Primary Angle-Closure Disease Preferred Practice Pattern®

Efficacy and Tolerability of Single-Dose Timolol Eye Drops in the Sequential Treatment of Acute Angle-Closure Crisis: A Double-Blind, Randomized, Placebo-Controlled Trial

PURPOSE

To observe and compare the efficacy of timolol eye drops in sequential treatment of acute angle-closure crisis (AACC).

METHODS

In this prospective, randomized, double-blind case-control study, patients diagnosed with AACC at the Affiliated Hospital of Hebei University from April 2021 to October 2023 were continuously enrolled. The patient data were collected and randomly divided into timolol group (group A) and placebo group (group B). All patients were sequentially treated with drug therapy, anterior chamber paracentesis, and argon laser peripheral iridoplasty. The primary outcomes were decreased intraocular pressure (IOP), success rate, and treatment time.

FINDINGS

At 2 hours, 4 hours, and 6 hours after the start of treatment, the reduction in IOP in group A was 13.87 ± 13.85 mm Hg, 28.42 ± 12.87 mm Hg, and 35.69 ± 8.51 mm Hg, respectively, and the number of controlled eyes was 23 (29.87%), 51 (66.23%), and 71 (92.20%), respectively. The reduction in IOP in group B was 15.88 ± 14.95 mm Hg, 28.17 ± 13.63 mm Hg, and 33.90 ± 13.59 mm Hg, respectively, and the number of controlled eyes was 30 (36.59%), 58 (70.73%), and 75 (91.46%) eyes, respectively. Among patients whose crises were relieved, the times for AACC relief were 3.29 ± 1.31 hours in group A and 3.38 ± 1.34 hours in group B. There were no significant differences in IOP reduction, numbers of eyes remission, and times for AACC relief between the 2 groups at each point of sequential treatment (P > 0.05).

IMPLICATIONS

In the sequential treatment of AACC, timolol is not helpful to improve the success rate of treatment.

The Role of Vitreous Zonule Attachments to the Posterior Lens Equator in Primary Angle Closure Glaucoma

PRCIS

Shorter axial length was associated with the absence of the attachments between the posterior insertion zone of the vitreous zonules and the posterior lens equator. Primary angle closure disease eyes without vitreous zonules had a more anteriorly rotated ciliary body.

PURPOSE

To assess the clinical significance of the attachments between the posterior insertion zone of the vitreous zonules and the posterior lens equator (PVZ INS-LE strands) and vitreous zonules (VZ) in primary angle closure disease (PACD).

METHODS

This cross-sectional study consisted of 90 PACD and 30 cataract eyes from an eye clinic. PVZ INS-LE strands, VZ, and anterior segment parameters were assessed by ultrasound biomicroscopy (UBM). The presence of PVZ INS-LE strands and VZ was compared between groups. Baseline ocular characteristics and UBM parameters were compared among PACD eyes. Factors associated with the absence of PVZ INS-LE strands and VZ were identified.

RESULTS

Forty percent of control eyes and 71.1% of PACD showed PVZ INS-LE strands absent. PACD 22.2% and no control eyes showed VZ absent. PVZ INS-LE strands absent group had shorter axial length ( P =0.018), larger ciliary-ciliary angle ( P =0.010), and smaller trabecular-ciliary process distance at 750 μm ( P =0.022). Shorter axial length was independently associated with absence of PVZ INS-LE strands (OR=2.230; 95% CI: 1.027-4.838; P =0.043). VZ absent group had larger ciliary-ciliary angle ( P <0.001), smaller trabecular-ciliary angle ( P =0.040), shorter iris-ciliary process distance at 750 μm ( P =0.092), and shorter trabecular-ciliary process distance at 750 μm ( P =0.026).

CONCLUSIONS

PVZ INS-LE strands were less likely to be seen in APACD and their fellow eyes. All types of PACD eyes had less presence of VZ. PACD eyes without VZ appeared to have more anterior rotation of the ciliary body. Shorter AL was independently associated with the absence of PVZ INS-LE strands.

A Study of 24-h Efficacy and Safety of Sepetaprost vs. Latanoprost in Patients with Primary Open-Angle Glaucoma or Ocular Hypertension

INTRODUCTION

Understanding the 24-h efficacy and safety of a novel therapy option, sepetaprost ophthalmic solution 0.002% vs. latanoprost ophthalmic solution 0.005%, may delineate its future position in glaucoma treatment.

METHODS

In this exploratory study (EudraCT 2020-004836-93), adults with primary open-angle glaucoma (POAG) or ocular hypertension (OHT) were randomized to sepetaprost or latanoprost for 3 months following a ≤ 35-day screening period. The primary endpoint was mean 24-h intraocular pressure (IOP) at month 3 with sepetaprost vs. latanoprost. Safety outcomes included rate of adverse events (AEs).

RESULTS

Overall, 33 participants received treatment (sepetaprost, n = 17; latanoprost, n = 16). Mean 24-h IOP was numerically lower with sepetaprost vs. latanoprost at month 3 (- 0.88 mmHg; 95% confidence interval [CI] - 2.89, 1.14; not statistically significant at the 0.05 level [NS]). Mean change from baseline in IOP at month 3 ranged from - 5.63 to - 7.00 mmHg for sepetaprost and - 3.84 to - 6.66 mmHg for latanoprost. Lower nocturnal IOP was observed with sepetaprost vs. latanoprost at month 3 (- 1.61 mmHg difference; 95% CI - 4.05, 0.83; not statistically significant; however, the 90% CI was - 5.27, - 0.17 and therefore, nominal statistical significance was achieved at the 0.10 level). Mean difference between groups indicated similar, or numerically lower, IOP with sepetaprost at individual time points at week 6 and month 3. At 36 and 48 h following sepetaprost cessation, mean IOP was lower vs. baseline IOP at the same time points. AEs occurred in 13 (76.5%) vs. 11 (68.8%) participants treated with sepetaprost vs. latanoprost.

CONCLUSION

In participants with POAG or OHT, mean 24-h IOP and nocturnal IOP at month 3 were consistently numerically lower with sepetaprost vs. latanoprost. Safety profiles were similar between groups.

TRIAL REGISTRATION

EudraCT 2020-004836-93.

Short-Term Ocular Biometric Changes as Predictors of Long-Term Angle Closure Progression

Importance

Baseline ocular biometrics of the anterior segment forecast progression from primary angle closure suspect (PACS) to primary angle closure (PAC). As ocular biometrics change with aging, it is also important to understand the progression risk associated with these longitudinal anatomical changes.

Objective

To assess 18-month ocular biometric changes as risk factors for progression from PACS to PAC between 36 and 72 months.

Design, Setting, and Participants

This retrospective cohort study analyzed data from the prospective Zhongshan Angle Closure Prevention (ZAP) Trial, which was a randomized clinical trial conducted from September 2008 to November 2018. Participants were aged 50 to 70 years and had bilateral PACS, defined as inability to visualize pigmented trabecular meshwork in 2 or more quadrants on gonioscopy. Participants were evaluated at baseline, at 2 weeks, and at 6, 18, 36, 54, and 72 months for progression to PAC, defined as development of intraocular pressure greater than 24 mm Hg, peripheral anterior synechiae, or acute angle closure. Untreated eyes without progression at or before 18 months were eligible. Cox regression models assessed risk factors for progression. Data were analyzed from November 2023 to June 2024.

Main Outcome and Measure

Progression from PACS to PAC between 36 and 72 months.

Results

A total of 785 untreated eyes (759 without progression, 26 with progression) of 785 participants were analyzed (mean [SD] age, 58.7 [5.0] years; 651 females [82.9%], 134 males [17.1%]). In univariable Cox models, baseline trabecular-iris space area at 500 μm (TISA500) and 18-month change in lens vault (ΔLV) and TISA at 750 μm (ΔTISA750) were associated with progression. In age-adjusted multivariable Cox models, baseline TISA500 (hazard ratio [HR], 1.28 per -0.01 mm2; 95% CI, 1.09-1.50; P = .006) and ΔLV (HR, 1.22 per 0.1 mm; 95% CI, 1.07-1.41; P = .008) (concordance index, 0.73) or baseline TISA500 (HR, 1.31 per -0.01 mm2; 95% CI, 1.11-1.54; P = .003) and ΔTISA750 (HR, 1.06 per -0.01 mm2; 95% CI, 1.02-1.10; P = .009) (concordance index, 0.73) were more predictive than baseline TISA500 alone (HR, 1.27 per -0.01 mm2; 95% CI, 1.09-1.49; P = .007) (concordance index, 0.69). A multivariable model with categorical TISA500 in the lowest quartile (<0.031 mm2; HR, 2.65; 95% CI, 1.20-5.86; P = .03) and ΔLV in the highest quartile (>0.663 mm; HR, 2.70, 95% CI, 1.23-5.93; P = .02) independently conferred greater risk of progression (concordance index, 0.69).

Conclusions and Relevance

Short-term (18-month) changes in LV and TISA750 were associated with long-term (36-72 month) angle closure progression in untreated PACS eyes, suggesting that monitoring changes in lens size or position and angle width could augment predictive performance of baseline ocular biometrics for long-term angle closure progression.

Inequities in glaucoma research: an analysis of Cochrane systematic reviews and randomized trials

OBJECTIVES

To understand the level of equity considerations within Cochrane systematic reviews (CSR) on glaucoma and their primary studies.

METHODS

A review of equity considerations in systematic reviews on glaucoma published in The Cochrane Library from inception (2003) to January 31, 2024 and a sample of recently published primary studies included in those reviews (n = 122). Extraction was performed by two independent reviewers using a prepiloted extraction form based on a validated, contemporary, structured equity framework. If consensus could not be reached, a third reviewer was involved.

