Phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle-closure glaucoma without cataract

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.

Intraocular pressure spikes after gonioscopy-assisted transluminal trabeculotomy (GATT)

PURPOSE

Intraocular pressure (IOP) spikes (IOP > 30 mmHg or > 10 mmHg above baseline IOP) are a common and worrisome complication of gonioscopy-assisted transluminal trabeculotomy (GATT). The purpose of this study is to identify risk factors for IOP spikes and to describe their characteristics, management, and clinical course in a large cohort of patients.

METHODS

A retrospective, single-center study which included 217 consecutive eyes of patients that underwent GATT between December 2019 and April 2022 with follow-up of at least 90 days.

RESULTS

IOP spikes occurred in 52 of 217 (24%) eyes. Spikes occurred in 15.5% of patients in whom pre-operative IOP-lowering medications were continued after surgery (90 eyes), and in 29.9% in whom IOP-lowering medications were stopped after surgery (127 eyes). Spikes were diagnosed at a mean of 7.7 ± 6.5 days after surgery. All IOP spikes occurred within the first month of surgery. The mean duration of a spike was 4.9 ± 5.4 days. Management of IOP spikes included adding a mean of 3.13 ± 1.7 groups of glaucoma medications. Thirty-seven (72.5%) eyes were treated with oral carbonic anhydrase inhibitor, 11 (21.6%) were treated with IV mannitol, and anterior chamber paracentesis was performed in 16 (31.4%). Six (11.8%) eyes underwent additional glaucoma surgery to control IOP. Patients that continued their pre-operative IOP-lowering medications after surgery were 2.3 times less likely to develop a spike as compared to patients who discontinued their medications (P = 0.016). Spikes were found to be a risk factor for failure of GATT.

CONCLUSIONS

IOP spikes are a common occurrence after GATT. They most commonly appear during the first two post-operative weeks and usually resolve with topical and systemic IOP-lowering treatment. The continuation of IOP-lowering medications after GATT is recommended to lower the risk of IOP spikes.

Outcomes of Filtering Surgery Versus Clear Lens Extraction in Young Patients With Angle-Closure Glaucoma

PURPOSE

To compare the effect of filtering surgery versus clear lens extraction in young patients with medically uncontrolled angle-closure glaucoma (ACG).

DESIGN

Retrospective, nonrandomized, comparative, interventional study.

METHODS

We reviewed the medical charts of patients with the following scenarios: (1) age ≤40 years; (2) diagnosis of ACG without cataract, including primary angle-closure glaucoma (PACG), nanophthalmic ACG, and ACG combined with retinal dystrophies; and (3) ACG undergoing filtering surgery or clear lens extraction. The main outcomes including intraocular pressure (IOP), number of medications, best-corrected visual acuity, and severe complications were extracted at the postoperative early (within 1 week) and late stage (>3 months) follow-up.

RESULTS

Data from 160 eyes of 130 young patients with ACG were available. Eyes with 76 PACG, 12 nanophthalmic ACG, and 26 ACG with retinal diseases underwent filtering surgery, whereas eyes with 22 PACG, 12 nanophthalmic ACG, and 12 ACG with retinal diseases received clear lens extraction. Overall, filtering surgery and clear lens extraction resulted in significant but comparable IOP and drug reductions at the postoperative late stage in each ACG subgroup, with similar complete success rates between 2 treatments (all P > .05). Regarding the safety, filtering surgery and patients with retinal diseases were independent factors associated with postoperative malignant glaucoma (P < .05 in both multivariable logistic regression models).

CONCLUSIONS

This study highlights that the efficacy of clear lens extraction is comparable to that of filtering surgery in medically uncontrolled ACG in young patients, but clear lens extraction is safer, especially for young patients with ACG comorbid with retinal diseases.

Does Cataract Extraction Significantly Affect Intraocular Pressure of Glaucomatous/Hypertensive Eyes? Meta-Analysis of Literature

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the effect of cataract extraction on intraocular pressure at 6, 12, and 24 months and their difference compared to the baseline in diverse glaucoma subtypes.

MATERIALS AND METHODS

We carried out research in the MEDLINE, Cochrane Library and EMBASE databases, as of April 2022 for relevant papers, filtered according to established inclusion and exclusion criteria. The meta-analysis evaluated the Mean Reduction and relative Standard Error in these subpopulations at predetermined times. A total of 41 groups (2302 eyes) were included in the systematic review. Due to the significant heterogeneity, they were analysed through a Random Effects Model.

RESULTS

We obtained these differences from baseline: (1) Open Angle Glaucoma at 6, 12 and 24 months, respectively: -2.44 mmHg, -2.71 mmHg and -3.13 mmHg; (2) Angle Closure Glaucoma at 6, 12 and 24 months, respectively: -6.81 mmHg, -7.03 mmHg and -6.52 mmHg; (3) Pseudoexfoliation Glaucoma at 12 months: -5.30 mmHg; (4) Ocular Hypertension at 24 months: -2.27 mmHg.

CONCLUSIONS

Despite a certain variability, the reduction in ocular pressure was statistically significant at 6, 12 and 24 months in both Open Angle Glaucoma and Angle Closure Glaucoma, the latter being superior. Data for Pseudoexfoliation Glaucoma and for Ocular Hypertension are available, respectively, only at 12 months and at 24 months, both being significant.

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.

Comparison of Long-Term Effects Following Phacoemulsification Combined with Goniosynechialysis and Trabeculectomy in Patients with Primary Angle-Closure Glaucoma and Cataract

INTRODUCTION

Goniosynechialysis (Phaco-GSL) is a logical therapeutic approach for patients with primary angle-closure glaucoma (PACG) and cataract. The aim of this study was to compare the long-term effectiveness and safety of Phaco-GSL and trabeculectomy (TRB) in the management of PACG with coexisting cataract.

METHODS

A review was conducted on 96 Chinese patients (96 eyes) with PACG and cataract from Peking Union Medical College Hospital (PUMCH). Among them, 56 patients underwent Phaco-GSL, while 40 underwent TRB. Intraocular pressure (IOP), best corrected visual acuity (BCVA), use of supplemental antiglaucoma medical therapy, surgery success rates, and complications for both procedures were assessed.

RESULTS

The average follow-up period was 50.3 ± 18.7 months in the Phaco-GSL group and 61.2 ± 15.1 months in the TRB group. At the final follow-up, IOP decreased from 27.0 ± 11.1 mmHg to 13.5 ± 2.1 mmHg in the Phaco-GSL group and in the TRB group IOP decreased from 27.1 ± 7.7 mmHg to 16.5 ± 5.5 mmHg. The long-term postoperative IOP in the Phaco-GSL group was significantly lower than that in the TRB group. There was a statistically significant reduction in medication usage in both groups, with the TRB group having a higher number of postoperative medications at the final follow-up. The incidence of postoperative complications was significantly higher in the TRB group compared to the Phaco-GSL group.

