Anterior Chamber Angle Assessment by Anterior-segment Optical Coherence Tomography After Phacoemulsification With or Without Goniosynechialysis in Patients With Primary Angle Closure Glaucoma

Anterior Chamber Angle and Intraocular Pressure Control After Phacoemulsification in Primary Angle Closure With Different Mechanisms

PRCIS

Different mechanisms of angle closure represented distinct aspects of intraocular pressure (IOP) control after phacoemulsification. Classification of angle closure mechanisms is necessary for postoperative IOP management and glaucoma progression in primary angle closure eyes.

PURPOSE

To investigate the relationship between the anterior chamber angle (ACA) characteristics, measured by swept-source anterior segment optical coherence tomography (SS AS-OCT), and intraocular pressure (IOP) control after phacoemulsification in eyes with primary angle closure disease (PACD) with different angle closure mechanisms.

METHODS

PACD eyes were classified into 3 groups according to angle closure mechanisms using preoperative SS AS-OCT images; pupillary block (PB), plateau iris configuration (PIC), exaggerated lens vault (ELV). This retrospective, clinical cohort study included eighty-five eyes of 85 PACD patients: 34 with PB, 23 with PIC, and 28 with ELV. ACA parameters were measured preoperatively and 1 month postoperatively using SS AS-OCT. IOP measurements were performed preoperatively and during 6 months postoperatively. Postoperative IOP reduction and fluctuation were calculated, and their correlations with SS AS-OCT parameters were analyzed.

RESULTS

PIC group showed the lowest postoperative IOP reduction compared with the other groups ( P =0.023). Preoperative ACA measurements were significantly associated with postoperative IOP reduction in ELV and PB groups, while postoperative measurements were in PIC group. Preoperative and postoperative change of iridotrabecular contact (ITC) index and area were correlated with postoperative IOP reduction in PB and ELV groups but not in PIC group. Postoperative ITC index ( P =0.031) and area ( P =0.003) showed significant correlations with postoperative IOP fluctuation only in PIC group.

CONCLUSIONS

SS AS-OCT parameters including ITC index and area showed different associations with postoperative IOP control, which should be considered in determination of lens extraction and treatment of PACD eyes.

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.

Phacoemulsification combined with goniosynechialysis versus phacoemulsification alone for patients with primary angle‑closure disease: A meta-analysis

This meta-analysis aims to systematically compare the efficacy between phacoemulsification (PE) combined with goniosynechialysis (GSL) and PE alone for primary angle-closure disease (PACD) patients. All the data were searched from the PubMed, EMBASE and the Cochrane Library. The Cochrane Handbook was used to evaluate the quality of the included studies. Additionally, this meta-analysis was performed by using the Revman 5.4 software. Nine randomized controlled trials (RCTs) were included in this study. Compared with PE alone group, PE+GSL could result significant reduction in the IOP (MD, 1.81; p = 0.002). In the instrumental subgroup, also more reduction of IOP was shown in the PE+GSL group (MD, 2.11; p = 0.02). In the viscogonioplasty (VGP) subgroup, there was not no statistical difference between PE alone group and PE+GSL group (MD, 1.53; p = 0.11). Also, more reduction of peripheral anterior synechiae (PAS) was shown in the PE+GSL group (MD,59.15; p<0.00001). For the change in angle open distance (AOD)500, AOD 750, trabecular-iris space (TISA)500, number of glaucoma medications and best corrected visual acuity (BCVA), there was no difference between two groups (p = 0.25, 0.35, 0.17, 0.56, 0.08). For TISA 750, more improvement was shown in the PE+GSL group (p<0.00001). Instrumental separation had better effect on lowering IOP when it combined with PE. Both instrumental separation and VGP could reduce postoperative PAS. The operation of GSL has no obvious effect on postoperative vision.

Efficacy and Safety of Different Types of Intraocular Pressure-Lowering Surgeries in Patients with Primary Angle Closure (PAC) or PAC Glaucoma: Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

To compare the intraocular pressure (IOP)-lowering effect of different types of surgery available in the literature using a network meta-analysis (NMA) based on a systematic review.

METHODS

PubMed and the Cochrane database were searched. Randomized clinical trials involving surgical interventions for high IOP for PAC (primary angle closure) or PACG (primary angle closure glaucoma) were included. Descriptive statistics and outcomes were extracted. Bayesian NMA was performed to compare the IOP-lowering effect and the change in the number of antiglaucoma drugs required between baseline and endpoint, as well as success rates.

RESULTS

This NMA included 21 articles with 1237 eyes with PAC or PACG. Interventions were characterised as phacoemulsification (phaco), trabeculectomy, goniosynechialysis (GSL) with viscoelastic or blunt device, goniosurgery (GS) (trabeculotomy or goniotomy), micro-bypass stent (Istent®), endocyclophotocoagulation (ECPL) or various combinations of these procedures. Phaco+GSL [-1.73 (95%CrI: -3.53 to -0.13)] and phaco+GSL+GS [-3.92 (95%CrI: -6.91 to -1.31)] provided better IOP lowering effects than phaco alone. Phaco+trabeculectomy [-3.11 (95%CrI: -5.82 to -0.44)] was inferior to phaco+GSL+GS. Phaco+trabeculectomy [-0.45 (95%CrI: -0.81 to -0.13)] provided a better outcome in terms of reducing the need for antiglaucoma drug compared to phaco alone. There were no differences between the other surgeries in terms of reduction of antiglaucoma drug number and IOP lowering effect. Success rates were similar for all surgical procedures.

CONCLUSIONS

Phaco+GSL+GS showed the most promising results for lowering IOP. Phaco+trabeculectomy resulted in a significant reduction in the number of antiglaucoma drugs compared to phaco alone.

