To compare argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure: mid-term results

Refractive outcomes after immediate primary phacoemulsification for acute primary angle closure

This study investigated the refractive outcomes of 64 eyes overall including 32 immediate primary phacoemulsification in acute primary angle closure (APAC) eyes and 32 of their fellow eyes. We investigated best-corrected visual acuity, intraocular pressure (IOP), average keratometric diopter (K), spherical equivalent, axial length (AL), central corneal thickness, and anterior chamber depth (ACD) at preoperative examination (Pre) and more than 1-month post-phacoemulsification (1 m), and changes in values. Using SRK/T, Barrett Universal II (Barrett), Hill-Radial Basis Function Version 3.0 (RBF 3.0), and Kane formulas, we calculated and compared refractive prediction error (PE), absolute value of PE (AE), and changes in K, AL, and ACD from Pre to 1 m between APAC and fellow eyes. From Pre to 1 m, K remained similar in APAC and fellow eyes (p = 0.069 and p = 0.082); AL significantly decreased in APAC and in fellow eyes (both p < 0.001); and ACD significantly increased in APAC and in fellow eyes (both p < 0.001). The change in AL differed significantly between the two groups (p = 0.007). Compared to the fellow eyes, PE with SRK/T and Barret formulas (p = 0.0496 and p = 0.039) and AE with Barrett and RBF 3.0 formula (p = 0.001 and p = 0.024) were significantly larger in the APAC eyes. Thus, attention should be paid to refractive prediction error in immediate primary phacoemulsification for APAC eyes caused by preoperative AL elongation due to high IOP.

Malignant Glaucoma After Immediate Primary Phacoemulsification for Acute Primary Angle Closure: A Case Report

Malignant glaucoma is characterized by ciliary block or aqueous misdirection, shallowing of the anterior chamber with elevated intraocular pressure (IOP), resistance to treatment, and rapid progression to blindness. However, the exact pathogenic mechanism is yet to be established. Here, we report a case of malignant glaucoma caused by immediate primary phacoemulsification for acute primary angle closure (APAC). A 90-year-old woman, who had experienced right eye pain and blurred vision one day prior, had a cataract in the same eye without phacodonesis. The right eye IOP was 39 mmHg, preoperative anterior chamber depth was 1.00 mm, and the axial length was 22.31 mm. We diagnosed APAC in the right eye and performed phacoemulsification. On postoperative day one, the IOP decreased to the normal range (15 mmHg), the anterior chamber deepened, and the angle became open. However, one week after phacoemulsification, the anterior chamber and angle became shallower and closer again. We diagnosed the patient with malignant glaucoma, performed hyaloid-zonulo-iridectomy, and administered 1% atropine eye drops postoperatively. As a result, the IOP was limited to a 10 mmHg range with an open angle and deep anterior chamber. Malignant glaucoma can be caused by immediate primary phacoemulsification for APAC.

Three-Year Outcomes of Immediate Primary Phacoemulsification on Acute Primary Angle Closure Eyes and the Fellow Eyes

Purpose

This study investigated the long-term outcomes (> 3 years) of immediate primary phacoemulsification in eyes with acute primary angle closure (APAC) and in the fellow eyes with shallow anterior chamber to prevent APAC development.

Patients and Methods

This is a retrospective study of phacoemulsification for APAC using bilateral eyes. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of IOP-lowering medications at the preoperative examination (Pre), postoperative month 1 (1m), year 3 (3y), and last visit were compared between 14 eyes with APAC and their 14 fellow eyes. The number of corneal endothelial cells (CECs) at Pre and at more than 2 weeks after phacoemulsification was compared. The visual field mean deviation (MD) within 1 year after phacoemulsification and at the last visit was also compared.

Results

For APAC eyes, BCVA was significantly improved at 1m, 3y, and at the last visit as compared with Pre (p < 0.05). IOP significantly decreased at 1m, 3y, and at the last visit compared with Pre (p < 0.05). IOP-lowering medication use decreased significantly from Pre to 1m (p < 0.05). The number of CECs was not significantly different between Pre and more than 2 weeks after phacoemulsification. BCVA was significantly worse in APAC eyes than in fellow eyes at Pre (p < 0.05). IOP and the number of IOP-lowering medications were significantly higher in APAC eyes than in fellow eyes at Pre (p < 0.05).

Conclusion

Primary phacoemulsification improved visual acuity for APAC eyes and maintained good IOP control without the need for reoperation. Moreover, it preserved the number of CECs for the APAC and fellow eyes in the long term.

