Effect of Phacoemulsification on Drainage Angle Status in Angle Closure Eyes with or without Extensive Peripheral Anterior Synechiae

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.

Long-Term Effect of Early Phacoemulsification in Primary Angle Closure Glaucoma Patients with Cataract: A 10-Year Follow-Up Study

Purpose

To assess the 10-year effects of early phacoemulsification with intraocular lens (IOL) implantation in primary angle closure glaucoma (PACG) patients with cataract.

Patients and Methods

This prospective cohort study included 102 eyes of 102 patients with PACG. All patients had coexisting cataracts compromising vision. Patients underwent phacoemulsification and foldable IOL implantation. The main outcome measures were anterior chamber depth (ACD), angle width, value of intraocular pressure (IOP), and number of medications needed postoperatively and during follow-up.

Results

Half (53%) of the patients were female, with ages ranging from 55 to 73 with a mean of 59.82±5.19 years. Mean IOP decreased significantly from 22.15±2.08 mmHg at baseline to 14.08±2.13 mmHg postoperatively (p˂ 0.05). The ACD increased from 2.2±0.21 preoperatively to 3.73±0.25 postoperatively (p˂0.001). Nasal angle width increased postoperatively to 40.05±2.09 compared to the preoperative value of 16.02±2.08 (p˂0.001). Temporal angle width increased from 13.05±2.07 to 41.9600±1.94 (p˂0.001). Anti-glaucoma treatment significantly decreased postoperatively (p˂0.001). A significant positive correlation was detected between ACD and angle width, while a negative correlation was detected between IOP and both ACD and angle width (p˂0.001). There was also a significant negative correlation between postoperative angle width and IOP (p˂0.001). Preoperative lens thickness was positively correlated with preoperative IOP and number of medications, while it was negatively correlated with preoperative AC depth and angle width. Preoperative lens thickness positively correlated with postoperative IOP and medications. Complete and qualified success was achieved in 69.65% and 30.4% of cases, respectively, while 2.9% failed to be controlled. Visual acuity significantly improved from 0.17±0.1 to 0.9±0.08 (p˂0.001). All parameters showed high stability throughout the follow-up period.

Conclusion

Phacoemulsification with IOL implantation is a safe and effective early modality for long-term control of IOP in PACG patients with coexisting cataract. The effects can persist for at least 10 years.

Changes in ocular morphology after cataract surgery in open angle glaucoma patients

The purpose of this study was to evaluate intraocular pressure (IOP) pre- and postoperatively, together with anterior chamber angle (ACA) parameters and biometrical results in cataract patients with or without open angle glaucoma (OAG). The prospective observational case-control study included 15 eyes with cataract and OAG in the glaucoma group and 25 eyes with only cataract in control group. Examination included full ophthalmic evaluation, IOP, ocular biometry and anterior segment optical coherence tomography measuring ACA pre- and 6 months postoperatively. OAG patients had a larger absolute IOP reduction compared to control group. Anterior chamber depth (ACD) and ACA width significantly increased in both groups. The OAG group had a tendency of narrower ACA preoperatively, but overall ACA parameters did not differ in either group pre- and postoperatively. The ACD change after surgery correlated with ACA parameters in the control group, but not in OAG group. Axial length was shorter postoperatively in the control group, but remained similar in the OAG group. Absolute IOP reduction was more pronounced in cataract patients with OAG than in cataract patients without glaucoma. ACD and ACA postoperatively increased in both groups and AL shortening was observed in non-OAG in cataract group.

Intraocular pressure changes after phacoemulsification in pseudoexfoliation versus healthy eyes

Background

Pseudoexfoliation (PXF) syndrome is the most common cause of secondary glaucoma worldwide. This systemic disorder causes further damage to the optic nerve and ultimately increases the need for surgical interventions. Therefore, intraocular pressure (IOP) control is very important in these patients. The aim of this study was to compare IOP changes after phacoemulsification in subjects with PXF syndrome compared to those without this syndrome.

Methods

61 patients were enrolled in this prospective clinical study. Subjects were assigned into two groups based on presence or absence of PXF syndrome. IOP and anterior chamber angle parameters including: angle opening distance (AOD) and trabecular-iris surface area (TISA) measured one day preoperatively and 3 months postoperatively. Intraoperative metrics factors including: infusion fluid usage (IFU), cumulative dissipated energy (CDE) and aspiration time (AT) were obtained from the phacoemulsification machine at the end of each surgery. IOP changes, anterior chamber angle parameters and intraoperative metrics factors were compared between groups.