Machine learning-couched treatment algorithms tailored to individualized profile of patients with primary anterior chamber angle closure predisposed to the glaucomatous optic neuropathy

Background

Primary angle closure glaucoma (PACG) is still one of the leading causes of irreversible blindness, with a trend towards an increase in the number of patients to 32.04 million by 2040, an increase of 58.4% compared with 2013. Health risk assessment based on multi-level diagnostics and machine learning-couched treatment algorithms tailored to individualized profile of patients with primary anterior chamber angle closure are considered essential tools to reverse the trend and protect vulnerable subpopulations against health-to-disease progression.

Aim

To develop a methodology for personalized choice of an effective method of primary angle closure (PAC) treatment based on comparing the prognosis of intraocular pressure (IOP) changes due to laser peripheral iridotomy (LPI) or lens extraction (LE).

Methods

The multi-parametric data analysis was used to develop models predicting individual outcomes of the primary angle closure (PAC) treatment with LPI and LE. For doing this, we suggested a positive dynamics in the intraocular pressure (IOP) after treatment, as the objective measure of a successful treatment. Thirty-seven anatomical parameters have been considered by applying artificial intelligence to the prospective study on 30 (LE) + 30 (LPI) patients with PAC.

Results and data interpretation in the framework of 3P medicine

Based on the anatomical and topographic features of the patients with PAC, mathematical models have been developed that provide a personalized choice of LE or LPI in the treatment. Multi-level diagnostics is the key tool in the overall advanced approach. To this end, for the future application of AI in the area, it is strongly recommended to consider the following:Clinically relevant phenotyping applicable to advanced population screeningSystemic effects causing suboptimal health conditions considered in order to cost-effectively protect affected individuals against health-to-disease transitionClinically relevant health risk assessment utilizing health/disease-specific molecular patterns detectable in body fluids with high predictive power such as a comprehensive tear fluid analysis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00337-1.

Meta-Analysis of Phacoemulsification and Laser Peripheral Iridotomy in the Treatment of Primary Angle-Closure Glaucoma

Background

In this meta-analysis, we aimed to systematically compare the efficacy and safety of phacoemulsification and laser peripheral iridotomy (LPI) in the treatment of primary angle-closure glaucoma (PACG).

Method

We searched PubMed, MEDLINE, EMBASE, the Cochrane Library, the Chinese Journal Full-text Database (CNKI), the Wanfang database, and the China Science and Technology Journal Database for randomized controlled trials (RCTs) of phacoemulsification and LPI in the treatment of PACG published up to September 30, 2022. Postoperative intraocular pressure (IOP), anterior chamber depth (ACD), complications, corneal endothelial cell count, and best-corrected visual acuity (BCVA) were compared. The effective quantity of measurement data was measured by the mean difference (MD) and 95% confidence interval (CI). The effect of counting data was measured by the odds ratio (OR).

Result

A total of 1731 potential studies were identified, and after screening, 8 RCT studies were included. The results of the meta-analysis showed that, compared to the LPI group, the patients in the phacoemulsification group showed lower IOP six and twelve months after operation (MD-3.39, 95% CI -4.15∼-2.63, P < 0.00001; -2.29, -3.52∼-1.06, 0.0003). The ACD in the phacoemulsification group was significantly deeper than that in the LPI group (1.59, 1.10∼2.09, 0.00001). Meanwhile, the incidence of complications in the phacoemulsification group was lower than that in the LPI group (OR = 0.46, 0.29∼0.72, 0.0006). There was no statistically significant difference between the phacoemulsification group and the LPI group in corneal endothelial cell count and BCVA at 6 and 12 months after operation (P=0.38; 0.11; 0.81).

Conclusion

Compared with LPI, phacoemulsification is safer and more effective in the treatment of PACG, especially in controlling IOP and minimizing postoperative complications.

Efficacy of Combined Phacoemulsification and Goniosynechialysis in Primary Angle Closure Disease With Different Degrees of Peripheral Anterior Synechiae

PRCIS

Phacoemulsification and goniosynechialysis (Phaco-GSL) was equally effective in the treatment of primary angle-closure disease (PACD) with preoperative peripheral anterior synechiae (PAS) <180 degrees and larger than 180 degrees. Patients with a larger preoperative PAS range required more range of mechanical separation intraoperatively and displayed more recurrence of PAS (re-PAS) range postoperatively.

PURPOSE

To evaluate the long-term efficacy of combined phaco-GSL in PACD with different extent of PAS.

PATIENTS AND METHODS

A retrospective study was conducted on 67 patients (79 eyes) who received phaco-GSL. The patients were divided into 2 groups according to the extent of PAS (group A: PAS ≤180 degrees; group B: PAS >180 degrees). Changes in intraocular pressure (IOP), the number of anti-glaucoma drugs, intraoperative mechanical separation of PAS and range of re-PAS during the last follow-up ≥12 months were analyzed.

RESULTS

At baseline, eyes in group B presented with higher IOP and more anti-glaucoma drugs usage ( P =0.008 and 0.004). The PAS range, IOP, number of anti-glaucoma medication were reduced both in 2 groups at the final visit. The range of mechanical separation intraoperatively and re-PAS postoperatively were both larger in group B ( P =0.002 and <0.001). The postoperative re-PAS range was positively correlated with the range of mechanical separation ( R2 =0.17). The complete success rates at 12, 24, 36, and 48 months were 86.8%, 71.1%, 71.1%, and 71.1% in group A; and 80.5%, 74.6%, 69.9%, and 69.9% in group B. The qualified success rates were 100%, 96.6%, 92.0%, and 92.0% in group A; and 100%, 89.5%, 85.1%, and 85.1% in group B.

CONCLUSION

Phaco-GSL for the treatment of PACD showed equally effective IOP control regardless of the extent of preoperative PAS.

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.

Lens extraction for chronic angle-closure glaucoma

BACKGROUND

Primary angle-closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block being the most common underlying mechanism. There is increasing evidence that lens extraction may relieve pupillary block and thereby improve IOP control. As such, comparing the effectiveness of lens extraction against other commonly used treatment modalities can help inform the decision-making process.

