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Gupta V. Rethinking laser iridotomy in angle-closure disease. Indian J Ophthalmol 2024; 72:307-308. [PMID: 38421287 PMCID: PMC11001235 DOI: 10.4103/ijo.ijo_53_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Viney Gupta
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India E-mail:
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Filippopoulos T, Danias J, Karmiris E, Mégevand GS, Rhee DJ, Gazzard G, Topouzis F, Xu B. Rethinking Prophylactic Laser Peripheral Iridotomy in Primary Angle-Closure Suspects: A Review. Ophthalmol Glaucoma 2023; 6:657-667. [PMID: 37321374 DOI: 10.1016/j.ogla.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
| | - John Danias
- Department of Ophthalmology at SUNY Downstate Health Sciences University, New York, New York
| | | | | | - Douglas J Rhee
- University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom
| | - Fotis Topouzis
- First Department of Ophthalmology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Benjamin Xu
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
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Foster PJ, Ng WS, Nolan WP, Tanner L, Gazzard G, Day AC, Sanders R, Foot B, Salmon JF, Azuara-Blanco A. Prevention of angle-closure glaucoma: balancing risk and benefit. Eye (Lond) 2022; 36:2229-2231. [PMID: 35725765 PMCID: PMC9674842 DOI: 10.1038/s41433-021-01881-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Paul J Foster
- Moorfields Eye Hospital NHS Foundation Trust, London, UK.
- UCL Institute of Ophthalmology, London, UK.
| | | | - Winifred P Nolan
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Luke Tanner
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gus Gazzard
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, London, UK
| | - Alex C Day
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, London, UK
| | - Roshini Sanders
- Queen Margaret Hospital, Dunfirmline, Fife, UK
- Department of Ophthalmology, University of Edinburgh, Edinburgh, UK
| | - Barny Foot
- Royal College of Ophthalmologists, London, UK
| | - John F Salmon
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Augusto Azuara-Blanco
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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The Singapore Asymptomatic Narrow Angles Laser Iridotomy Study: Five-Year Results of a Randomized Controlled Trial. Ophthalmology 2021; 129:147-158. [PMID: 34453952 DOI: 10.1016/j.ophtha.2021.08.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To examine the efficacy of laser peripheral iridotomy (LPI) in patients who received a diagnosis of primary angle-closure suspect (PACS). DESIGN Prospective, randomized controlled trial. PARTICIPANTS This multicenter, randomized controlled trial (ClinicalTrials.gov identifier, NCT00347178) enrolled 480 patients older than 50 years from glaucoma clinics in Singapore with bilateral asymptomatic PACS (defined as having ≥2 quadrants of appositional angle closure on gonioscopy). METHODS Each participant underwent prophylactic LPI in 1 randomly selected eye, whereas the fellow eye served as a control. Patients were followed up yearly for 5 years. MAIN OUTCOME MEASURES The primary outcome measure was development of primary angle closure (PAC; defined as presence of peripheral anterior synechiae, intraocular pressure [IOP] of >21 mmHg, or both or acute angle closure [AAC]) or primary angle-closure glaucoma (PACG) over 5 years. RESULTS Of the 480 randomized participants, most were Chinese (92.7%) and were women (75.8%) with mean age of 62.8 ± 6.9 years. Eyes treated with LPI reached the end point less frequently after 5 years (n = 24 [5.0%]; incidence rate [IR], 11.65 per 1000 eye-years) compared with control eyes (n = 45 [9.4%]; IR, 21.84 per 1000 eye-years; P = 0.001). The adjusted hazard ratio (HR) for progression to PAC was 0.55 (95% confidence interval [CI], 0.37-0.83; P = 0.004) in LPI-treated eyes compared with control eyes. Older participants (per year; HR, 1.06; 95% CI, 1.03-1.10; P < 0.001) and eyes with higher baseline IOP (per millimeter of mercury; HR, 1.35; 95% CI, 1.22-1.50; P < 0.0001) were more likely to reach an end point. The number needed to treat to prevent an end point was 22 (95% CI, 12.8-57.5). CONCLUSIONS In patients with bilateral asymptomatic PACS, eyes that underwent prophylactic LPI reached significantly fewer end points compared with control eyes over 5 years. However, the overall incidence of PAC or PACG was low.