CONCLUSIONS

Phaco-GSL is the recommended surgical approach for Chinese patients with primary angle-closure glaucoma (PACG) and cataract. Compared to traditional TRB, eyes undergoing Phaco-GSL show a reduced requirement for antiglaucomatous medications, improved management of IOP, decreased risk of complications, and higher long-term cumulative probability of treatment success for patients with PACG.

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.

Gonioscopy-assisted transluminal trabeculotomy in patients with advanced glaucoma

Purpose

To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with advanced glaucoma.

Methods

Records of 46 patients with advanced glaucoma were reviewed retrospectively in this single-center chart review. The main outcome measure was surgical success; intra-ocular pressure (IOP) and IOP lowering medication use were secondary outcome measures. Success was defined as an IOP of 18 mmHg or lower (criterion A) or 14 mmHg or lower (criterion B) and one of the following: IOP reduction >30% from baseline on the same or fewer medications or IOP ≤ of baseline on fewer medications as compared to baseline.

Results

Forty-seven eyes were included in the analysis. The average mean deviation was -17.5 ± 7.2 dB (range -8.0 to -33.0). The average follow-up was 6.8 months (range 3.2-22.3). Success at 6 months was 91% for criterion A and 75% for criterion B (n = 33). Mean IOP was reduced from 19.3 ± 6 mmHg (12-40) on 3.7 ± 1.4 medications to 13.2 ± 5.8 mmHg on 1.6 ± 1.4 medications at the 6th post-operative month (P < 0.001 for both IOP and medications). At the last follow-up visit, 37 patients (78%) had an IOP of 14 mmHg or lower, and ten of these patients were unmedicated. Transient hyphema and IOP spikes were the most prevalent adverse events following surgery. Three eyes required further surgery for IOP control. None of the patients lost vision because of surgery.

Conclusions

GATT is a viable surgical option in cases of advanced glaucoma. Careful patient selection and attentive post-operative management are imperative.

Factors defining the intraocular pressure-lowering effect of phacoemulsification and laser peripheral iridotomy in patients with primary angle closure : Factors defining IOP lowering effect of PE and LPI in PAC

To identify whether gonioscopic ciliary body visibility and factors including anterior chamber depth (ACD), axial length (AL), acute attack history, and preoperative intraocular pressure (IOP) had any effect on IOP decrease in primary angle closure (PAC) and primary angle-closure glaucoma (PACG) after phacoemulsification (PE) and/or laser peripheral iridotomy (LPI). This retrospective-design study was conducted with 81 eyes with PAC and PACG; 33 eyes whose IOP was controlled with LPI and PE constituted group 1, and 48 eyes whose IOP was controlled using LPI alone comprised group 2. The effects on preoperative and last-visit IOP levels, ciliary body visibility, ACD, AL, and acute attacks were analyzed. Eyes within the groups were similar in AL, ACD, and preoperative IOP except for acute attack history, which was found to be higher in group 1. For group 1, none of the factors was found to have a differentiative effect on IOP decrease after PE, except eyes with preoperative IOP > 21 mm Hg, which had significantly more IOP reduction. For group 2, no difference was found in ciliary body visibility, and higher or lower ACD. However, eyes with AL ≥ 22 mm, positive acute attack history, and higher preoperative IOP were associated with significantly better IOP reduction. We found no relationship between ciliary body visibility and an IOP-reducing effect of PE and LPI. Although we found PE effective in IOP reduction in all eyes, we determined LPI to have a lesser IOP-reducing effect in eyes with IOP ≤ 21 mm Hg and AL < 22 mm.

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.

Risk factors of surgical failure in combined phacoemulsification and excisional goniotomy for angle-closure glaucoma

PURPOSE

To evaluate the therapeutic success, and risk factors for combined phacoemulsification and Kahook Dual Blade excisional goniotomy (Phaco/KDB) in primary angle-closure glaucoma (PACG).

METHODS

A retrospective review was conducted on glaucoma patients who underwent Phaco/KDB between September 2019 and August 2021 at 2 ophthalmology centers. Complete success was defined as unmedicated intraocular pressure (IOP) ≤ 18 mmHg with no further glaucoma surgery, while the medicated IOP ≤ 18 mmHg was defined as qualified success with lesser medications than at baseline.

RESULTS

Seventy-two eyes (64 patients) with a mean age of 67.1 ± 8.1 years were included in this study, and 70.2% were female. The mean medicated baseline IOP decreased from 23.4 ± 8.1 to 16.6 ± 3.9 mmHg at an average of 11.6 ± 3.7 months of follow-up (- 29.1%; P < 0.00). Medications decreased from 2.6 ± 1.3 to 0.4 ± 0.9 (- 82.6%; P < 0.001). Complete success and qualified success were achieved in 65.3% and 79.2% of eyes, respectively. Male gender [hazard ratio (HR): 6.00 (1.57-22.9); P = 0.009] was observed a risk factor for surgical failure, whereas higher axial length (HR:0.37 (0.16-0.86); P = 0.021), and a combined circumferential goniosynechialysis procedure (HR: 0.13 (0.02-0.74); P = 0.022) lowered the risk of surgical failure. Hyphema, postoperative shallowing anterior chamber, and IOP spike were the most common complications. The cumulative survival proportion for qualified success at 12 months was 82.5% ± 0.05 (95% CI, 0.70-0.90).

CONCLUSION

Phaco/KDB provided acceptable therapeutic success rate and may, therefore, be recommended in patients with coexisting cataract and PACG. Identifying patients with risk factors preoperatively may help clinicians predict surgical success.

