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

Efficacy and safety of primary customized phacoemulsification combined with goniosynechialysis for refractory acute primary angle closure

PURPOSE

To assess the safety, efficacy, and long-term clinical outcomes of primary customized phacoemulsification (phaco) combined with goniosynechialysis (GSL; phaco-GSL) in refractory acute primary angle closure (APAC) eyes with uncontrolled high intraocular pressure (IOP).

METHODS

This retrospective case series comprised 51 eyes of 42 consecutive patients with refractory APAC and high IOP who were treated using primary customized phaco-GSL at 3 hospitals in China, from 2014 to 2021. Preoperative and postoperative IOP, corrected distant visual acuity (CDVA), corneal endothelial cell density (CECD), intraoperative and postoperative complications were recorded. The safety, efficacy and subsequent long-term clinical outcomes were analyzed.

RESULTS

The mean CDVA (LogMAR) was improved from 1.67 ± 0.94 preoperatively to 0.23 ± 0.26 postoperatively (P < 0.001). Preoperative CECD was 2309.39 ± 541.03 cells/mm2 in 33 eyes and inaccessible in 18 eyes due to severe corneal edema; at the final follow-up, the mean CECD of all patients was 1823.50 ± 533.40 cells/mm2 (P < 0.001). The mean IOP decreased from 48.51 ± 6.25 mmHg preoperatively to 15.66 ± 2.27 mmHg at the final follow-up (P < 0.001). Among 51 eyes, additional customized procedures performed were corneal indentation in 42 eyes, epithelial debridement in 9 eyes, giant epithelial bullae view in 4 eyes, pars-plana fluid aspiration in 3 eyes, and secondary intraocular lens implantation in 7 eyes. The IOP of all eyes was well controlled eventually and 47 eyes (92.16%) were successfully treated by phaco-GSL alone. No significant intraoperative or postoperative complications were observed.

CONCLUSIONS

Primary customized phaco-GSL is a safe and effective surgical management strategy for patients with refractory APAC and high IOP.

Phaco-goniosynechialysis versus phaco-trabeculectomy in patients with refractory primary angle-closure glaucoma: a comparative study

PURPOSE

To compare the effects of phacoemulsification with intraocular lens implantation (phaco) combined with goniosynechialysis (phaco + GSL) versus phaco with trabeculectomy (phaco + trab) for the management of primary angle-closure glaucoma (PACG) refractory to peripheral anterior synechiae (PAS) of over 180°.

METHODS

This retrospective study followed 77 eyes of 77 patients for at least 6 months. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of glaucoma drugs, and PAS were recorded at the preoperative baseline and evaluated at each postoperative follow-up visit. The National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) was administered to patients enrolled in this study. Pearson's correlation analysis and multivariate linear analysis were performed to identify factors influencing changes in NEI VFQ-25 scores and to identify factors associated with increases in NEI VFQ-25 scores after the operation.

RESULTS

In total, seventy-seven eyes were included (43 with phaco + GSL and 34 with phaco + trab). Comparing preoperative baseline and month 6 after surgery measurements revealed that both groups found significant improvements in IOP, PAS, BCVA and the number of glaucoma drugs (P < 0.05). Baseline NEI VFQ-25 scores were similar in the two groups, but there was a significant difference in postoperative NEI VFQ-25 scores (74.47 ± 10.39 in phaco + GSL vs. 69.57 ± 8.54 in phaco + trab, P = 0.048 < 0.05), and the phaco + GSL group had better scores at the time of the last follow-up. The change in preoperative scores and the number of glaucoma drugs was significantly correlated with postoperative scores in the phaco + GSL group.

CONCLUSION

Phaco + GSL treatment is as safe and effective as phaco + trab for refractory PACG patients, and patients' subjective experience improved significantly after phaco + GSL surgery.

Measurement of Retinal Changes in Primary Acute Angle Closure Glaucoma under Different Durations of Symptoms

Purpose

To investigate the changes of retinal nerve fiber layer (RNFL) in patients after an attack of primary acute angle closure glaucoma (PAACG) and to assess the impact of attack time on prognosis of retinal changes.

Design

cross-sectional study.