RESULTS

A total of 40 CSRs on glaucoma were identified, all of which exclusively included randomized control trials (RCTs) or quasi-RCTs. Twenty-nine (72.5%) reviews acknowledged populations experiencing inequities in glaucoma care; none were able to perform subgroup analysis due to data unavailability in primary studies. Six (15.0%) reviews considered equity-relevant factors when discussing applicability or limitations of study findings to specific populations. Seventy-four (46.8%) review authors were women, while 84 (53.2%) were men. Most review authors were primarily affiliated with institutions in the European Region (85, 53.8%) or the Americas (55, 34.8%), while none were primarily affiliated with institutions in Africa or low-income countries. Most RCTs were conducted in the Americas (32.8%), European Region (27.9%), or in high-income countries (72.1%). While most RCTs reported gender or sex of participants (107, 87.7%), only half reported race or ethnicity (61, 50.0%). No RCTs reported place of residence, occupation, socioeconomic status (SES), or social capital of participants. Approximately half (51.7%) of the participants in these RCTs were female.

CONCLUSION

Equity considerations can be better addressed in research on glaucoma. Reporting of patient sociodemographic in RCTs, particularly race and ethnicity, as well as global representation were insufficient. This may limit the generalizability and applicability of intervention efficacy to populations experiencing inequities and people from low-income countries.

Novel predictors for malignant glaucoma in primary angle-closure glaucoma patients

PURPOSE

To identify potential structural predictors for malignant glaucoma (MG) using ultrasonic biomicroscopy (UBM) images in primary angle-closure glaucoma (PACG) eyes.

METHODS

This study enrolled 99 MG inpatients (110 eyes) from 1 January 2014 to 30 June 2024 in Shanghai Eye & ENT Hospital of Fudan University. Based upon surgical methods, the MG patients were divided into the trabeculectomy-MG group (70 eyes) and the phacoemulsification-MG group (40 eyes). PACG patients who did not develop MG were 1:1 matched to MG patients as controls. Preoperative information was collected, and four novel parameters were measured on UBM images, namely Sc-vz (the area enclosed by ciliary body and vitreous zonule), Hc-vz (the height of Sc-vz), Zmin (the length of the shortest zonule) and sCLD (simulated cilio-lenticular distance).

RESULTS

Compared to PACG patients without MG, MG patients exhibited shorter axial length (AL), shallower anterior chamber depth (ACD) and smaller trabecular ciliary process angle (TCPA). Additionally, patients with MG exhibited shorter Zmin and sCLD, as well as smaller Sc-vz and Hc-vz than patients without MG, regardless of the surgical method. Zmin, sCLD, Sc-vz and Hc-vz demonstrated significantly higher predictive power than AL, ACD and TCPA. The combination of the four parameters reliably predicted MG with a sensitivity of 88.9% and a specificity of 76.5%.

CONCLUSION

PACG eyes with a shorter cilio-lenticular distance and a narrower ciliary body-to-vitreous zonule area are more likely to develop malignant glaucoma. Four novel UBM-measured parameters performed well in the prediction of malignant glaucoma either alone or in combination.

Occult zonulopathy detected during cataract surgery in patients with acute primary angle closure: a retrospective study

Background

Whether occult zonulopathy contributes to the development of acute primary angle closure (APAC) remains elusive. This study aimed to determine the association between occult zonulopathy detected during cataract surgery and APAC and to investigate the biometric characteristics of APAC patients with or without occult zonulopathy.

Methods

Retrospective case-control study. A total of 27 Chinese unilateral APAC subjects and 132 control subjects with comprehensive ophthalmic examinations were recruited. Occult zonulopathy was identified with the intraoperative signs during cataract surgery. The proportion of occult zonulopathy was compared between the APAC and control groups. A multivariate logistic analysis was conducted to determine the association between occult zonulopathy and APAC. The ocular biometric parameters were compared between APAC and the contralateral eyes in APAC patients with or without occult zonulopathy.

Results

APAC patients (63.0%) had a significantly larger proportion of occult zonulopathy than control subjects (1.5%, P < 0.001). In the multivariate logistic analysis, occult zonulopathy was significantly associated with APAC after adjusting the axial length (AL) and sex (OR = 126.49, 95% CI [20.89-766.02]; P < 0.001). Compared to contralateral eyes, shallower central anterior chamber depth, more anterior lens position and relative lens position were found in APAC eyes both with and without occult zonulopathy (all P < 0.05), but no difference in AL and lens thickness.

Conclusion

A larger proportion of occult zonulopathy was significantly associated with APAC. Occult zonulopathy could be a risk factor for APAC by inducing forward shifting of the lens.

Peripheral Iridectomy With Goniosynechialysis and Goniotomy vs Trabeculectomy for Advanced PACG: A Randomized Clinical Trial

Importance

The safety and effectiveness of combining surgical peripheral iridectomy (SPI) with goniosynechialysis (GSL) and goniotomy (GT) vs trabeculectomy for intraocular pressure (IOP) reduction remains unknown.

Objective

To investigate the safety and effectiveness at 1 year of SPI + GSL + GT vs trabeculectomy in advanced primary angle-closure glaucoma (PACG) without cataract.

Design, Setting, and Participants

This noninferiority randomized clinical trial was conducted at 8 tertiary eye centers in China. A total of 88 Chinese patients (88 eyes) with advanced PACG without cataract were enrolled from January 2022 to July 2023. Data were analyzed from August 2024 to September 2024. Mean (SD) patient age was 60.3 (7.3) years, and 52 patients (59.1%) were female. Forty-three patients were randomized to SPI + GSL + GT and 45 were randomized to trabeculectomy; 86 patients (97.7%) completed the 12-month follow-up.

Interventions

Participants were randomized 1:1 to receive SPI + GSL + GT or trabeculectomy.

Main Outcomes and Measures

The primary outcome was IOP at 12 months (noninferior margin: 4 mm Hg). Secondary outcomes included surgical success (IOP: 5-18 mm Hg, ≥20% reduction from baseline, with or without antiglaucoma medications); postoperative complications and interventions, including bleb massage, suture lysis, or releasable sutures; and number of antiglaucomatous medications prescribed.

Results

At 12 months, the SPI + GSL + GT group had a mean (SD) IOP of 15.6 (4.0) mm Hg vs 14.9 (4.2) mm Hg in the trabeculectomy group (difference, 0.5 mm Hg; 95% CI, -1.2 to 2.2; P = .55), which was within the 4-mm Hg noninferiority margin. Qualified success rates were 38 of 43 participants (88.4%) for SPI + GSL + GT and 42 of 45 participants (93.3%) for trabeculectomy (difference, -5.0%; 95% CI, -19.6% to 8.5%; P = .48). However, complete success rates were lower in the SPI + GSL + GT group (26 participants [60.5%]) vs the trabeculectomy group (37 participants [82.2%]; difference, -21.8%; 95% CI, -40.2% to -2.4%; P = .03). Postoperative complications were present for 8 participants (18.6%) in the SPI + GSL + GT group vs 9 participants (20.0%) in the trabeculectomy group (difference, -1.4%; 95% CI, -17.9% to 15.1%; P = .71). Postoperative interventions were lower in the SPI + GSL + GT group (3 participants [7.0%] vs 25 participants [55.6%]; difference, 48.6%; 95% CI, 32.2%-65.0%; P < .001). Median (IQR) numbers of medications used decreased from 2 (0-3) to 0 (0-1) in the SPI + GSL + GT group and from 2 (2-3) to 0 (0-0) in the trabeculectomy group (difference, -0.81; 95% CI, -1.36 to -0.26; P = .004).

Conclusions and Relevance

In this randomized clinical trial among patients with advanced PACG without cataract, SPI + GSL + GT demonstrated noninferiority (4-mm Hg margin) to trabeculectomy for IOP at 12 months, with fewer interventions (including bleb massage, suture lysis, or releasable sutures) but no difference in postoperative medication use. This suggests SPI + GSL + GT as a potential alternative to trabeculectomy for similar cases, pending validation in larger sample sizes with smaller noninferiority margins.

Trial Registration

ClinicalTrials.gov Identifier: NCT05163951.

Two-Year Outcomes of Phacogoniotomy vs Phacotrabeculectomy for Advanced Primary Angle-Closure Glaucoma With Cataract: A Noninferiority Randomized Clinical Trial

Importance

Intraocular pressure (IOP) reduction with phacogoniotomy (phacoemulsification plus goniosynechialysis plus goniotomy) was not less than that of phacotrabeculectomy for advanced primary angle-closure glaucoma (PACG) with cataract at 1-year follow-up, but longer-term outcomes are needed.

Objective

To investigate if phacogoniotomy is noninferior to phacotrabeculectomy for advanced PACG with cataract at 2 years.

Design, Setting, and Participants

This multicenter, noninferiority, randomized clinical trial took place in 7 ophthalmology centers in China. The trial started May 31, 2021, and 2-year follow-up ended May 31, 2024. Included in this analysis were patients with advanced PACG and cataract. Study data were analyzed from September 2024 to January 2025.

Interventions

Random assignment (1:1) to phacogoniotomy or phacotrabeculectomy.

Main Outcomes and Measures

The primary outcome measure was reduction in IOP from baseline to the 2-year visit with a noninferiority margin of 4 mm Hg.

Results

A total of 124 participants (124 eyes) were randomized (mean [SD] age, 66.4 [8.6] years; 67 female [54.0%]), 65 (52.4%) to the phacogoniotomy group and 59 (47.6%) to the phacotrabeculectomy group. A total of 59 patients (90.7%) in the phacogoniotomy group and 52 patients (88.1%) in the phacotrabeculectomy group completed 2-year visits. All participants were Chinese. Mean (SD) IOP reduction was -25.6 (10.2) mm Hg and -24.7 (9.4) mm Hg in the phacogoniotomy and phacotrabeculectomy groups, respectively, and the upper boundary of the CI for difference in change between groups was lower than the 4-mm Hg noninferiority margin (mean difference, -0.5 mm Hg; 97.5% CI, -1.7 mm Hg to 0.8 mm Hg; P = .42). The mean difference for complete success for phacogoniotomy vs phacotrabeculectomy was -6.7% (95% CI, -21.4% to 8.8%; P = .47) and for qualified success was 1.4% (95% CI, -11.0% to 14.3%, P = .30). Median (IQR) number of antiglaucomatous medication was 0 (0) vs 0 (0; Hodges-Lehmann estimate of location shift, 0; 95% CI, 0; P =.12) with phacogoniotomy vs phacotrabeculectomy, respectively (mean difference, 0.13; 95% CI, -0.36 to 0.63; P = .60).

