Phaco outperforms laser iridotomy at 2 years in acute primary angle closure

Thomas W. Samuelson, MD

This article compares two surgical treatment options for acute angle closure glaucoma following initial stabilization with medical therapy. It is important to note that to qualify for enrollment, all eyes had IOP less than 30 mm Hg following initial treatment with an aggressive medical regimen including intravenous acetazolamide. Further, only patients with reduced best corrected vision were enrolled (vision worse than 6/15). In this carefully selected population, phacoemulsification was found to be more effective at controlling IOP than laser iridotomy over a 2-year follow-up period. Additionally, two-thirds of patients in the laser peripheral iridotomy (LPI) group required additional surgery (six of 18 had subsequent phacoemulsification and six of 18 had subsequent phaco-trabeculectomy) during the 2-year follow-up period. 

The study supports early cataract surgery in eyes with compromised angles. Whether or not the findings of this study can be extrapolated to eyes with earlier lens opacities in the setting of compromised angles is unclear. But increasingly, in my own practice, I discuss both options (LPI and cataract extraction/IOL implantation, or CE/IOL) with patients whom I believe to have occludable angles. If such patients are symptomatic from their cataract, I tend to favor CE/IOL, even if the vision has not yet declined to the level traditionally required for phacoemulsification. This study adds to the mounting evidence that cataract surgery is a favorable event in the management of glaucoma.