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Phaco alone has advantages in patients with uncontrolled primary angle closure glaucoma
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MILAN — Lens extraction may be an appropriate alternative to trabeculectomy in eyes with uncontrolled primary angle closure glaucoma, according to one surgeon.
“PACG eyes have a shallower anterior chamber with a narrower drainage angle. The lens is abnormally thick, with a steeper anterior surface, and is positioned more anteriorly. By taking off the lens and implanting an IOL, we deepen the anterior chamber, widen the angle and reverse the anatomical predisposition to angle closure,” Clement C.Y. Tham, BM, BCh, FCOphth, FRCS, said at the annual joint meeting of Ocular Surgery News and the Italian Society of Ophthalmology.
Clement C.Y. Tham
Effective IOP lowering and reduction of drugs are obtained, along with a decreased need for subsequent filtration surgery and related complications.
In a study carried out in Hong Kong, PACG patients with cataract and uncontrolled IOP were treated surgically with phacoemulsification alone or combined phacoemulsification and trabeculectomy. Phacoemulsification alone resulted in a one-third reduction of IOP and 50% reduction of medications immediately after surgery and sustained over 24 months.
“With phacotrabeculectomy, fewer drugs were needed postoperatively and we had some additional benefits on IOP, which was on average 2 mm Hg lower compared to phaco alone, but this advantage disappeared over the 24-month period,” Tham said.
In addition, the complication rate was double in the phacotrabeculectomy group, including cases of re-intervention. The benefits of phacotrabeculectomy, he noted, are probably not sufficient to justify the risk of complications and additional interventions.
“The situation might be less straightforward with a clear lens because it makes you feel as if you were committing a sin. But believe me, you are not. The lens in these patients is not normal: It is anterior, it is thick, and it causes angle closure. We should not emphasize the only normal aspect of this lens,” Tham said.
The combined procedure remains a better option in cases in which drug reduction is a priority, he said. - by Michela Cimberle
Disclosure: Tham reports he is a consultant for Alcon, Allergan, Bausch + Lomb, IOPtima, Merck & Co., Pfizer and Santen.