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Mou DP, Liang YB, Fan SJ, Peng Y, Wang NL, Thomas R. Progression rate to primary angle closure following laser peripheral iridotomy in primary angle-closure suspects: a randomised study. Int J Ophthalmol 2021; 14:1179-1184. [PMID: 34414081 DOI: 10.18240/ijo.2021.08.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/17/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To report the progression rate (PR) to primary angle closure (PAC) following laser peripheral iridotomy (LPI) in PAC suspects (PACS). METHODS Prospective, randomized controlled interventional clinical trial conducted at the Handan Eye Hospital, China. Totally 134 bilateral PACS, defined as non-visibility of the posterior trabecular meshwork for ≥180 degrees on gonioscopy were randomly assigned to undergo LPI in one eye. Gonioscopy and Goldmann applanation tonometry were performed prior to, on day 7 and 12mo post LPI. RESULTS Eighty of 134 patients (59.7%) could be followed up at one year. The mean intraocular pressure (IOP) in treated eyes was 15.9±2.6 mm Hg at baseline, 15.4±3.0 mm Hg on day 7; 16.5±2.9 mm Hg at one month, and 15.5±2.9 mm Hg at 12mo; the IOP in untreated eyes was similar (P=0.834). One or more quadrants of the angle opened in 93.7% of the LPI treated eyes, but 67.0% (53/79) remained closed in two or more quadrants. The PR to PAC in untreated eyes was 3.75% and one developed acute angle-closure glaucoma (AACG); the PR to PAC in treated eyes was 2.5% and none had developed peripheral anterior synechia (PAS) or AACG. CONCLUSION LPI can open some of the occludable angle in the majority of eyes with PACS, but 67% continue to have non-visibility of the trabecular meshwork for over 180 degrees.
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Affiliation(s)
- Da-Peng Mou
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology&Visual Science Key Lab, Beijing 100730, China
| | - Yuan-Bo Liang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology&Visual Science Key Lab, Beijing 100730, China.,Handan Eye Hospital, Handan 056001, Hebei Province, China
| | - Su-Jie Fan
- Handan Eye Hospital, Handan 056001, Hebei Province, China
| | - Yi Peng
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology&Visual Science Key Lab, Beijing 100730, China
| | - Ning-Li Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology&Visual Science Key Lab, Beijing 100730, China
| | - Ravi Thomas
- Queensland Eye Institute, Brisbane 4343, Australia.,University of Queensland, Brisbane 4343, Australia
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Xiao X, Xue L, Ye L, Li H, He Y. Health care cost and benefits of artificial intelligence-assisted population-based glaucoma screening for the elderly in remote areas of China: a cost-offset analysis. BMC Public Health 2021; 21:1065. [PMID: 34088286 PMCID: PMC8178835 DOI: 10.1186/s12889-021-11097-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/17/2021] [Indexed: 12/04/2022] Open
Abstract
Background Population-based screening was essential for glaucoma management. Although various studies have investigated the cost-effectiveness of glaucoma screening, policymakers facing with uncontrollably growing total health expenses were deeply concerned about the potential financial consequences of glaucoma screening. This present study was aimed to explore the impact of glaucoma screening with artificial intelligence (AI) automated diagnosis from a budgetary standpoint in Changjiang county, China. Methods A Markov model based on health care system’s perspective was adapted from previously published studies to predict disease progression and healthcare costs. A cohort of 19,395 individuals aged 65 and above were simulated over a 15-year timeframe. Fur illustrative purpose, we only considered primary angle-closure glaucoma (PACG) in this study. Prevalence, disease progression risks between stages, compliance rates were obtained from publish studies. We did a meta-analysis to estimate diagnostic performance of AI automated diagnosis system from fundus image. Screening costs were provided by the Changjiang screening programme, whereas treatment costs were derived from electronic medical records from two county hospitals. Main outcomes included the number of PACG patients and health care costs. Cost-offset