Changes in Anterior Chamber Angle and Choroidal Thickness in Patients with Primary Angle-Closure Glaucoma after Phaco-Goniosynechialysis

We aimed to observe changes in angle width and choroidal thickness (CT) before and after phacoemulsification intraocular lens implantation (PEI) combined with goniosynechialysis (GSL) in patients with primary angle-closure glaucoma (PACG) complicated by cataracts. This prospective cohort study included 60 patients with PACG complicated by cataracts from the Department of Ophthalmology of Shaoxing People’s Hospital, China. Patients underwent PEI combined with GSL (PEI-GSL group) or laser peripheral iridotomy (LPI) followed by PEI (PEI group). Intraocular pressure (IOP) and endothelial counts were significantly decreased in both groups after surgery, while best-corrected visual acuity and central anterior chamber depth were significantly increased. However, there were no significant differences between the two groups. The opening degrees of room corners at 12, 3, 6, and 9 o’clock were recorded as AA12, AA3, AA6, and AA9, respectively. Anterior chamber depth was significantly increased postoperatively compared to preoperatively in both groups, with no significant between-group differences (all ps > 0.05). At 1, 3, and 6 months postoperatively, the width at AA12, AA3, and AA9 points was higher in the PEI-GSL group than in the PEI group (all ps < 0.05). Significant between-group differences at AA6 were observed preoperatively (p = 0.023) and at 1 (p = 0.027) and 3 (p = 0.033) months postoperatively but not at 6 months postoperatively (p = 0.055). CT was smaller postoperatively than preoperatively (all ps < 0.001). The present study suggests that patients with PACG who underwent PEI with or without GSL had reduced IOP and CT after surgery.

Anterior segment pars plana vitrectomy combined with posterior capsulorhexis, phacoemulsification and trabeculectomy in treatment of medically uncontrolled acute primary angle-closure glaucoma: A retrospective study

To explore the clinical efficacy of quadruple surgery (anterior segment pars plana vitrectomy + phacoemulsification + posterior capsulorhexis + intraocular lens (IOL) implantation + trabeculectomy) and dual surgery (phacoemulsification + IOL implantation + trabeculectomy) to treat medically uncontrolled acute primary angle-closure glaucoma (APACG). The clinical data of 44 patients (45 eyes) with APACG treated in the Department of Ophthalmology of Taihe Hospital were retrospectively analyzed. They were divided into 2 groups based on quadruple surgery and dual surgery. There were 20 patients (20 eyes) underwent quadruple surgery in group A. And there were 24 patients (25 eyes) dual surgery in group B. The changes in intraocular pressure (IOP), visual improvement, and complications were observed between the 2 groups preoperatively and 1 month, 3 months, and 6 months postoperatively. Preoperative best corrected visual acuity (BCVA) was the influencing factor of postoperative BCVA at 1 month, 3 months and 6 months. Before surgery, the mean IOP of group A was significantly higher than that of group B (P < .001), and no significant difference was found in the BCVA, age, gender, eyes, axial length (AL), anterior chamber depth (ACD) (PBCVA = 0.12, Page = 0.76, Peyes = 0.20, Pgender = 0.37, PAL = 0.94, PACD = 0.08). On comparison at postoperative 1week, there was no significant difference in the IOP and BCVA between the 2 groups (PIOP = 0.64, PBCVA = 0.66). The mean IOP of group A was significantly lower than that of group B 1 month, 3 months, and 6 months postoperatively (P1month = 0.002, P3months < 0.001, P6months < 0.001). The degree of visual acuity recovery was significantly higher in group A at 1 month, 3 months, and 6 months postoperatively (P1month = 0.03, P3months = 0.02, P6months = 0.02). During treatment, the incidence of complications in group B was significantly higher than that in group A (P < .01). The clinical efficacy of anterior segment pars plana vitrectomy combined with posterior capsulorhexis, phacoemulsification, and trabeculectomy elicits clinical safety in treating medically uncontrolled APACG. It has remarkable effects and leads to a significant decrease in the occurrence of complications.

Trabeculectomy: Does It Have a Future?

The trabeculectomy (TRAB) procedure has undergone various modifications to increase the long-term surgical success and safety profiles. The main issues with TRAB include short and long-term complications, that are more common with the concomitant use of anti-fibrotic agents. While many surgeons have predicted the demise of trabeculectomy amidst newer non-penetrating glaucoma surgeries, it is still the gold standard procedure for patients with an advanced or rapidly progressing disease and for those patients who need very low intraocular pressures. This review article is unique in summarizing the evolution of trabeculectomy and its efficacy compared to neoteric shunt procedures while trying to predict if trabeculectomy has a future in the modern surgical world. We have compared the outcomes and complications of trabeculectomy to all the surgical procedures available to date and have tried to evolve an algorithm to help surgeons to decide on their preferred technique.

Clinical implication of recent randomized control trial in primary angle-closure disease management

Blindness due to primary angle-closure glaucoma (PACG) can be reduced significantly if the ongoing angle-closure process is arrested at an early stage. Various treatments such as laser peripheral iridotomy (LPI), iridoplasty, and clear lens extraction (CLE) have been advocated as first-line therapy for primary angle-closure (PAC), PACG, and high-risk cases of primary angle-closure suspect (PACS). EAGLE study, propagated the effectiveness of CLE over LPI for the management of primary angle closure and have sparked controversy regarding the role of LPI as a first line procedure. Randomized controlled trials (RCT), systematic reviews, and meta-analyses of RCTs done on the same question provide us with a solid base for creating guidelines/modules for our day-to-day clinical practice. A systematic review was conducted, searching several databases, including PubMed, Cochrane Library, EMBASE, and ClinicalTrials.gov, for the last 16 years (January 2005–December 2021) for RCTs with data published related to primary angle-closure disease (PACD). The search strategy included the following terms: “Primary Angle Closure disease,” “Primary Angle Closure Glaucoma,” “Primary Angle Closure,” “Primary Angle Closure Suspect,” “clear lens extraction,” “laser iridotomy,” “laser peripheral iridotomy,” “argon laser peripheral iridoplasty,” “selective laser trabeculoplasty,” “trabeculectomy,” “randomized control trial,” and “meta-analysis of randomized control trial.” In this review, we will discuss recently published RCTs (within the last 16 years) for the management of PACD and their clinical implications in day-to-day practice.

Efficacy and safety of trabeculectomy versus peripheral iridectomy plus goniotomy in advanced primary angle-closure glaucoma: study protocol for a multicentre, non-inferiority, randomised controlled trial (the TVG study)

INTRODUCTION

Primary angle-closure glaucoma (PACG) is a major subtype of glaucoma that accounts for most bilateral glaucoma-related blindness globally. Filtering surgery is a conventional strategy for PACG, yet it has a long learning curve and undesirable disastrous complications. Minimally invasive glaucoma surgery (MIGS) plays an increasing role in the management of glaucoma due to its safer and faster recovery profile; cataract surgery-based MIGS is the most commonly performed such procedure in PACG. However, for patients with a transparent lens or no indications for cataract extraction, incorporation of MIGS into PACG treatment has not yet been reported. Therefore, this multicentre, non-inferiority, randomised controlled clinical trial aims to compare the efficacy and safety of trabeculectomy versus peripheral iridectomy plus an ab interno goniotomy in advanced PACG with no or mild cataracts.

