Glaucome et crise aiguë par fermeture de l’angle : phakoémulsification en première intention

Factors Associated With Zonular Instability During Cataract Surgery in Eyes With Acute Angle Closure Attack

PURPOSE

To compare the demographics and ocular characteristics, including anterior segment optical coherence tomography images and zonular instability, in eyes with a history of acute angle closure (AAC) attack and subsequent cataract surgery.

DESIGN

Retrospective case-control study.

METHODS

A total of 68 eyes of 56 patients with a history of AAC attack who underwent cataract surgery were enrolled. Fourteen eyes were assigned to the zonular instability (+) group and 54 were assigned to the zonular instability (-) group based on the presence of zonular instability during cataract surgery. The peak intraocular pressure, preoperative spherical equivalent (SE), axial length (AL), anterior chamber depth (ACD), and lens vault (LV) were measured and compared between 2 groups. Intereye (intraindividual) comparison was also performed. Factors associated with zonular instability were assessed.

RESULTS

In the zonular instability (+) group, 9 eyes were from male and 5 from female participants. Eyes in the zonular instability (+) group showed less hyperopic SE values, longer AL, shallower ACD, and higher LV, as compared with those in the zonular instability (-) group (all P ≤ .001). Moreover, eyes in the zonular instability (+) group had less hyperopic SE, shallower ACD, and higher LV than their fellow eyes. Less hyperopic SE, longer AL, and higher LV were significantly associated with zonular instability on multivariate logistic regression analysis.

CONCLUSIONS

Clinicians should consider the possibility of zonular instability during cataract surgery for eyes with less hyperopic SE, longer AL, and higher LV among those with a history of AAC attack.

Cataract surgery and intraocular pressure

Cataract surgery is one of the most performed surgeries in the developed world. In addition to its significant impact on visual acuity, phacoemulsification has been hailed as a potential intraocular pressure (IOP)-lowering procedure. While current evidence suggests an overall significant and sustained decrease in IOP to exist after cataract surgery, the specific ocular characteristics that could help predict which patients are likely to benefit from this IOP-lowering effect remain unclear. This definition is important in glaucoma patients if this surgery is to be used in the treatment for this disease. Our review aims to summarize the literature on the subject, depicting possible mechanisms behind this IOP decrease, which type of patients are more likely to benefit from this surgery for IOP-lowering purposes and ultimately help optimizing disease management for the increasing number of patients with concomitant glaucoma and cataract.

[Demographic evolution of acute primary angle closure between 2001-2003 and 2008-2010: impact of modern cataract surgery]

PURPOSE

To study the demographic evolution of acute primary angle closure.

MATERIALS AND METHODS

Retrospective study of patients with acute primary angle closure treated between 2001-2003 and 2008-2010. For each period, a comparison was made of demographic data (number of cases, age at diagnosis, sex), clinical data (biometry, presence or absence of iris plateau or cataract) and therapeutic data (iridotomy, phacoemulsification, trabeculectomy).

RESULTS

Fifty-two cases of acute primary angle closure were treated in the University Hospital of Nantes, France: 34 eyes in 2001-2003 and 18 in 2008-2010, representing a decrease of 47% in acute primary angle closure cases in 7years. The incidence of acute primary angle closure attacks significantly decreased from 0.0596% in 2001-2003 to 0.0224% in 2008-2010. Acute angle closure attacks secondary to cataract decreased significantly from 82% in 2001-2003 to 50% in 2008-2010. In cataractous cases with ocular hypertension persisting after peripheral iridotomy, cataract extraction was performed. Early phacoemulsification less than 10days was significantly more common in 2008-2010 than in 2001-2003 (40% versus 10%).

CONCLUSION

This study confirms the recent decrease in acute primary angle closure attacks. The consistent increase in cataract surgery in the elderly has probably played a preventive role, since the highest decrease in acute primary angle closure cases was observed among the 70-80-year-old population. Recently, acute primary angle closure cases are less often due to cataract than to primary pupillary block or iris plateau. The prevention of acute primary angle closure by gonioscopic monitoring in patients at risk is indispensable.

[Combined glaucoma cataract surgeries]

The combined cataract-glaucoma surgery is a procedure gaining a higher role in the surgical treatment for patients having both cataract and glaucoma. Both these pathologies are strongly related to the age. A good knowledge of surgical indications and techniques, complications and postoperative follow-up can improve the outcome of this surgery, which is considered to be the best technique in the treatment of combined cataract and glaucoma. The combined glaucoma and cataract surgery enables us to lower the intraocular pressure and gain in visual acuity in one surgery, with the treatment of two distinct disorders. This kind of surgery requires a close follow-up to spot and manage the post-operative complications.

Determination of anterior segment changes with Pentacam after phacoemulsification in eyes with primary angle-closure glaucoma

BACKGROUND

To investigate changes of anterior segment morphology in primary angle-closure glaucoma after phacoemulsification using the Pentacam system.

DESIGN

Prospective, interventional study, Zhongshan Hospital of Sun Yat-sen University.

PARTICIPANTS

Eighty-five eyes from 60 patients with primary angle-closure glaucoma undergoing phacoemulsification.

METHODS

  Intraocular pressure was measured by Goldmann applanation tonometry. Anterior segment morphology was assessed using the Pentacam camera.

MAIN OUTCOME MEASURES

The intraocular pressure, central anterior chamber depth, peripheral anterior chamber depth, anterior chamber volume, pupil diameter and anterior chamber angle preoperative and 3 months postoperative.

RESULTS

A total 78 eyes of 55 patients with primary angle-closure glaucoma were included in the analysis. Thirty-two eyes (41.0%) had acute primary angle-closure glaucoma, and 46 eyes (59.0%) had chronic primary angle-closure glaucoma. In both groups, statistically significant decreases in intraocular pressure and increases in anterior chamber volume, central anterior chamber depth, peripheral anterior chamber depth and anterior chamber angle inferiorly, nasally, temporally and superiorly were observed at 3 months after phacoemulsification (all P < 0.001).

CONCLUSIONS

Phacoemulsification induces significant changes in anterior segment morphology in primary angle-closure glaucoma accompanied by a significant fall in intraocular pressure in the short term.

Use of pars plana vitrectomy with phacoemulsification in vitreous cavity to treat complete posterior dislocation of lens

Background

The purpose of this study was to evaluate pars plana vitrectomy (PPV) with phacoemulsification in the vitreous cavity for treatment of complete posterior dislocation of the lens without any damage to the lens capsule.

Methods

We evaluated factors such as cause of dislocation, scleral fixation of an intraocular lens (IOL), preoperative and postoperative visual acuity, corneal endothelial cell density, and intraoperative and postoperative complications.

Results

Displacement in the eleven eyes studied was mostly caused by ocular trauma and was idiopathic (four eyes each). Scleral fixation of the IOL was performed in seven of the eyes during first-time PPV. Visual acuity was improved in two eyes, unchanged in eight eyes, and worse in one eye. Mean corneal endothelial cell density was 2485 cells/mm² preoperatively and 2301 cells/mm² postoperatively. No significant differences were seen before and after the surgeries (P = 0.15, paired t-test). Intraoperative complications included retinal detachment and suprachoroidal hemorrhage in one eye each. The most common postoperative complication was transient ocular hypertension, which occurred in three eyes. IOL dislocation and vitreous incarceration of the anterior chamber in one eye required a second operation, while retinal detachment in one eye required a third operation.

Conclusion

When treating a completely dislocated lens, prevention of retinal detachment which subsequently can affect the visual prognosis is the most important factor to be addressed after PPV with intravitreal phacoemulsification.