Conclusions and Relevance

Mean IOP reduction with phacogoniotomy was noninferior to phacotrabeculectomy for advanced PACG and cataract at 2-year follow-up with no differences detected in complete or qualified success or mean number of antiglaucomatous medications. These findings support phacogoniotomy as an alternative to phacotrabeculectomy for patients with advanced PACG and cataract.

Trial registration

ClinicalTrials.gov Identifier: NCT04878458.

Genetic Association of Primary Angle-Closure Glaucoma and Disease Progression

BACKGROUND

To investigate single-nucleotide polymorphisms (SNPs) reported in the largest up-to-date systematic review and meta-analysis on primary angle-closure disease (PACD), on their associations with primary angle-closure glaucoma (PACG) and disease progression.

METHODS

This study involved a case-control design for PACG risk and a case-only design for PACG progression risk, including 628 PACG patients and 564 controls for disease association and 386 PACG patients with up to 10-year follow-up for PACG progression analysis. Associations of 17 SNPs in 15 genes with PACG were analysed using logistic regression. Sex-stratified association analysis was performed, followed by the Breslow-Day test. Genetic risk for PACG progression was evaluated using logistic regression. Bonferroni correction of p values was adopted for multiple comparisons.

RESULTS

LOXL1 rs3825942 (G153D; p = 0.0026; OR = 0.65) was significantly associated with PACG, while ABCC5 rs1401999 showed a nominal association (p = 0.023; OR = 1.32). ABCA1 rs2422493 was significantly associated with PACG in females (p = 0.0016; OR = 0.70) but not in males (p = 0.95; OR = 0.99); and the Breslow-Day Test (p = 0.046) suggested a sex-specific association in females. VAV3 rs6689476 showed nominal associations with PACG progression at 3-year (p = 0.045; OR = 2.86), 5-year (p = 0.037; OR = 2.84) and 10-year follow-ups (p = 0.03; OR = 2.74), but the p values could not withstand Bonferroni correction.

CONCLUSION

This study demonstrated a role of LOXL1 in PACG and a sex-specific effect of ABCA1 in the Hong Kong Chinese population while suggesting a potential role of VAV3 in PACG progression, which has yet to be further confirmed.

ACM-Assessor: An Artificial Intelligence System for Assessing Angle Closure Mechanisms in Ultrasound Biomicroscopy

Primary angle-closure glaucoma (PACG), characterized by angle closure (AC) with insidious and irreversible progression, requires precise assessment of AC mechanisms for accurate diagnosis and treatment. This study developed an artificial intelligence system, ACM-Assessor, to evaluate AC mechanisms in ultrasound biomicroscopy (UBM) images. A dataset of 8482 UBM images from 1160 patients was retrospectively collected. ACM-Assessor comprises models for pixel-to-physical spacing conversion, anterior chamber angle boundary segmentation, and scleral spur localization, along with three binary classification models to assess pupillary block (PB), thick peripheral iris (TPI), and anteriorly located ciliary body (ALCB). The integrated assessment model classifies AC mechanisms into pure PB, pure non-PB, multiple mechanisms (MM), and others. ACM-Assessor's evaluation encompassed external testing (2266 images), human-machine competition and assisting beginners' assessment (an independent test set of 436 images). ACM-Assessor achieved accuracies of 0.924 (PB), 0.925 (TPI), 0.947 (ALCB), and 0.839 (integrated assessment). In man-machine comparisons, the system's accuracy was comparable to experts (p > 0.05). With model assistance, beginners' accuracy improved by 0.117 for binary classification and 0.219 for integrated assessment. ACM-Assessor demonstrates expert-level accuracy and enhances beginners' learning in UBM analysis.

Phacoemulsification combined with trabecular meshwork-Schlemm canal-based minimally invasive glaucoma surgery in primary angle-closure glaucoma: a systematic review and meta-analysis

BACKGROUND

To summarize the efficacy and safety of the phacoemulsification with intraocular lens implantation (PEI) ± goniosynechialysis (GSL) + trabecular meshwork-Schlemm canal (TM-SC)-based minimally invasive glaucoma surgery (MIGS) in primary angle-closure glaucoma (PACG).

METHODS

A comprehensive literature search was conducted across seven electronic databases: PubMed, ScienceDirect, The Cochrane Library, Scopus, Embase, Ovid MEDLINE, and Web of Science. Studies focused on TM-SC-based MIGS with PEI for PACG were included in this review. The efficacy was assessed by the reduction in intraocular pressure (IOP) values and the decrease in the number of anti-glaucoma medications (AGMs), while safety was evaluated by incidence of complications.

RESULTS

Out of 5158 studies initially identified, this meta-analysis included 12 articles with a total of 633 eyes with PACG. At 12 months postoperatively, PEI ± GSL + TM-SC-based MIGS yielded an IOP decrease of 10.25 mmHg (95% CI: 7.06 to 13.43), PEI ± GSL + goniotomy yielded an IOP decrease of 13.10 mmHg (95% CI: 7.59 to 18.62), PEI ± GSL + gonioscopy-assisted transluminal trabeculotomy yielded an IOP decrease of 11.54 mmHg (95% CI: 7.18 to 15.90), and PEI ± GSL + trabecular micro-bypass stent yielded an IOP decrease of 3.94 mmHg (95% CI: 2.58 to 5.30). The most common complications were hyphema (16.3%) and IOP spike (7.4%). Specifically, the iStent group had the lowest incidence of each complication.

CONCLUSIONS

PEI ± GSL + TM-SC-based MIGS is effective in reducing IOP and medication burden while maintaining a favorable safety profile in PACG. More randomized controlled trials are required to support this therapeutic recommendation.

REGISTRATION

This meta-analysis was registered on PROSPERO (registration number: CRD42024583864).

Minimally invasive glaucoma surgery in angle closure

PURPOSE OF REVIEW

This review discusses the evidence on the efficacy, safety and role of minimally invasive glaucoma surgery (MIGS) in eyes with angle closure glaucoma. While cataract surgery remains the most established surgical treatment for primary angle closure glaucoma (PACG), the intraocular pressure (IOP) may remain elevated after cataract surgery despite open angles due to trabecular meshwork damage from chronic iridotrabecular contact.

RECENT FINDINGS

There is emerging evidence that combining cataract surgery with MIGS in eyes with PACG, though an off-label indication for some MIGS devices, can achieve greater IOP and glaucoma medication reduction than cataract surgery alone.

SUMMARY

Trabecular bypass MIGS procedures and less destructive forms of ciliary body treatment have been shown to be effective in PACG and are safer alternatives to traditional incisional surgeries. Evidence for the use of subconjunctival MIGS and suprachoroidal MIGS in angle closure eyes is lacking at present, and further investigation is indicated.

Comparative evaluation of phacoemulsification combined with goniosynechi-alysis with goniotomy versus trabeculectomy in patients with angle-closure glaucoma and cataract

PURPOSE

This study aims to evaluate the effectiveness and safety of phacoemulsification cataract extraction with intraocular lens implantation (PEI) combined with Goniosynechialysis (GSL), Goni-otomy (GT), and PEI combined with Trabeculectomy (TRAB), in managing mid to late-stage Primary Angle-Closure Glaucoma (PACG) combined with cataract.

METHODS

A retrospective analysis was conducted on 42 patients (54 eyes) with mid to late-stage PACG combined with cataracts, who were previously treated at Dongyang People's Hospital from December 3, 2020, to November 30, 2023. Among them, 16 (24 eyes) underwent PEI-GSL-GT, and 26 (30 eyes) underwent PEI-TRAB. After minimum of 6 months of postoperative follow-up, observations were made on intraocular pressure (IOP), best-corrected visual acuity (BCVA), use of antiglaucoma medications, and complications for both surgical procedures.

RESULTS

Postoperative BCVA improved significantly in both groups. In the PEI-GSL-GT group, IOP decreased by 26% (from 17.75 to 13.13 mmHg); in the PEI-TRAB group, it decreased by 14.5% (from 17.87 to 15.27 mmHg). At the 6-month follow-up, IOP was significantly lower in the PEI-GSL-GT group compared to the PEI-TRAB group. The number of patients using antiglaucoma medications decreased significantly in both groups. By the 6-month follow-up, no patients in the PEI-GSL-GT group were using antiglaucoma medications.

CONCLUSIONS

PEI-GSL-GT is more effective than PEI-TRAB in lowering IOP in patients with mid to late-stage PACG, potentially reducing or discontinuing postoperative antiglaucoma medications, decreasing postoperative complications, and improving visual acuity.

Two-year outcomes of combined surgical peripheral iridectomy, goniosynechialysis, and goniotomy for advanced primary angle-closure glaucoma without cataract: A multicenter study

PURPOSE

To evaluate the two-year outcomes of combined surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) for advanced primary angle-closure glaucoma (PACG) without cataract.

DESIGN

Multicenter prospective study.

METHODS

The study included patients who received a combined SPI + GSL + GT for advanced PACG without cataract, all completed a 24-month follow-up. Outcome measures included changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA), use of anti-glaucoma medications, surgical success, and postoperative complications over the 24-month period.