OBJECTIVES

To assess the effectiveness of lens extraction compared with other interventions in the treatment of chronic PACG in people without previous acute angle-closure attacks.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, one other database, and two trials registers (December 2019). We also screened the reference lists of included studies and the Science Citation Index database. We had no date or language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing lens extraction with other treatment modalities for chronic PACG.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology.

MAIN RESULTS

We identified eight RCTs with 914 eyes. We obtained data for participants meeting our inclusion criteria for these studies (PACG only, no previous acute angle-closure attacks), resulting in 513 eyes included in this review. The participants were recruited from a diverse range of countries. We were unable to conduct meta-analyses due to different follow-up periods and insufficient data. One study compared phacoemulsification with laser peripheral iridotomy (LPI) as standard care. Participants in the phacoemulsification group were less likely to experience progression of visual field loss (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13 to 0.91; 216 eyes; moderate certainty evidence), and required fewer IOP-lowering medications (mean difference [MD] -0.70, 95% CI -0.89 to -0.51; 263 eyes; moderate certainty evidence) compared with standard care at 12 months. Moderate certainty evidence also suggested that phacoemulsification improved gonioscopic findings at 12 months or later (MD -84.93, 95% CI -131.25 to -38.61; 106 eyes). There was little to no difference in health-related quality of life measures (MD 0.04, 95% CI -0.16 to 0.24; 254 eyes; moderate certainty evidence), and visual acuity (VA) (MD 2.03 ETDRS letter, 95% CI -0.77 to 4.84; 242 eyes) at 12 months, and no observable difference in mean IOP (MD -0.03mmHg, 95% CI -2.34 to 2.32; 257 eyes; moderate certainty evidence) compared to standard care. Irreversible loss of vision was observed in one participant in the phacoemulsification group, and three participants in standard care at 36 months (moderate-certainty evidence). One study (91 eyes) compared phacoemulsification with phaco-viscogonioplasty (phaco-VGP). Low-certainty evidence suggested that fewer IOP-lowering medications were needed at 12 months with phacoemulsification (MD -0.30, 95% CI -0.55 to -0.05). Low-certainty evidence also suggested that phacoemulsification may have improved gonioscopic findings at 12 months or later compared to phaco-VGP (angle grading MD -0.60, 95% CI -0.91 to -0.29; TISA500 MD -0.03, 95% CI -0.06 to -0.01; TISA750 MD -0.03, 95% CI -0.06 to -0.01; 91 eyes). Phacoemulsification may result in little to no difference in best corrected VA at 12 months (MD -0.01 log MAR units, 95% CI -0.10 to 0.08; low certainty evidence), and the evidence is very uncertain about its effect on IOP at 12 months (MD 0.50 mmHg, 95% CI -2.64 to 3.64; very low certainty evidence). Postoperative fibrin reaction was observed in two participants in the phacoemulsification group and four in the phaco-VGP group. Three participants in the phaco-VGP group experienced hyphema. No data were available for progression of visual field loss and quality of life measurements at 12 months. Two studies compared phacoemulsification with phaco-goniosynechialysis (phaco-GSL). Low-certainty evidence suggested that there may be little to no difference in mean IOP at 12 months (MD -0.12 mmHg, 95% CI -4.72 to 4.48; 1 study, 32 eyes) between the interventions. Phacoemulsification did not reduce the number of IOP-lowering medications compared to phaco-GSL at 12 months (MD -0.38, 95% CI -1.23 to 0.47; 1 study, 32 eyes; moderate certainty evidence). Three eyes in the phaco-GSL group developed hyphemas. No data were available at 12 months for progression of visual field loss, gonioscopic findings, visual acuity, and quality of life measures. Three studies compared phacoemulsification with combined phaco-trabeculectomy, but the data were only available for one study (63 eyes). In this study, low-certainty evidence suggested that there was little to no difference between groups in mean change in IOP from baseline (MD -0.60 mmHg, 95% CI -1.99 to 0.79), number of IOP-lowering medications at 12 months (MD 0.00, 95% CI -0.42 to 0.42), and VA measured by the Snellen chart (MD -0.03, 95% CI -0.18 to 0.12). Participants in the phacoemulsification group had fewer complications (risk ratio [RR] 0.59, 95% CI 0.34 to 1.04), and the phaco-trabeculectomy group required more IOP-lowering procedures (RR 5.81, 95% CI 1.41 to 23.88), but the evidence was very uncertain. No data were available for other outcomes.

AUTHORS' CONCLUSIONS

Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow-up; ultimately, the decision for intervention should be part of a shared decision-making process between the clinician and the patient. For people with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. There was insufficient evidence to draw any meaningful conclusions regarding phacoemulsification versus trabeculectomy. Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. These conclusions only apply to short- to medium-term outcomes; studies with longer follow-up periods can help assess whether these effects persist in the long term.

Phacoemulsification with Goniosynechialysis versus Phacoemulsification Alone in Angle-Closure Glaucoma: A Meta-Analysis of Randomized Controlled Trials

Purpose

This meta-analysis aimed to compare the efficacy and safety of phacoemulsification with goniosynechialysis (Phaco-GSL) with those of phacoemulsification alone (Phaco-alone) in patients with angle-closure glaucoma and cataract.

Methods

Randomized controlled trials (RCTs) were selected through a search of electronic databases. Trial eligibility and risk of bias were assessed using Cochrane review methods. Primary measures included the intraocular pressure (IOP), number of antiglaucoma medications, peripheral anterior adhesion (PAS) extent, and their pre- and postoperative changes. For continuous parameters, we calculated weighted mean differences and 95% confidence intervals. Statistical analysis was performed using RevMan 5.3 software.

