients were randomized into undergoing either phacoemulsification or trabeculectomy with adjunctive mitomycin C. After surgery, patients were followed up every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for glaucoma drugs.

RESULTS

Twenty-six CACG eyes were randomized to receive phacoemulsification, and 24 eyes underwent trabeculectomy with mitomycin C. Phacoemulsification and trabeculectomy resulted in significant and comparable IOP reduction at 24 months after surgery (reduction of 8.4 mmHg or 34% for phacoemulsification vs. 8.9 mmHg or 36% for trabeculectomy; P=0.76). Over first 24 months, trabeculectomy-treated eyes required on average 1.1 fewer drugs than phacoemulsification-treated eyes (P<0.001). However, trabeculectomy was associated with significantly more surgical complications than phacoemulsification (46% vs. 4%; P=0.001). Eight (33%) of 24 trabeculectomy eyes demonstrated cataract during follow-up.

CONCLUSIONS

Both phacoemulsification and trabeculectomy are effective in reducing IOP in medically uncontrolled CACG eyes without cataract. Trabeculectomy is more effective than phacoemulsification in reducing dependence on glaucoma drugs, but is associated with more complications.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Microcoaxial phacoemulsification combined with viscogoniosynechialysis for patients with refractory acute angle-closure glaucoma

PURPOSE

To evaluate the safety and efficacy of microcoaxial phacoemulsification combined with viscogoniosynechialysis in managing refractory acute angle-closure glaucoma (AACG) unresponsive to conventional therapy.

METHODS

Seventeen consecutive eyes of patients with AACG>270 degrees peripheral anterior synechiae were treated with microcoaxial phacoemulsification combined with viscogoniosynechialysis. After intraocular lens implantation, a heavy viscoelastic agent was used to deepen the anterior chamber, and then injected near the angle for 360 degrees without touching any ocular structure, to release the peripheral anterior synechiae under gonioscopy. The viscoelastic agent was then removed.

RESULTS

Intraocular pressure was reduced from a median of 45.0 mm Hg initially to 15.0 mm Hg after the combined procedures at the final follow-up visit (P<0.001). All angles showed exposure of the trabecular meshwork over 360 degrees postoperatively without residual synechiae. The mean best corrected visual acuity improved from 0.7 to 0.18 logMAR at 6-month follow-up (P<0.001). Surgically induced astigmatism was 0.29 at 6-month follow-up. There was a 6.4% reduction in the mean corneal endothelial cell count. No severe complications were observed in any patient.

CONCLUSIONS

Microcoaxial phacoemulsification combined with viscogoniosynechialysis is an effective and safe treatment for managing refractory AACG. Using a 2.2-mm incision caused less surgically induced astigmatism and also improved visual quality.

Conventional and emerging treatments in the management of acute primary angle closure

The management of acute primary angle closure is directed at lowering the intraocular pressure and relieving pupil block. Conventional treatment involves the use of medical treatment and laser peripheral iridotomy, respectively, as a means for achieving these aims. Newer therapeutic strategies have been described that are potentially useful adjuncts or alternatives to conventional treatment. Emerging strategies that lower intraocular pressure include anterior chamber paracentesis, as well as laser procedures such as iridoplasty and pupilloplasty. A possible alternative to relieving pupil block is lens extraction, and may be combined with adjunctive measures such as goniosynechiolysis and viscogoniosynechiolysis. Trabeculectomy has a limited role in the acute setting. This review paper reviews the current evidence regarding conventional and newer treatment modalities for acute primary angle closure.

Long-term changes in endothelial cell counts after early phacoemulsification versus laser peripheral iridotomy using sequential argon:YAG laser technique in acute primary angle closure

OBJECTIVE

To compare the change in endothelial cell counts (ECC) after early phacoemulsification and laser peripheral iridotomy (LPI) using sequential argon:yttrium-aluminum-garnet (YAG) laser technique for the treatment of acute primary angle closure (APAC).