Safety and Efficacy of Rapid Primary Phacoemulsification on Acute Primary Angle Closure with and without Preoperative IOP-Lowering Medication

This study aimed to investigate the safety and efficacy of rapid primary phacoemulsification in patients with acute primary angle closure (APAC) (n = 41), with or without preoperative IOP-lowering medication. The best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of corneal endothelial cells (CECs), and number of IOP-lowering medications at the preoperative examination (Pre), postoperative day 1 (1d), week 1 (1w), and month 1 (1m) were used as indicators and compared. BCVA significantly improved at 1d, 1w, and 1m compared with Pre (p < 0.05) and significantly improved at 1m compared to 1d (p < 0.05) for all eyes. IOP significantly decreased at 1d, 1w, and 1m compared with Pre (p < 0.05). CECs were not significantly different between Pre and 1m; the number of IOP-lowering medications decreased significantly from Pre to 1m (p < 0.05). BCVA and IOP were not significantly different between the two groups for all periods. CECs were not significantly different between the two groups at Pre and 1m. Rapid primary phacoemulsification improved visual acuity due to improvement of corneal edema without central visual field defects and good IOP control without reoperation or IOP-lowering medication and maintained the number of corneal endothelial cells with or without preoperative IOP-lowering medication in patients with APAC.

Pentacam changes in primary angle-closure glaucoma after different lines of treatment

AIM

To assess the changes in the anterior chamber parameters using Pentacam following four different lines of treatment of primary angle-closure glaucoma (PACG).

METHODS

A retrospective comparative study included 126 patients (126 eye) presented within 24-48h after acute angle-closure glaucoma (AACG). Patients were divided into 2 groups: group A (68 eyes) with controlled intraocular pressure (IOP) ≤21 mm Hg, which included subgroup A1 (34 eyes) with clear lens underwent Nd:YAG laser peripheral iridotomy (LPI) and subgroup A2 (34 eyes) with cataract underwent standard phacoemulsification; and group B (58 eyes) with uncontrolled IOP, which included subgroup B1 (30 eyes) with clear lens underwent trabeculectomy and subgroup B2 (28 eyes) with cataract underwent combined phacoemulsification and trabeculectomy. Patients were followed up for at least 3mo. Primary outcomes were Pentacam anterior segment measurements [anterior chamber angle (ACA) and depth (ACD)]. Secondary outcomes were changes in IOP, visual acuity (VA) and recorded complications.

RESULTS

At the 3rd month, there was significant increase in the ACA values in all studied groups compared to preoperative values (P<0.001). The highest percent of increase in ACA was recorded in phacotrabeculectomy group B2 (128.40%). There was significant increase in ACD values at 3rd month compared with baseline values (P<0.001) for groups A1, A2, and B2; without change in B1 trabeculectomy group. The maximum deepening of ACD was noticed in group B2 with 94.27% increase. Significant decrease in postoperative IOP in groups A2, B1 and B2 (P<0.001, P=0.014, and P<0.001 respectively). In group A1 there was significant increase in 3rd month postoperative IOP from baseline values (P<0.001). The maximum decrease in IOP was noticed in group B2 with 59.54% decrease. VA improvement in 3rd month postoperative was recorded in all studied groups, maximum VA improvement was observed in group B2 up to 0.2 logMAR.

CONCLUSION

Pentacam can be a helpful tool in studying and comparing the effect of the different lines of management of PACG on the anterior chamber measures. Phacotrabeculectomy was proved to be an effective line for managing PACG with resultant significant increase in the anterior chamber parameters, IOP reduction as well as maximum VA improvement. LPI has only temporary effect on IOP with significant changes in ACA and ACD. Phacoemuslification alone can be an option in treating PACG. Trabeculectomy resulted in temporary increase in the anterior chamber parameter which subsequently returned to baseline values.

Efficacy and Safety of Argon Laser Peripheral Iridoplasty and Systemic Medical Therapy in Asian Patients with Acute Primary Angle Closure: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

The purpose of this meta-analysis was to assess the percent reduction in the intraocular pressure (IOP) after argon laser peripheral iridoplasty (ALPI) and systemic medical therapy in patients with acute primary angle closure (APAC).

METHODS

We searched a number of electronic databases, including MEDLINE, EMBASE, PubMed, and Cochrane Library. We searched the electronic databases from the inception of the databases to August 2018. The primary outcomes included the IOP reduction (IOPR), percent reduction in IOP (IOPR%) from baseline to the endpoint and peripheral anterior synechiae (PAS). The secondary outcomes included the cup-to-disc ratio (CDR), mean endothelial count, and percent of patients requiring topical glaucoma medication. Summary weighted mean difference (WMD), odds ratio (OR), and 95% confidence intervals (CIs) were calculated.

