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Cataract surgery in patients with acute primary angle-closure glaucoma
Abstract
We investigated the results of cataract surgery in acute angle-closure glaucoma patients whose intraocular pressure (IOP) was not controlled with conventional treatment. We compared postoperative IOP and best corrected visual acuity (BCVA) with preoperative data in 10 eyes of 10 patients who had undergone cataract surgery for acute angle-closure glaucoma. Initial and preoperative mean IOP were 50.0 +/- 6.4 mmHg and 34.9 +/- 9.3 mmHg, respectively. Mean follow-up was 6.3 +/- 5.9 months. Postoperative mean IOP was 12.0 +/- 4.2 mmHg. All eyes were controlled at less than 21 mmHg and seven of them (70%) were controlled at less than 21 mmHg without medication. Postoperative BCVA was improved in 9 eyes. The complications were transient IOP elevation in 2 eyes and exudative membrane in 4. Cataract surgery may be effective to control IOP and improve visual acuity in patients with acute angle-closure glaucoma. However, follow up is necessary because of a high incidence of postoperative complications.
... CACG increases in prevalence with age and frequently coexists with cataract. Although lens removal may effectively lower IOP in some patients with CACG, [1][2][3][4] many patients do not experience a sufficient IOP decrease following cataract extraction alone. These patients may therefore require additional glaucoma surgery. ...
... [7] Combined filtering procedures generally result in a greater decrease in IOP compared With minimally invasive glaucoma surgeries, but carry an increased risk of postoperative complications. [1][2][3][4] Goniosynechialysis (GSL) involves the physical breaking of the PAS under direct visualization in an attempt to clear the aqueous pathway to Schlemm's canal (SC) through the trabecular meshwork (TM). Several studies have reported that this procedure combined with cataract extraction effectively lowers IOP, while minimizing significant postoperative complications such as hypotony. ...
Purpose
To compare surgical outcomes of patients after phacoemulsification with goniosynechialysis (phaco/GSL) versus phaco with GSL and endocyclophotocoagulation (phaco/GSL/ECP) in patients with chronic angle closure glaucoma (CACG) through 12-month follow-up.
Methods
A retrospective, nonrandomized, comparative case series was performed. Patients with CACG who underwent phaco in combination with either GSL alone (group 1) or GSL with ECP with intracameral injection of kenalog (group 2) from 2011 to 2018 were included. Group 1 included 6 eyes of 6 patients and group 2 included 11 eyes of 10 patients. All surgeries were performed by a single surgeon (RSA). Primary outcome measures included changes in intraocular pressure (IOP), visual acuity (VA), failure based on IOP (>18 or <6 mmHg at 1 year), and secondary operative procedures and complication rates. Data were analyzed using a paired two-tailed T-test.
Results
The mean preoperative IOP decreased from 23.5 ± 11.2 to 14.2 ± 2.4 mmHg (P < 0.0073) in group 1 and 24.4 ± 8.2 to 14.5 ± 2.7 mmHg (P < 0.0001) in group 2. The mean % IOP reduction was 33.7% in group 1 and 34.2% in group 2. The mean improvement in VA (logMAR units) was 0.24 (P = 0.085) in group 1 and 0.13 (P = 0.657) in group 2. The mean number of topical meds decreased from 2.50 ± 1.76 to 1.80 ± 1.64 in group 1 (P = 0.513) and from 2.82 ± 1.25 to 1.17 ± 0.98 in group 2 (P = 0.014).
Conclusion
Phaco/GSL and phaco/GSL/ECP both achieve a significant reduction in IOP without the complications associated with traditional glaucoma filtration surgeries.
... The procedure can separate the PAS from the angle under direct visualization, exposing the functional trabecular meshwork and restoring its filtering function. This procedure, combined with phaco under an endoscope for CACG, effectively lowers IOP and minimizes the postoperative complications of the filtering procedures [6][7][8] . Endocyclophotocoagulation (ECP; Endo Optiks, Little Silver, NJ, USA) was first reported by Uram in 1992 and delivers laser energy via an ab interno approach under direct visualization of ciliary processes [6] . ...