METHODS AND ANALYSIS

This non-inferiority, multicentre, randomised controlled trial will be conducted at seven ophthalmic departments and institutes across China. Eighty-eight patients with no or mild cataracts and advanced PACG will be enrolled and randomised to undergo trabeculectomy or peripheral iridectomy plus ab interno goniotomy. Enrolled patients will undergo comprehensive ophthalmic examinations before and after surgery. The primary outcome is intraocular pressure (IOP) at 12 months postoperatively. The secondary outcomes are cumulative success rate of surgery, surgery-related complications and number of IOP-lowering medications. Participants will be followed up for 36 months postoperatively.

ETHICS AND DISSEMINATION

The study protocol was approved by the ethical committees of the Zhongshan Ophthalmic Center, Sun Yat-sen University, China (ID: 2021KYPJ191) and of all subcentres. All participants will be required to provide written informed consent. The results will be published in peer-reviewed journals and disseminated in international academic meetings.

TRIAL REGISTRATION NUMBER

NCT05163951.

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.

Efficacy of bleb-independent penetrating canaloplasty in primary angle-closure glaucoma: one-year results

PURPOSE

To report the efficacy and safety of bleb-independent penetrating canaloplasty in the management of primary angle-closure glaucoma (PACG).

METHODS

This single-centre prospective interventional case series enrolled 57 eyes from 53 PACG patients with medically uncontrolled intraocular pressure (IOP) and peripheral anterior synechiae of over 270°. Penetrating canaloplasty, mainly consisted of tensioning suture-aided Schlemm's canal dilation and a trabeculectomy, was performed to create a direct communication between the anterior chamber and the Schlemm's canal. Postoperative IOP, number of glaucoma medications and procedure-related complications were evaluated. Rate of success was defined as IOP ≤ 21, ≤18 and ≤15 mmHg, and a ≥30% IOP reduction without (complete) or with/without (qualified) IOP-lowering medications.

RESULTS

A total of 45 eyes had 360° catheterization successfully completed. The mean preoperative IOP was 33.9 ± 11.7 mmHg (range, 13-59.6 mmHg), on 3.2 ± 0.8 glaucoma medications (range 2-5), which was decreased to 15.4 ± 3.7 mmHg (range, 8.6-22.5) and 0.2 ± 0.6 (range, 0-3) medications at 6 months and 14.8 ± 3.5 mmHg (range, 9-24) and 0.1 ± 0.3 (range, 0-1) medications at 12 months postoperatively. Complete success at 12 months were achieved in 78.9% (95% CI: 0.65-0.93), 71.1% (0.56-0.86) and 50.0% (0.33-0.67) eyes at IOP ≤ 21, ≤18 and ≤15 mmHg, respectively. Transient IOP elevation (>30 mmHg, 26.7%) and hyphema (11.1%) were the most common early surgical complications.

CONCLUSION

Penetrating canaloplasty in PACG appeared to have good efficacy and safety profiles in this pilot study. Further studies are justified.

Efficacy and safety of phacotrabeculectomy versus phacogoniotomy in advanced primary angle-closure glaucoma: study protocol for a multicentre non-inferiority randomised controlled trial (PVP Study)

INTRODUCTION

Primary angle-closure glaucoma (PACG) has a high prevalence and blinding rate across Asia. The first-line treatment of PACG is surgery, and phacotrabeculectomy remains the mainstream surgery for advanced PACG. However, it may cause vision-threatening complications with long learning curve. Minimally invasive glaucoma surgery has been gradually used in PACG combined with cataract surgery and achieved efficacy without excessive injury, of which goniotomy is the most commonly performed. Therefore, this study aimed to conduct a multicentre, non-inferiority randomised controlled clinical trial to compare the efficacy and safety of phacotrabeculectomy versus phacogoniotomy in advanced PACG.

METHODS AND ANALYSIS

This is a non-inferiority multicentre randomised controlled trial and will be conducted at eight ophthalmic departments and institutes in China. 124 patients with advanced PACG will be enrolled and randomised to undergo phacotrabeculectomy or phacogoniotomy. Comprehensive ophthalmic examinations will be performed before and after the surgery. The primary outcome is the change of intraocular pressure at 12 months after surgery compared with the baseline intraocular pressure. An extended follow-up period of 36 months will be required. Cumulative success rate of surgery, intraoperative and postoperative complications, and number of anti-glaucomatous medications will also be compared between the groups as secondary outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the ethical committee of Zhongshan Ophthalmic Center, Sun Yat-sen University, China (ID: 2021KYPJ090) and all subcentres. All the participants will be required to provide written informed consent. The results will be disseminated through scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04878458.

Combined Phacoemulsification-Endoscopic Cyclophotocoagulation versus Phacoemulsification Alone in Primary Angle-Closure Glaucoma: A Pilot Randomized Controlled Trial

PURPOSE

To compare combined phacoemulsification plus endoscopic cyclophotocoagulation (ECP) versus phacoemulsification alone in primary angle-closure glaucoma (PACG) with coexisting cataract.

DESIGN

Prospective randomized controlled clinical trial-a pilot study.

PARTICIPANTS

Forty-eight PACG eyes of 48 patients with coexisting cataract.

INTERVENTION

Recruited patients were randomized into undergoing phacoemulsification plus ECP or phacoemulsification alone. After surgery, patients were followed up every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Twenty-seven PACG eyes were randomized to receive combined phacoemulsification plus ECP, and 21 PACG eyes underwent phacoemulsification alone. There was no statistically significant difference in mean preoperative IOP between combined phacoemulsification plus ECP and phacoemulsification groups (20.0 mmHg vs. 20.7 mmHg; P = 0.71). Phacoemulsification plus ECP resulted in lower mean postoperative IOP than phacoemulsification alone at all follow-up visits, but the differences only reached statistical significance at 1 month (P = 0.01), 12 months (P = 0.01), and 24 months (P = 0.04) postoperatively. There was no statistically significant difference in mean preoperative number of topical glaucoma drugs between combined phacoemulsification plus ECP and phacoemulsification groups (3.3 vs 3.1, P = 0.71). Combined phacoemulsification plus ECP resulted in lower glaucoma drug requirement than phacoemulsification alone at all follow-up visits, but the differences did not reach statistical significance at any time points postoperatively (P ≥ 0.05). Both groups were comparable in visual improvement, complication rate, need for additional surgical intervention, and visual field changes.

CONCLUSIONS

Combined phacoemulsification plus ECP is noninferior to phacoemulsification alone in controlling IOP in PACG eyes with cataract. Combined phacoemulsification plus ECP resulted in lower mean IOP and glaucoma drug requirement than phacoemulsification alone at all follow-up visits in this pilot study, but the differences did not reach statistical significance at the majority of time points. A large-scale randomized controlled trial is in progress to evaluate these differences.