RESULTS

A total of 63 eyes from 51 patients with advanced PACG were included in the study. Among these, 37 eyes (58.7 %) achieved complete success, and 55 eyes (87.3 %) achieved qualified success. The mean IOPs at baseline and after 24 months were 28.8 ± 7.51 mm Hg and 15.8 ± 4.40 mm Hg, respectively (P < 0.001). The average number of anti-glaucoma medications decreased from 1.9 ± 1.4-0.8 ± 1.2 over the 24-month period (P < 0.001). The overall BCVA was stable during the follow-up period (P = 0.225). The primary complications observed included IOP spike (n = 9), hyphema (n = 7), and shallow anterior chamber (n = 3), all of which occurred within the first month postoperatively. Regression analysis showed that older age was positively associated with both complete success [odds ratio (OR) = 1.05; P = 0.030] and qualified success (OR = 1.08; P = 0.024).

CONCLUSIONS

SPI + GSL + GT demonstrated safety and effectiveness in treating advanced PACG without cataract over the 24-month study period. This combined surgical approach should be considered a viable alternative to trabeculectomy for these patients.

Outcomes of Glaucoma Referrals in Adults Aged 18 to 40 Years

Importance

While early detection of glaucoma is vital to prevent irreversible vision loss, there are sparse data on the effectiveness of glaucoma referrals and methods to establish evidence-based referral guidelines in large, diverse populations.

Objective

To assess the prevalence and risk factors for diagnosed glaucoma and loss to follow-up among adult patients aged 18 to 40 years after a new diagnosis of referable glaucoma (ie, with glaucoma or suspected glaucoma).

Design, Setting, and Participants

This retrospective cohort study included patients aged 18 to 40 years presenting to Kaiser Permanente Southern California, a large managed health care system, for first-time eye examinations between January 1, 2013, and December 31, 2018. Data analysis occurred between September 2022 and August 2024.

Main Outcomes and Measures

The primary outcome was glaucoma diagnosed within 2 years of the first eye examination. The secondary outcome was the loss to follow-up, defined as failure to receive a glaucoma evaluation with visual field or optical coherence tomography testing within 2 years.

Results

The cohort included 292 453 patients aged 18 to 40 years who underwent first-time eye evaluations (mean [SD] age, 29.8 [6.4] years). Among 12 050 identified patients with referable glaucoma (52.3% female), 6827 (56.7%) completed glaucoma evaluations, of whom 563 (8.2%) were diagnosed with glaucoma (344 [61.1%] with open angle, 28 [5.0%] with angle closure, 84 [14.9%] with secondary glaucoma, and 107 [19.0%] with unspecified glaucoma). On multivariable analysis, male sex (odds ratio [OR], 1.55 [95% CI, 1.07-2.27]), higher intraocular pressure (IOP) (OR, 1.19 [95% CI, 1.15-1.23] per 1 mm Hg), and greater cup-disc ratio (CDR) (OR, 1.53 [95% CI, 1.34-1.75] per 0.1 unit) were associated with greater odds of glaucoma. Dichotomized age, IOP, and CDR models stratified 51 of 1613 patients (3.2%) into the low-risk group and 202 of 1477 patients (13.7%) into the high-risk group. Being younger than 32 years and having an IOP less than 18 mm Hg and a CDR less than 0.7 yielded a negative predictive value of 98.2% for a glaucoma diagnosis.

Conclusions and Relevance

In this cohort study, the diagnostic yield of glaucoma referrals was low among adults aged 18 to 40 years with first-time eye examinations. A simple risk-stratification strategy could help identify individuals with low and high risks of developing glaucoma, and adoption of evidence-based risk stratification and referral guidelines by health care systems and clinicians could improve equity of glaucoma care and use of eye-care resources.

Factors Associated with Gonioscopy Before Glaucoma Procedures in the IRIS® Registry

Purpose

To analyze nationwide pre-operative gonioscopy utilization patterns for various glaucoma surgeries and laser surgeries over time using the IRIS® Registry (Intelligent Research in Sight).

Design

Retrospective cohort study.

Participants

All adults who underwent a glaucoma surgery or laser surgery between January 1, 2014 and April 14, 2023.

Methods

The first glaucoma procedure from the first eye of each patient was recorded as the index event and time was measured between the most recent pre-operative gonioscopy date to the index event. Baseline demographics, pre-operative clinical characteristics, glaucoma diagnosis, procedure type, and type of subspecialist performing the procedure were collected.

Main Outcome Measures

Primary outcomes were the percentage of patients who had gonioscopy before a glaucoma procedure (1) at any prior visit and (2) within 1 year prior to the procedure. Secondary outcomes were the baseline factors that were associated with higher gonioscopy utilization at any prior visit using multivariable logistic regression.

Results

The study included 1.1 million patients (mean age 69.5±12.0 years). A majority had an in-office laser surgery (71.9%), while 16.2% had microinvasive glaucoma surgeries (MIGS), 6.5% had a trabeculectomy or tube (traditional), and 4.6% had other glaucoma surgeries. Pre-operative gonioscopy was identified in 64.7% of patients, and 85.0% of those were within 1 year of the index event.In multivariable models, Asian (OR 1.16, 95%CI 1.13-1.18, P<0.001) and Black (OR 1.13, 95%CI 1.12-1.15, P<0.001) racial and ethnic groups were associated with higher odds of gonioscopy compared to White groups. When compared to traditional surgery, MIGS were associated with lower utilization (OR 0.69, 95%CI 0.68-0.71, P<0.001), but in-clinic laser surgeries were not (P=0.231). Glaucoma subspecialists were more likely to perform pre-operative gonioscopy compared to non-glaucoma subspecialists (OR 2.65, 95%CI 2.62-2.69, P<0.001).

Conclusions

Pre-operative gonioscopy use and/or coding is lower than expected, given current guidelines. Among glaucoma procedures, ab interno MIGS were associated with lower pre-operative gonioscopy utilization.

Relationship Between Glaucoma and Chronic Stress Quantified by Allostatic Load Score in the All of Us Research Program

PURPOSE

To assess the relationship between glaucoma and allostatic load (AL), an established framework for quantifying the physiologic effects of chronic stress through measurements of systemic biomarkers.

DESIGN

Retrospective case-control study.

METHODS

Participants of the National Institutes of Health All of Us (AoU) Research Program with complete AL biomarker data between December 1984 and June 2022 and with (cases) or without (controls) primary glaucoma were identified. AL scores were calculated using the adapted Seeman AL scale consisting of 10 systemic biomarkers: body mass index, systolic blood pressure, diastolic blood pressure, glycated hemoglobin, total cholesterol, triglycerides, glomerular filtration rate, albumin, C-reactive protein, and homocysteine. AL score was defined as the number of biomarkers with measurements in the highest risk quartiles. Age was calculated as the median age at the time of biomarker measurements. Logistic regression analysis was performed to assess the association between the earliest possible AL score and glaucoma adjusted for race or ethnicity. Mediation analysis was performed to estimate the relationship between race or ethnicity and glaucoma mediated by AL score.

RESULTS

The study cohort consisted of 349 cases (16.1%) and 1819 controls (83.9%) with 52.7% females, 2.2% Asians, 10.7% Blacks, 10.0% Hispanics, and 72.5% non-Hispanic Whites. At the earliest time point (median [interquartile range (IQR)] = 6.4 [1.9-12.2] years prior to diagnosis), cases had higher AL score than controls (3 [1-4] vs 2 [1-3], respectively; P < .001). On multivariable analysis, a higher AL score (OR=1.09 per point), Black race (OR=2.58), and Hispanic ethnicity (OR=2.12) conferred higher risk of glaucoma (P ≤ .02). The AL score partially mediated higher glaucoma risk among Blacks (7.5%) and Hispanics (5.0%) compared with non-Hispanic Whites. On subgroup analysis, higher AL score was significantly associated with primary open angle glaucoma (OR=1.11; P = .01) but not primary angle closure glaucoma (P = .87).

CONCLUSION

AoU participants with glaucoma had greater AL 6.4 years before diagnosis, and the AL score partially mediated racial or ethnic differences in glaucoma risk. These findings suggest chronic stress may increase risk for glaucoma and contribute to racial disparities in glaucoma burden.

Impact of COVID-19 on acute angle-closure attack: A retrospective study

To systematically review the characteristics of patients experiencing acute angle closure (AAC) attacks during the COVID-19 outbreak in Beijing. Patients with AAC attacks during the COVID-19 epidemic and those in the same period the following year were recruited. Demographic characteristics, ocular biometry, ocular signs, sequential relationships, and the prognosis of operative management outcome were recorded and compared between the 2 groups. We included 60 eyes of 55 patients with AAC attacks in the COVID-19 group and 34 eyes of 33 patients in the control group. There was a significantly higher incidence of bilateral attacks during the COVID-19 outbreak compared to the control group (9 vs 1, P = .043). Additionally, a higher proportion of AAC attacks were observed in the COVID-19 group (P = .035). The COVID-19 group had a higher mean peak intraocular pressure (53.42 ± 8.87 mm Hg vs 47.86 ± 11.22 mm Hg; P = .007), larger pupil diameter (5.75 ± 1.04 mm vs 4.86 ± 1.26 mm; P < .001), more pigmented keratic precipitates (39 vs 8, P < .001), and segmental atrophy of the iris (32 vs 10, P = .019). Coronavirus infection was simultaneous with or slightly preceded the appearance of AAC attacks. Most patients had an ideal prognosis after comprehensive management. An increased incidence of AAC attacks, more bilateral cases and severe anterior segment inflammation were observed during the COVID-19 outbreak in Beijing. There may be a correlation between the onset of AAC attacks and coronavirus infection, but further research is needed to explore this link.

Zonulopathy and Its Relation to Primary Angle Closure Disease: A Review

PRCIS

This paper aims to discuss the anatomical features of zonule fibers that center the lens in the eye and summarizes the relationship between zonulopathy and PACD.

