Clear lens extraction in eyes with primary angle closure and primary angle-closure glaucoma

How much does cataract surgery contribute to intraocular pressure lowering?

PURPOSE OF REVIEW

To review the literature evaluating the effect of cataract surgery on intraocular pressure (IOP) in patients with glaucoma.

RECENT FINDINGS

Recent high-quality secondary analyses of large and primary trials continue to show IOP lowering following cataract surgery. Likewise, cataract surgery remains a key treatment for angle closure glaucoma. Some micro-invasive glaucoma surgeries (MIGS) have strong evidence to be performed at the time of cataract surgery. Data clarifying when these surgeries should be combined with cataract surgery is emerging. The mechanism underlying IOP lowering after cataract surgery remains unclear.

SUMMARY

Patients who are glaucoma suspects with visually significant cataracts would benefit from cataract surgery alone. Those with mild-moderate damage on 1-2 classes of medications would most likely benefit from additional MIGS. Patients with advanced disease would benefit from cataract surgery and a choice of additional surgery, which depends on disease status and patient factors. Clear lens extraction is becoming a more accepted practice as a primary procedure for patients with angle closure and high IOP or glaucoma. The role of additional MIGS in angle closure needs further study.

Low expression of TGF-β2 and matrilin2 in human aqueous humour with acute primary angle closure

Primary angle-closure glaucoma (PACG) is the leading cause of irreversible blindness in the world. Angle closure induced by pupil block and secondary iris synechia is the fundamental pathology of the PACG. The molecular mechanisms of angle closure have not yet been clearly illustrated. This study was designed to investigate the protein difference in the aqueous humour and explore new biomarker of the PACG. Aqueous humour (AH) was collected from patients with acute primary angle closure (APAC) and cataract (n = 10 in APAC group) and patients with cataract only (n = 10 in control group). Samples were pooled and measured using label-free proteome technology. Then, the differentially expressed proteins (DEPs) were verified by ELISA using independent AH samples (n = 20 each group). More than 400 proteins were revealed in both groups through proteomics. Comparing the two groups, there were 91DEPs. These proteins participate in biological activities such as inflammation, fibrosis, nerve growth and degeneration and metabolism. We found that the expression of transforming growth factor-β2 and matrilin2 was downregulated in the APAC group. The two proteins are related to inflammation and extracellular matrix formation, which might be involved in angle closure. This study characterized DEPs in AH of the APAC and found a downregulated protein matrilin2.

Angle, anterior chamber parameters, and intraocular pressure changes after early phacoemulsification in acute angle-closure glaucoma

PURPOSE

To evaluate the safety and efficacy of phacoemulsification as a first line treatment of acute angle closure glaucoma (AACG) and to evaluate the preoperative and postoperative anterior chamber angle width and anterior chamber parameters using anterior segment OCT(AS-OCT) and Pentacam.

SITTINGS

Sohag University Hospital, Sohag city, Egypt.

DESIGN

Prospective comparative interventional case series study.

METHODS

Patients presented with AACG. After control of high intraocular pressure (IOP), all participants were scheduled for phacoemulsification within a week after the attack. Preoperative and postoperative angle width, anterior chamber volume and anterior chamber depth was measured by AS-OCT and Pentacam to evaluate angle changes.

RESULTS

Fifty eyes with AACG were enrolled in the study. The mean IOP was lowered significantly from 40.23 ± 10.4 mmHg preoperatively to 11.4 ± 3.3 mmHg 3 months after surgery. The mean preoperative temporal angle widened from 18.13 ± 3.65 degree to 36.16 ± 4.46 3 months after phacoemulsification. Also, the mean preoperative nasal angle widened from 17.80 ± 3.45 preoperatively to 36.18 ± 4.47 3-month postoperative. The mean preoperative AC volume was 49.4 ± 5.73 μL. After surgery the AC volume increased significantly to 138.2 ± 29.78 μL. The mean preoperative ACD was 1.58 ± 0.12 mm that deepened significantly after surgery to 3.19 ± 0.43 mm.

CONCLUSION

Early phacoemulsification is very effective in treatment of AACG cases immediately after medical control of high IOP and resolution of corneal oedema. This was proved by imaging and measuring the angle width, anterior chamber volume and anterior chamber depth using AS- OCT and Pentacam.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

Ten-year outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease

PURPOSE

To investigate the long-term outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease (PACD).

STUDY DESIGN

Retrospective case series.