Aim:
To investigate the surgical outcomes of patients with chronic angle-closure glaucoma (CACG) treated with phacoemulsification (phaco)/endocyclophotocoagulation (ECP) with and without endoscopic goniosynechialysis (E-GSL).
Methods:
A retrospective, nonrandomized, comparative case series was conducted. Patients with CACG who underwent phaco in combination with either ECP alone (ECP group) or GSL with ECP (E-GSL group) from 2018 to 2019 were followed for 12mo and reviewed. Clinical features and outcomes were identified and analyzed. The ECP and E-GSL groups were matched in age and baseline intraocular pressure (IOP). Changes in IOP, mean of visual acuity (VA), peripheral anterior synechiae (PAS) formation, and the number of glaucoma medications was examined.
Results:
The ECP group included 32 eyes of 27 patients, and the E-GSL group included 32 eyes of 26 patients. The preoperative baseline IOP was 22.18±6.48 mm Hg in the ECP group and 22.95±6.71 mm Hg in the E-GSL group (P=0.644). The mean IOP reduction was 26.2% in the ECP group and 41.6% in the E-GSL group at 12mo. The mean postoperative VA (logMAR units) at 12mo was 0.47 in the ECP group and 0.36 in the E-GSL group. The reduction in PAS formation and the number of glaucoma medications was also higher in the ECP group than E-GSL group at 12mo.
Conclusion:
The phaco/ECP and phaco/E-GSL groups both achieve a significant reduction in IOP without complications associated with traditional glaucoma filtration surgeries.
... Prum et al., 2016;Lai & Gangwani, 2012). There are anatomical factors that have been associated with increased incidence of an acute angle closure event, including narrow iridotrabecular angles, a shallow anterior chamber, thicker crystalline lens, cataracts, and shorter axial length(Lai & Gangwani, 2012;Prum et al., 2016;Yoon et al., 2003). While our survey noted that 64% of researchers examined the iridocorneal angle prior to dilation, none said that they examined the angle after dilation. ...
Standards in pupil dilation practices regarding the safety of human subjects are not present in vision research despite the potential for significant adverse effects. We developed two surveys to examine current practices around pupil dilation among vision researchers and individuals associated with oversight of human subjects research. While both groups note an absence of adverse events associated with pupil dilation, vision researcher practices differed with informed consent use and measures taken to minimize complications. For Institutional Review Boards, general risk assumption associated with dilation was not unanimous and there was a lack of specific guidance available to researchers for minimizing risk. These results uncover the need for standardized practices regarding pupil dilation in human subjects research.
... -대한안과학회지 2019년 제 60 권 제 5 호 -보고되었다. [4][5][6][7] ...
Purpose: To report the results of cataract surgery with vitrectomy for acute angle-closure glaucoma. Cases and Method: This retrospective study was made on 16 eyes of 14 patients who received surgery during the past 20 months. The series comprised 4 male and 12 female eyes. The age ranged from 57 to 86 years, average 74 years. Intraocular pressure (IOP) averaged 56.3 mmHg before surgery. All the eyes received phacoemulsification-aspiration followed by implantation of intraocular lens (IOL). Additional core vitrectomy was performed on 6 eyes. Goniosynechialysis was performed on one eye. Cataract surgery was performed in 10 eyes by surgeons with less than 3 years of training. Results: Intraocular lens could be fixated in the bag in all the eyes. There was no postoperative complications except one eye each that needed laser iridotomy or goniosynechialysis. Final IOP was below 22 mmHg in all the eyes and averaged 11.8 mmHg. Medication could be discontinued in 12 out of 16 eyes after surgery. Conclusion: Cataract surgery and IOL implantation with or without core vitrectomy is effective for acute angle-closure glaucoma, induces IOP control, and has minor intra- or postoperative complications. This surgical modality can be performed by surgeons with less than 3 years of experience.