ABSTRACT

The increasing lens vault (LV) and lens thickness (LT) is a recognized mechanism for primary angle closure glaucoma (PACG). Zonulopathy, causing the abnormal lens position, is an important factor in this mechanism. Several anatomically distinct sets of zonular fibers are present in primate eyes, including ciliary zonules, vitreous zonules, and attachments between the posterior insertion zone of the vitreous zonules and the posterior lens equator (PVZ INS-LE strands). Zonulopathy, as a clinical diagnosis, exhibits zonular laxity and loss, long anterior lens zonules (LAZ). Slit lamp, gonioscopy, ultrasound biomicroscopy (UBM), anterior segment optical coherence tomography (AS-OCT) aid in the diagnosis of zonulopathy. The proportion of underdiagnosed zonulopathy among primary angle closure disease (PACD) patients before operation is high. According to the intraoperative signs, zonulopathy could be determined better. There is a high prevalence of zonulopathy among PACD patients compared with the general population. Because of the different insertion zone in lens capsules, different zonular fibers play different parts in lens position and shape. Zonular laxity and loss cause the lens to be thicker and move anteriorly, forming narrow-angle and high intraocular pressure, and then the higher intraocular pressure damages zonule fibers further and causes angle closure. Loss of vitreous zonules may make the ciliary body rotate anterior excessively and pull iris forward, leading to iridotrabecular contact. LAZ eyes tend to be hyperopic and have short axial length, increased LT and anterior lens position, plateau iris configuration, and characteristics that are consistent with elevated risk for angle closure. Zonulopathy may be a risk for PACD. A clear knowledge of zonulopathy and its relation to PACD would be helpful to the diagnosis and treatment.

Cost-Utility Analysis of Prophylactic Laser Peripheral Iridotomy for Primary Angle Closure Suspects

PURPOSE

To assess the cost-utility of prophylactic laser peripheral iridotomy (LPI) for primary angle closure (PAC) suspects (PACS).

DESIGN

Economic evaluation.

METHODS

Our Markov model randomized PACS eyes to LPI or observation for 40 one-year cycles (100,000 iterations per strategy). Each cycle, an eye remained in its current health state, advanced linearly through PAC, mild, moderate, severe, and end-stage PAC glaucoma (PACG), or died. Transition rates were derived from the literature including the Zhongshan Angle Closure Prevention (ZAP) trial and the Singapore Asymptomatic Narrow Angles Laser Iridotomy Study (ANA-LIS). Eyes with acute-angle closure advanced to either PAC or directly to various PACG severities. A tracker monitored accumulated perimetric decibel reduction to progress PACG through increasing severities, with an annual probability of either stable or severity-dependent perimetry loss. We set a willingness to pay of an incremental cost-effectiveness ratio (ICER) <$50,000/quality-adjusted life-years.

RESULTS

At age 50 years, LPI was cost-saving using ZAP data and cost-effective using ANA-LIS data. The ZAP iterations became cost-effective from the societal perspective when the model started at age 55 years and third-party perspective at age 70 years. LPI was no longer cost-effective from the societal perspective using ANA-LIS data at age 80 years or from the societal perspective using ZAP data or third-party perspective with ANA-LIS data at age 85. Probabilistic sensitivity analyses favored LPI until starting age 85.

CONCLUSIONS

Prophylactic LPI for PACS is cost-effective across a spectrum of ages and should be considered from a public health perspective.

Efficacy and Safety of Surgical Peripheral Iridectomy, Goniosynechialysis, and Goniotomy for Advanced Primary Angle Closure Glaucoma Without Cataract: 1-Year Results of a Multicenter Study

PRCIS

The combination of surgical peripheral iridectomy, goniosynechialysis, and goniotomy is a safe and effective surgical approach for advanced primary angle closure glaucoma without cataract.

PURPOSE

To evaluate the efficacy and safety of surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) in advanced primary angle closure glaucoma (PACG) eyes without cataract.

PATIENTS AND METHODS

A prospective multicenter observational study was performed for patients who underwent combined SPI, GSL, and GT for advanced PACG without cataract. Patients were assessed before and after the operation. Complete success was defined as achieving intraocular pressure (IOP) between 6 and 18 mm Hg with at least a 20% reduction compared with baseline, without the use of ocular hypotensive medications or reoperation. Qualified success adopted the same criteria but allowed medication use. Factors associated with surgical success were analyzed using logistic regression.

RESULTS

A total of 61 eyes of 50 advanced PACGs were included. All participants completed 12 months of follow-up. Thirty-six eyes (59.0%) achieved complete success, and 56 eyes (91.8%) achieved qualified success. Preoperative and postsurgical at 12 months mean IOPs were 29.7±7.7 and 16.1±4.8 mm Hg, respectively. The average number of ocular hypotensive medications decreased from 1.9 to 0.9 over 12 months. The primary complications included IOP spike (n=9), hyphema (n=7), and shallow anterior chamber (n=3). Regression analysis indicated that older age (odds ratio [OR]=1.09; P =0.043) was positively associated with complete success, while a mixed angle closure mechanism (OR=0.17; P =0.036) reduced success rate.

CONCLUSIONS

The combination of SPI, GSL, and GT is a safe and effective surgical approach for advanced PACG without cataract. It has great potential as a first-line treatment option for these patients.

Zonular ligament abnormalities intermingled in acute primary angle closure: A diagnostic and therapeutic challenge

Purpose

This study aims to investigate patient characteristics with lens zonular ligament abnormalities in Acute Primary Angle Closure (APAC), identifying related risk factors, and evaluating the efficacy of Pilocarpine, a miotic agent.

Design

Retrospective case-control study.

Methods

Conducted as a retrospective case-control study at Hebei Provincial Eye Hospital from January 1, 2019, to December 31, 2021, the study included APAC cases undergoing ultrasound phacoemulsification with or without glaucoma surgery. Zonular ligament status was determined by intraoperative indicators such as lens equator visibility post-mydriasis and anterior capsule wrinkling during capsulorhexis. Patients were categorized into APAC and APAC with Lens Subluxation (APACLS) groups. Demographic details, Central Anterior Chamber Depth (ACD), Axial Length (AL), ACD difference between eyes (ACDD), Lens Thickness (LT), Lens Position (LP), and Relative Lens Position (RLP) were recorded and compared. Pilocarpine's impact on intraocular pressure reduction was assessed. Statistical analysis involved bilateral t-tests (for normally distributed data comparing both eyes in each group), non-parametric tests (for comparing two groups with non-normally distributed data), binary logistic regression, and Receiver Operating Characteristic (ROC) curve analysis for cutoff value determination related to zonular abnormalities.

Results

The APAC and APACLS groups showed no significant difference in age of onset (70.11 ± 8.67 years vs. 70.11 ± 8.67 years, P = 0.159) or axial length of the eye (22.35 ± 0.64 mm vs. 22.36 ± 0.78 mm, P = 0.929). In the APACLS group, LT was greater (5.24 ± 0.37 mm vs. 5.01 ± 0.36 mm, P = 0.011), ACD was shallower (1.42 ± 0.24 mm vs. 1.69 ± 0.24 mm, P = 0.000), and ACDD was larger (0.38 ± 0.22 mm vs. 0.18 ± 0.18 mm, P = 0.000). The LP was lower (4.04 ± 0.32 vs. 4.20 ± 0.22, P = 0.013), and RLP was also lower (0.18 ± 0.02 vs. 0.19 ± 0.01, P = 0.015) in the APACLS group. A shallow ACD and a large ACDD were identified as risk factors associated with lens zonular abnormalities in the affected eyes (ACD OR value 63.97, P = 0.027; ACDD OR value 0.029, P = 0.027). Using ROC curve analysis, the cutoff value for ACDD was determined to be 0.375 mm, and for ACD, it was 1.6 mm. After pupil constriction with Pilocarpine eye drops, the proportion of patients whose intraocular pressure normalized was 75.36 % (52/69) in the APAC group and 71.43 % (25/35) in the APACLS group.

Conclusion

ACD and ACDD in the affected eye are indicative of increased risk for APACLS. An ACD <1.6 mm and ACDD >0.375 mm should prompt consideration of zonular ligament abnormalities. Pilocarpine as a miotic treatment is safe and effective for such patients.

Automated classification of angle-closure mechanisms based on anterior segment optical coherence tomography images via deep learning

Purpose

To develop and validate deep learning algorithms that can identify and classify angle-closure (AC) mechanisms using anterior segment optical coherence tomography (AS-OCT) images.

Methods

This cross-sectional study included participants of the Handan Eye Study aged ≥35 years with AC detected via gonioscopy or on the AS-OCT images. These images were classified by human experts into the following to indicate the predominant AC mechanism (ground truth): pupillary block, plateau iris configuration, or thick peripheral iris roll. A deep learning architecture, known as comprehensive mechanism decision net (CMD-Net), was developed to simulate the identification of image-level AC mechanisms by human experts. Cross-validation was performed to optimize and evaluate the model. Human-machine comparisons were conducted using a held-out and separate test sets to establish generalizability.

Results

In total, 11,035 AS-OCT images of 1455 participants (2833 eyes) were included. Among these, 8828 and 2.207 images were included in the cross-validation and held-out test sets, respectively. A separate test was formed comprising 228 images of 35 consecutive patients with AC detected via gonioscopy at our eye center. In the classification of AC mechanisms, CMD-Net achieved a mean area under the receiver operating characteristic curve (AUC) of 0.980, 0.977, and 0.988 in the cross-validation, held-out, and separate test sets, respectively. The best-performing ophthalmologist achieved an AUC of 0.903 and 0.891 in the held-out and separate test sets, respectively. And CMD-Net outperformed glaucoma specialists, achieving an accuracy of 89.9 % and 93.0 % compared to 87.0 % and 86.8 % for the best-performing ophthalmologist in the held-out and separate test sets, respectively.

Conclusions

Our study suggests that CMD-Net has the potential to classify AC mechanisms using AS-OCT images, though further validation is needed.

Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States

PURPOSE

To assess patterns in gonioscopy during initial glaucoma evaluations in the United States.

DESIGN

Retrospective, case-control study.

