Speaker: Cataract surgery, goniosynechialysis together increase IOP control in angle closure glaucoma

Issue: April 10, 2014

WASHINGTON — Cataract removal and goniosynechialysis work together to lower IOP in patients with angle closure glaucoma and significant synechiae, possibly avoiding further surgery, a speaker said here.

Perspective from Steven D. Vold, MD

Even though phacoemulsification alone may result in significant widening of the anterior chamber angle, combining goniosynechialysis with the cataract surgery could achieve better IOP control while also avoiding a trabeculectomy, Marlene R. Moster, MD, told colleagues at the American Glaucoma Society meeting.

Marlene R. Moster

In these cases, Moster said she works through very small 1-mm incisions, using a gonioprism, MST micro-grabbers and viscoelastic, to pull the iris away from the angle.

It is critically important to remove all viscoelastic so as not to have a pressure spike the next day, she said.
To finish the case, Moster applies Miostat (carbachol, Alcon) and hydrates the wound.

“Phacoemulsification and goniosynechialysis for the management of chronic angle closure glaucoma makes perfect sense,” Moster said. “Often times it will restore the anatomy to make this surgery a win-win outcome, with good vision, lower pressure and a more normal-appearing angle structure.”

Disclosure: Moster has no relevant financial disclosures.

Perspective

Steven D. Vold, MD

At the recent annual meeting of the American Glaucoma Society, Dr. Marlene Moster gave an outstanding presentation discussing the role of cataract surgery combined with goniosynechialysis in the management of angle closure glaucoma. Classically, goniosynechialysis has been recommended in patients with more acute angle closure glaucomas. Many experts feel that long-standing synechial closure may not respond as well to this procedure. Under intraoperative gonioscopic visualization, microforceps or even the automated irrigation-aspiration instrument tip may be utilized to gently tease peripheral anterior synechiae out of the anterior chamber angle to expose the pigmented trabecular meshwork. If performed within the first few months after synechiae formation, trabecular meshwork function and patient vision may be restored. With cataract extraction, deepening of the anterior chamber and traction on the trabecular beams may enhance aqueous outflow as well. With proper patient selection, this combined procedure may help surgeons avoid the potential risks of filtration surgery and the need for glaucoma medication postoperatively.

Steven D. Vold, MD

Vold Vision, Fayetteville, Ark.

Disclosures: Vold has no relevant financial disclosures.