Results

Mean IOP before surgery was significantly higher in the PXF group (14.70 mm Hg) compared to controls (12.87 mm Hg) (P-value < 0.01). Phacoemulsification decreased IOP in both, but to greater extent in the PXF group (p-value < 0.01). AOD and TISA also increased significantly following surgery in both groups. The results showed that postoperative IOP was negatively correlated with preoperative IOP in both groups (p-value < 0.01). Also, IOP after phacoemulsification was negatively correlated with IFU in the PXF group (p-value = 0.03).

Conclusions

Patients with PXF syndrome exhibited a reduction in IOP and increase in anterior chamber angle parameters after phacoemulsification. We observed a greater IOP reduction in PXF subjects when it was compared to controls. Higher preoperative IOP and intraoperative IFU were associated with more IOP reduction in the PXF group.

The effects of peripheral anterior synechiae on refractive outcomes after cataract surgery in eyes with primary angle-closure disease

Objective of the study was to investigate the effects of peripheral anterior synechiae (PAS) on refractive outcomes after cataract surgery in eyes with primary angle-closure disease (PACD).This is a retrospective, cross-sectional study. Seventy eyes of 70 PACD patients who underwent phacoemulsification and intraocular lens implantation. Patients were divided into 2 groups based on the presence of PAS on preoperative gonioscopy. The predictive power of the intraocular lens was calculated by the SRK/T, Hoffer Q, Haigis, and Holladay formulae. The mean absolute error (MAE) and predicted refractive errors were compared between PAS (+) and PAS (-) groups. We also evaluated the refractive errors with regards to the extent of PAS in the subanalyses.The mean MAE was greater in the PAS (+) group with all formulae (0.61-0.70 diopters [D] vs 0.33-0.45 D, all P < .05). The eyes with PAS tended towards myopia (-0.30 D to -0.51 D vs -0.05 D to +0.24 D, all P < .05). However, the MAEs or predicted refractive errors were not different, irrespective of the extent of PAS in the subanalyses (all, P > .05).The presence or absence of PAS may influence the postoperative refractive outcomes in PACD patients.

Anterior Segment Optical Coherence Tomography: Is There a Clinical Role in the Management of Primary Angle Closure Disease?

Primary angle closure disease (PACD) covers a spectrum that includes primary angle closure suspect, primary angle closure, primary angle closure glaucoma, and acute primary angle closure. Accumulating evidence suggests that the pathogenesis of PACD is complex, with multiple contributory factors including variations in the anatomic or biometric characteristics of the angle segment structures. Advances in anterior segment optical coherence tomography technology have further enhanced our understanding of the risk factors and mechanisms involved in the disease process. This review discusses the potential clinical role of the anterior segment optical coherence tomography in the diagnosis, mechanistic evaluation, and as a predictor for future clinical outcomes of patients with PACD.

The change of anterior segment parameters after cataract surgery in normal-tension glaucoma

AIM

To investigate the change of anterior chamber angle morphology and intraocular pressure (IOP) reduction after cataract surgery in patients with normal-tension glaucoma (NTG) using swept-source optical coherence tomography (SS-OCT).

METHODS

This prospective, comparative, observational study recruited patients into two groups. Group 1 was the control group including normal subjects except those with cataracts (cataract group, n=67 eyes of 67 patients), and group 2 was NTG group including patients who were diagnosed with NTG and cataracts (n=43 eyes of 43 patients), which were treated with phacoemulsification and intraocular lens implantation. Before surgery, and at postoperative 1 and 6mo, anterior chamber angles were evaluated by SS-OCT under dark conditions using three-dimensional angle analysis scan protocol. Angle opening distance (AOD), angle recess area (ARA), and trabecular-iris surface area (TISA) at four quadrants (temporal, nasal, superior, and inferior) were calculated automatically by SS-OCT, after the observer marked scleral spurs.

RESULTS

A total of 106 patients (54 males and 52 females) were enrolled in the study. Angle parameters, AOD, ARA, and TISA were increased after surgery in both groups. However, changes of angle parameters were only significant in group 2. In group 2, preoperative IOP was 13.2±2.9 mm Hg, and postoperative IOP at 1 and 6mo were 10.5±3.0 and 10.7±2.8 mm Hg, respectively. In group 1, preoperative IOP was 12.4±2.8 mm Hg, and postoperative IOP at 1 and 6mo were 11.6±2.5 and 12.0±2.8 mm Hg, respectively. After cataract surgery, angle parameters changed significantly while IOP significantly reduced and was maintained in group 2 (P<0.001). The changes in angle parameters (ΔAOD500, ΔTISA500 at temporal; ΔAOD500, ΔARA500 at nasal) were linearly correlated with postoperative IOP changes.