Purpose: To report changes in refraction following lens removal with implantation of intraocular lens (IOL) in eyes with acute glaucomatous attack. Cases: This study was made on 14 eyes that received lens removal with implantation of intraocular lens (IOL) during acute glaucomatous attack in the past 3 years. The series comprised 4 males and 10 females. The age averaged 68 years. Results: Intraocular pressure averaged 52.5 mmHg before and 15.2 mmHg after surgery. Length of ocular axis averaged 22.3 ±0.77 mm. Corneal curvature, expressed as K1 and K2, averaged 7.72 mm and 7.49 mm respectively before, and 7.63 mm and 7.50 mm after surgery. The difference was not significant. No difference was present between target refraction before and actual one after surgery. Conclusion: There was no difference between target and actual refraction in eyes that received lens removal with IOL implantation during acute glaucomatous attack.
Aim: To evaluate the clinical presentation, progression, and treatment outcome after acute primary angle closure in Thai patients. Methods: This was a retrospective study of 68 eyes of 66 consecutive patients with acute primary angle closure presenting to the Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand, from 2000 to 2002. Acute angle closure from secondary causes was excluded. The predictive factors for the need for filtration surgery were studied. Results: There were 15 men and 51 women with a mean age of 60.5 years (range, 35 to 81 years). The mean intraocular pressure at presentation was 58.2 mm Hg (SD, 14.3 mm Hg). After initial treatment with antiglaucoma medications, all eyes underwent laser peripheral iridotomy. Three eyes needed additional surgical peripheral iridotomy. The intraocular pressure of 45 eyes (66.2%) was successfully controlled at <21 mm Hg without further intervention. Of the 45 eyes, only 7 (15.5%) required no antiglaucoma medication at discharge. The remaining 23 eyes (33.83%) underwent filtration surgery. The filtration surgery group had a mean duration of symptoms significantly longer than that of the non-filtration surgery group (p < 0.05) and a significantly greater mean pupil size within 24 hours of the initial treatments (p < 0.05). Conclusion: Prompt diagnosis and early treatment for acute primary angle closure is important to prevent subsequent morbidity. Laser peripheral iridotomy and medications can control acute episodes of angle closure and its sequelae for most patients, with one-third requiring surgical intervention for control of intraocular pressure.
We performed phacoemulsification and intraocular lens (IOL) implantation as the primary procedure for acute angle-closure glaucoma in 23 eyes of 21 patients. The series comprised 2 eyes of 2 males and 21 eyes of 19 females. Their ages averaged 67.6±8.9 years. The axial length averaged 22.1±0.9 mm. The initial intraocular pressure (IOP) ranged from 24 to 70 mmHg, average 48.7 mmHg. The duration of surgery averaged 24.6 minutes. Additional core vitrectomy was performed in 3 eyes. There was no intraoperative complication except one eye in which IOL was not implanted due to ruptured zonule. IOP on next day of surgery ranged from 8 to 26 mmHg average 14.8 mmHg. Additional glaucoma surgery had to be performed in one eye only. Final IOP averaged 14.0 mmHg. Two eyes were using topical antiglaucoma medication. Visual acuity improved in 18 eyes (78%) and remained unchanged in 5 eyes (22%). No case developed bullous keratopathy during the period of observation. The findings show that phacoemulsification with IOL implantation is safe and effective for acute angle-closure glaucoma.
Purpose: to study the efficacy and safety of phacoemulsification with intraocular lens implantation for controlled angle closure glaucoma. Design: prospective non randomized comparative study. Methods: 50 eyes of 36 patients were included in the study.25 eyes were treated by primary phacoemulsification with IOL implantation (IOL group) and 25 eyes were treated by laser iridotomy (LI group). IOP, number of antiglucoma medications, corneal endothelial cell counts were assessed in each group. Results: in IOL group, IOP was significantly reduced from preoperative mean of 16.014±0.27mmHg to a 6 months postoperative mean of 11.68±0.12mmHg (P=0.001). However in LI group, the mean preoperative IOP was 15.99±0.003mmHg and the 6 months postoperative IOP was 15.95±0.20 (P=0.264). In IOL group, no cases used antiglucoma medications 6 months postoperatively while in LI group the mean number of antiglucoma medications was 0.23±0.04 (P=0.0001). There were no significant differences in preoperative and postoperative corneal endothelial cell counts between IOL &LI groups (P=0.63). Conclusion: phacoemulsification with intraocular lens implantation for controlled CACG is a safe and effective method in reducing IOP, so the procedure could be the treatment of choice for controlled CACG with cataract.