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.

Long-term perimetric stabilization with a management algorithm of set target intraocular pressure in different severities of primary angle-closure glaucoma

Purpose

To evaluate long-term perimetric stabilization at set Target (IOPs) in primary angle-closure glaucoma with visual field defects.

Methods

Two hundred forty-eight eyes, of 124 primary angle-closure glaucoma (PACG) patients on medical treatment, and 124 eyes, of 95 patients after trabeculectomy performed at least 5 years prior were evaluated. One hundred eighty-five eyes had a follow-up of ≥10 years. Target IOPs for mild, moderate, and severe glaucomatous optic neuropathy were set at ≤18, ≤15, and ≤12 mmHg, respectively. Progression was evaluated by event-based changes on guided progression analysis. Primary outcome measure was therapy required to achieve individualized Target IOP. Secondary outcome measure was assessment of perimetric change over time.

Results

Mean baseline IOP was 23.34 ± 6.16 mmHg in medically treated and 36.08 ± 9.73 mmHg in surgically treated eyes (P = 0.0001). All eyes with a baseline IOP of <25 mmHg were on medications alone, 65.33%, of those with a baseline IOP of 25-30 mmHg were on medications, while 34.67% required trabeculectomy. In total, 91.4% of eyes with a baseline IOP of >30 mmHg underwent a trabeculectomy for achieving Target IOP. Perimetric stabilization was achieved in 98.17% of PACG eyes. "Target" IOP was achieved for mild, moderate, and severe glaucomatous optic neuropathy, medically in 90.2, 73.9, and 29.7%, and surgery was required in 9.8, 26.1, and 70.3%, respectively. Overall analysis found that percentage reduction in IOP was significantly more after trabeculectomy than medical treatment, 64.16 ± 14.91 and 43.61 ± 13.73%, P = 0.0001. Decrease in IOP was significantly greater 5-9 years after trabeculectomy, in comparison to ≥10 years, P = 0.001.

Conclusion

Medications controlled IOP to "Target" in PACG eyes with mild and moderate glaucoma for over ≥10 years, when the baseline IOP off treatment was <30 mmHg. Trabeculectomy was necessary in PACG eyes having severe glaucomatous optic neuropathy, or with a baseline IOP of >30 mmHg to achieve Target IOP. These appropriate initial therapeutic interventions and Target IOPs are therefore suggested as a clinically validated algorithm of care for different severities of PACG.

Cataract extraction and intraocular pressure-lowering agents delivery: A nationwide French study between 2005 and 2017

PURPOSE

Cataract and glaucoma are among the leading causes of blindness worldwide in older people, and they are often concomitant. To assess topical intraocular (IOP)-lowering agents delivery changes after cataract extraction.

MATERIAL AND METHODS

Longitudinal matched exposed-unexposed study from the French national healthcare database from January 1, 2005 to January 1, 2017. We compared individuals using topical IOP-lowering agents who underwent bilateral cataract extraction with individuals matched on IOP-lowering agents load, age, and sex who did not undergo cataract extraction. IOP-lowering agents number of drops was assessed 12 months before the first cataract extraction and compared with number of drops 12 months after the second cataract extraction.

RESULTS

About 1194 individuals treated with IOP-lowering agents were included, 597 exposed to bilateral cataract extraction and 597 unexposed to any surgery (total mean age 74.8 ± 8.3 years; 69.0% women). Mean IOP-lowering agents delivery at baseline was 1.4 daily drops in both groups. The mean number of drops decreased greater in the exposed than unexposed group (-25.5% vs -3.5%; p < 0.0001). Overall, 159 (26.6%) and 48 (8.0%) individuals in the exposed and unexposed groups interrupted medication (p < 0.0001).

CONCLUSIONS

A decrease of around one quarter of IOP-lowering agents delivery was observed after cataract extraction in the present real-life study with a longstanding interruption observed in one quarter of patients. Phacoemulsification as a standalone procedure reduces IOP-lowering agents delivery in ocular hypertension and glaucoma.

Real-world Surgical Outcomes of Primary Angle-closure Glaucoma

Purpose

To evaluate surgical outcomes of the four common procedures utilized for primary angle-closure glaucoma (PACG).

Methods

A retrospective study of survival rate in surgical management of PACG was conducted in a referral eye center. One hundred and ninety-nine eyes from 173 PACG patients were collected for chart review. The procedures used were phacoemulsification (PE), combined PE with goniosynechialysis (PE-GSL), combined PE with trabeculectomy (PE-Trab), and trabeculectomy alone. Failure was defined as postoperative IOP >21 mmHg in patients who needed second surgical intervention or those who had IOP <5 mmHg with loss of light perception. Cumulative survival rates, risk of surgical failure, and complications were analyzed.

Results

PE, PE-GSL, PE-Trab, and trabeculectomy were performed in 84 eyes (42.2%), 76 eyes (38.2%), 21 eyes (10.6%), and 18 eyes (9%), respectively. Cumulative survival rates at 60 months were 13%, 55%, 42% and 43%, respectively. Cox regression analysis indicated that each mmHg IOP increased, the risk of surgical failure decreased by 13% (adjusted hazard ratio (HR) 0.87; 95%CI: 0.84-0.93, p<0.001).

Conclusion

Real-world surgical outcomes of PACG showed that PE alone had a low survival rate of 13% in 60-month follow-up whereas PE-GSL achieved the highest rate of 55%. PE-GSL should be initially considered for management of PACG, since it can restore and sustain the physiologic aqueous pathway and preserve the conjunctiva for future filtering surgery if needed.

Comparison of Treatment Outcomes of Selective Laser Trabeculoplasty for Primary Open-Angle Glaucoma and Pseudophakic Primary Angle-Closure Glaucoma Receiving Maximal Medical Therapy

Selective laser trabeculoplasty (SLT) is a useful treatment for intraocular pressure (IOP) control. However, there are only a few reports which compare the outcomes of SLT between primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). We compared the efficacy of SLT for patients with PACG following phacoemulsification with POAG receiving maximal medical therapy (MMT). Consecutive glaucoma patients followed up for at least 1 year after SLT were retrospectively evaluated and IOP reductions at 6 months and 12 months were analyzed. Seventy-six patients were included in the analyses. The baseline IOPs in the POAG and PACG group were 18.5 ± 3.3 mmHg and 16.9 ± 2.5 mmHg, respectively, with 2.8 ± 0.9 and 2.7 ± 0.8 types of IOP lowering medication. The average IOP at the 6-month and 12-month follow-up after SLT was significantly decreased and comparable in both the POAG and PACG groups. For those with a low baseline IOP, the effect of SLT on IOP reduction at 12 months was significantly better in the PACG than in the POAG group (p = 0.003). IOP reduction at 6 and 12 months after SLT was significantly greater in those with a high baseline IOP than those with a low baseline IOP (p < 0.0065). In summary, the one-year efficacy of SLT was equivalent in POAG and pseudophakic PACG patients receiving MMT; however, SLT was more effective in eyes with PACG than eyes with POAG when focusing on those with a lower baseline IOP.