METHODS

We reviewed the medical records of 87 eyes of 87 patients with PACD who underwent uncomplicated cataract surgery alone at the Kobe City Medical Center General Hospital. Only patients with a minimum follow-up of 10 years were included. The patients were divided into PACD spectrum categories: primary angle-closure glaucoma (PACG), primary-angle closure (PAC), and primary angle-closure suspect (PACS). The treatment outcomes were compared among the 3 groups. Intraocular pressure (IOP), number of glaucoma eye drops, requirement of additional glaucoma treatment, visual field progression, and progression to glaucoma during the follow-up period were evaluated.

RESULTS

Among the 87 patients, 39 had PACG; 26, PAC; and 22, PACS. Ten years after surgery, the IOP had significantly decreased from baseline in all 3 groups. The rate of requirement of additional glaucoma treatment during the follow-up period was significantly higher in the PACG group than in the other groups. Almost half of the patients with PACG required additional glaucoma treatment; of those patients, six (15.4%) underwent glaucoma surgery. Three patients (11.5%) with PAC required additional glaucoma medication. Visual field progression was observed in 28.1% of the patients with PACG. In 1 patient with PAC, the condition progressed to PACG, but there was no such progression in any of the patients with PACS.

CONCLUSIONS

We confirmed that cataract surgery had a long-term (> 10 years) effect on IOP reduction in eyes with PACD. Early intervention with cataract surgery may be preferable for glaucoma management in patients with PACD.

Preventing blindness from glaucoma with patient education, the NIDEK GS-1 Gonioscope, lensectomy and microinvasive glaucoma surgery

OBJECTIVES

The purpose of this report is to demonstrate the patient education ability and benefits in treating glaucoma and preventing blindness with the NIDEK GS-1 Gonioscope and earlier surgical intervention with cataract surgery/lensectomy and microinvasive glaucoma surgery (MIGS).

METHODS

This data was collected using a NIDEK GS-1 Gonioscope. Informed consent was obtained from all participants following explanation of possible risks.

RESULTS AND DISCUSSION

NIDEK GS-1 automated gonioscopy offers many advantages, including (1) the ability to capture high quality, 360-degree chromatic documentation of the iridocorneal angle and trabecular meshwork, (2) improved patient education on the condition at hand through images; and (3) visualization of the change in the angle and trabecular meshwork before and after surgical intervention in patients with glaucoma.

CONCLUSION AND IMPLICATIONS

Gonioscopic imaging is helpful in educating patients on the anatomy of the angle and how its anatomical configuration can contribute to glaucoma. It also gives clinicians a supplementary tool to document features of the ICA; to evaluate anatomical changes before and after surgical treatment of glaucoma and cataracts; and to demonstrate to patients how a specific surgical device or technique is controlling their intraocular pressure (IOP).

Biometric indicators of anterior segment parameters before and after laser peripheral iridotomy by swept-source optical coherent tomography

Background

Primary angle closure glaucoma (PACG) is the most common type of glaucoma in China. Laser peripheral iridotomy (LPI) is the primary choice to treat PAC: We aim to evaluate the changes of biometric parameters of anterior segment and to find possible biometric predictors of the effect of laser peripheral iridotomy (LPI) in primary angle closure (PAC) eyes using swept-source optical coherent tomography (OCT).

Methods

LPI was performed in 52 PAC eyes of 28 participants. The change of intraocular pressure and anterior segment parameters, including angle opening distance (AOD500), AOD500 area, trabecular iris space area (TISA500), TISA500 volume, trabecular iris angle (TIA500), iridotrabecular contact (ITC) index, ITC area, anterior chamber volume (ACV), anterior chamber depth (ACD), lens vault (LV) and lens thickness (LT) before and 1 week after LPI were measured by Tomey CASIA2 anterior segment OCT. We also estimate and analyze potential associated factors possibly affecting the change of anterior chamber parameters.

Results

No post-laser complications were found. The ACD, LV and LT did not change significantly 1 week after LPI. AOD500, AOD500 area, TISA500, TISA500 volume, TIA500, ACV increased significantly after LPI. There was significant decrease in ITC index and ITC area. LT was positively correlated to the change of ITC index (β = 0.239, *p = 0.045).

Conclusions

The anterior segment architecture significantly changed after LPI in PAC spectrum eyes. Crystalline lens measurements remained unchanged before and after LPI. AS-OCT can be used to follow anterior chamber parameter changes in PAC spectrum eyes. LT may play a role in the therapeutic effect of LPI.