Among Caucasians, it is well known that 75-95% of primary glaucoma is due to open-angle glaucoma (POAG), with angle-closure (PACG) comprising only a very small minority of cases. These figures are reversed among other groups such as Asians and Eskimos, where PACG makes up 80-90% of primary glaucoma. Among Eskimos, the prevalence of PACG has been reported as 2-8%, as compared to 0.1% among Caucasians. It appears that a population tendency toward shallow anterior chambers may explain the excess burden of PACG morbidity. Among Asians, the prevalence of PACG is intermediate between Caucasians and Eskimos. Existing biometrical data do not show a clear tendency toward shallower anterior chambers among Asians. PACG may be screened for on a population basis by means of various techniques that estimate axial or limbal anterior chamber depth, measure intraocular pressure, or evaluate the optic disc or visual fields. Demographic information and medical and family history will also be of great importance in screening for PACG in large populations. Groups at increased risk for the disease include women, individuals over 50, first-degree relatives of PACG probands, and hyperopes.
To estimate the prevalence of glaucoma among people worldwide.
Available published data on glaucoma prevalence were reviewed to determine the relation of open angle and angle closure glaucoma with age in people of European, African, and Asian origin. A comparison was made with estimated world population data for the year 2000.
The number of people with primary glaucoma in the world by the year 2000 is estimated at nearly 66.8 million, with 6.7 million suffering from bilateral blindness. In developed countries, fewer than 50% of those with glaucoma are aware of their disease. In the developing world, the rate of known disease is even lower.
Glaucoma is the second leading cause of vision loss in the world. Improved methods of screening and therapy for glaucoma are urgently needed.
To determine the prevalence of glaucoma and suspect glaucoma, and to classify the cases detected according to mechanism.
A population-based prevalence study.
Rural and urban locations in Hövsgöl province, northern Mongolia.
Nine hundred forty-two (94.2%) of 1000 individuals 40 years of age and older were examined.
Primary angle-closure glaucoma was diagnosed in subjects with previous acute or intermittent symptoms of angle closure and in individuals with an occludable angle and an intraocular pressure greater than 19 mm Hg or a glaucomatous visual field.
The prevalence of manifest primary angle-closure glaucoma was 1.4% (14 subjects). The prevalence of gonioscopically occludable angles was 6.4% (64 subjects, including those with glaucoma). Primary open-angle glaucoma was diagnosed in 5 subjects (prevalence, 0.5%). As all these subjects were older than 60 years, the prevalence became 2.1% for this age group. Three cases (prevalence, 0.3%) of secondary open-angle glaucoma were detected. No cases of secondary angle-closure glaucoma were diagnosed. The prevalence of blindness was 1.2% (12 subjects), and primary glaucoma accounted for one third of these cases (4 subjects).
We confirmed glaucoma as a major public health problem in northern Mongolia. Primary angle-closure glaucoma is more prevalent than primary open-angle glaucoma, supporting clinic-based data from other east Asian countries. Among the subjects examined, 97 (9.7%) had either manifest, latent, or suspect glaucoma. Neighboring populations may be similarly affected owing to a shared genetic heritage.
Data on prevalence of glaucoma in East Asia are scarce.
To determine the prevalence and clinical characteristics of glaucoma in adult Chinese Singaporeans.
A group of 2000 Chinese people, aged 40 to 79 years, were selected from the electoral register of Tanjong Pagar district in Singapore using a disproportionate, stratified, clustered, random-sampling procedure. Glaucoma was diagnosed in people with an excavated optic neuropathy and a reproducible visual field defect or on the basis of severe structural disc abnormality alone, if reliable field results could not be obtained. The diagnosis was also made in blind subjects with raised intraocular pressure or previous glaucoma surgery.