Comparing the Safety and Efficacy of Phacogoniosynechialysis With Phacotrabeculectomy in the Management of Refractory Acute Primary Closure Angle Glaucoma With Cataract: A Multicenter Randomized Trial

PRCIS

Combined phacoemulsification-goniosynechialysis (phaco-GSL) and unaugmented phacotrabeculectomy were both found to be effective in treating eyes with significant cataract and medically unresponsive acute primary angle closure glaucoma (PACG). Phaco-GSL seemed to be safer, with fewer surgical complications, and achieved better visual acuity than phacotrabeculectomy.

OBJECTIVES

To compare the results of combined phaco-GSL with unaugmented phacotrabeculectomy in the management of eyes with medically unresponsive acute PACG and cataract.

PARTICIPANTS AND RESEARCH METHODS

This was a prospective randomized controlled trial involving patients with significant cataract and acute PACG who were not responsive to maximal medical therapy. Three ophthalmic centers in Hanoi, Vietnam, participated in this trial. Study subjects were randomized into 2 groups: phaco-GSL or phacotrabeculectomy. Of note, mitomycin-C or 5-fluorouracil were not used during trabeculectomy, but postoperative bleb needling with 5-fluorouracil injection(s) was allowed. The primary outcome of the study was the rate of postoperative surgical complications in the first 3 months after surgery. The secondary outcome, determined at 1 year, assessed whether treatment was completely successful [defined as intraocular pressure (IOP)<21 mm Hg without IOP-lowering drops], or partially successful (IOP<21 mm Hg with IOP-lowering drops). Treatment failure was defined as IOP≥21 mm Hg with maximal IOP-lowering drops.

RESULTS

In total, 79 eyes from 79 patients (62 females, 17 males) were recruited (42 and 37 eyes in the phaco-GSL and phacotrabeculectomy groups, respectively). There were no statistically significant differences between the 2 groups at baseline in terms of age, visual acuity, IOP, anterior angle width, or preoperative ultrasound biomicroscopy index. Postoperative complications in the first 3 months were seen more frequently in the phacotrabeculectomy group (62.2%) than in the phaco-GSL group (14.3%, P<0.01). At 1 year postsurgery, treatment was 100% successful in both groups, with no difference in the mean IOP (15.38±3.42 vs. 15.72±4.47 mm Hg). The visual field index improved significantly following surgery in both groups, but there was also no significant difference between the 2 groups. However, there was a significant difference in the best corrected visual acuity at 1 year, with patients in the phaco-GSL group achieving better vision (0.45±0.21 logMAR in the phaco-GSL group vs. 0.64±0.27 logMAR in the phacotrabeculectomy group, P=0.04). The mean angle width was also significantly larger in the phaco-GSL group than the phacotrabeculectomy group (2.34±0.33 vs. 1.25±0.41 Shaffer degrees). Similarly, on ultrasound biomicroscopy, the anterior chamber was deeper after 12 months (2.87±0.28 to 2.48±0.33 mm), and the mean trabecular-iris angle area was wider at 12 months (21.88±7.07 vs. 14.95±4.39 degrees) in the phaco-GSL than the phacotrabeculectomy group.

CONCLUSIONS

Phaco-GSL and phacotrabeculectomy were both effective in treating medically unresponsive cases of acute PACG with cataracts. However, phaco-GSL showed better visual outcomes, wider drainage angles postsurgery, and fewer complications than phacotrabeculectomy.

Safety and efficacy of incisional goniotomy as an adjunct with phacoemulsification in primary angle-closure glaucoma

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of incisional goniotomy as an adjunct to phacoemulsification in primary angle-closure glaucoma (PACG) patients.

METHODS

Consecutive patients with PACG (high or borderline IOP) deemed fit for phacoemulsification were enrolled. After phacoemulsification, incisional goniotomy was performed with or without goniosynechialysis. Patient demographic profile, clinical data, and adverse events, if any, were analyzed during at least a 6-month follow-up period. Success was defined as IOP of 18 mm Hg or lesser with or without medications.

SETTING

Tertiary care Ophthalmic hospital.

DESIGN

Prospective interventional case series.

RESULTS

Of 46 eyes (38 patients) included, 69.6% eyes were classified as having advanced glaucoma. The mean treated IOP decreased by 7.3 ± 1.0 (SE) mm Hg (95% CI, 5.2-9.3) from 21.4 ± 6.6 to 14.2 ± 3.7 mm Hg at a mean duration of 11.7 ± 5.5 months (6-22 months) postoperatively (P < .001, paired t test). There was 66.6% reduction in median number of hypotensive medications (P < .001, Wilcoxon signed-rank test). Observed complications included hyphema (13 eyes [28%]), IOP spike (3 eyes [6.5%]), and cyclodialysis (1 eye [2.17%]). High treated IOP and number of medications were significantly associated with failure in univariate analysis (P < .05, Fisher exact test). The cumulative survival probability for qualified success at 22 months was 87.8% ± 0.07 (95% CI, 0.65-0.96).

CONCLUSIONS

Incisional goniotomy as an adjunct with phacoemulsification resulted in a significant and sustained reduction in IOP along with decrease in number of glaucoma medications in chronic PACG eyes, irrespective of the disease stage.

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.

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.

The role of lens extraction in glaucoma management

Cataract extraction has become a much safer procedure with the development of phacoemulsification, extending its application in ocular conditions such as glaucoma for better disease control. This review aims at summarizing the effect of lens extraction with or without combined glaucoma surgeries in different types of glaucoma and describing the intraoperative techniques and changes of glaucoma care postoperatively. A comprehensive literature search was performed through Medline and PubMed, and 67 studies were selected for this review. In primary angle closure (PAC) diseases, studies have revealed significant intraocular pressure (IOP) and medication requirement reduction after lens extraction. Fewer studies described its application in primary open angle glaucoma (POAG) and ocular hypertension (OHT), but literature available suggests that it can also lead to better disease control. Likewise, lower postoperative IOP and pressure fluctuations have been shown in normal tension glaucoma (NTG). Advanced glaucoma, shallow anterior chamber and pseudoexfoliation glaucoma (PXG) are three difficult scenarios that are commonly encountered in cataract operations. Special techniques in preventing complications such as wipe out phenomenon are depicted. Goniosynechialysis, endoscopic cyclophotocoagulation and trabecular microbypass stents are a few of the popular choices of glaucoma procedures that can be performed concomitantly with phacoemulsification but evidence of their efficacy needs to be further verified. Cataract operation can improve visual field and retinal nerve fiber layer examination parameters and it is advised to set new baselines after the surgery for subsequent progression monitoring. Clearance of an optically significant cataract results in better quality of life, and with detailed and thorough explanation of the indications, expectations and risks of the surgery, cataract extraction could be considered even in cases of advanced glaucoma.