METHODS

This was a retrospective chart review, case-control study; 86 APAC patients were enrolled. Sixteen patients who underwent early phacoemulsification with intraocular lens implantation and 32 patients who underwent LPI were matched by propensity score analysis. All subjects underwent a complete ophthalmic examination, including intraocular pressure (IOP) measurements, optic disc examinations, and gonioscopy. ECC were acquired at the center of the cornea with a noncontact specular microscope before treatment, and at 1, 6, 12, and 24 months following phacoemulsification or LPI.

RESULTS

The mean follow-up was 26.1 ± 4.7 months in the phacoemulsification group and 26.3 ± 4.5 months in the LPI group. After intervention, the changes in anterior chamber depth and Shaffer grading by gonioscopy were significantly different between groups. ECC were not different before treatment; however, after phacoemulsification or LPI at 12 months (2280 ± 320 vs 1993 ± 380 cells/mm(2)) and 24 months (2113 ± 333 vs 1880 ± 422 cells/mm(2)), there was a significant difference between the two groups (P = 0.040 and P = 0.032 respectively). Regression analysis showed that anterior chamber depth at baseline (P = 0.041) and intervention modality (phacoemulsification vs LPI; P < 0.001) were significantly related to the change in ECC.

CONCLUSIONS

Early phacoemulsification showed lower endothelial cell loss than did LPI in the treatment of APAC after a 2-year follow-up. In terms of ECC, early phacoemulsification could be a better intervention modality for APAC.

There is insufficient evidence to recommend lens extraction as a treatment for primary open-angle glaucoma: an evidence-based perspective

Cataract extraction in primary open-angle glaucoma has not been thought to provide a clinically useful or predictable decrease in IOP. This concept has now been challenged, with the opposite belief being promulgated: namely, that lens exchange should be considered as treatment for glaucoma. This revelation could bring a significant change in the glaucoma treatment paradigm. There are no randomised controlled trials to guide the role of lens extraction in primary open-angle glaucoma. The available evidence suggests at most a modest reduction in IOP from cataract extraction - greater in the presence of pseudoexfoliation - which is likely to be of marginal benefit, and only in milder forms of open-angle glaucoma. There is currently no evidence of any quality to suggest that lens extraction routinely represents a clinically useful treatment for primary open-angle glaucoma.

Association of biometric factors with anterior chamber angle widening and intraocular pressure reduction after uneventful phacoemulsification for cataract

PURPOSE

To evaluate anterior chamber biometric factors associated with the degree of angle widening and intraocular pressure (IOP) reduction after phacoemulsification.

SETTING

University of California, San Francisco, California, USA.

DESIGN

Case series.

METHODS

Anterior chamber parameters obtained by anterior segment coherence tomography were compared preoperatively and 3 months postoperatively. Measurements included the angle opening distance 500 μm anterior to the scleral spur (AOD500), trabecular-iris space area 500 μm from the scleral spur (TISA500), iris curvature (I-Curv), anterior chamber angle (ACA), trabecular-iris space area, anterior chamber volume, anterior chamber width, and lens vault (LV).

RESULTS

The study enrolled 73 eyes. The mean patient age was 77.45 years ± 7.84 (SD); 65.75% of patients were women. From preoperatively to 3 months postoperatively, the mean AOD500 increased significantly (0.254 ± 0.105 to 0.433 ± 0.108 mm) and the mean IOP decreased significantly (14.97 ± 3.35 to 12.62 ± 3.37 mm Hg) (P<.001). The reduction in IOP was correlated with the increase in AOD500 (r = 0.240, P=.041) and preoperative LV (r = 0.235, P=.045). After adjusting for related factors, AOD500 widening was positively correlated with LV (β = 0.458, P=.044) and I-Curv (β = 0.235, P=.043) and negatively correlated with preoperative TISA500 (β = -0.269, P=.025) and ACA (β = -0.919, P=.027).

CONCLUSIONS

Surgically induced AOD widening was significantly correlated with anterior chamber biometric factors. Preoperative LV appears to be a significant factor in angle widening and IOP reduction after phacoemulsification.