METHODS

Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics DataMart. Initial evaluation was defined as follows: (1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; (2) continuously observable during a 36-month lookback period; (3) no history of glaucoma medications, laser, or surgical procedures; and (4) optical coherence tomography (OCT) or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes.

RESULTS

Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (P < .001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared with Asians. Age ≥60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (P < .001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (P < .01).

CONCLUSIONS

More than 70% patients undergoing initial glaucoma evaluation in the United States do not have a record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.

Impact of Peripheral Anterior Synechiae on the Outcome of Combined Phacoemulsification, Goniosynechialysis, and Goniotomy for Primary Angle Closure Glaucoma and Cataract: A Multicenter Observational Study

PRCIS

The combination of phacoemulsification, goniosynechialysis and goniotomy is an effective treatment for primary angle closure glaucoma patients with cataract, and this is not linked to the extent of preoperative peripheral anterior synechiae.

PURPOSE

To evaluate the impact of the extent of peripheral anterior synechiae (PAS) on the effectiveness and safety of combined phacoemulsification (PEI), goniosynechialysis (GSL), and goniotomy (GT) in eyes with primary angle closure glaucoma (PACG) and cataract.

PATIENTS AND METHODS

This study included patients diagnosed with PACG and cataracts who underwent combined PEI and 120 degrees GSL plus GT (PEI+GSL+GT) between April 2020 and October 2022 at 10 ophthalmic institutes. Eligible patients were divided into 3 groups based on the extent of PAS: 180°≤PAS<270°, 270°≤PAS<360°, and PAS=360°. Data on intraocular pressure (IOP), the number of ocular hypotensive medications, and complications were collected and compared. The study defined complete success as postoperative IOP within the 6-18 mm Hg range and a 20% reduction from baseline without the use of topical medications. Qualified success was defined in the same way as complete success, but it allowed for the use of ocular hypotensive medications.

RESULTS

Three hundred four eyes of 283 patients were included. The mean follow-up was 12.50±1.24 months. All groups experienced a significant reduction in IOP after the surgery ( P <0.05). There were no significant differences in final IOP, number of medications, and cumulative complete and qualified success rates among the 3 groups ( P >0.05). The groups with 270°≤PAS<360°had a higher frequency of hyphema compared with 180°≤PAS<270° ( P = 0.044).

CONCLUSIONS

PEI+GSL+GT has proven to be an effective treatment for PACG with cataracts over a 1 year period. However, the outcome was not correlated with the preoperative extent of PAS.

Acute primary angle closure concurrent with coronavirus disease 2019 recurrence in Northern China: A retrospective multi-centre study

Aims and objectives

During the new coronavirus disease 2019 (COVID-19) outbreak period, there was increasing presentation in the number of patients with acute primary angle closure (APAC). This study aimed to report the occurrence of APAC during the COVID-19 post-restriction period and investigate the related characteristics of these patients with APAC.

Methods

This retrospective, multi-center study included consecutive patients seeking APAC treatment at two eye centers in China from December 7, 2022 to January 13, 2023 (post-restriction period) and from December 7, 2021 to January 13, 2022 (control period). Electronic medical records were reviewed, and ocular data of the affected eye(s) were analyzed for patients with unilateral or bilateral APAC. Information including COVID-19 related symptoms, medications used for COVID-19 infection, and living habits and emotions related to the COVID-19 outbreak during the post restriction period were collected using a questionnaire.

Results

Overall, 189 (219 APAC eyes) and 51 (54 APAC eyes) patients with APAC were identified during the post-restriction and control periods, respectively. The patients identified during the post-restriction period were younger (P = 0.043) and had a longer duration from symptoms to treatment (P = 0.039), shorter axial length (P = 0.002), larger pupil diameter (P = 0.004), larger vertical cup disc ratio (P = 0.004), poorer mean deviation values (P = 0.003), and more glaucomatous optic neuropathy diagnoses (P = 0.032) compared with the patients with APAC identified during the control period. Among 151 included patients with APAC who completed the questionnaires, 130 patients with APAC were diagnosed with concurrent COVID-19 infection, of which 54 (41.5 %) had coughing and/or vomiting as the main symptoms. Of these, 89.2 % spent 0 h per day on outdoor activity; 44.6 % drank more water than usual, with 14.6 % drinking more than twice the amount of water than usual; 91.5 % used antipyretics; and 20.0 % had mood swings, including anxiety, depression, and tension, during the concurrent COVID-19 infection.

Conclusion

In our study, a significant increase in the number of patients presenting with APAC with certain characteristics was observed during the COVID-19 post-restriction period. And whether COVID-19 symptoms, such as coughing and vomiting, and behavioral and psychological changes caused by COVID-19 infection contributing to the concurrence of APAC and COVID-19 recurrence require further investigation.

Canaloplasty and Trabeculotomy Using the OMNI Surgical System in Three Patients with Angle Closure: A Case Series

Aim and background

The OMNI surgical system allows for 360° canaloplasty and trabeculotomy for patients with glaucoma, either as a standalone procedure or in combination with cataract surgery. There is currently limited evidence on its use in forms of angle-closure glaucoma, though other microinvasive glaucoma surgeries have been used. We present three patients with angle closure who underwent the procedure.

Methods

Retrospective review of three patients who underwent canaloplasty and trabeculotomy with the OMNI surgical system with forms of angle closure. Data on demographics, intraocular pressure (IOP), glaucoma medication use, best corrected visual acuity (BCVA), visual fields (VFs), and complications were collected for a 6-month period.

Results

Three eyes of three patients underwent the procedure: one with primary angle closure glaucoma (PACG), one acute angle closure, and one primary angle closure (PAC). All had surgery combined with phacoemulsification and intraocular lens (IOL) implantation. The mean age was 56 years. Preoperative IOP was 25.33 ± 2.49 mm Hg, improving to 11.67 ± 2.87 mm Hg at 6 months. Mean glaucoma medication use was reduced by 3.00, from 3.67 ± 1.21 to 0.67 ± 0.94. Preoperative mean BCVA was 0.10 ± 0.08 and 0.20 ± 0.08 LogMAR at 6 months. Mean deviation (MD) on VFs was -9.67 preoperatively and -6.72 at 6 months. Two patients had mild, self-limiting hyphema postoperatively which resolved without further intervention; no other complications were reported.

Conclusion

We have found the OMNI surgical system to be a safe, effective tool in the management of angle-closure glaucomas in a small cohort of patients.

Clinical significance

The OMNI surgical system has the potential to add a less invasive surgical solution in the management of angle closure glaucoma, prior to the use of filtering surgery such as trabeculectomy or glaucoma drainage device. Larger trials assessing the use of microinvasive glaucoma surgery (MIGS) in these patients will be eagerly received.

How to cite this article

Richardson-May J, Ibrahim SA, Law K, et al. Canaloplasty and Trabeculotomy Using the OMNI Surgical System in Three Patients with Angle Closure: A Case Series. J Curr Glaucoma Pract 2024;18(3):117-120.

Trends in admission rates of primary angle closure diseases for the urban population in China, 2011-2021

Background

Cataract surgery and laser peripheral iridotomy (LPI) are effective approaches for preventing primary angle closure diseases (PACDs), as well as acute primary angle closure (APAC). Due to the development of population screening and increases in cataract surgery rates, this study aimed to examine trends in the admission rates of PACD among the urban population in China.

Methods

This cross-sectional study examined patients who were admitted to a hospital for PACD, and who underwent cataract surgery or LPI operations. The data were obtained from the Yinzhou Regional Health Information Platform (YRHIP) from 2011 to 2021. The annual rates of PACD and APAC admissions, cataract surgery and LPI were analyzed, with the number of cases used as numerators and the annual resident population in Yinzhou district used as denominators.

Results

A total of 2,979 patients with PACD admissions, 1,023 patients with APAC admissions, 53,635 patients who underwent cataract surgery and 16,450 patients who underwent LPI were included. The number of annual admissions for PACD gradually increased from 22 cases (1.6/100000) in 2011 to 387 cases (30.8/100000) in 2016, after which it decreased to 232 cases (16.2/100000) in 2019 and then increased to 505 cases (30.6/100000) in 2021. The number of cataract surgeries gradually increased from 1728 (127.7/100000) in 2011 to 7002 (424.9/100000) in 2021. Similarly, the number of LPI gradually increased from 109 (8.0/100000) in 2011 to 3704 (224.8/100000) in 2021.

Conclusion

The admission rates of PACD for the urban population in China have declined in recent years after a long increasing trend in the rates of cataract surgery and LPI. However, it increased rapidly during the COVID-19 epidemic. The national health database should be further utilized to investigate temporal trends in the prevalence of PACD.

Systematic review and appraisal of quality, definitions and treatment recommendations of clinical guidelines for glaucoma suspects

BACKGROUND

To appraise the quality of clinical practice guidelines for glaucoma suspects, and to assess their consistency for how a 'glaucoma suspect' is defined and their recommendations for treatment initiation for such individuals.

METHODS

This study included all documents that self-identified as a 'guideline' and provided recommendation(s) for the clinical care of glaucoma suspects. The quality of eligible guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

From 1196 records retrieved from comprehensive searches and two records manually included, 20 clinical practice guidelines were deemed eligible. Based on an appraisal using the AGREE II instrument, 16 (80%) guidelines had ≤2 domains with scores >66%. Overall, the lowest scoring domains were for applicability, editorial independence and stakeholder involvement. There was relatively poor agreement across the guidelines for what defines a 'glaucoma suspect' or 'primary open angle glaucoma [POAG] suspect', as well as the recommendations and criteria for treatment initiation in these populations. There was better agreement for the definition and recommendations for treatment initiation for 'primary angle closure suspects'.