Results

Eight RCTs were included, where 224 and 236 eyes were in the Phaco-GSL and Phaco-alone groups, respectively. Both postoperative IOP and number of medications were not significantly different between the study groups at the six- and twelve-month follow-up. However, the 12-month postoperative PAS extent was significantly smaller in the Phaco-GSL group than in the Phaco-alone group. Similarly, changes from the preoperative to 12-month postoperative PAS extent were significantly greater in the Phaco-GSL group than in the Phaco-alone group, but IOP and the number of medication changes were not different.

Conclusions

Our results provide evidence that Phaco-GSL provides advantages over Phaco-alone treatment regarding PAS reduction. In terms of IOP and medication reduction, both groups were comparable. Thus, Phaco-GSL can be considered for the treatment of patients with angle-closure glaucoma and cataract due to its ease, safety, and potential benefit for the anterior chamber angle.

MicroPulse Transscleral Laser Therapy with Kahook Dual Blade Excisional Goniotomy and Goniosynechialysis Combined with Phacoemulsification for Angle-Closure Glaucoma: A Case Report

Purpose

To report the efficacy and safety of MicroPulse transscleral laser therapy (TLT) and Kahook Dual Blade excisional goniotomy and goniosynechialysis combined with phacoemulsification for chronic angle-closure glaucoma (ACG).

Patients and Methods

A 39-year-old hyperopic female with a known history of ACG presented with a 2-week history of blurry vision, headache, and photophobia in the right eye (RE) following surgical peripheral iridectomy at another hospital. On examination, her uncorrected visual acuity was 20/50 in the RE, and 20/25 in the left eye (LE). Goldman applanation tonometry revealed an intraocular pressure (IOP) of 51 mmHg in the RE and 12 mmHg in the LE. Ocular examination of the RE revealed conjunctival hyperemia, corneal edema, shallow anterior chamber, posterior synechia, mid-dilated non-reactive pupil, and early cataractous changes. Anterior segment examination findings in the LE were normal except for a shallow anterior chamber. Gonioscopy revealed a closed angle (Schaffer grade 0) with 360° peripheral anterior synechia in the RE and a narrow angle (Schaffer grade 2) in the LE. The cup-to-disc ratios were 0.5 RE and 0.3 LE. The patient underwent MicroPulse TLT with phacoemulsification, Kahook Dual Blade-assisted goniosynechialysis, and excisional goniotomy in the RE.

Results

At the 1-year follow-up, her IOP remained stable without the need for antiglaucoma medications. No further optic nerve or visual field deterioration was noted.

Conclusion

MicroPulse TLT combined with phacoemulsification and Kahook Dual Blade-assisted goniosynechialysis and excisional goniotomy safely reduced IOP and the need for antiglaucoma medications in chronic ACG, avoiding the complications associated with incisional glaucoma surgery.

Effect of Phacoemulsification on Anterior Chamber Angle in Eyes with Medically Uncontrolled Filtered Primary Angle-Closure Glaucoma

Purpose

To evaluate the effect of phacoemulsification and intraocular lens (IOLs) implantation in eyes with medically uncontrolled primary angle-closure glaucoma (PACG) previously treated with trabeculectomy and to quantify the anatomical changes in the anterior chamber angle by ultrasound biomicroscopy (UBM).

Methods

Forty-four eyes of 37 consecutive patients with medically uncontrolled PACG coexisting cataracts with a surgical history of trabeculectomy were included in this study. Each patient underwent phacoemulsification and IOL implantation. Indentation gonioscopy and UBM were performed preoperatively and then again 3 months after surgery. The main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of antiglaucoma medications and anatomical changes in the anterior chamber angle.

Results

The mean logarithm of the minimum angle of resolution BCVA significantly improved from 0.52 ± 0.30 preoperatively to 0.26 ± 0.23 postoperatively (p < 0.001). The mean IOP significantly decreased from 24.33 ± 9.65 mmHg preoperatively to 18.04 ± 7.86 mmHg postoperatively (p < 0.05). 001). The median number of antiglaucoma medications decreased from 2 preoperatively to 1 postoperatively (p < 0.001). There was no significant difference in the extent of peripheral anterior synechia after the surgery (p > 0.05). Some parameters, including anterior central chamber depth, angle opening distance at 500 μm, trabecular-iris angle, and scleral ciliary process angle, were significantly higher after than before surgery (p < 0.001). However, the crystalline lens rise was significantly smaller following the surgery (p < 0.001).

Conclusions

Phacoemulsification and IOL implantation reduced the IOP and improved vision in eyes with medically uncontrolled filtered PACG. The mechanism underlying the outcomes observed following surgery might be related to the anterior chamber deepening, widened drainage angle, and improved aqueous fluid flow to the trabecular meshwork.

Cataract surgery and intraocular pressure in glaucoma

PURPOSE OF REVIEW

To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP).

RECENT FINDINGS

Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years.

SUMMARY

Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.

Systematic Review and Meta-Analysis of Comparing Phacoemulsification Combined with goniosynechialysis to other mainstream procedures in treating patients with angle-closure glaucoma

BACKGROUND

The aim of this meta-analysis is to compare the efficacy and safety of combined phacoemulsification (Phaco) with goniosynechialysis (GSL) to either Phaco or to Phaco combined with trabeculectomy or trabeculectomy alone in patients with angle closure glaucoma (ACG).

METHODS

Five main electronic databases were searched for the eligible studies. Intraocular pressure (IOP) decrease was set as the primary outcome, while anti-glaucomatous medication decrease, changes of anterior chamber depth (ACD), range of peripheral anterior synechia (PAS), and complication occurrence were the secondary outcomes. Standard mean difference (SMD) and relative risk (RR) were the size effects for continuous and binomial data, respectively. Either fixed-effects model or random-effects model was chosen to pool the data based on the heterogeneities.