RESULTS

Four eligible studies including 183 eyes (92 in the ALPI group and 91 in the medical therapy group) were identified. When comparing ALPI to medical therapy, the WMDs of the IOPR% were 30.03 (95% CI: 21.33 to 38.72, p < 0.00001) at 15 minutes, 27.39 (95% CI: 18.89 to 35.89, p < 0.00001) at 30 minutes, 18.15 (95% CI: 10.63 to 25.68, p < 0.00001) at 1 hour, and 12.91 (95% CI: 4.50 to 21.32, p=0.003) at 2 hours. There was no statistically significant difference between the two groups at 24 hours and at more than 6 months after therapy. Meanwhile, no significant difference was observed in the degree of PAS, CDR, mean endothelial count, and percent of patients requiring topical glaucoma medication after treatment between the two groups.

CONCLUSIONS

Both ALPI and systemic medications were effective with regard to decreasing the IOP. ALPI was more effective in lowering the IOP within the first two hours. Therefore, ALPI may be a better choice for rapidly lowering the IOP in patients with APAC within a short period.

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.

Temporal ocular coherence tomography-measured changes in anterior chamber angle and diurnal intraocular pressure after laser iridoplasty: IMPACT study

Aims

To evaluate temporal change in anterior chamber angle anatomy following argon laser peripheral iridoplasty (ALPI) in eyes with occludable angles postlaser peripheral iridotomy (LPI) compared with control eyes. Additionally, the effect on diurnal intraocular pressure (DIOP) fluctuation (maximum-minimum IOP) was investigated.

Methods

Twenty-two patients with bilateral primary angle closure/suspects with gonioscopically occludable anterior chamber angles following LPI were randomised to receive ALPI (n=11) or no further treatment (n=11). Angle opening distance (AOD), trabecular-iris angle, angle recess area and trabecular-iris space area were measured over eight sections with swept-source anterior segment optical coherence tomography and DIOP was measured pre-LPI and repeated at 3 months after ALPI (hourly measures).

Results

All angle parameters increased following ALPI. This change was maintained for 3 months in seven of the eight sections (eg, inferotemporal AOD500 increased by 0.063 mm, p=0.004 at 1 day; 0.051 mm, p=0.029 at 1 week; 0.059 mm, p=0.006 at 6 weeks and 0.056 mm, p=0.011 at 3 months). The only exception was in the inferior sector (eg, AOD500 increased by 0.041 mm, p=0.025 at 1 day and by 0.029 mm, p=0.054 at 3 months). DIOP at 3 months was significantly reduced (5.04 mm Hg; ±1.61 mm Hg) compared with controls (6.61 mm Hg; ±1.63 mm Hg). Maximum IOP was significantly greater in the non-ALPI group (1.87 mm Hg, p=0.026).

Conclusions

ALPI widened all angle sections in eyes that remained occludable post-LPI. Changes were maintained for 3 months. ALPI decreased DIOP fluctuation in the treated eyes by lowering the maximum IOP value.

Current and Future of Laser Therapy in the Management of Glaucoma

There has been tremendous progress in the past decades in the utilization of lasers for treating patients with glaucoma. This article reviews the use of lasers in different areas of glaucoma, including the shift from argon laser trabeculoplasty (ALT) to selective laser trabeculoplasty (SLT), laser trabeculoplasty as an initial treatment for glaucoma, new laser trabeculoplasty procedures under investigation, and other recent laser treatment modalities such as endoscopic cyclophotocoagulation and laser-assisted deep sclerectomy.

Anterior segment morphology after acute primary angle closure treatment: a randomised study comparing iridoplasty and medical therapy

PURPOSE

To compare the effect of argon laser peripheral iridoplasty (ALPI) and conventional medical therapy in the immediate treatment of acute primary angle closure (APAC) using anterior segment optical coherence tomography (ASOCT).

METHODS

In this single tertiary centre, prospective comparative study, we randomised 30 consecutive patients with unilateral APAC into two groups: ALPI and medical treatment (n=15 each). Immediately before and 1 h after either intervention, ASOCT imaging was performed. Custom software was used to measure pupil diameter, anterior chamber depth, iris curvature (I-Curv), iris area (I-Area), and the angle opening distance (AOD750), trabecular iris space area (TISA750) and the iris thickness at 750 µm from the scleral spur. The main outcome measure was the change in anterior segment biometrical parameters.