[Phacoemulsification in prevention of acute angle-closure glaucoma attack]

Analysis of the effectiveness of preventative phacoemulsification (PE) in anatomically short eyes with an increased risk of an acute glaucoma attack in thickened lens can help in choosing the optimal management tactics for these patients.

PURPOSE

To study the changes in morphometric parameters of the anterior segment of anatomically short eyes with an increased risk of acute glaucoma attack before and after preventative PE.

MATERIAL AND METHODS

The study included 70 patients (70 eyes) with a high risk of acute glaucoma attack in short anatomical axial length and thickened lens, with posterior and middle positions of the ciliary body. They were divided into 2 groups: the main group consisted of 45 patients who agreed to undergo PE; the comparison group consisted of 25 patients who refused to undergo PE due to good visual functions and no complaints about vision. B-mode ultrasound examination of the anterior segment of the eye was used to evaluate the cross-sectional surface area of the lens (CSAL) and the cross-sectional surface area of the anterior chamber (CSAAC).

RESULTS

In the main group, on day 2-3 after PE the anterior chamber depth increased in all eyes, the CSAAC index increased, the anterior chamber angle (ACA) widened to Schaffer grade to II-III. After 1-3 years and 4-5 years, the anterior chamber depth, the CSAAC index and the width of the ACA remained stable. In the comparison group, after 1-3 years the anterior chamber depth and the CSAAC index significantly decreased, the ACA narrowed, and the intraocular pressure increased; after 4-5 years, there was a progressive increase in the CSAL index, the ACA was completely closed (0°).

CONCLUSION

In all cases of timely performed preventative PE, already on days 2-3 after surgery there was a statistically significant improvement in the main morphometric parameters of the eye, which remained stable for 4-5 years.

The surgical management of glaucoma: A review

After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not-Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.

Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial

PRCIS

We used anterior segment optical coherence tomography to investigate anterior chamber angle in primary angle-closure glaucoma (PACG) eyes following phacoemulsification and phacotrabeculectomy. Angle widening was significantly greater after phacoemulsification up to 6 months after the surgery.

PURPOSE

To compare anterior chamber angle following 2 common surgeries for PACG.

METHODS

One hundred ten glaucoma patients were evaluated in this single center, prospective, randomized clinical trial. Those with concomitant PACG and senile cataract and without a history of ocular surgery, trauma, or chronic miotic use were recruited. Monocular patients were also excluded. Finally, 52 eligible subjects were randomly assigned to phacoemulsification ("Phaco" group, 25 eyes) or phacotrabeculectomy ("Combined" group, 27 eyes) surgeries. A swept-source, anterior segment optical coherence tomography device (CASIA SS-1000 OCT) was used to image the anterior segment. Mask graders used the images to measure the following parameters before and 1 week, 1 month, and 6 months after surgery: angle opening distance at 500 µm, trabecular iris surface area at 500 µm, and trabecular iris angle at 500 µm.

RESULTS

There was no significant difference between study groups regarding best-corrected visual acuity, intraocular pressure (IOP), and the number of glaucoma medications in preoperative or postoperative visits (P>0.076). Also, the measured angle parameters were not statistically significantly different between the 2 groups before surgery (P>0.123). After surgery, all measured parameters were significantly increased in both groups (P<0.0001). At the 6-month follow-up, nasal angle opening distance at 500 µm was 0.383±0.027 vs. 0.349±0.017, trabecular iris surface area at 500 µm was 0.141±0.007 vs. 0.125±0.005, and trabecular iris angle at 500 µm was 40.1±12.9 vs. 34.6±3.1 in Phaco and Combined groups, respectively (P<0.0001 for all).

CONCLUSIONS

Anterior chamber angle widening by anterior segment optical coherence tomography was observed in PACG patients following surgery and was significantly greater after phacoemulsification compared with combined phacotrabeculectomy at all time points. Similar IOP and medication burden were noted for up to 6 months as secondary outcomes. The contribution of angle changes to the IOP-lowering effect of phacoemulsification in PACG eyes needs further study.

Time trends, associations and prevalence of blindness and vision loss due to glaucoma: an analysis of observational data from the Global Burden of Disease Study 2017

OBJECTIVE

To estimate global prevalence of blindness and vision loss caused by glaucoma, and to evaluate the impact of socioeconomic factors on it.

DESIGN

A population-based observational study.