RESULTS

A total of 7 eligible studies were included. The combined data showed the IOP decreased more significantly after Phaco-GSL than that after Phaco alone (SMD = -0.42,95%CI: -0.70 - 0.14, I = 17.6%, Z = 2.90, P = .004). However, there were no distinct differences regarding medication decrease (SMD =  -0.25,95%CI: -0.70 - 0.21, I = 0%, Z = 1.06, P = 0.29), ACD, the range of PAS and complication occurrence rate when compared Phaco-GSL to Phaco. Moreover, Phaco-GSL was comparable to Phaco-trabeculectomy/trabeculectomy in decreasing IOP (SMD =  -0.08, 95%CI = -0.32 - 0.15, I = 0%, Z = 0.70, P = .49).

CONCLUSIONS

Phaco-GSL might be an optimal procedure to treat ACG with concomitant cataract due to its bleb-less nature, and its capacity for lowering IOP seems superior to Phaco alone and comparable to Phaco-trabeculectomy/trabeculectomy.

Efficacy of Phacoemulsification Alone vs Phacoemulsification With Goniosynechialysis in Patients With Primary Angle-Closure Disease: A Randomized Clinical Trial

Importance

The effectiveness of intraocular pressure (IOP) lowering phacoemulsification combined with goniosynechialysis (GSL) compared with phacoemulsification without GSL remains unknown.

Objective

To compare the IOP outcome after 1 year in patients with synechial primary angle-closure disease (PACD) and cataract who underwent phacoemulsification with intraocular lens implantation (PEI) alone compared with PEI with GSL (PEI-GSL).

Design, Setting, and Participants

A multicenter randomized clinical trial was conducted from September 29, 2011, to March 16, 2015; data analysis was performed from April 1, 2015, to March 4, 2019. Patients with PACD, defined as primary angle closure or primary angle-closure glaucoma, and at least 90° peripheral anterior synechiae (PAS) with cataract were included. Patients were randomized to undergo PEI alone or PEI-GSL. Patients were followed up for 1 year with standardized evaluations. Intention-to-treat analysis was performed.

Interventions

Phacoemulsification with intraocular lens implantation alone or with GSL.

Main Outcomes and Measures

Successful control of IOP at 12 months, defined as IOP 21 mm Hg or lower without use of topical IOP-lowering medications and a decrease in IOP of 20% or more from baseline IOP.

Results

Data from 78 patients (78 eyes) were analyzed. Of these, 37 patients were Chinese (47.4%) and 54 were women (69.2%); mean (SD) age was 67.7 (8.9) years. Mean deviation (SD) at baseline was -13.5 dB (9.4 dB). Forty patients were randomized to the PEI group and 38 to the PEI-GSL group. The mean (SD) IOP at baseline was 22.3 (8.5) mm Hg for the PEI group and 22.9 (5.3) mm Hg for the PEI-GSL group. At 1 year, the mean IOP was 14.3 (5.0) mm Hg for the PEI group and 15.9 (4.5) mm Hg for the PEI-GSL group. Successful control at 1 year occurred in 21 patients (52.5%) in the PEI group and 22 patients (57.9%) in the PEI-GSL group (mean difference, 5.4%; 95% CI, -18.0% to 28.2%; P = .63). In eyes that achieved successful control, mean IOP at 1 year was 12.5 (2.7) mm Hg (range, 7.0-19.0) for the PEI group and 13.6 (2.4) mm Hg (range, 9.0-18.0) for the PEI-GSL group. The number of medications at baseline and 1 year decreased from a mean of 2.2 (0.8) to 0.5 (0.9) in the PEI group and 1.9 (0.9) to 0.6 (1.2) in the PEI-GSL group (P < .001 for each), with a mean change difference of 0.4% (95% CI, -0.02% to 0.9%; P = .06). There were 3 postoperative complications (7.5%) in the PEI group and 3 (7.9%) in the PEI-GSL group. These included IOP spike (IOP≥30 mm Hg) (n = 3), excessive anterior chamber inflammation (n = 1), and posterior capsule opacification (n = 2).

Conclusions and Relevance

This randomized clinical trial was unable to show that PEI-GSL added additional IOP lowering compared with PEI alone in patients with PACD.

Trial Registration

ClinicalTrials.gov identifier: NCT02376725.

Comparative Evaluation of Phacoemulsification Alone versus Phacoemulsification with Goniosynechialysis in Primary Angle-Closure Glaucoma: A Randomized Controlled Trial

PURPOSE

Comparative evaluation of phacoemulsification (phaco) alone versus phacoemulsification combined with goniosynechialysis (phacoGSL) in primary angle-closure glaucoma (PACG).

DESIGN

Prospective, randomized, parallel group, active controlled trial.

PARTICIPANTS

Patients with PACG.

METHODS

A total of 120 consecutive patients with PACG were screened, of whom 80 met inclusion criteria, with PACG uncontrolled on maximal hypotensive therapy and were recruited. Patients were randomized into 2 groups and underwent phaco alone in group 1 or phacoGSL in group 2. The patients were examined at baseline and at 1 week and 1, 3, and 6 months. The anterior chamber angle parameters on swept-source anterior segment OCT (SS-ASOCT) were noted at 1 and 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was intraocular pressure (IOP) reduction. A reduction in IOP of ≥ 20% from baseline IOP with or without medications was considered a success. Secondary outcome measures included change in the anterior chamber angle temporal parameters, angle-opening distance, trabecular-iris space area and scleral spur angle, surgical safety, visual acuity, and reduction in the number of glaucoma medications postoperatively.

RESULTS

The average age of patients was 58.77±8.14 years and 56.50±9.17 years in groups 1 and 2, respectively (P = 0.31). The mean baseline IOP was 29.48±6.76 mmHg and 30.72±3.88 mmHg in groups 1 and 2, respectively (P = 0.13). Success was obtained in 93.33% of patients in group 1 and 91.18% of patients in group 2 at 6 months (P = 0.39). Mean IOP was 13.17±1.66 mmHg and 13.21±1.97 mmHg at 6 months in groups 1 and 2, respectively (P = 0.001). The reduction in IOP was 55.32% and 56.99% at 6 months in groups 1 and 2 (P = 0.48). Significant widening of the angle parameters was noted at 6 months with an increase compared with baseline values in both groups. In multivariate analysis, the significant predictor of decrease in IOP was the higher baseline IOP.