CONCLUSION

Cataract surgery may have improved anterior chamber angle parameters and decreased IOP in NTG patients.

Lens Position Parameters as Predictors of Intraocular Pressure Reduction After Cataract Surgery in Glaucomatous Versus Nonglaucomatous Eyes

Purpose

To evaluate the relationship between lens position parameters and intraocular pressure (IOP) reduction after cataract surgery in patients with primary open-angle glaucoma (POAG) and in nonglaucomatous patients.

Methods

The main outcomes of this prospective study were percent and absolute IOP change, which were calculated using the preoperative IOP and the IOP 4 months after cataract surgery in POAG and nonglaucomatous eyes. Lens position (LP), defined as anterior chamber depth (ACD) + one-half lens thickness (LT), was assessed preoperatively using parameters from optical biometry. Preoperative IOP, axial length (AL), ACD, LT, relative lens position (RLP), and the ratio of preoperative IOP to ACD (PD ratio) were also evaluated as potential predictors of IOP change.

Results

Four months postoperatively, the average IOP reduction was 2.80 ± 3.83 mm Hg (15.79%) from the preoperative mean of 14.73 ± 2.89 mm Hg for nonglaucomatous eyes. The average IOP reduction was 2.66 ± 2.07 mm Hg (16.98%) from the preoperative mean of 14.86 ± 2.97 mm Hg for POAG eyes. Preoperative IOP, sex, AL, ACD, PD ratio, and LP predicted IOP change in nonglaucomatous eyes. Preoperative IOP and PD ratio predicted IOP change in POAG eyes.

Conclusions

Intraocular pressure reduction after phacoemulsification cataract surgery in nonglaucomatous eyes is significantly greater in more anteriorly positioned lenses. Though it did not reach statistical significance in patients with glaucoma, the association of LP with IOP reduction is in the same direction as in nonglaucomatous patients where smaller LP appears to predict greater IOP reduction. Lens position is a simple, easily calculable, accurate, and widely available parameter, which clinicians can potentially utilize in managing glaucoma.

Anterior Chamber Angle and Intraocular Pressure Changes After Phacoemulsification: A Comparison Between Eyes With Closed-angle and Open-angle Glaucoma

PURPOSE

To compare the angle and intraocular pressure (IOP) changes after phacoemulsification between eyes with closed-angle or open-angle glaucoma.

METHODS

Angle measurements using Visante AS-OCT imaging was performed for a prospective cohort of 24 subjects with closed-angle and 30 subjects with open-angle glaucoma before and 3 months after phacoemulsification. IOP measurement was measured at 6 and 12 months after surgery using Goldmann applanation tonometry as secondary outcome measures.

RESULTS

Eyes with closed angles were smaller than those with open angles (mean axial length 22.88 vs. 24.11 mm, P<0.001). Mean anterior chamber depth, area, volume, AOD500, AOD750, ARA, TISA500, and TISA750 increased after phacoemulsification in all eyes regardless of preexisting angle status (all P<0.001). Increase in AOD500, AOD750, TISA500, and TISA750 were greater in eyes with open angles compared with closed angles (P=0.03, 0.04. 0.04, 0.04, respectively). Mean IOP decreased by 1.8 and 2.1 mm Hg at 6 and 12 months, respectively, after phacoemulsification for all eyes (P<0.001 for both timepoints compared with preoperative baseline). However, postoperative reduction in the mean IOP was not significantly different between eyes with closed and open angles (Mann-Whitney test P=0.32 at 6 mo and P=0.75 at 12 mo postsurgery compared with preoperative).

CONCLUSIONS

Angle opening postphacoemulsification was considerable in all eyes. A similar IOP reduction after phacoemulsification was observed in all eyes regardless of angle status.

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.

Early phacoemulsification in patients with acute primary angle closure

PURPOSE

To compare long term efficacy of phacoemulsification in the early management of acute primary angle closure (APAC) after aborting an acute attack and performing laser peripheral iridotomy (LPI).