SETTING

The prevalence of blindness and vision loss due to glaucoma were obtained from the Global Burden of Disease Study 2017 database. The Human Development Index (HDI), inequality-adjusted HDI and other socioeconomic data were acquired from international open databases.

MAIN OUTCOME MEASURES

The prevalence of blindness and vision loss due to glaucoma by age, gender, subregion and Socio-Demographic Index (SDI) levels. Multiple linear regression analysis was performed to explore the associations between the prevalence and socioeconomic indicators.

RESULTS

The overall age-standardised prevalence of blindness and vision loss due to glaucoma worldwide was 81.5 per 100 000 in 1990 and 75.6 per 100 000 in 2017. In 2017, men had a higher age-standardised prevalence than women (6.07% vs 5.42%), and the worldwide prevalence increased with age, from 0.5 per 100 000 in the 45-49 year age group to 112.9 per 100 000 among those 70+. Eastern Mediterranean and African regions had the highest prevalence during the whole period, while the Americas region had the lowest prevalence. The prevalence was highest in low-SDI and low-income regions while lowest in high-SDI and high-income regions over the past 27 years. Multiple linear regression showed cataract surgery rate (β=-0.01, p=0.009), refractive error prevalence (β=-0.03, p=0.024) and expected years of schooling (β= -8.33, p=0.035) were associated with lower prevalence, while gross national income per capita (β=0.002, p<0.001) was associated with higher prevalence.

CONCLUSIONS

Lower socioeconomic levels and worse access to eyecare services are associated with higher prevalence of glaucoma-related blindness and vision loss. These findings provide evidence for policy-makers that investments in these areas may reduce the burden of the leading cause of irreversible blindness.

Bilateral Refractive Lens Exchange With Trifocal Intraocular Lens for Hyperopia in Patients Younger Than 40 Years: A Case-Control Study

PURPOSE

To evaluate visual outcomes, satisfaction, and spectacle independence in non-presbyopic hyperopic patients who underwent bilateral refractive lens exchange with a trifocal intraocular lens (IOL) and to compare them with presbyopic hyperopic patients.

METHODS

In this retrospective study, patients younger than 40 years underwent bilateral refractive lens exchange with a diffractive trifocal IOL (FineVision Micro F; PhysIOL SA) for hyperopia with at least 3 months of follow-up. A control group of patients older than 50 years was matched by axial length, sex, and follow-up. Safety, efficacy, predictability, patient satisfaction, and spectacle independence were evaluated.

RESULTS

One hundred thirty-three patients (average age = 36.94 ± 2.91 years; range = 21.50 to 40 years) were included in this study. After a mean follow-up of 8.83 ± 5.69 months (range = 2.75 to 77.63 months), the safety and efficacy indexes and predictability within ±1.00 diopters (D) were 1.02%, 0.98%, and 99.62%, respectively, which was not different from the control group (P > .05). No intraoperative complications were recorded. The only postoperative complication was posterior capsule opacification in 21 eyes (7.89%), which was similar to the control group (P > .05). Ninety-seven percent of patients in each group expressed that they were satisfied and all of them in each group reported that they did not use spectacles for distance, intermediate, or near vision.

CONCLUSIONS

Refractive lens exchange and trifocal IOL implantation for hyperopia in patients without presbyopia provided the same good visual outcomes as in presbyopic patients with a high rate of patient satisfaction and spectacle independence. [J Refract Surg. 2021;37(8):524-531.].

Lessons From Management: Perioperative Phacoemulsification Planning Following Resolution of Acute Angle Closure

Patients with loose zonular apparatus after acute angle closure may require phacoemulsification cataract surgery. The authors' experience from management of such patients provides excellent instruction on the surgical intervention for their cataracts. This is because patients who have recovered from acute angle closure glaucoma may not have evident zonular laxity preoperatively, as the iris may be taut secondary to the effects of associated ischaemia. If the surgeon’s preoperative planning is directed to the possibility of loose zonular apparatus, then appropriate preoperative, intraoperative, and postoperative planning and management can be effected. This may permit preoperative patient counselling regarding the potentially increased complexity of the case. Intraoperatively, deliberately gentle capsulorrhexis, the use of iris hooks or a pupil expander to dilate the pupil, iris hooks to support the capsular bag, and the employment of a capsular tension ring may be helpful. Postoperatively, due to the previous ocular ischaemia, intraocular pressure elevation may ensue, and should be actively managed. The authors provide a summary of factors that require consideration in patients undergoing cataract surgery following acute angle closure.