CONCLUSIONS

Both phaco and phacoGSL are associated with a significant reduction in IOP along with a noteworthy widening of the anterior chamber angle parameters. Both procedures succeeded in reducing the necessity of glaucoma medications postoperatively in PACG eyes. There is no additional benefit of phacoGSL over phaco in PACG.

Phacoemulsification with or without goniosynechialysis for angle-closure glaucoma: a global Meta-analysis based on randomized controlled trials

AIM

To compare the benefits and potential harms of routine phacoemulsification (phaco) alone and combined surgery with goniosynechialysis (GSL) for angle-closure glaucoma (ACG) and coexisting lens opacity, as shown in different randomized controlled trials (RCTs).

METHODS

A systematic review was conducted searching several databases including PubMed, Cochrane Library, EMBASE, ClinicalTrials.gov from the inception to September 2018 for RCTs with data published on the effects and safety of phaco and intraocular lens implantation combined with GSL or routine cataract surgery alone. Several studies were recruited which reported data at baselines and postoperative follow-up, including the mean values of postoperative intraocular pressure (IOP) and mean numbers of anti-glaucoma medications using postoperatively. The numbers of complications happening were also included. Fixed-effect and random-effect models were applied, and the quality of evidence was evaluated.

RESULTS

Analysis of the seven included RCTs, with a total number of 321 participants (358 eyes) diagnosed with ACG and cataract, received a solo procedure (phaco group) or a combined surgery (phaco-GSL group) randomly, and follow-up periods ranging from 2 to 12mo postoperatively. The involved studies showed that the mean value of IOP between the two groups at 3 (four studies, one study follow-up at 2mo postoperative was included), 6, 12mo postoperative were not significantly different. Only two studies reported the change in IOP value at 12mo compared with baseline but showed no significant differences between the two interventions. Although three studies did not have the significant difference in the number of medications using to reduce IOP at 3mo postoperatively, two studies reported that the participants using fewer anti-glaucoma medications at 12mo postoperative in the phaco group than in the phaco-GSL surgery group.

CONCLUSION

The analysis provides a low to moderate-quality evidence that phaco-GSL surgery lead to an equivalent IOP-lowering effect. The phaco-GSL surgery may not help patients to reduce the consumption of anti-glaucoma eyedrops in the long period. The results of this analysis suggested that additional GSL may not be necessary for primary angle closure glaucoma (PACG) patients. Further studies, especially RCTs with more participants and longer follow-up time were needed to provide more sufficient data.

The effect of phacoemulsification plus goniosynechialysis in acute and chronic angle closure patients with extensive goniosynechiae

BACKGROUND

Patients with primary angle closure/glaucoma (PAC/PACG) with extensive peripheral anterior synechiae (PAS), and coexisting cataract, increasingly have been treated with phacoemulsification combined with goniosynechialysis (Phaco-GSL). Since the mechanisms of acute and chronic PAC/PACG may differ, the treatment effect of this procedure also may differ. The purpose of this study was to establish whether there was a difference in the therapeutic effect of Phaco-GSL on these two groups of patients, the results of which could provide clinical evidence for improvement in treatment protocols for patients with PAC/PACG and extensive PAS.

METHODS

This study was a retrospective cohort study. Twenty-seven patients, 13 with acute PAC/PACG and 14 with chronic PAC/PACG, were treated surgically by Phaco-GSL. The intraocular pressure (IOP), surgical success rate, the need of medication, the extent of PAS, the time and the rate of recurrence of PAS (re-PAS) and other indicators were observed post-operatively for at least 3 months.

RESULTS

After surgery, IOP decreased (preoperative vs postoperative: 29.77 ± 11.55 mmHg vs 14.92 ± 1.66 mmHg in the acute group and 26.00 ± 11.2 mmHg vs 14.93 ± 2.7 mmHg in the chronic group), the extent of PAS reduced (preoperative vs. postoperative: 314.23 ± 49.07° vs 116.54 ± 73.78° in the acute group and 285.00 ± 53.28° vs 156.43 ± 56.35° in the chronic group), the topical and systemic anti-glaucoma drug requirements decreased, in both groups and in the acute group, respectively. Compared with the acute group, the success rate (acute vs chronic: 100% vs 64.3%) was lower in the chronic group, while the incidence of re-PAS (acute vs chronic: 30% vs 83.3%) were higher in the chronic group. All differences mentioned above were statistically significant (p < 0.05). In addition, there were five patients in total who showed re-PAS of more than 90° (4 in chronic group and 1 in acute group) and all these re-PASs formed within 1 week postoperatively.

CONCLUSION

Although Phaco-GSL is effective in both groups, there may be differences in the effect between the two groups. Chronic patients are more susceptible to re-PAS. Thus, these patients should be observed closely and treated appropriately in the early post-surgical time period.

Expression of matrix Metalloproteinases-2 and aquaporin-1 in corneoscleral junction after angle-closure in rabbits

Background

To investigate the expression of Matrix Metalloproteinases 2 and aquaporin-1 in corneoscleral junction and explore the mechanism of trabecular damageafter angle-closure.

Methods

Thirty New Zealand white rabbits were randomly assigned into 2 groups, theexperimental group (Group 1) including twenty five rabbits and the control group (Group 2) including 5 rabbits. The rabbits in the experimental group were used to establish angle-closure models, and the rabbits in the control group were not subjected to any operation. All the rabbits were followed by slit lamp microscopy, Tonopen tonometer, and anterior segment optical coherent tomography (AS-OCT). The expressions of metalloproteinase MMP-2, aquaporin-1, and tissue inhibitors of metalloproteinase-2 in corneoscleral junctionwere evaluatedin both groups byimmunofluorescence, quantitative reverse-transcription polymerase chain reaction (qRT-PCR), and enzyme-linked immunosorbent assay (ELISA).