CONCLUSIONS

There is substantial room to improve the methodological quality of most current international clinical guidelines for glaucoma suspects. Clinicians should consider this finding when using such guidelines to inform their care of glaucoma suspects. Substantial variation in the definition of a POAG suspect and recommendations for treatment initiation underscores important gaps in the current evidence for the accurate prediction of glaucoma development and treatment effectiveness in these individuals.

Canaloplasty and Trabeculotomy Combined With Phacoemulsification for Primary Angle-Closure Glaucoma: A Single-Surgeon Case Series

PURPOSE

To evaluate the outcomes of combined canaloplasty and trabeculotomy with phacoemulsification for primary angle-closure glaucoma (PACG).

METHODS

In this retrospective, consecutive, single-surgeon case series, we analyzed the pre- and postoperative measurements of PACG patients who had the procedure. Adverse events were recorded. The main outcomes were mean intraocular pressure (IOP) in each quartile of the follow-up year and the number of IOP-lowering medications the patients were on by the end of each quartile compared to their baseline values.

RESULTS

 A total of 46 eyes from 39 PACG patients were included. The preoperative IOP and glaucoma medications taken were 19.33±6.03 mm Hg and 1.80±1.39, respectively (N=46). Postoperative IOP means (mm Hg) in the subsequent four quartiles were 14.00±3.33 (N=44), 13.44±2.83 (N=32), 14.38±2.39 (N=16), and 14.92±2.90 (N=13) (p<0.0001). The mean number of meds was 0.32±0.80, 0.22±0.42, 0.59±0.80, and 0.08±0.28 in each respective quartile (p<0.0001), while the median was 0 across all quartiles.

CONCLUSIONS

Combining the OMNI surgical system with phacoemulsification led to substantial reductions in mean IOP and the number of IOP-lowering medications when compared to baseline measurements.

Practice Patterns and Sociodemographic Disparities in the Clinical Care of Anatomical Narrow Angles in the United States

PURPOSE

To assess treatment and visit patterns among patients with newly diagnosed anatomical narrow angle (ANA) and identify sociodemographic factors associated with disparities in care.

DESIGN

Retrospective practice pattern evaluation study.

METHODS

A total of 263,422 patients diagnosed with ANA between 2007 and 2019 were identified in the Optum Clinformatics Data Mart. Inclusion was limited to newly diagnosed ANA, defined as (1) continuous enrollment during a 2-year lookback period and 1-year study period from first diagnosis; (2) diagnosis by an ophthalmologist or optometrist; and (3) no history of pseudophakia, ANA treatments, or prior primary angle closure glaucoma diagnosis. Outcome measures were treatment with laser peripheral iridotomy (LPI), cataract surgery, or intraocular pressure-lowering medications and number of eye care visits. Logistic and Poisson regression were performed to assess factors associated with treatment and eye care visits, respectively.

RESULTS

Among 52,405 eligible cases, 27.7% received LPI, 13.9% received drops, and 15.1% received cataract surgery. Odds of LPI were higher in Asians and Hispanics (odds ratio [OR] ≥ 1.16, P < .001). Non-Whites had higher odds of drops (OR ≥ 1.19, P < .001), but Hispanics had lower odds of cataract surgery (OR = 0.79, P < .001). The mean number of eye care visits was 2.6±2.1 including the day of diagnosis. Older age and treatment were associated with higher rates of eye care visits (rate ratio > 1.15, P < .001).

CONCLUSION

More than a quarter of patients with newly diagnosed ANA receive treatment with LPI. Racial minorities are more likely to receive ANA-specific treatments but less likely to receive cataract surgery. These differences may reflect racial differences in disease severity and the need for clearer practice guidelines in ANA care.

Performance of anterior segment OCT-based algorithms in the opportunistic screening for primary angle-closure disease

Purpose

This study aimed to investigate the performance of deep learning algorithms in the opportunistic screening for primary angle-closure disease (PACD) using combined anterior segment parameters.

Methods

This was an observational, cross-sectional hospital-based study. Patients with PACD and healthy controls who underwent comprehensive eye examinations, including gonioscopy and anterior segment optical coherence tomography (ASOCT) examinations under both light and dark conditions, were consecutively enrolled from the Department of Ophthalmology at the Beijing Tongren Hospital between November 2020 and June 2022. The anterior chamber, anterior chamber angle, iris, and lens parameters were assessed using ASOCT. To build the prediction models, backward logistic regression was utilized to select the variables to discriminate patients with PACD from normal participants, and the area under the receiver operating characteristic curve was used to evaluate the efficacy of the opportunistic screening.

Results

The data from 199 patients (199 eyes) were included in the final analysis and divided into two groups: PACD (109 eyes) and controls (90 eyes). Angle opening distance at 500 μm, anterior chamber area, and iris curvature measured in the light condition were included in the final prediction models. The area under the receiver operating characteristic curve was 0.968, with a sensitivity of 91.74 % and a specificity of 91.11 %.

Conclusion

ASOCT-based algorithms showed excellent diagnostic performance in the opportunistic screening for PACD. These results provide a promising basis for future research on the development of an angle-closure probability scoring system for PACD screening.

Anterior Segment OCT for Detection of Narrow Angles: A Community-Based Diagnostic Accuracy Study

PURPOSE

To assess the diagnostic accuracy of anterior segment OCT (AS-OCT) screening for detecting gonioscopically narrow angles.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

A stratified random sample of individuals aged ≥ 60 years, selected from a door-to-door census performed in low-lying Nepal.

TESTING

Participants underwent AS-OCT, posterior segment OCT, and intraocular pressure (IOP) testing in the community. Those meeting referral criteria in either eye were invited to have a comprehensive eye examination including gonioscopy. Referral criteria included (i) the lowest 2.5% of AS-OCT measurements, (ii) retinal OCT results suggestive of glaucomatous optic neuropathy, diabetic retinopathy, or age-related macular degeneration, and (iii) elevated IOP.

MAIN OUTCOME MEASURES

Sensitivity and specificity of 5 semiautomated AS-OCT parameters relative to gonioscopically narrow angles, defined as the absence of visible trabecular meshwork for ≥ 180° on nonindentation gonioscopy.

RESULTS

Of 17 656 people aged ≥ 60 years enumerated from 102 communities, 12 633 (71.6%) presented for AS-OCT testing. Referral was recommended for 697 participants based on AS-OCT criteria and 2419 participants based on other criteria, of which 858 had gonioscopy performed by a glaucoma specialist. Each of the 5 AS-OCT parameters offered good diagnostic information for predicting eyes with gonioscopically narrow angles, with areas under the receiver operating characteristic curve ranging from 0.85 to 0.89. The angle opening distance at 750 μm from the scleral spur (AOD750) provided the most diagnostic information, providing an optimal sensitivity of 87% (95% confidence interval [CI], 75%-96%) and specificity of 77% (71%-83%) at a cutpoint of 367 μm, and a sensitivity of 65% (95% CI, 54%-74%) when specificity was constrained to 90% (cutpoint, 283 μm).

CONCLUSIONS

On AS-OCT, the AOD750 parameter detected approximately two-thirds of cases of gonioscopically narrow angles when test specificity was set to 90%. Although such a sensitivity may not be sufficient when screening solely for narrow angles, AS-OCT requires little additional effort if posterior segment OCT is already being performed and thus could provide incremental benefit when performing OCT-based screening.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Outcomes of newly referred patients with suspected angle closure: do we need to redefine the clinical pathways?

BACKGROUND/OBJECTIVES

To investigate outcomes of referrals for suspected angle closure and explore whether anterior segment optical coherence tomography (AS-OCT) can be used to tighten triaging criteria in a glaucoma virtual clinic.

SUBJECTS/METHODS

Retrospectively collected data. The first audit (04/2018-03/2019) identified referrals for suspected angle closure without other glaucoma-related findings (primary angle closure suspect (PACS) referrals). All patients underwent gonioscopy. The second audit (04-08/2019) identified patients with suspected angle closure in a virtual clinic. Management outcomes were assessed, using gonioscopy as reference standard. The outcomes of the second audit were re-audited after changing the triaging criterion from angle width <10° to iridotrabecular contact (ITC) in ≥1 quadrants on AS-OCT.

RESULTS

Out of 1754 glaucoma referrals (first audit), 24.6% (431/1754) were PACS referrals. Of these, only 10.7% (42/393) had an occludable angle on gonioscopy, with 97.6% (41/42) being PACS. Of these, 78% (32/41) underwent laser peripheral iridotomy. Out of 137 referrals in the virtual clinic (second audit), 66.4% (91/137) were triaged to the face-to-face clinic. Of these, 31.9% (29/91) were discharged. AS-OCT had positive and negative predictive value of 74.3% (95% confidence intervals (CI) 57.8-86.0) and 82.1% (95% CI 70.0-90.2%), respectively, in detecting ITC in ≥1 quadrants. In the re-audit 45.9% (45/98) of those with suspected angle closure were triaged for gonioscopy, with 24.4% (11/45) of them being discharged.

CONCLUSION

PACS referrals represent a substantial burden to hospital-based services and their accuracy is low. ITC in ≥1 quadrants on AS-OCT can be useful in triaging those who need further evaluation with gonioscopy.

Phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized non-inferiority trial

PURPOSE

To investigate the effectiveness and safety of phacogoniotomy versus phacotrabeculectomy (PVP) among patients with advanced primary angle-closure glaucoma (PACG) and cataracts.

DESIGN

Multicenter, randomized controlled, non-inferiority trial.

METHODS

A total of 124 patients (124 eyes) with advanced PACG and cataracts were enrolled, with 65 in the phacogoniotomy group and 59 in the phacotrabeculectomy group. Patients were followed up for 12 months with standardized evaluations. The primary outcome was the reduction in intraocular pressure (IOP) from baseline to 12 months postoperatively, of which a non-inferiority margin of 4 mmHg was evaluated. Secondary outcomes included the cumulative surgical success rate, postoperative complications, and changes in the number of glaucoma medications.