Of 1717 eligible subjects, 1232 were examined, with a response rate of 71.8%. There were 45 cases of glaucoma: 27 were men and 18 were women. The main diagnoses were primary open-angle glaucoma (n = 22 [49%]), primary angle-closure glaucoma (n = 14 [31%]), and secondary glaucoma (n = 7 [16%]). It was not possible to determine the mechanism in 2 (4%).
The age-standardized prevalence of glaucoma was 3.2% (95% confidence interval, 2.3-4.1) in the population 40 years and older. Glaucoma was the leading cause of blindness. Primary angle-closure glaucoma and secondary glaucoma were the most visually destructive forms of the disease. Our findings suggest current projections of glaucoma prevalence among ethnic Chinese are a substantial underestimate. Arch Ophthalmol. 2000;118:1105-1111
To assess the prevalence and features of angle-closure glaucoma (ACG) in an urban population in southern India.
A population-based, cross-sectional study.
A total of 2522 (85.4% of those eligible) persons of all ages, including 1399 persons 30 years of age or older, from 24 clusters representative of the population of Hyderabad city.
The participants underwent an interview and detailed eye examination that included logarithm of minimum angle of resolution visual acuity, refraction, slit-lamp biomicroscopy, applanation tonometry, and gonioscopy; pupil dilatation and stereoscopic fundus evaluation was performed if the risk of angle-closure as a result of dilatation was not believed to be imminent. Humphrey threshold 24-2 visual fields (Humphrey Instruments Inc., San Leandro, CA) were performed when indicated by standardized criteria for disc damage or if intraocular pressure (IOP) was 22 mmHg or more.
An occludable angle was defined as pigmented posterior trabecular meshwork not visible by gonioscopy in three quarters or more of the angle circumference. Manifest primary angle-closure glaucoma (PACG) was defined as IOP of 22 mmHg or more or glaucomatous optic disc damage with visual field loss in the presence of an occludable angle. An IOP of 22 mmHg or more or glaucomatous optic disc damage in the presence of an occludable angle secondary to an obvious cause was defined as secondary ACG.
Manifest PACG and occludable angles without ACG were present in 12 and 24 participants, respectively, with age- and gender-adjusted prevalence (95% confidence interval [CI]) of 0.71% (0.34%-1.31%) and 1.41% (0.73%-2.09%) in participants 30 years of age or older, and 1.08% (0.36%-1.80%) and 2.21% (1.15%-3.27%) in participants 40 years of age or older, respectively. With multivariate analysis, the prevalence of these two conditions considered together increased significantly with age (P < 0.001); although not statistically significant, these were more common in females (odds ratio 1.70; 95% CI, 0.82-3.54) and in those belonging to lower socioeconomic strata as compared with middle and upper strata (odds ratio, 1.82; 95% CI, 0.88-3.74). The odds of manifest PACG were higher in the presence of hyperopia of more than 2 diopters ([D]; odds ratio, 3.69; 95% CI, 0.89-15.2). Only four of 12 participants (33.3%) with manifest PACG had been previously diagnosed, and one of 12 (8.3%) had peripheral iridotomy performed previously. Manifest PACG had caused blindness in one or both eyes in five of these 12 participants (41.7%); best-corrected distance visual acuity less than 20/400 in one or both eyes in four patients, and acuity less than 20/200 in one eye in another patient. Most (83.3%) of those with manifest PACG could be classified as having chronic form of the disease. We may have underestimated manifest PACG because visual fields were per- formed only on those with clinical suspicion of optic disc damage. Secondary ACG was present in two participants.
The prevalence of PACG in this urban population in southern India is close to that reported recently in a Mongolian population. A large proportion of the PACG in this population was undiagnosed and untreated. Because visual loss resulting from PACG is potentially preventable if peripheral iridotomy or iridectomy is performed in the early stage, strategies for early detection of PACG could reduce the high risk of blindness resulting from PACG seen in this urban population in India.
Choice of operation in eyes with primary glaucoma and cataracts
- J Guyton
Guyton J S. Choice of operation in eyes with primary glaucoma and cataracts. Trans Am Acad Ophthalmol Otolaryngol. 1945;49:216-214.