Ultrasound biomicroscopic assessment of angle parameters in patients with primary angle closure glaucoma undergoing phacoemulsification

PURPOSE

To evaluate the effect of phacoemulsification and foldable intraocular lens (IOL) implantation on biometric determinants of the anterior chamber angle in primary angle closure glaucoma (PACG) using ultrasound biomicroscopy (UBM).

METHODS

Forty-six eyes of 46 patients with chronic PACG and cataract having a patent laser iridotomy were included in this prospective, interventional case series. Angle parameters were measured using UBM before surgery and 3 months after phacoemulsification with IOL implantation. Intraocular pressure (IOP) was measured by applanation tonometer and records of glaucoma medication administered were maintained. Main outcome measures were IOP, central anterior chamber depth (ACD), trabecular iris angle (TIA), and angle opening distance at 250 and 500 µm from scleral spur (AOD250 and AOD500).

RESULTS

The mean age of study participants was 56.5 ± 9.9 years (range 44-75). The preoperative mean IOP was 25.0 ± 5.4 mmHg on maximum antiglaucoma medication, which was reduced to 15.8 ± 3.8 mmHg (p = 0.0001) at 3 months. Number of antiglaucoma medications also decreased from 2.4 ± 1.1 to 0.4 ± 1.1 (p = 0.0001). There was a significant widening of the anterior chamber angle with the TIA increasing significantly after phacoemulsification (p<0.001) with an associated increase in AOD250, AOD500, and ACD (p<0.001).

CONCLUSIONS

Phacoemulsification in eyes with PACG results in significant widening of the anterior chamber angle. This results in better IOP control after surgery and decreases the need for glaucoma medications. These findings are of clinical significance in obviating the need for simultaneous filtering surgery in eyes with PACG undergoing phacoemulsification cataract surgery.

Primary lens extraction for glaucoma management: A review article

Recently, primary lens extraction alone gained more acceptance as an alternative surgical approach for glaucoma management. This view was supported by the advances in phacoemulsification and intraocular lenses with greater safety and visual recovery, in addition to a substantial reduction of intraocular pressure and deepening of the anterior chamber and filtration angle. The decrease in IOP after cataract surgery in primary open-angle glaucoma (POAG) is mild, less predictable, related to baseline levels, and may return to presurgical values after an initial period of reduction. Therefore, the IOP-lowering effect of primary cataract extraction in POAG may be insufficient to achieve adequate IOP control. The IOP reduction after lens extraction is consistently greater in eyes with primary angle closure glaucoma (PACG) than in eyes with POAG. Primary lens extraction in acute PACG eliminates, or at least, reduces the risk of recurrence of acute attacks and deepens the anterior chamber and widens the angle which reduces the risk of progression of peripheral anterior synechiae and development of chronic PACG. Primary lens extraction may be more preferable to glaucoma incisional surgery in mild to moderate PACG eyes with appositional angle closure. The decision to do lens extraction as a primary treatment for glaucoma should be individualized based upon several factors other than the effect on IOP. These factors include patients' characteristics, surgeons' skills and preferences, status of glaucoma control, type of cataract and intraocular lens implanted, and potential harm of laser treatment for late capsular opacification and fibrosis.

Surgical treatment for primary angle closure-glaucoma: a Meta analysis

AIM

To evaluate the efficacy and safety of trabeculectomy, phacotrabeculectomy plus intraocular lens implantation(phacotrab+IOL group) and phacoemulsification with IOL(phaco+IOL) in primary angle-closure glaucoma(PACG).

METHODS

It was a systematic review and meta-analysis, randomized controlled trials(RCT) and clinical controlled trials(CCT) were collected through electronic searches of the Cochrane Library, PubMed, EMbase, Wanfang Database online, Chinese journal Full-text Database, Chinese Scientific Journals Full-text Database (from the date of building the database to October 2010) We also checked the bibliographies of retrieved articles. All the related data that matched our standards were abstracted. The quality of included trials was evaluated according to the Dutch Cochrane Centre. RevMan 5.0 software was used for Meta-analysis.