Differential Efficacy of Combined Phacoemulsification and Endocyclophotocoagulation in Open-angle Glaucoma Versus Angle-closure Glaucoma

PRéCIS:: This retrospective study found that combined phacoemulsification and endocyclophotocoagulation reduced intraocular pressure (IOP) to a greater degree in angle-closure glaucoma versus open-angle glaucoma and was effective for all stages of glaucoma.

PURPOSE

Endocyclophotocoagulation (ECP) laser treatment of the ciliary processes is believed to decrease IOP by reducing aqueous production. Anecdotal experience in angle-closure glaucoma suggests that it may also lower IOP by opening the drainage angle to promote aqueous outflow. This study sought to evaluate combined phacoemulsification and ECP (phaco/ECP) in eyes with different types and stages of glaucoma.

PATIENTS AND METHODS

A Retrospective chart review of eyes that underwent phaco/ECP between October 2010 and December 2016 at one institution was conducted.

RESULTS

In 63 eyes of 63 patients with an average of 3.0±1.7 years of follow-up, the 22 eyes with chronic angle-closure glaucoma (CACG) had greater IOP reduction and medication reduction than the 41 eyes with primary open-angle glaucoma at both 1 year (6.4 vs. 2.1 mm Hg, P=0.01; 0.9 vs. 0.2 medications, P=0.04) and final follow-up (6.2 vs. 2.4 mm Hg, P=0.02; 0.9 vs. 0.3 medications, P=0.05). There was no difference in IOP reduction or medication reduction for eyes with mild, moderate, or advanced glaucoma at both 1 year (3.5, 3.9, 0.5 mm Hg, respectively, P=0.18; 0.3, 0.6, 0.4 medications, P=0.58) and final follow-up (3.3, 4.8, 0.7 mm Hg, P=0.11; 0.1, 0.8, 0.4 medications, P=0.14).

CONCLUSIONS

Eyes with CACG were more responsive to phaco/ECP in terms of IOP and medication reduction compared with eyes with primary open-angle glaucoma. This finding could be partially or entirely due to concurrent cataract extraction and greater CACG preoperative IOP. Phaco/ECP was effective in all stages of glaucoma.

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.

Long term outcomes of cataract surgery in severe and end stage primary angle closure glaucoma with controlled IOP: a retrospective study

Background

To investigate the long term surgical outcomes of cataract surgery in severe and end stage glaucoma patients with preoperative intraocular pressure less than 21 mmHg, and to detect the associated factors.

Methods

A retrospective study of primary angle closure glaucoma patients was conducted on who underwent cataract surgery or combined with goniosynechialysis from March 2015 to April 2018. Main outcome measures were visual acuity, intraocular pressure, number of glaucoma medications and complications.

Results

Sixteen patients (19 eyes) were included. The mean age was 64.89 ± 11.68 years and the mean followed up duration was 21.89 ± 7.85 months. The final visual acuity was significantly improved from 0.69 ± 0.55 to 0.46 ± 0.52 logMAR, within 12 (63.2%) eyes improved, 4 (21.1%) eyes kept unchanged, and 3 (15.8%) eyes reduced. Linear regression analysis indicated that higher mean deviation, higher visual field index and lower glaucoma stage associated with better final visual acuity (r = − 0.511, r = − 0.493, r = 0.537 respectively). Moreover, the final number of medications were reduced from 1.26 ± 0.99 to 0.26 ± 0.56 (p < 0.01). The mean intraocular pressure was not significantly reduced with the final IOP of 14.48 ± 3.74 mmHg (p = 0.97). While the eyes with intraocular pressure above 15 mmHg was decreased to 6 (31.6%) eyes compared to 10 (52.6%) eyes at baseline. Moreover, the number of eyes free of medications was increased from 4 (21.1%) preoperatively to 15 (78.9%) eyes postoperatively.

Conclusions

Final visual acuity was significantly improved in the severe and end stage primary angle closure glaucoma patients and the number of eyes came off medications increased by 57.8% after cataract surgery. Preoperatively, the glaucoma stage, mean deviation and visual field index are important parameters to predict the final visual acuity after cataract surgery.

Two-year outcome of Trabeculo-Canalectomy for Chinese Glaucoma Patients

To evaluate the efficacy of trabeculo-canalectomy in treating glaucoma patients, a retrospective investigation of 53 glaucoma patients (53 eyes) who underwent trabeculo-canalectomy was conducted at the First Affiliated Hospital of Nanjing Medical University, China, from April 2017 to January 2019. Intraocular pressure (IOP), visual acuity, surgical success rates, medications, and complications were monitored at post-operative 1 day, 1 week, 1, 3, 6, 12 and 24 months. Surgical success criteria were defined as 6 mm Hg≤IOP≤21 mmHg with or without additional medications. Our results showed that average IOP was statistically significant between pre-operative visit and each follow-up visit (all P <0.05). The total success rate of trabeculo-canalectomy at 1, 3, 6, 12 and 24 months was 92.5%, 86.8%, 94.3%, 92.5% and 90.6% respectively. After 3 months post-operatively, all patients had no obvious filtering blebs. The main early complications included postoperative hyphema (7.5%), elevated IOP (5.7%) and anterior chamber exudation (3.8%), which were all cured after conservative treatment. No blebitis, shallow anterior chamber, choroidal detachment and endophthalmitis were observed. Logistic regression analysis showed that patients with secondary glaucoma were more likely to undergo surgical failure 24 months post-operatively (P= 0.008). Thus, we conclude that trabeculo-canalectomy is effective and safe for the treatment of glaucoma.

Factors Associated With Long-term Intraocular Pressure Fluctuation in Primary Angle Closure Disease: The CUHK PACG Longitudinal (CUPAL) Study

PURPOSE

To determine the demographic, ocular, and systemic factors associated with long-term intraocular pressure (IOP) fluctuation in primary angle closure disease (PACD).