RESULTS

After 12 months, phacogoniotomy demonstrated non-inferiority to phacotrabeculectomy in terms of IOP reduction, with mean IOP reductions of - 26.1 mmHg and - 25.7 mmHg (P = 0.383), respectively, from baseline values of around 40 mmHg. Both groups experienced a significant reduction in the mean number of medications used postoperatively (P < 0.001). The cumulative success rate was comparable between the groups (P = 0.890). However, phacogoniotomy had a lower rate of postoperative complications and interventions (12.3% and 4.6%) compared to phacotrabeculectomy (23.7% and 20.3% respectively). The phacogoniotomy group reported shorter surgery time (22.1 ± 6.5 vs. 38.8 ± 11.1 min; P = 0.030) and higher quality of life (EQ-5D-5 L) improvement at 12 months (7.0 ± 11.5 vs. 3.0 ± 12.9, P = 0.010) than the phacotrabeculectomy group.

CONCLUSIONS

Phacogoniotomy was non-inferior to phacotrabeculectomy in terms of IOP reduction for advanced PACG and cataracts. Additionally, phacogoniotomy provided a shorter surgical time, lower postoperative complication rate, fewer postoperative interventions, and better postoperative quality of life.

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.

Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US

BACKGROUND

Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions.

METHODS

A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing.

RESULTS

Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases.

CONCLUSIONS

We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Evaluation of Publications from the American Academy of Ophthalmology: A 5-Year Analysis of Ophthalmology Literature

Objective

To analyze recent publications in Ophthalmology, the journal of the American Academy of Ophthalmology.

Design

Retrospective review of published articles.

Participants

No human participants were involved in the study.

Methods

Articles published in Ophthalmology from January 2018 to December 2022 were reviewed and analyzed.

Main Outcome Measures

Research and review articles were included and analyzed per the following: total number of published articles based on related subspecialty area, level of evidence using the modified Oxford level of evidence, number of citations, number of listed authors, gender of the corresponding author, country of affiliation of the corresponding and contributing author(s), and involvement of consortium(s), group(s), or committee(s).

Results

A total of 965 articles were included. The mean (standard deviation) number of authors per article was 8.6 (5.7) and the majority of corresponding authors were male (665, 70.7%). The greatest number of published articles were related to retina (296, 30.7%) followed by glaucoma (172, 17.8%). The greatest number of Preferred Practice Pattern guidelines were also related to retina (7/24, 29.1%), followed by cornea/dry eye syndrome/external disease (6/24, 25%). Retina (77) had the most level 1 evidence, glaucoma (30) for level 2 evidence, and retina for levels 3 (69) and 4 (65). There were 223 articles contributed by consortia/groups/committees, with most from retina (73, 32.7%) followed by glaucoma (40, 17.9%). The mean number of citations per subspecialty article was highest in retina (45.8/article), followed by uveitis (31.7/article). The United States had the greatest number of affiliated corresponding authors (544, 56.4%), followed by the United Kingdom (68, 7.0%). There were 357 (37.0%) articles with coauthors affiliated outside the corresponding author's country of affiliation, although with a downward trend over the most recent 5-year period. There has been an increasing trend in the number of authors and consortia/group/committee involvement in publications.

Conclusions

Although team science and collaborations have increased recently, ongoing efforts to diversify individuals, groups, and subspecialties may be needed.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Rethinking Prophylactic Laser Peripheral Iridotomy in Primary Angle-Closure Suspects: A Review

PURPOSE

To examine the generalizability, discuss limitations, and critically appraise recommendations on the management of primary angle-closure suspects (PACSs) that emerged as a result of recent randomized clinical trials challenging the widely accepted clinical practice of offering laser peripheral iridotomy (LPI) to PACS patients. To synthetize findings from these and other studies.

DESIGN

Narrative review.

SUBJECTS

Patients classified as PACS.

METHODS

The Zhongshan Angle-Closure Prevention (ZAP)-Trial and the Singapore Asymptomatic Narrow Angle Laser Iridotomy Study (ANA-LIS) along with accompanying publications were reviewed. Epidemiologic studies reporting on the prevalence of primary angle-closure glaucoma and other precursor forms of the disease were also analyzed along with publications reporting on the natural course of the disease or studies reporting on outcomes after prophylactic LPI.

MAIN OUTCOME MEASURES

Incidence of progression to more severe forms of angle closure.

RESULTS

Patients recruited in recent randomized clinical trials are asymptomatic, do not have cataracts, may be younger, and have, on average, deeper anterior chambers depth compared with patients treated with LPI in clinics.

CONCLUSIONS

The ZAP-Trial and ANA-LIS clearly represent the best available data on PACS management, additional parameters however may need to be considered when physicians face patients in clinic. PACS patients encountered at tertiary referral centers may represent more advanced cases with respect to ocular biometric parameters and may be at higher risk for disease progression compared with those recruited through population-based screening.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Parapapillary choroidal microvascular density in acute primary angle-closure and primary open-angle glaucoma: an optical coherence tomography angiography study

BACK GROUND/AIMS

To determine whether parapapillary choroidal microvasculature (PPCMv) density, measured by optical coherence tomography angiography, differed between acute primary angle-closure (APAC), primary open-angle glaucoma (POAG) and controls.

METHODS

This is a prospective, cross-sectional, observational study. Data from 149 eyes from two academic referral centres were analysed. Automated PPCMv density was calculated in inner and outer annuli around the optic nerve region in addition to the peripapillary superficial vasculature, using customised software. A generalised estimating equation was used to compare vessel densities among groups, adjusted for confounders.

RESULTS

Data from 40 eyes with APAC, 65 eyes with POAG and 44 eyes in healthy controls were gathered and analysed. Global radial peripapillary capillary densities were reduced in eyes with APAC and POAG compared with controls (p=0.027 and 0.136, respectively). Mean outer annular PPCMv density in the POAG group was lower vs the APAC group by 3.6% (95% CI 0.6% to 6.5%) (p=0.018) in the multivariable model adjusted for confounders. The mean difference in inner and outer superior PPCMv between the POAG and APAC groups was 5.9% and 4.4% (95% CI 1.9% to 9.9% and 1.0% to 7.7%, respectively; both p<0.010). Furthermore, POAG and APAC groups both had significantly lower PPCMv compared with controls (both, p<0.001).

CONCLUSIONS

While superficial peripapillary vessels were affected to similar degrees in POAG and APAC, PPCMv drop-out was greater with POAG versus APAC, suggesting that choroidal vessel density may be affected to a lesser extent following an acute increase in intraocular pressure before glaucoma develops.

Factors associated with severe corneal endothelial damage following acute primary angle closure in Chinese subjects

PURPOSE

To investigate the corneal endothelial damage caused by acute primary angle closure (APAC) and related risk factors for severe corneal endothelial cell damage in Chinese subjects.

METHODS

In this multicentre retrospective study, 160 Chinese patients (171 eyes) diagnosed with APAC were recruited. Endothelial cell density (ECD) and morphological changes short after APAC were studied. Univariate regression and multivariate regression were used to identify risk factors associated with the extent of ECD reduction, including age, gender, education level, patients' location, systemic diseases, APAC duration (hours), highest recorded intraocular pressure (IOP), and presenting IOP. Factors associated with the probability of severe corneal damage (ECD lower than 1000/mm2) were analysed based on a linear function.

RESULTS

After one APAC episode, 12.28% eyes had ECD lower than 1000/mm2, 30.41% had ECD between 1000 and 2000/mm2, and 57.31% had ECD more than 2000/mm2. Attack duration was the only factor associated with severe endothelial damage (p < 0.0001). If the attack were to be subsided within 15.0 h, possibility of ECD lower than 1000/mm2 could be controlled under 1%.

CONCLUSION

Shortly after the abortion of APAC, 12.28% patients experienced severe endothelial cell damage with ECD less than 1000/mm2. The only factor associated with severe ECD decrease was attack duration. Immediate and effective treatment is pivotal for preserving corneal endothelial function in APAC patients.

Zonulopathy Identified During Cataract Extraction in Patients With Primary Angle Closure Disease

PRCIS

The proportion, clinical characteristics, and risk factors of zonulopathy in primary angle closure disease (PACD) were analyzed. Zonulopathy is an underrecognized common finding in PACD, especially in patients with acute angle closure (AAC).

PURPOSE

To examine the proportion and risk factors associated with intraoperative zonulopathy in PACD.

PATIENTS AND METHODS

This is a retrospective analysis of 88 consecutive patients with PACD who underwent bilateral cataract extraction at Beijing Tongren Hospital from August 1, 2020 to August 1, 2022. Zonulopathy was diagnosed based on intraoperative findings including the presence of a lens equator, radial folds of the anterior capsule while making capsulorhexis, and other signs of the unstable capsular bag. The subjects were grouped based on their PACD subtype diagnoses: AAC, primary angle closure glaucoma (PACG), primary angle closure (PAC), or primary angle closure suspect (PACS). Multivariate logistic regression was performed to identify risk factors associated with zonulopathy. The proportion and the risk factors of zonulopathy were estimated in patients with PACD and in PACD subtypes.

RESULTS

Of 88 patients with PACD (67.3 ± 6.9 y old, 19 males and 69 females), the overall proportion of zonulopathy was 45.5% of patients (40/88) and 30.1% of eyes (53/176). Among the PACD subtypes, the proportion of zonulopathy was highest (69.0%) in AAC, followed by 39.1% in PACG, and 15.3% in PAC and PACS combined. AAC was an independent risk factor associated with zonulopathy ( P = 0.015, AAC vs PACG, PAC, and PACS combined; odds ratio: 0.340, CI: 0.142-0.814). Shallower anterior chamber depth ( P = 0.031) and greater lens thickness ( P = 0.036), but not laser iridotomy, were associated with an increased proportion of zonulopathy.

CONCLUSIONS

Zonulopathy is common in PACD, especially in patients with AAC. Shallow anterior chamber depth and thick lens thickness were associated with an increased proportion of zonulopathy.