analysis was employed to compare projected health outcomes and medical care costs under the screening with what they would have been without screening. One-way sensitivity analysis was conducted to quantify uncertainties around model results. Results Among people aged 65 and above in Changjiang county, it was predicted that there were 1940 PACG patients under the AI-assisted screening scenario, compared with 2104 patients without screening in 15 years’ time. Specifically, the screening would reduce patients with primary angle closure suspect by 7.7%, primary angle closure by 8.8%, PACG by 16.7%, and visual blindness by 33.3%. Due to early diagnosis and treatment under the screening, healthcare costs surged dramatically to $107,761.4 dollar in the first year and then were constantly declining over time, while without screening costs grew from $14,759.8 in the second year until peaking at $17,900.9 in the 9th year. However, cost-offset analysis revealed that additional healthcare costs resulted from the screening could not be offset by decreased disease progression. The 5-, 10-, and 15-year accumulated incremental costs of screening versus no screening were estimated to be $396,362.8, $424,907.9, and $434,903.2, respectively. As a result, the incremental cost per PACG of any stages prevented was $1464.3. Conclusions This study represented the first attempt to address decision-maker’s budgetary concerns when adopting glaucoma screening by developing a Markov prediction model to project health outcomes and costs. Population screening combined with AI automated diagnosis for PACG in China were able to reduce disease progression risks. However, the excess costs of screening could never be offset by reduction in disease progression. Further studies examining the cost-effectiveness or cost-utility of AI-assisted glaucoma screening were needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11097-w.
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Affiliation(s)
- Xuan Xiao
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Long Xue
- School of Public Health, Fudan University, Shanghai, 200433, China
| | - Lin Ye
- Department of Eye Plastic and Lacrimal Disease, Shenzhen Eye Hospital of Jinan University, Shenzhen, 518040, China
| | - Hongzheng Li
- School of Public Health, Fudan University, Shanghai, 200433, China
| | - Yunzhen He
- School of Public Health, Fudan University, Shanghai, 200433, China.
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Tanner L, Gazzard G, Nolan WP, Foster PJ. Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated? Eye (Lond) 2019; 34:40-50. [PMID: 31649349 DOI: 10.1038/s41433-019-0634-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/25/2022] Open
Abstract
Angle-closure glaucoma is an aggressive condition that causes millions to become blind worldwide. This review explores the use of prophylactic laser peripheral iridotomy (PI) in patients classified as primary angle-closure suspects (PACS), and additionally, the use of clear lens exchange as a primary treatment option in established angle-closure disease with or without glaucoma. As PI has a strong prophylactic effect in fellow eyes of patients who have had an acute attack, its use has been widely adopted in those patients classified as PACS, but with limited evidence to support this. A large randomised trial conducted in China has demonstrated that although PI reduces the risk of incident angle-closure disease, the incidence of disease that would threaten vision was much lower than anticipated. This suggests that the benefit of prophylactic PI is very limited. Health services data shows an association between rising cataract surgical rates and of decreasing rates of acute angle-closure. Age-related growth of the lens is a major component of angle-closure disease. Several studies have shown that clear lens extraction (CLE) effectively lowers IOP in angle-closure. The use of CLE as a primary treatment option has been tested against LPI in the EAGLE study, a large RCT that enroled people with angle-closure and an IOP > 30 mmHg, and those with angle-closure glaucoma. The trial showed CLE to be superior to PI both for IOP control and patient reported quality of life. On these grounds, CLE should be considered for first-line treatment of more advanced angle-closure disease.
