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Lens extraction controls IOP long-term in PACG patients
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A review of recent studies showed that lens extraction is a valid treatment option for patients with primary angle closure glaucoma.
Trikha and colleagues reported in Current Opinion in Ophthalmology that lens extraction should be considered for patients with hyperopia or an anteriorly vaulted and thick lens, especially.
Researchers reviewed recent cohort, randomized and case-control studies in order to clarify the role that lens extraction should play in primary angle closure glaucoma (PACG) patients.
They noted that there were various clinical factors that had to be evaluated in all PACG patients to identify a treatment strategy.
"The extent of optic disc/visual field damage; the extent of peripheral anterior synechiea and residual angle closure; magnitude of IOP (untreated) and number of glaucoma medications; magnitude of the lens vault or lens thickness; visual acuity; and refractive error, particularly the degree of hyperopia," they stated.
The authors explained that, in terms of timing of surgery, a reasonable wait was about 1 to 2 weeks from presentation. They also emphasized that it was vital to consider the individual risks for each patient and whether the surgery would ultimately prove beneficial.
"The role of lens extraction in PACG has been the subject of increasing interest," the authors wrote. "While imaging has yielded new insights into the mechanical role of the lens in angle closure, randomized clinical trials are paving the way toward stronger, evidence-based management options.”
They noted that recent studies suggest phaco alone as a feasible option for controlling IOP in patients with PACG, with these patients experiencing superior long-term IOP control. The risks should be considered, however.
Phaco can be combined with trabeculectomy in eyes that require greater IOP reduction, and phaco with or without GSL “seems to have an impressive impact” for patients with acute primary angle closure, the researchers said.
They concluded: "In the presence of a clear lens, lens extraction for PACG is more controversial but may be considered if there is increased lens thickness or lens vault, once balanced against the potential risks of surgery." – by Chelsea Frajerman Pardes
Disclosure: The authors report to relevant financial disclosures.
Perspective
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Carl H. Jacobsen, OD, FAAO
Angle closure occurs when the iris obstructs aqueous outflow, which leads to significant IOP elevation and often quickly progressing glaucoma. Although many possible mechanisms exist, most cases are caused by pupil block. The stereotypic angle closure patient would be an older (thicker lens narrows the angle), Asian (racial predilection) hyperope (shorter axial length).
Laser peripheral iridotomy is a good prophylactic angle closure treatment for at-risk patients, but it may not sufficiently treat some angle closure patients or suspects. Because cataract extraction significantly increases anterior chamber depth, it stands to reason that this procedure may be therapeutic for angle closure.
Additionally, goniosynechialysis and trabeculectomy procedures may be performed in conjunction with cataract extraction.
Trikha and colleagues have provided us with an excellent overview on this topic. Not surprisingly, they found cataract extraction to be an effective treatment for angle closure.
Surgical best practices need scientific evidence of efficacy regardless of how intuitively obvious the intervention. Emboldened with scientific proof, surgeons will hopefully consider cataract extraction sooner when more conventional treatments are showing signs of failure.
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