METHODS

This prospective cohort study included 422 PACD eyes from 269 Chinese patients, including 274 primary angle closure glaucoma (PACG) eyes and 152 primary angle closure/primary angle closure suspect (PAC/PACS) eyes. Long-term IOP fluctuation defined as the SD of all IOP measurements over 2 years (at least 5 measurements in total). Chinese patients with PACD were recruited and followed up 3 monthly. Eyes with IOP-lowering surgery or lens extraction performed within the 2-year study period were excluded. Patient demographics, received treatments, ocular biometry, retinal nerve fiber layer thickness, and systemic factors (eg, hypertension, smoking) were evaluated. Generalized estimating equations adjusting for inter-eye correlation were used to determine the associations.

RESULTS

Eyes with PACG had significantly higher IOP fluctuation than PAC/PACS (2.4±1.2 versus 2.1±0.9 mm Hg; P=0.04). In the multivariate analysis with PACG eyes, higher baseline IOP (P<0.001), greater number of IOP-lowering medications (P<0.001), previous trabeculectomy (P=0.002), and current smoking (P=0.03) were significantly associated with larger IOP fluctuation, whereas diabetes mellitus was associated with lower IOP fluctuation (P=0.03). Among PAC/PACS eyes, younger age group (P<0.001), male sex (P=0.002), and higher baseline IOP (P<0.001) were significantly associated with larger IOP fluctuation.

CONCLUSIONS

PACG eyes have greater IOP fluctuation than PAC/PACS eyes. Certain demographic, ocular, and systemic factors are associated with IOP fluctuation in PACD eyes.

Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated?

Angle-closure glaucoma is an aggressive condition that causes millions to become blind worldwide. This review explores the use of prophylactic laser peripheral iridotomy (PI) in patients classified as primary angle-closure suspects (PACS), and additionally, the use of clear lens exchange as a primary treatment option in established angle-closure disease with or without glaucoma. As PI has a strong prophylactic effect in fellow eyes of patients who have had an acute attack, its use has been widely adopted in those patients classified as PACS, but with limited evidence to support this. A large randomised trial conducted in China has demonstrated that although PI reduces the risk of incident angle-closure disease, the incidence of disease that would threaten vision was much lower than anticipated. This suggests that the benefit of prophylactic PI is very limited. Health services data shows an association between rising cataract surgical rates and of decreasing rates of acute angle-closure. Age-related growth of the lens is a major component of angle-closure disease. Several studies have shown that clear lens extraction (CLE) effectively lowers IOP in angle-closure. The use of CLE as a primary treatment option has been tested against LPI in the EAGLE study, a large RCT that enroled people with angle-closure and an IOP > 30 mmHg, and those with angle-closure glaucoma. The trial showed CLE to be superior to PI both for IOP control and patient reported quality of life. On these grounds, CLE should be considered for first-line treatment of more advanced angle-closure disease.

One-month IOP in mitomycin C-augmented trabeculectomy can predict long-term IOP control in chronic primary angle-closure glaucoma

PURPOSE

To investigate the predictors of long-term intraocular pressure (IOP) in chronic primary angle-closure glaucoma (CPACG) treated with primary trabeculectomy.

METHODS

This study systematically reviewed cases of CPACG treated with primary trabeculectomy. The scleral flaps in all cases were sutured with two stitches in situ and two releasable sutures to ensure watertight under normal IOP conditions during surgery. Mitomycin C was used in all eyes. All patients were followed for 2 years. Digital massage of the bulbus and removal of the releasable suture were performed according to the IOP and shape of the filtering bleb. Demographic data and clinical outcomes were recorded. Factors predicting long-term IOP were identified.

RESULTS

A total of 72 patients (88 eyes) with a mean age of 58.51 ± 10.60 years were included in this study. The complete success rate was 89.77% after 2 years. The IOP began to stabilize after 7 days and reached its lowest point at the 1-month follow-up. The preoperative and early postoperative high or low IOP does not affect long-term effects (P > 0.05). There was a positive correlation between postoperative IOP at the 1-month and 2-year follow-ups (r = 0.64, P < 0.001).

CONCLUSION

In CPACG patients undergoing primary trabeculectomy, scleral flaps sutured watertightly with two stitches in situ and two releasable sutures under normal IOP conditions can ensure controllable, effective and safe treatment of CPACG. The preoperative and early postoperative high or low IOP does not affect long-term effects. One-month postoperative IOP can be used as a predictor of long-term IOP control.

Acute primary angle closure-treatment strategies, evidences and economical considerations

Acute primary angle closure requires emergency management that involves a rapid lowering of the intraocular pressure and resolution of relative pupil block - the most common mechanism of angle closure. Emergency strategies for lowering intraocular pressure include medical treatment and argon laser peripheral iridoplasty. Anterior chamber paracentesis and diode laser transcleral cyclophotocoagulation may be considered in special situations. Relative pupil block can be relieved by peripheral laser iridotomy and primary lens extraction; the latter is a more effective treatment according to the results of clinical trials. However, primary lens extraction can be technically demanding in the acute setting. Peripheral laser iridotomy has a role in relieving pupil block and should also be considered in most cases. Lens extraction may be combined with procedures such as goniosynechialysis, trabeculectomy or endoscopic cyclophotocoagulation. In this review, we aim to discuss the available evidence regarding the different treatment modalities. We also discuss the economic consideration, including cost-effectiveness and life expectancy, in the management of acute primary angle closure.

Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma

Primary angle closure glaucoma (PACG) is more blinding (1 in 4 cases) than primary open angle glaucoma (1 in 10 cases). Cataract surgery is an effective initial treatment for majority of cases of PACG. However, cataract surgery alone may not be enough to control intraocular pressure (IOP) in cases with extensive synechial angle closure glaucoma. It is reported that glaucoma drainage surgery is needed in 12% of PACG cases after cataract surgery. Some experts combine cataract surgery with either goniosynechialysis (GSL) or endocyclophotocoagulation (ECP) to enhance IOP control. However, neither combination ensures complete success. We report three subjects with extensive synechia! angle closure in whom we facilitated a technique that combines lens extraction with ECP and endoscopic-GSL (PIECES). We demonstrated that this combined technique was a more effective and efficient method of achieving lower IOP in the presence of extensive synechial PACG. We believe that it addresses both the inflow and outflow of the aqueous humor simultaneously. Two out of three patients had good IOP control without medication and one patient needed one drop after a minimum 12 months of follow up. Furthermore, it may reduce the need for medical therapy and future more invasive glaucoma drainage surgery. How to cite this article: Alaghband P, Rodrigues IAS, Goyal S. Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma. J Curr Glaucoma Pract 2018;12(1):45-49.

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.