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Affiliation(s)
- Luke Tanner
- University of Exeter Medical School, College of Medicine & Health, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Gus Gazzard
- Glaucoma Service, Moorfields Eye Hospital, City Road, London, EC1V 2PD, UK.,UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Winifred P Nolan
- Glaucoma Service, Moorfields Eye Hospital, City Road, London, EC1V 2PD, UK.,NIHR Biomedical Research Centre at Moorfields Eye Hospital & UCL Institute of Ophthalmology, London, EC1V 2PD, UK
| | - Paul J Foster
- Glaucoma Service, Moorfields Eye Hospital, City Road, London, EC1V 2PD, UK. .,UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK. .,NIHR Biomedical Research Centre at Moorfields Eye Hospital & UCL Institute of Ophthalmology, London, EC1V 2PD, UK.
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Gupta V, Dada T. Should we perform peripheral laser iridotomy in primary angle closure suspects: implications of the ZAP trial? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S157. [PMID: 31576364 DOI: 10.21037/atm.2019.06.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vivek Gupta
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Tanuj Dada
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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He M, Jiang Y, Huang S, Chang DS, Munoz B, Aung T, Foster PJ, Friedman DS. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial. Lancet 2019; 393:1609-1618. [PMID: 30878226 DOI: 10.1016/s0140-6736(18)32607-2] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 10/06/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Primary angle-closure glaucoma affects 20 million people worldwide. People classified as primary angle closure suspects have a higher but poorly quantified risk of developing glaucoma. We aimed to assess efficacy and safety of laser peripheral iridotomy prophylaxis against primary angle-closure glaucoma in Chinese people classified as primary angle closure suspects. METHODS In this randomised controlled trial, bilateral primary angle closure suspects aged 50-70 years were enrolled at the Zhongshan Ophthalmic Center, a tertiary specialised hospital in Guangzhou, China. Eligible patients received laser peripheral iridotomy in one randomly selected eye, with the other remaining untreated. The primary outcome was incident primary angle closure disease as a composite endpoint of elevation of intraocular pressure, peripheral anterior synechiae, or acute angle-closure during 72 months of follow-up in an intention-to-treat analysis between treated eyes and contralateral controls. This trial is registered with the ISRCTN registry, number ISRCTN45213099. FINDINGS Of 11 991 screened individuals, 889 individuals were randomly assigned from June 19, 2008 (889 treated and 889 untreated eyes). Incidence of the primary outcome was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes (hazard ratio 0·53; 95% CI 0·30-0·92; p=0·024). A primary outcome event occurred in 19 treated eyes and 36 untreated eyes with a statistically significant difference using pair-wise analysis (p=0·0041). No serious adverse events were observed during follow-up. INTERPRETATION Incidence of angle-closure disease was very low among individuals classified as primary angle closure suspects identified through community-based screening. Laser peripheral iridotomy had a modest, albeit significant, prophylactic effect. In view of the low incidence rate of outcomes that have no immediate threat to vision, the benefit of prophylactic laser peripheral iridotomy is limited; therefore, widespread prophylactic laser peripheral iridotomy for primary angle-closure suspects is not recommended. FUNDING Fight for Sight, the Sun Yat-Sen University 5010 Project Fund, Moorfields Eye Charity, and the National Natural Science Foundation of China.
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Affiliation(s)
- Mingguang He
- State Key Laboratory of Ophthalmology, Clinical Research Center, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China; Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia; National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK; UCL Institute of Ophthalmology, London, UK.
| | - Yuzhen Jiang
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK; UCL Institute of Ophthalmology, London, UK
| | - Shengsong Huang
- State Key Laboratory of Ophthalmology, Clinical Research Center, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Dolly S Chang
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Beatriz Munoz
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tin Aung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul J Foster
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital, London, UK; UCL Institute of Ophthalmology, London, UK.
