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Consider clear-lens extraction first-line treatment for PACG
Clear-lens extraction improved overall health status, visual impairment and disability, and glaucoma-specific disability in primary angle closure and primary angle-closure glaucoma, according to researchers in The Lancet.
Of 419 patients enrolled from 30 hospital eye services in five countries, 155 had primary angle closure and 263 had primary angle-closure glaucoma (PACG). A total of 208 were assigned to clear-lens extraction and 211 to standard care.
European Quality of Life-5 Dimensions scores and intraocular pressure at 36 months significantly favored the clear-lens extraction group, according to the study.
National Eye Institute Visual Function Questionnaire-25 and Glaucoma Utility Index scores at 36 months were significantly higher in the clear-lens extraction group than in the standard care group.
Significantly fewer patients in the clear-lens extraction group needed treatment to control IOP, and fewer needed glaucoma medications than patients who received standard care, researchers found.
At 3 years, the mean IOP was about 1 mm Hg lower in the clear-lens extraction group.
The clear-lens extraction group showed higher total quality-adjusted life-years, and the procedure was more cost-effective than laser peripheral iridotomy.
“...the consistent superiority of clear-lens extractions in terms of patient-reported and clinical benefits and the absence of serious safety issues provide strong support for considering this approach as the first-line treatment for individuals with primary angle-closure disease,” researchers wrote. – by Abigail Sutton
Disclosure: The researchers reported no relevant financial disclosures.
Perspective
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Laser peripheral iridotomy has long been the initial treatment of choice for primary angle closure glaucoma.
Although an excellent prophylactic treatment, laser peripheral iridotomy (LPI) often fails to reverse angle closure after it occurs. Azuara-Blanco and colleagues have designed and executed a multicenter clinical trial that provides strong evidence that clear lensectomy should be considered over LPI for the treatment of primary angle closure glaucoma (PACG).
Angle closure occurs primarily by pupil block in patients with shallow anterior chambers. It stands to reason that removing the lens would resolve the anatomic factors that lead to angle closure by significantly deepening the anterior chamber. As cataract surgery has evolved, complication rates have also fallen, making this option generally safe.
Reports on LPI leading to cataract formation notwithstanding, as optometrists we may best serve our patients by using gonioscopy to help identify patients at risk for PACG and promptly recommending prophylactic LPI. This simple procedure may prevent an often aggressive and sight-threatening condition.
For those patients with PACG, referral to a progressive cataract surgeon for clear lensectomy now appears to be an excellent option.