Results

Slit-lamp examination showed that angle-closure model was successfully established in twenty rabbits. The extent of angle-closure was about 2 to 4 clock hours in all the rabbit models, but the intraocular pressure (IOP) of the rabbits distributed from 8.57 to 15.25 mmHg and no significant high IOP was found in the follow-up period. The AQP-1-positive cells mainly located in Schlemm’s canal, the inner surface of trabecular meshwork (TM), and the surface of iris, which began to decline on 1 month after angle-closure. MMP2 staining was diffuse in trabecular meshwork and iris. Immunofluorescence signal of MMP2 was strong within 1 month after angle-closure, and subsequently became weak. qRT-PCR and ELISA showed that the expression of MMP-2 and TIMP-2 increased within 1 month after angle-closure and then declined gradually. The AQP-1 levels showed slightly declined on 1 month after angle-closure.

Conclusions

Altered levels of MMPs, TIMPs, and AQP-1 were found in the area of angle-closure, which may be involved in the damage of TM and Schlemm’s canal after angle-closure.

Post-phacoemulsification iris changes in eyes with glaucoma or glaucoma suspect status

Purpose

This prospective study used anterior segment optical coherence tomography (AS-OCT) to determine how phacoemulsification (phaco) changes iris parameters in eyes with glaucoma or glaucoma suspect status.

Methods

Using Visante AS-OCT (Carl Zeiss Meditec AG), the following pre- and post-phaco parameters were measured: IT750 = iris thickness at 750 μm from the scleral spur; IT2000 = iris thickness 2000 μm from the scleral spur; ITCM = the maximum iris thickness at the middle one third of the iris; ICURV = iris curvature; IAREA = iris area; and pupil size = pupil diameter (mm). Only high-quality images with an identifiable scleral spur were included, and only the nasal quadrant was analyzed. A single glaucoma specialist analyzed the parameters according to the Zhongshan Angle Assessment Program (ZAAP, Guangzhou, China). Multivariate analysis was performed using mixed effects regression correcting for age, gender, and ethnicity.

Results

89 subjects and 110 eyes were included in this study. The mean age of subjects was 74.83 {+/-} 8.69 years old. Most common diagnoses were POAG and glaucoma suspect (23% and 52%, respectively), and 16% of subjects had an LPI. In multivariate analysis of AS-OCT parameters, decreases in IT750, IT2000, ITCM, ICURV, and pupil size were statistically significant (p<0.05).

Conclusions

After phacoemulsification, eyes with glaucoma as well as glaucoma suspect eyes have thinner irises and smaller pupils. This may lead to less iris-mediated aqueous outflow obstruction, providing support for early phacoemulsification glaucoma treatment.

Translational relevance

Our AS-OCT imaging findings may guide clinical practice as iris parameters become increasingly relevant in preoperative phaco planning.

Contemporary approach to the diagnosis and management of primary angle-closure disease

The primary angle-closure disease spectrum varies from a narrow angle to advanced glaucoma. A variety of imaging technologies may assist the clinician in determining the pathophysiology and diagnosis of primary angle closure, but gonioscopy remains a mainstay of clinical evaluation. Laser iridotomy effectively eliminates the pupillary block component of angle closure; however, studies show that, in many patients, the iridocorneal angle remains narrow from underlying anatomic issues, and increasing lens size often leads to further narrowing over time. Recent studies have further characterized the role of the lens in angle-closure disease, and cataract or clear lens extraction is increasingly used earlier in its management. As a first surgical step in angle-closure glaucoma, lens extraction alone often effectively controls the pressure with less risk of complications than concurrent or stand-alone glaucoma surgery, but may not be sufficient in more advanced or severe disease. We provide a comprehensive review on the primary angle-closure disease nomenclature, imaging, and current laser and surgical management.

Reproducibility and Agreement of Anterior Segment Parameter Measurements Obtained Using the CASIA2 and Spectralis OCT2 Optical Coherence Tomography Devices

PURPOSE

To assess the reproducibility and agreement of measurement values obtained from the Tomey CASIA2 and Heidelberg Spectralis OCT2 anterior segment optical coherence tomographic devices.

METHODS

Twenty eyes from 10 subjects ranging from age 28 to 45 years with no history of eye conditions or intraocular surgery were included. Two scans were obtained with each device in a standardized dark room environment after a period of dark adaptation. One anterior segment optical coherence tomography image along the horizontal (temporal nasal) meridian was analyzed per eye and per scan. Lens vault, pupil diameter, anterior chamber width, angle opening distance, trabecular iris space area, and scleral spur angle were measured using manufacturer-provided image analysis programs. Intraclass correlation coefficient (ICC) values, coefficients of variation, and Bland-Altman plots were computed to assess the intradevice correlation and interdevice agreement of measurement values.

RESULTS

There was excellent intradevice reproducibility of measurement values for both the CASIA (ICC range, 0.86 to 0.99) and Spectralis (ICC range, 0.79 to 1.00). There was also excellent interdevice correlation of measurement values (ICC range, 0.78 to 0.93) for all parameters except anterior chamber width (ICC 0.20). Linear regression models and Bland-Altman plots showed that this relationship was strongest when measurement values were small.

CONCLUSIONS

There is excellent intradevice reproducibility and good interdevice agreement of anterior segment parameter measurement values for the CASIA2 and Spectralis OCT2. However, the measurements obtained with each device should not be considered interchangeable.

Benefit of Measuring Anterior Segment Structures Using an Increased Number of Optical Coherence Tomography Images: The Chinese American Eye Study

Purpose

The purpose of this study was to evaluate the benefit of analyzing an increased number of anterior segment optical coherence tomography (AS-OCT) images on measurement values of various anterior segment parameters.