| | - David S Friedman
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Longitudinal Change in Peripheral Anterior Chamber Depth of Eyes with Angle Closure after Laser Iridotomy. J Ophthalmol 2019; 2018:9106247. [PMID: 30671261 PMCID: PMC6323459 DOI: 10.1155/2018/9106247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/11/2018] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate longitudinal changes in peripheral anterior chamber depth (pACD) of eyes with angle closure after laser iridotomy (LI) and factors related to prognosis. Design Retrospective cohort study. Methods Eyes with primary angle closure (PAC), acute PAC, or chronic angle closure glaucoma (CACG) that underwent LI (LI group) and eyes that underwent phacoemulsification and intraocular lens insertion (PEA + IOL group) were employed. Longitudinal changes in pACD were evaluated with a scanning peripheral anterior chamber depth analyzer (SPAC) in addition to routine ophthalmic examination. Results Forty-eight eyes of LI groups (69.8 ± 8.5 years) and 21 eyes of PEA + IOL group (65.6 ± 12.7 years) were enrolled. Mean follow-up times of LI group and PEA + IOL group were 43.4 ± 12.7 months and 36.5 ± 2.5 months, respectively. LI significantly increased pACD as indicated by the SPAC grade change from 3.8 ± 1.1 to 4.6 ± 1.2 (p < 0.001). However, SPAC grade was gradually reduced and reached the pre-LI level by the third year of follow up. PEA + IOL also significantly increased SPAC grade from 6.7 ± 1.6 to 8.7 ± 2.0 (p < 0.001), but no time-related change was observed. Twenty-three cases of LI group presented with deterioration of glaucoma control. The type of angle closure, plateau iris configuration, peripheral anterior synechia, and glaucomatous visual field defects were significantly associated with prognosis of glaucoma after LI. Conclusions Peripheral ACD is temporarily deepened by LI, but returns to the pre-LI level in approximately three years. The type of angle closure and some factors may be related to glaucoma prognosis after LI.
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Abstract
BACKGROUND Primary angle-closure glaucoma is a type of glaucoma associated with a physically obstructed anterior chamber angle. Obstruction of the anterior chamber angle blocks drainage of fluids (aqueous humor) within the eye and may raise intraocular pressure (IOP). Elevated IOP is associated with glaucomatous optic nerve damage and visual field loss. Laser peripheral iridotomy (often just called 'iridotomy') is a procedure to eliminate pupillary block by allowing aqueous humor to pass directly from the posterior to anterior chamber through use of a laser to create a hole in the iris. It is commonly used to treat patients with primary angle-closure glaucoma, patients with primary angle closure (narrow angles and no signs of glaucomatous optic neuropathy), and patients who are primary angle-closure suspects (patients with reversible obstruction). The effectiveness of iridotomy on slowing progression of visual field loss, however, is uncertain. OBJECTIVES To assess the effects of iridotomy compared with no iridotomy for primary angle-closure glaucoma, primary angle closure, and primary angle-closure suspects. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 9) which contains the Cochrane Eyes and Vision Trials Register; MEDLINE Ovid; Embase Ovid; PubMed; LILACS; ClinicalTrials.gov; and the ICTRP. The date of the search was 18 October 2017. SELECTION CRITERIA Randomized or quasi-randomized controlled trials that compared iridotomy to no iridotomy in primary angle-closure suspects, patients with primary angle closure, or patients with primary angle-closure glaucoma in one or both eyes were eligible. DATA COLLECTION AND ANALYSIS Two authors worked independently to extract data on study characteristics, outcomes for the review, and risk of bias in the included studies. We resolved differences through discussion. MAIN RESULTS We identified two trials (2502 eyes of 1251 participants) that compared iridotomy to no iridotomy. Both trials recruited primary angle suspects from Asia and randomized one eye of each participant to iridotomy and the other to no iridotomy. Because the full trial reports are not yet available for both trials, no data are available to assess the effectiveness of iridotomy on slowing progression of visual field loss, change in IOP, need for additional surgeries, number of medications needed to control IOP, mean change in best-corrected visual acuity, and quality of life. Based on currently reported data, one trial showed evidence that iridotomy increases angle width at 18 months (by 12.70°, 95% confidence interval (CI) 12.06° to 13.34°, involving 1550 eyes, moderate-certainty evidence) and may be associated with IOP spikes at one hour after treatment (risk ratio 24.00 (95% CI 7.60 to 75.83), involving 1468 eyes, low-certainty evidence). The risk of bias of the two studies was overall unclear due to lack of availability of a full trial report. AUTHORS' CONCLUSIONS The available studies that directly compared iridotomy to no iridotomy have not yet published full trial reports. At present, we cannot draw reliable conclusions based on randomized controlled trials as to whether iridotomy slows progression of visual field loss at one year compared to no iridotomy. Full publication of the results from the studies may clarify the benefits of iridotomy.