METHODS

In this nonrandomized comparative prospective study, we included 35 subjects presenting with APAC who had responded to medical treatment and LPI with intraocular pressure (IOP) less than 25 mmHg. Twenty patients with visually significant cataract with visual acuity of <20/30 were assigned to the "Phaco/LPI" group and underwent phacoemulsification within 6 weeks of the attack. Fifteen subjects with clear lens were assigned to the "LPI Only" group and were followed clinically. The primary measured outcome was the prevalence of IOP rise after 1 month (treatment failure), defined as 1) if a patient developed IOP rise resulting in IOP >21 mmHg with or without medication, or 2) if a patient required any medication to have IOP ≤21 mmHg after 1 month. Patients were followed for at least one year.

RESULT

IOP, number of medications, gonioscopy grading, and amount of synechiae were not significantly different at baseline between the two groups. Acute attack did not recur in any patient. There was more significant failure in the LPI Only group compared with the Phaco/LPI group (40% vs. 5%; p = 0.02). There was a significant difference in final IOP between the two study groups (13.90 ± 2.17 vs. 17.8 ± 4.16 in the Phaco/LPI and LPI Only groups, respectively; p = 0.001). Patients in the Phaco-LPI group needed less medication than the other group at final follow-up. No serious complications have arisen from the immediate LPI or phacoemulsification.

CONCLUSION

Phacoemulsification is a safe procedure for preventing IOP rise after aborting acute primary angle closure if performed within a few weeks of the attack.

Lens thickness assessment: anterior segment optical coherence tomography versus A-scan ultrasonography

AIM

To assess lens thickness measurements with anterior segment-optical coherence tomography (AS-OCT) in comparison with A-scan ultrasonography (A-scan US).

METHODS

There were 218 adult subjects (218 eyes) aged 59.2±9.2y enrolled in this prospective cross-sectional study. Forty-three eyes had open angles and 175 eyes had narrow angles. Routine ophthalmic exam was performed and nuclear opacity was graded using the Lens Opacities Classification System III (LOCS III). Lens thickness was measured by AS-OCT (Visante OCT, Carl Zeiss Meditec, Dublin, CA, USA). The highest quality image was selected for each eye and lens thickness was calculated using ImageJ software. Lens thickness was also measured by A-scan US.

RESULTS

Interclass correlations showed a value of 99.7% for intra-visit measurements and 95.3% for inter-visit measurements. The mean lens thickness measured by AS-OCT was not significantly different from that of A-scan US (4.861±0.404 vs 4.866±0.351 mm, P=0.74). Lens thickness values obtained from the two instruments were highly correlated overall (Pearson correlation coefficient=0.81, P<0.001), and in all LOCS III specific subgroups except in grade 5 of nuclear opacity. Bland-Altman analysis revealed a 95% limit of agreement from -0.45 to 0.46 mm. Lens thickness difference between the two instruments became smaller as the lens thickness increased and AS-OCT yielded smaller values than A-scan US in thicker lens (β=-0.29, P<0.001).

CONCLUSION

AS-OCT-derived lens thickness measurement is valid and comparable to the results obtained by A-scan US. It can be used as a reliable noncontact method for measuring lens thickness in adults with or without significant cataract.

Lens parameters as predictors of intraocular pressure changes after phacoemulsification

PURPOSE

To evaluate intraocular pressure (IOP) change after cataract surgery in non-glaucomatous eyes with narrow and open angles (OAs) and its relation to novel lens parameters measured by anterior segment optical coherence tomography (AS-OCT).

SETTING

University affiliated hospital, Farabi Eye Hospital, Tehran, Iran.

DESIGN

Prospective interventional case series.

METHODS

In this prospective study, 85 non-glaucomatous eyes underwent phacoemulsification and lens implantation. Thirty-nine eyes had OAs and 46 eyes had narrow angles (NAs). IOP and biometric parameters were measured by AS-OCT preoperatively and 3 months after surgery. Change in IOP and its relation to biometric parameters, including lens vault (LV), anterior vault (AV), defined as the sum of the LV and the ACD, and relative LV (rLV), defined as the ratio of the LV to the AV, were evaluated. The main outcome measure was degree of IOP change after phacoemulsification.

RESULTS

Of the 85 patients included in the analysis, 35 were male and 50 were female with an overall mean age of 62.2 ± 8.9 years. The average IOP reduction was -4.95 ± 2.26 mm Hg, from a preoperative mean of 17.12 ± 2.47 mm Hg, at 3 months after cataract surgery. The amount of IOP reduction was significantly greater in the NA compared with the OA group. In multivariate linear regression analysis, preoperative IOP and AV were significantly associated with IOP decrease (all ≤ 0.03).

CONCLUSION

Cataract surgery results in IOP reduction in both OA and NA eyes. The amount of IOP reduction is related to AV.