RESULTS

A total of 5 RCT and 11 CCT involving 1495 eyes were included. The results of meta-analysis showed that phacotrab+IOL group was superior than trabeculectomy(trab group) (MD -3.93,95%CI [-7.31, -0.54]) which was also superior than phaco+IOL group(MD 0.52,95%CI [0.10, 0.95]) in decreasing Intraocular Pressure(IOP). Phacotrab group(MD -1.45,95%CI [-1.68, -1.22])and phaco group (MD-1.12,95%CI [-1.87, -0.37])are both deeper than trab group in the anterior chamber depth. In increasing the coefficient of outflow facility of aqueous humor(C values) there was no statistical difference in the three groups. And there was no statistical difference between phacotrab groups and phaco groups in visual acuity but phacotrab group was superior than phaco group (MD 1.07, 95%CI [0.73, 1.40])in the use of IOP-lowering drugs. There was no statistical difference among three groups.

CONCLUSION

Current evidence suggests that phacotrab+ IOL group was superior than trab group which was also superior than phaco+IOL group in decreasing IOP. Phacotrab group and phaco group are both deeper than trab group in the anterior chamber depth. Phacotrab group was superior than phaco group in the use of IOP-lowering drugs.

Capsule wrinkling during capsulorhexis in patients with primary angle-closure glaucoma and cataract

PURPOSE

To evaluate the frequency of capsule wrinkling and associated factors during capsulorhexis in patients with primary angle-closure glaucoma (PACG) undergoing cataract surgery.

METHODS

This prospective study enrolled 91 eyes of 91 patients (26 eyes with PACG, 65 control eyes) who underwent cataract surgery. Capsule wrinkling during capsulorhexis was determined intraoperatively. The PACG group was evaluated for factors associated with capsule wrinkling such as intraocular pressure (IOP) on presentation, history of acute attacks, previous laser or trabeculectomy surgery, iris atrophy, peripheral anterior synechiae, and posterior synechiae.

RESULTS

The frequency of capsule wrinkling was higher in the PACG group (7/26, 26.9%) than in the control group (0/65, 0%) (P < 0.0001). Among the PACG patients, capsule wrinkling was associated with a higher IOP on presentation (54.71 ± 16.15 mmHg) than in patients without capsule wrinkling (32.95 ± 11.21 mmHg) (P = 0.001). Iris atrophy was significantly related to capsule wrinkling (P = 0.028), and the location of iris atrophy correlated with that of capsule wrinkling in 80% of cases (4/5).

CONCLUSIONS

Capsule wrinkling during capsulorhexis was a significant finding in some patients with cataract and PACG, especially when the IOP on presentation was high and iris atrophy was present.

Phacoemulsification alone versus phacoemulsification combined with trabeculectomy for primary angle-closure glaucoma

Surgical outcomes of phacoemulsification only and phacoemulsification combined with trabeculectomy were compared in patients with primary angle-closure glaucoma (PACG). Clinical records of 41 consecutive patients were retrospectively reviewed, and there was no difference in best-corrected visual acuity and intraocular pressure preoperatively and at the final follow-up in both study groups. Regarding the number of anti-glaucoma medications, it was higher in the phacoemulsification combined with trabeculectomy group preoperatively than the phacoemulsification only group (p = 0.045), but both groups were taking similar quantities of medication at the final follow-up (p = 0.6). In addition, postoperative hypotony (two cases) occurred only after phacoemulsification combined with trabeculectomy, but not after phacoemulsification only. In one case after phacoemulsification only, a second operation was needed. There were no additional postoperative complications. In conclusion, both phacoemulsification only and phacoemulsification combined with trabeculectomy showed good surgical outcomes in PACG patients. Both procedures might be equally effective in treating patients with PACG.

Phacoemulsification and trabeculotomy combined with goniosynechialysis for uncontrollable chronic angle-closure glaucoma

BACKGROUND AND OBJECTIVE

To assess and explore the effectiveness of phacoemulsification and trabeculotomy combined with goniosynechialysis in lowering intraocular pressure in eyes with uncontrollable chronic angle-closure glaucoma.