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Affiliation(s)
- Jimmy T Le
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Gus Gazzard
- Moorfields Eye Hospital NHS Foundation TrustNIHR Biomedical Research Centre162 City RoadLondonUK
- UCL Institute of Ophthalmology11‐43 Bath StreetLondonUK
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Pentacam sensitivity and specificity in detecting occludable angles. Eur J Ophthalmol 2018; 22:701-8. [DOI: 10.5301/ejo.5000108] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2011] [Indexed: 11/20/2022]
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Chen S, Lv J, Fan S, Zhang H, Xie L, Xu L, Jiang B, Yuan H, Liang Y, Li S, Chen P, Zhang X, Wang N. Laser peripheral iridotomy versus laser peripheral iridotomy plus laser peripheral iridoplasty in the treatment of multi-mechanism angle closure: study protocol for a randomized controlled trial. Trials 2017; 18:130. [PMID: 28302178 PMCID: PMC5356270 DOI: 10.1186/s13063-017-1860-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND China has the largest burden of primary angle-closure glaucoma (PACG) worldwide. The mechanism of the angle closure is complex and includes pupillary block and non-pupillary block. Currently, opinion is that laser peripheral iridotomy (LPI) alone is not sufficient to prevent disease progression. Laser peripheral iridoplasty (LPIP) is an alternative and effective way of widening the angle recess in eyes that are affected by primary angle closure (PAC). However, it is not known if greater benefit would be achieved using LPI plus LPIP for PAC with multiple mechanisms (MAC). Thus, the aim of this study is to demonstrate if LPI plus LPIP would be more effective than single LPI in controlling the progression of PAC with multiple mechanisms, based on ultrasound biomicroscopy (UBM) classification. A secondary aim is to determine whether or not this would result in the use of less medication and/or prolong the time to antiglaucoma surgery. METHODS This multiple-mechanism angle-closure study will comprise a 3-year, multicenter, randomized, parallel-group, open-label, superiority trial, the aim of which will be to evaluate the safety and efficacy of LPI plus LPIP versus LPI for PAC. It is anticipated that 240 adults, diagnosed with PAC (the mechanism of angle closure will be assessed by UBM and it will be determined whether or not it involves multiple mechanisms) will be recruited from ten ophthalmic centers in China. Participants will be randomly allocated to receive either single LPI or LPI plus LPIP. Participant assessment will be designed to test the rate of disease progression and who will be followed up for 3 years. The primary outcome will be the disease progression rate and a comparison will be made between the LPI and LPI plus LPIP groups using Pearson's χ2 test. Logistic regression analysis will be performed to account for the central effect. DISCUSSION If the LPI plus LPIP is found to significantly decrease the rate of PAC progression, this intervention could potentially be a standard therapy to be used to treat PAC when multiple mechanisms are involved in angle closure. Subsequently, this would have the potential to delay the rate of PAC progression to PACG and delay the time to the administration of antiglaucoma medication or trabeculectomy surgery. TRIAL REGISTRATION ClinicalTrials.gov, NCT02613013 . Registered on 24 November 2015. In fact, the study was due to start in late October 2015, however, there were no patients recruited in October, and when we registered at ClinicalTrials.gov on 5 November 2015, we received suggestions on the English translation of our protocol from the PRS Team at Clinicaltrial.gov, so the final successful registration date was on 24 November 2015.