RESULTS

The mean age of the patients was 62.8±7.7 years; 13 (43.3%) were male. APAC eyes treated with ALPI had a larger increase in AOD750 (p=0.002) and TISA750 (p=0.006); a smaller increase in I-Area (p=0.004) and a decrease in I-Curv (p=0.001) after treatment compared with those eyes which received medical therapy. An optimal model consisting of age, gender, pretreatment and post-treatment pupil diameter, treatment modality and pretreatment I-Curv explained 53.2% of the variance in AOD750 change after treatment, with the treatment modality accounting for 35.0% and I-Curv accounting for 12.4% of the variability.

CONCLUSIONS

We observed a greater increase in angle width after ALPI compared with after medical treatment in eyes with APAC. Treatment modality and pretreatment I-Curv were the most significant predictors of angle width change after treatment.

Diode laser transscleral cyclophotocoagulation followed by phacotrabeculectomy on medically unresponsive acute primary angle closure eyes: the long-term result

Background

To explore the intraocular pressure-lowering effect and complications of diode laser transscleral cyclophotocoagulation (DLTSC) followed by phacotrabeculectomy on medically unresponsive acute primary angle closure eyes.

Methods

Nine eyes of nine medically unresponsive acute primary angle closure patients were enrolled. All the patients underwent cyclophotocoagulation followed by phacotrabeculectomy to control the prolonged acute attack. Data were recorded prospectively and then analyzed retrospectively. The reduction in intraocular pressure, improvement of vision and the complications were evaluated.

Results

After DLTSC, the IOP of all the patients were reduced, but all were above 21 mmHg under topical anti-glaucoma medications. After phacotrabeculectomy, the IOP of all the patients was decreased. At the final visit, the vision of all the patients was improved and the IOP of all the patients was below 21 mmHg without anti-glaucoma medications. There were no complications during the DLTSC and phacotrabeculectomy. Uveitis was the common complications after the both procedures, which were resolved by medication treatment.

Conclusion

Diode laser transscleral cyclophotocoagulation followed by phacotrabeculectomy is an alternative procedure to control the intraocular pressure of medically unresponsive acute primary angle closure eyes with few complications.

Effect of anterior chamber paracentesis on initial treatment of acute angle closure

OBJECTIVE

To compare anterior chamber paracentesis (ACP) with standard medical management of acute primary angle closure (APAC).

DESIGN

Prospective study.

PARTICIPANTS

Patients with APAC and intraocular pressure (IOP) ≥ 50 mm Hg were enrolled.

METHODS

Patients were randomized to receive ACP and medical treatment (group 1) or medical management alone (group 2).

RESULTS

There were 26 patients (mean age 69.3 ± 10.4 years, 31 eyes) in group 1 and 28 patients (mean age 67.0 ± 9.7 years, 30 eyes) in group 2. The IOP in group 1 was significantly lower at 15 minutes, 30 minutes, and 1 hour after treatment (p < 0.05). At 1, 2, and 24 hours after treatment, visual acuity was significantly better in group 1 than in group 2. At each time point after treatment, the grade of corneal edema was not different between the groups. Pain score at 1 and 2 hours after treatment was significantly lower in group 1 than in group 2; however, no difference was noted at 24 hours after treatment. The mean follow-up period in group 1 was 16.1 ± 1.3 months and in group 2 was 15.6 ± 1.4 months (p = 0.803). At last follow-up, IOP, pupil size, number of eyes with nonreactive pupils, and centre endothelial cell counts were not different; however, visual acuity was significantly better in group 1 (0.43 ± 0.06 logMAR vs 0.74 ± 0.10 logMAR, p = 0.007).

CONCLUSIONS

Immediate ACP is a safe and effective for rapidly lowering IOP, and is associated with better visual acuity than medical treatment alone.

A comparison of two approaches to managing acute primary angle closure in Asian eyes

Purpose

To review the management regimes of acute primary angle closure (APAC) in two hospitals in Singapore, and to identify the incidence of and risk factors for progression to glaucomatous optic neuropathy.

Methods

We conducted a retrospective review of 40 patients from National University Hospital (NUH) and 52 patients from Singapore National Eye Centre (SNEC) who were diagnosed with APAC. Patients were treated with similar protocols of intensive medical therapy until laser peripheral iridotomy could be performed. In the event of failed medical treatment, patients at NUH only underwent laser iridoplasty. The 1-year outcomes were reviewed.