PATIENTS AND METHODS

The medical charts of 24 eyes of 22 patients with chronic angle-closure glaucoma were reviewed retrospectively. The probability of successful treatment in 12 eyes that had earlier glaucoma attacks and 12 that did not have an attack were evaluated with Kaplan-Meier life-table analysis with the target pressure set at 15 mm Hg.

RESULTS

Mean preoperative intraocular pressure for all eyes was 33.3 +/- 12.0 mm Hg and decreased to 11.8 +/- 2.3 mm Hg. The success rate was 86.6% at 1 year after surgery. Life-table analysis showed that there was no significant difference in the two groups.

CONCLUSION

Phacoemulsification and trabeculotomy combined with goniosynechialysis is an effective surgical treatment for chronic angle-closure glaucoma in eyes with or without a previous glaucoma attack.

Effects of phacoemulsification versus combined phaco-trabeculectomy on drainage angle status in primary angle closure glaucoma (PACG)

PURPOSE

To document anatomic effects of phacoemulsification versus combined phaco-trabeculectomy on drainage angle in primary angle closure glaucoma (PACG).

METHODS

Indentation gonioscopy and ultrasound biomicroscopy were performed preoperatively, and then at 1 year after phacoemulsification alone or combined phaco-trabeculectomy in PACG patients.

RESULTS

Seventy-two PACG eyes of 72 patients were included in this study. Thirty-eight eyes were randomized into receiving phacoemulsification alone, whereas 34 eyes had combined phaco-trabeculectomy. The mean extent of synechial angle closure was significantly reduced from 266.4 degrees to 198.9 degrees (P<0.001) by phacoemulsification alone, and from 266.0 degrees to 227.2 degrees (P=0.03) by combined surgery. The mean angle opening distance (AOD 500) measured by ultrasound biomicroscopy was significantly increased from 208.0 to 468.0 microm (P<0.001) by phacoemulsification, and from 214.6 to 344.4 microm (P<0.001) by combined surgery. The mean trabecular-ciliary process distance was significantly increased from 824.6 to 1043.6 microm (P<0.001) by phacoemulsification, and from 800.9 to 951.5 microm (P=0.01) by combined surgery. The mean anterior chamber depth was significantly increased from 1798.6 to 3528.4 microm (P<0.001) by phacoemulsification alone, and from 1781.6 to 3297.8 microm (P<0.001) by combined surgery. Phacoemulsification alone resulted in significantly greater postoperative angle opening distance 500 (P<0.001) and anterior chamber depth (P<0.001) than phaco-trabeculectomy.

CONCLUSIONS

Phacoemulsification alone resulted in greater opening of drainage angle and greater deepening of anterior chamber than combined phaco-trabeculectomy in PACG eyes.

SYNOPSIS

Phacoemulsification alone resulted in greater opening of drainage angle and greater deepening of anterior chamber than combined phaco-trabeculectomy in PACG eyes.

Angle-closure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment

Primary angle-closure glaucoma is a major cause of blindness worldwide. It is a disease of ocular anatomy that is related to pupillary-block and angle-crowding mechanisms of filtration angle closure. Eyes at increased risk for primary angle-closure are small with decreased axial length, anterior chamber depth, and filtration angle width, associated with a proportionately large lens. Angle-closure glaucoma afflicts Asian and Eskimo eyes more frequently than eyes in other races with similar predisposing dimensions. The treatment of primary angle closure addresses its causal mechanisms. Laser peripheral iridotomy equalizes the anterior and posterior pressures and widens the filtration angle by reducing the effect of pupillary block. Argon laser peripheral iridoplasty contracts the iris stroma to reduce angle crowding and is helpful for some affected eyes. Lensectomy dramatically widens the angle and eliminates pupillary block. Clinical reports of lensectomy with posterior chamber intraocular lens implantation in the treatment of acute, chronic, and secondary angle-closure glaucoma describe very favorable results. The appropriate role for lensectomy in the management of primary angle closure, however, remains unproven. Prospective, randomized clinical trials are ongoing to determine the value and comparative risks and efficacy of lensectomy versus medical therapy, laser peripheral iridotomy, laser iridoplasty, and filtration procedures for the treatment of acute and chronic primary angle closure and for the prevention of chronic angle-closure glaucoma, both after and in place of laser peripheral iridotomy.

Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts

OBJECTIVE

To compare phacoemulsification alone versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma (CACG) with coexisting cataract.

DESIGN

Prospective randomized clinical trial.

PARTICIPANTS

Fifty-one medically uncontrolled CACG eyes with coexisting cataract of 51 patients.

INTERVENTION

Recruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Twenty-seven CACG eyes were randomized into group 1, and 24 CACG eyes were randomized into group 2. Combined phacotrabeculectomy resulted in lower mean postoperative IOP than phacoemulsification alone at 3 months (14.0 vs. 17.0 mmHg, P = 0.01), 15 months (13.2 vs. 15.4 mmHg, P = 0.02), and 18 months (13.6 vs. 15.9 mmHg, P = 0.01). Combined phacotrabeculectomy resulted in 1.25 fewer topical glaucoma drugs (P<0.001) in the 24-month postoperative period, compared with phacoemulsification alone. Combined surgery was associated with more postoperative complications (P<0.001) and more progression of optic neuropathy (P = 0.03), compared with phacoemulsification alone.

CONCLUSIONS

Combined phacotrabeculectomy with adjunctive mitomycin C is more effective than phacoemulsification alone in controlling IOP in medically uncontrolled CACG eyes with coexisting cataract. Combined phacotrabeculectomy is associated with more postoperative complications.

Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract

OBJECTIVE

To compare phacoemulsification alone versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma (CACG) with coexisting cataract.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Seventy-two medically controlled CACG eyes with coexisting cataract.

INTERVENTION

Recruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Thirty-five CACG eyes were randomized into group 1, and 37 CACG eyes were randomized into group 2. There were no statistically significant differences (P>0.05) in mean IOP between the 2 treatment groups preoperatively and postoperatively, except at 1 month (P = 0.001) and 3 months (P = 0.008). Combined phacotrabeculectomy with adjunctive mitomycin C resulted in 0.80 less topical glaucoma drugs (P<0.001) in the 24-month postoperative period compared with phacoemulsification alone. The differences in IOP control were, however, not associated with differences in glaucomatous progression. Combined surgery was associated with more postoperative (P<0.001) complications compared with phacoemulsification alone.

CONCLUSIONS

Combined phacotrabeculectomy with adjunctive mitomycin C may be marginally more effective than phacoemulsification alone in controlling IOP in medically controlled CACG eyes with coexisting cataract. Combined surgery may be associated with more complications and additional surgery in the postoperative period. Further study is needed to determine whether the marginally better IOP control of combined surgery justifies the potential additional risks of complications and further surgery.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Angle-closure: risk factors, diagnosis and treatment

INTRODUCTION

Primary angle-closure glaucoma (PACG) is the leading cause of blindness in East Asia. The disease can be classified into primary angle-closure suspect, primary angle closure (PAC), and PACG. Pupil-block, anterior nonpupil-block (plateau iris and peripheral iris crowding), lens related and retrolenticular mechanisms have been suggested as the four main mechanisms of angle closure.

RISK FACTORS

The risk factors for PAC are female gender, increasing age, Inuit or East Asian ethnicity, shallow anterior chamber, shorter axial length, and genetic factors.

DIAGNOSIS

The diagnosis of acute PAC is mainly clinical. Diagnosis can be made with careful slit lamp examination, including intraocular pressure (IOP) measurement and gonioscopy. The diagnosis of chronic PAC and chronic PACG also require a careful history to assess risk factors, slit lamp examination including IOP and gonioscopy. Further investigations may also be required including visual fields, ultrasound biomicroscopy, and other imaging methods.

MANAGEMENT

In acute PAC, rapid control of the IOP needs to be achieved to limit optic-nerve damage. This can be carried out medically, and/or by laser iridoplasty. Both the affected and fellow eye should undergo laser peripheral iridotomy (PI). The aim of treating chronic PAC is to eliminate the underlying pathophysiological mechanism and to reduce IOP. This can be done by carrying out laser PI, iridoplasty, medical therapy, or surgery (trabeculectomy, lens extraction, combined lens extraction with trabeculectomy and goniosynechialysis).