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Affiliation(s)
- Shida Chen
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, 54 South Xianlie Road, Guangzhou, People's Republic of China
| | - Jianhua Lv
- Hebei Provincial Eye Hospital, Xingtai City, Hebei, People's Republic of China
| | - Sujie Fan
- Handan Eye Hospital, Handan City, Hebei, People's Republic of China
| | - Hong Zhang
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Lin Xie
- Department of Ophthalmology, Daping Hospital, The Third Military Medical University, Chongqing, Hubei, People's Republic of China
| | - Ling Xu
- Liaoning He University, He Eye Hospital, Shenyang, Liaoning, People's Republic of China
| | - Bing Jiang
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Huipin Yuan
- Department of Ophthalmology, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Yuanbo Liang
- Clinical and Epidemiological Research Center, the Affiliated Eye Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Shuning Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Laboratory, No. 1 Dong Jiao Min Xiang Street, Dongcheng District, Beijing, People's Republic of China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Xiulan Zhang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, 54 South Xianlie Road, Guangzhou, People's Republic of China.
| | - Ningli Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Laboratory, No. 1 Dong Jiao Min Xiang Street, Dongcheng District, Beijing, People's Republic of China.
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Bilateral Same-day Laser Peripheral Iridotomy in the Philadelphia Glaucoma Detection and Treatment Project. J Glaucoma 2016; 25:e821-e825. [DOI: 10.1097/ijg.0000000000000409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Functional evaluation of an iridotomy in primary angle closure eyes. Graefes Arch Clin Exp Ophthalmol 2016; 254:1141-9. [DOI: 10.1007/s00417-016-3298-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/07/2015] [Accepted: 12/17/2015] [Indexed: 11/26/2022] Open
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Comparison of Physiologic versus Pharmacologic Mydriasis on Anterior Chamber Angle Measurements Using Spectral Domain Optical Coherence Tomography. J Ophthalmol 2015; 2015:845643. [PMID: 25878896 PMCID: PMC4386293 DOI: 10.1155/2015/845643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/13/2015] [Indexed: 11/17/2022] Open
Abstract
Purpose. To compare the effects of physiologic versus pharmacologic pupil dilation on anterior chamber angle (ACA) measurements obtained with spectral domain optical coherence tomography (SD-OCT). Methods. Forty eyes from 20 healthy, phakic individuals with open angles underwent anterior segment OCT imaging under 3 pupillary states: (1) pupil constricted under standard room lighting, (2) physiologic mydriasis in a darkened room, and (3) postpharmacologic mydriasis. Inferior angle Schwalbe's line-angle opening distance (SL-AOD) and SL-trabecular-iris-space area (SL-TISA) were computed for each eye and pupillary condition by masked, certified Reading Center graders using customized grading software. Results. SL-AOD and SL-TISA under pupillary constriction to room light were 0.87 ± 0.31 mm and 0.33 ± 0.14 mm(2), respectively; decreased to 0.75 ± 0.29 mm (P < 0.01) and 0.29 ± 0.13 mm(2) (P < 0.01), respectively, under physiologic mydriasis; and increased to 0.90 ± 0.38 mm (P < 0.01) and 0.34 ± 0.17 mm(2) (P = 0.06) under pharmacologic mydriasis compared to baseline. Conclusions. Using SD-OCT imaging, pharmacologic mydriasis yielded the widest angle opening, whereas physiologic mydriasis yielded the most angle narrowing in normal individuals with open iridocorneal angles. Accounting for the state of the pupil and standardizing the lighting condition would appear to be of importance for future studies of the angle.