Results

The demographic features of patients and presenting intraocular pressures (IOP) were similar in both centers. More patients from NUH presented within 3 days of symptom onset, compared to those from SNEC (90.0% versus 71.2%, respectively) (P = 0.037). The mean ± standard deviation time to break the attack was 18.2 ± 32.9 hours at SNEC and 9.80 ± 10.6 hours at NUH (P = 0.11). The mean follow up duration was 18.8 ± 14.0 months. Nineteen patients (36.5%) from SNEC and six patients (22.5%) from NUH developed raised IOP (P = 0.032) within 1-year of the attack. Of these, glaucomatous optic neuropathy developed in thirteen patients (68.4%) from SNEC and all six patients (100%) from NUH. At final review, the mean IOP of the APAC eye was 14.8 ± 4.3 mmHg from SNEC and 13.4 ± 3.0 mmHg from NUH. There was no significant difference in final visual acuity or IOP between both groups.

Conclusion

Treatment strategies in both centers were effective in aborting an APAC attack. The development of raised IOP appears to be associated with a longer period of attack suggesting that greater urgency in aborting APAC attacks may entail better long term outcomes.

Correlation of previous acute angle-closure attack with extent of synechial angle closure in chronic primary angle-closure glaucoma patients

AIM

To document any correlation between previous acute angle-closure attack and the extent of synechial angle closure in chronic primary angle-closure glaucoma (PACG) patients.

METHODS

Consecutive cases of chronic PACG with patent peripheral iridotomy had gonioscopy performed. The extents of synechial angle closure of those chronic PACG eyes with previous documented acute angle-closure attack were compared to those eyes without such a history.

RESULTS

A total of 102 chronic PACG eyes of 102 patients were recruited. Twenty-seven eyes (26.5%) had a previous documented acute angle closure, while 75 eyes (73.5%) did not. The mean extent of synechial angle closure +/-1 SD was 307+/-68 degrees (range, 150-360 degrees) in those chronic PACG eyes with a history of previous acute angle closure, compared to 266+/-89 degrees (range, 90-360 degrees) in those chronic PACG eyes without such a history (P=0.03, Student's t-test). There were no statistically significant differences between the two groups in age, LogMAR visual acuity, intraocular pressure (IOP), number of glaucoma eye drops, vertical cup-to-disk ratio, mean deviation or pattern SD in Humphrey automated perimetry, and anterior chamber depth (P>0.05).

CONCLUSION

Previous acute angle-closure attack correlated with more extensive synechial angle closure in chronic PACG patients in this study.

Argon Laser Peripheral Iridoplasty (ALPI): An Update

Argon laser peripheral iridoplasty is a useful procedure to eliminate appositional angle closure resulting from mechanisms other than pupillary block. For those eyes with angle closure originating at an anatomic level posterior to the iris, such as plateau iris, lens-induced angle closure, or posterior segment processes (malignant glaucoma, central retinal vein occlusion, etc.), laser iridotomy by itself may be insufficient to treat the underlying disease mechanism. Argon laser peripheral iridoplasty is often useful in these cases to further open the angle. It can be used to break an acute attack of angle-closure glaucoma and relieve appositional angle closure secondary to plateau iris syndrome, or lens-related angle closure, and to widen the angle prior to argon laser trabeculoplasty. Peripheral location of long-duration, low-power, large spot size laser burns is essential for optimal success.

Current approaches to the management of acute primary angle closure

PURPOSE OF REVIEW

Recent advances in the management of acute primary angle closure include argon laser peripheral iridoplasty, immediate anterior chamber paracentesis, and cataract or lens extraction by phacoemulsification. This review summarizes current thoughts on the role of these treatment modalities.

RECENT FINDINGS

Argon laser peripheral iridoplasty has been shown to be superior to treatments using combined topical and systemic medications in controlling intraocular pressure in acute primary angle closure. Immediate paracentesis has been shown to be very effective for aborting the condition. This is a good alternative for suitable cases and especially in settings in which laser equipment is not readily available. Cataract or lens extraction by phacoemulsification appears to be promising in preventing progression to chronic angle closure glaucoma after acute primary angle closure.

SUMMARY

Surgical trials are underway to examine the role of cataract/lens extraction in post-acute primary angle closure. This technique has the potential to prevent recurrence of the condition and progression to chronic angle closure glaucoma. With existing and upcoming new data on managing acute primary angle closure, it is hopeful that a more optimal treatment algorithm will be established soon.