CONCLUSION

Angle-closure glaucoma is usually an aggressive, visually destructive disease. By assessing the risk factors and diagnosing the mechanism involved in a patient's condition, the management of that patient can be tailored appropriately.

Intraocular Pressure Elevation within the First 24 Hours after Cataract Surgery in Patients with Glaucoma or Exfoliation Syndrome

OBJECTIVE

To investigate whether eyes with glaucoma or exfoliation syndrome without glaucoma are prone to exhibit intraocular pressure (IOP) elevation shortly after cataract surgery and, if so, whether timolol maleate 0.5% reduces these spikes.

DESIGN

Prospective randomized double-masked clinical trial.

PARTICIPANTS

One hundred twenty-two patients with normal eyes, medically well-controlled glaucoma, or exfoliation syndrome who underwent uneventful phacoemulsification cataract extraction.

METHODS

Patients were randomly assigned to an immediately postoperative drop of either timolol maleate 0.5% or no treatment. Intraocular pressure was measured preoperatively and 4, 8, and 24 hours and 1 week later.

MAIN OUTCOME MEASURES

Intraocular pressure measurements.

RESULTS

The changes in postoperative IOP over time differed significantly between glaucoma, exfoliation syndrome, and normal (P = 0.005). Intraocular pressure was significantly lower in the normal group (n = 25) than in both the glaucoma (n = 18) and exfoliation syndrome (n = 19) groups (P<0.001). With 1 drop of prophylactic timolol maleate 0.5% at completion of surgery, the normal group (n = 25) again had IOP significantly lower than those of the glaucoma (n = 15) and exfoliation syndrome (n = 20) groups (P<0.001). Treatment with timolol maleate 0.5% significantly changed postoperative IOP over time in the glaucomatous eyes (P = 0.003), but it made no difference in the exfoliation syndrome (P = 0.4) or normal (P = 0.5) eyes. Intraocular pressure > 25 mmHg did not occur among normal eyes. Intraocular pressure > 25 mmHg and > 30 mmHg occurred in 10 (55%) and 5 (28%) glaucoma patients, respectively, and 5 (27%) and 2 (11%) exfoliation syndrome patients, respectively. Timolol maleate 0.5% eliminated IOP spikes > 30 mmHg and reduced the frequency of IOP > 25 mmHg in both groups to 14% in the glaucoma group and 5% in the exfoliation syndrome group. Most IOP elevation occurred at 4 hours postoperatively. The mean IOP was <20 mmHg in all groups 1 day postoperatively.

CONCLUSIONS

Medically well-controlled glaucoma patients and patients with exfoliation syndrome may experience IOP elevation shortly after cataract surgery. Instillation of timolol maleate 0.5% at the end of the procedure in this series eliminated IOP > 30 mmHg, but IOP elevation below that level can still occur.

Long-term results of Molteno implant insertion in cases of chronic angle closure glaucoma

BACKGROUND

This study was undertaken to provide data on the long-term results of cases of chronic angle closure glaucoma with additional risk factors treated by Molteno implants between 1985 and 2004 at Dunedin Hospital, New Zealand.

METHODS

A prospective non-comparative case series followed 21 eyes (17 patients) for a mean of 5.7 years (range 1.3-16.3 years) in terms of intraocular pressure, visual acuity and subsequent procedures.

RESULTS

Insertion of a Molteno implant has controlled the intraocular pressure at 21 mmHg or less in 100% of cases at 5 years after surgery, the probability of control being 0.95 (95% CI 0.91-0.99). The mean number of hypotensive medications reduced from 2.04 (SD 0.92) preoperatively to 1.40, 0.64 and 0.66 at 1, 2 and 5 years, respectively. The mean visual acuity improved from 6/18 preoperatively to 6/12 at 1 year and declined to 6/13.5 at 2 and 5 years.

CONCLUSION

Insertion of Molteno implants was a safe and effective procedure in the management of complex cases of chronic angle closure glaucoma.