Methods

Twenty-six patients with unilateral PAACG attack and cataracts from 2017 to 2019 were enrolled. Eyes with PAACG attack time less than 1 day constituted the group A (n = 13), while eyes with PAACG attack time more than 1 day constituted the group B (n = 13). All patients received phacoemulsification and viscogoniosynechialysis after intraocular pressure (IOP) lowering. All patients underwent ophthalmic examinations including IOP, best-corrected visual acuity (BCVA), and visual field (VF). Optical coherence tomography angiography (OCTA) was used to obtain circumpapillary RNFL vessel density (cpVD). Spectral domain optical coherence tomography (SD-OCT) was used to examine the peripapillary RNFL and macular ganglion cell complex (GCC). All patients accepted 2 assessments before and 1 month after the procedure.

Results

The IOP of all patients recovered to normal (12.77 ± 2.65 mm Hgvs. 12.77 ± 3.85 mmHg, p=0.834) after the procedure. Patients in the group A had better BCVA improvement than those in the group B (1.32 ± 0.84 vs. 0.50 ± 0.21, p=0.004), as well as better mean defect (MD) values from VF (-3.65 ± 2.54 vs -16.05 ± 5.99, p < 0.001). Compared with group B, patients in the group A had thicker macula (Fovea area: 255.00 ± 27.94 μm vs. 203.92 ± 59.73 μm, p=0.010), thicker GCC (82.62 ± 8.76 μm vs. 65.23 ± 18.56 μm, p=0.005), and thicker RNFL (105.08 ± 9.38 μm vs. 77.69 ± 20.23 μm, p < 0.001). Higher blood flow density in all-plexus peripapillary retina was observed in the group A eyes compared with group B (full sector: 0.56 ± 0.02 vs. 0.41 ± 0.07, p < 0.001). In both groups, the association between average RNFL thickness and cpVD as well as MD values and pattern standard deviation (PSD) values from VF was stronger (R ² = 0.58, 0.60, -0.54, respectively, all p < 0.001) than the association between GCC thickness and cpVD, as well as MD values and PSD values (R ² = 0.37, p=0.001; R ² = 0.37, p=0.001; R ² = -0.27, p=0.007).

Conclusion

Patients with attack time less than 1 day had better retinal thickness and all-plexus peripapillary retina blood flow density. Controlling the attack time could decrease retinal damage by PAACG.

Management of Different Subtypes of Primary Angle Closure with Phacoemulsification and Viscogoniosynechialysis

PURPOSE

To retrospectively assess the effectiveness of combined phacoemulsification with viscogoniosynechialysis for patients with different subtypes of primary angle closure (PAC).

METHODS

Forty-three eyes of 37 patients diagnosed with PAC (12 eyes), PAC with glaucoma (PACG, 20 eyes), and acute PAC (11 eyes) were treated with phacoemulsification and viscogoniosynechialysis between November 2010 and October 2012. Main outcome measures were anterior chamber depth (ACD), intraocular pressure (IOP), the number of IOP-lowering medication, extent of peripheral anterior synechia (PAS), and visual acuity preoperatively and one month postoperatively.

RESULTS

All operations were successfully accomplished and no intra-operative complications were observed. The ACD, IOP, PAS, and visual acuity were all significantly improved postoperatively, especially in the acute PAC group, which resulted in few glaucoma drugs being needed. The IOP was decreased into equal or less than 21 mmHg in most patients postoperatively, except four patients had IOP slightly higher than 21 mmHg. However, they were restored to normal spontaneously or by medication at last follow-up. The extent of PAS was all reduced to less than 90 or 180°, with the visual acuity restored to more than 0.1.

CONCLUSIONS

Combined phacoemulsification with viscogoniosynechialysis seems to be an effective surgical procedure in the treatment of various subtypes of PAC.

Guidelines for treatment of chronic primary angle-closure glaucoma

OBJECTIVE

To present a clinical practice guideline update on the medical, laser, and surgical treatment of primary angle closure glaucoma (PACG) in adults.

METHODS

Following the formulation of key questions using the PICO scheme (Patient/Problem, Intervention, Comparison, Outcome), a systematic review was performed on the literature published to date, including international clinical practice guidelines. The AMSTAR and Risk of Bias tools were used for evaluating the quality of the information. The level of evidence and grade of recommendation was established following the Scottish Intercollegiate Guidelines Network (SIGN) system.

RESULTS

Following the above methodology, recommendations of medical, laser and surgical treatment in adult PACG and levels of evidence are presented.

CONCLUSIONS

Although the level of scientific evidence for many of the questions raised is not very high, a review is presented on updated treatment recommendations for adult PACG. Among the limitations for the implementation of these recommendations is that most studies have been conducted in Asian populations, and that the effectiveness is measured almost exclusively in terms of reducing intraocular pressure, and does not include visual function, quality of life or cost-effectiveness parameters.