Methods

Subjects for this cross-sectional study were recruited from the Chinese American Eye Study (CHES), a population-based study in Los Angeles, CA. Thirty-two AS-OCT images were acquired from one eye each of 83 consecutive subjects. Sixteen parameters were analyzed in each image, including angle opening distance (AOD), angle recess area (ARA), trabecular iris space area (TISA), trabecular iris angle (TIA), scleral spur angle (SSAngle), lens vault (LV), pupillary diameter (PD), anterior chamber depth (ACD), anterior chamber width (ACW), iris area (IA), and anterior chamber area (ACA). Data from 1, 2, 4, 8, 16, or 32 OCT images were averaged across subjects to calculate the range and mean of measurement values for each parameter.

Results

Anatomical variations were poorly captured with fewer OCT images for AOD, ARA, TISA, SSAngle, IA, and LV. For these parameters, the range and mean of measurement values obtained from one OCT image deviated from 32-image values by up to 43.9% and 13.3% of the 32-image mean, respectively. These deviations decreased when additional OCT images were analyzed. Deviations from 32-image range and mean values were less pronounced regardless of image number for PD, ACD, ACW, and ACA, measuring up to 3.5% and 5.0%, respectively.

Conclusions

A multi-image approach should be the standard in OCT-based studies of AOD, ARA, TISA, TIA, SSAngle, IA, and LV.

Aqueous outflow facility after phacoemulsification with or without goniosynechialysis in primary angle closure: a randomised controlled study

BACKGROUND

Goniosynechialysis (GSL) to remove peripheral anterior synechiae (PAS) alongside standard cataract surgery has potential theoretical advantages, Published randomised trials, however, have not shown conclusive functional benefits and aqueous outflow changes following GSL are unknown. This study aimed to compare electronic Shiøtz tonographic aqueous outflow facility (TOF) following phacoemulsification with or without GSL in patients with primary angle closure (PAC) and PAC glaucoma. Secondary outcomes were changes in intraocular pressure (IOP) and use of glaucoma medications.

METHODS

Prospective randomised pilot study of 26 patients on glaucoma medication, with ≥90° PAS and significant lens opacity. Patients were randomised 1:1 to receive phacoemulsification with intraocular lens (IOL) implantation only (phaco) or phacoemulsification with IOL plus GSL (phaco-GSL).

RESULTS

Fourteen patients were randomised to phaco-GSL and 12 to phaco alone. TOF increased with phaco-GSL from 0.099±0.07 μL/min/mm Hg to 0.194±0.07, μL/min/mm Hg, p=0.0006, while the phaco group showed no significant change. IOP reduced in both groups, but reduced significantly more following phaco-GSL (46.0%) compared with phaco alone (27.6%, p=0.04). Medication use and extent of PAS only reduced with phaco-GSL, from 0.923±0.86 to 0.384±0.18 medications, p=0.0279, and from 249.2±83.4 to 110.8±53.9° PAS, 6 months postoperatively. No serious adverse events occurred in either group.

CONCLUSIONS

Eyes randomised to both surgical groups had similar and good outcomes at 6 months in this pilot study. However, only eyes undergoing GSL combined with standard phacoemulsification had significantly increased TOF, reduced glaucoma medication dependence and PAS postoperatively. GSL should therefore be considered in such patients.

TRIAL REGISTRATION NUMBER

NCT00719290, Results.

Comparison of phacotrabeculectomy and sequential surgery in the treatment of chronic angle-closure glaucoma coexisted with cataract

AIM

To compare the safety and effectiveness of phacotrabeculectomy versus sequential surgery in chronic angle-closure glaucoma (CACG) with coexisting cataract.

METHODS

One hundred and sixty-two CACG patients (162 eyes) were retrospectively analyzed. Of them, 87 patients (87 eyes) in group A had underwent phacotrabeculectomy with intraocular lens (IOL) implantation, and 75 patients (75 eyes) in group B had underwent sequential surgery with IOL implanted. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), complications and anterior chamber angle (ACA) were measured.

RESULTS

Demographic characteristics of the two groups were similar. A mean follow-up period was 15±6mo (range 13 to 24mo), a mean IOP of 16.61±6.43 mm Hg in group A and 15.80±5.35 mm Hg in group B (P=0.84) at the last follow up. The Kaplan-Meier analysis revealed that the cumulative probability of success in both groups was similar (P=0.61). Anterior uveitis and hypotony were the most common complications in group A, whereas group B experienced shallow anterior chamber with trabeculectomy. With the exception of anterior uveitis, no complications occurred to 11 trabeculectomized eyes. All postoperative measurements of anterior chamber showed statistically significant differences in each group according to the preoperative data (P<0.05). However, fewer changes occurred in group B than in group A.

CONCLUSION

Phacotrabeculectomy and sequential surgery exhibit similar IOP reduction, visual recovery, and complications when treating CACG patients with cataract. However, for a wider ACA, phacotrabeculectomy has demonstrated higher effectiveness than sequential surgery.

Management of Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension caused by closure of the drainage angle. Angle closure is caused by appositional approximation or adhesion between the iris and the trabecular meshwork. The main treatment strategy for PACG lies in the reduction of intraocular pressure, reopening of the closed angle, and possible prevention of further angle closure. There is no universally agreed best surgical treatment for PACG. Trabeculectomy, goniosynechialysis (GSL), glaucoma implant, and cyclodestructive procedures are effective surgical options. Each of them plays an important role in the management of PACG with its own pros and cons. Accumulating evidence is available to show the effectiveness of visually significant and visually nonsignificant cataract extraction in the treatment of PACG. Trabeculectomy and GSL are often combined with cataract extraction, which may offer additional pressure control benefits to patients with PACG. This review article will discuss laser peripheral iridotomy, argon laser peripheral iridoplasty, and surgeries such as GSL, phacoemulsification, and phaco plus glaucoma surgeries that lower intraocular pressure and also alter the anterior segment and/or drainage angle anatomy. Currently, glaucoma implants and cyclodestruction are mainly reserved for PACG patients who have failed previous filtering operations. Their role as initial surgical treatment for PACG will not be discussed.