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Arora KS, Jefferys JL, Maul EA, Quigley HA. Choroidal thickness change after water drinking is greater in angle closure than in open angle eyes. Invest Ophthalmol Vis Sci 2012; 53:6393-402. [PMID: 22918644 DOI: 10.1167/iovs.12-10224] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To study change in choroidal thickness (CT) after water drinking test (WDT), comparing angle closure (AC) to open angle (OA) eyes. METHODS Before and 30 minutes after drinking 1 L of water, 88 glaucoma subjects underwent measurements of CT by spectral domain-optical coherence tomography, IOP, blood pressure (BP), axial length (AL), and anterior chamber depth (ACD). RESULTS Baseline CT was significantly greater in AC than in OA eyes (P = 0.002). After WDT, BP, IOP, and AL increased significantly (all P ≤ 0.0001). Mean CT increased significantly in the AC group (5.6 μm, P = 0.04, n = 40) and among 80 subjects whose IOP rose > 2 mm Hg (responders; 3.2 μm, P = 0.048), but not in the OA group or among all subjects (2.5 μm increase overall, <1% of baseline CT, P = 0.10). ACD decreased in AC (-18 μm, P = 0.07), but not in OA eyes (+3 μm, P = 0.74). AC eyes had a significantly greater IOP increase after WDT than OA eyes (P = 0.002, multivariate regression). Among responders, CT increased more in those with larger diastolic perfusion pressure increase and in AC compared to OA eyes (P = 0.04 and P = 0.053, respectively, multivariate regression). CONCLUSIONS A significant increase in CT and a decrease in ACD after WDT were observed in AC but not in OA eyes, and IOP increased significantly more in AC than in OA eyes, suggesting that the dynamic behavior of the choroid may play a role in the AC process. IOP increase after the WDT was not fully explained by CT increase.
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Affiliation(s)
- Karun S Arora
- Glaucoma Center of Excellence, Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Sng CC, Foo LL, Cheng CY, Allen JC, He M, Krishnaswamy G, Nongpiur ME, Friedman DS, Wong TY, Aung T. Determinants of Anterior Chamber Depth: The Singapore Chinese Eye Study. Ophthalmology 2012; 119:1143-50. [DOI: 10.1016/j.ophtha.2012.01.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 01/01/2012] [Accepted: 01/06/2012] [Indexed: 10/28/2022] Open
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Friedman DS, Foster PJ, Aung T, He M. Angle closure and angle-closure glaucoma: what we are doing now and what we will be doing in the future. Clin Exp Ophthalmol 2012; 40:381-7. [DOI: 10.1111/j.1442-9071.2012.02774.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Current World Literature. Curr Opin Ophthalmol 2012; 23:155-9. [DOI: 10.1097/icu.0b013e3283511bcf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The value of tests in the diagnosis and management of glaucoma. Am J Ophthalmol 2011; 152:889-899.e1. [PMID: 21924398 DOI: 10.1016/j.ajo.2011.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 06/24/2011] [Accepted: 06/24/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the noneconomic value of tests used in the diagnosis and management of glaucoma, and explore the contexts and factors that determine such value. DESIGN Perspective. METHODS Selected articles from primary and secondary sources were reviewed and interpreted in the context of the authors' clinical and research experience, influenced by our perspectives on the tasks of reducing the global problem of irreversible blindness caused by glaucoma. The value of any test used in glaucoma is addressed by 3 questions regarding: its contexts, its kind of value, and its implicit or explicit benefits. RESULTS Tonometry, slit-lamp gonioscopy, and optic disc evaluation remain the foundation of clinic-based case finding, whether in areas of more or less abundant resources. In resource-poor areas, there is urgency in identifying patients at risk for severe functional loss of vision; screening strategies have proven ineffective, and efforts are hindered by the inadequate allocation of support. In resource-abundant areas, the wider spectrum of glaucoma is addressed, with emphasis on early detection of structural changes of little functional consequence; these are increasingly the focus of new and expensive technologies whose clinical value has not been established in longitudinal and population-based studies. These contrasting realities in part reflect differences among the value ascribed, often implicitly, to the tests used in glaucoma. CONCLUSIONS The value of any test is determined by 3 aspects: its context of usage; its comparative worth and to whom its benefit accrues; and how we define historically what we are testing. These multiple factors should be considered in the elaboration of priorities for the development and application of tests in glaucoma.
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Yip JLY, Nolan WP, Davaatseren U, Baasankhuu J, Lee PS, Khaw PT, Johnson GJ, Foster PJ, Gilbert CE. Primary Angle Closure Glaucoma in East Asia: Educational Attainment as a Protective Factor. Ophthalmic Epidemiol 2011; 18:217-25. [DOI: 10.3109/09286586.2011.602507] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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