SURGICAL MANAGEMENT OF SURGICAL MANAGEMENT OF CHRONIC ANGLE CLOSURE CHRONIC ANGLE CLOSURE

H. George Tanaka, MD H. George Tanaka, MD

Assistant Clinical ProfessorAssistant Clinical ProfessorCalifornia Pacific Medical CenterCalifornia Pacific Medical Center

San Francisco, CASan Francisco, CA

Financial DisclosuresFinancial Disclosures

• Alcon• Allergan• Merck• iScience

When should I perform lens When should I perform lens extraction alone?extraction alone?

Take out the cataract!Take out the cataract!

Patient is a presbyopic hyperope = good candidate for multifocal IOLLaser-assisted cataract surgery (LACS)Treat corneal astigmatism with arcuate incisions“Kill FIVE birds with one stone”Cataract surgery will deepen the angle

PACSPrimary Angle Closure

Suspect

PACPrimary Angle Closure

PACGPrimary Angle Closure

Glaucoma

≥180° ITC IOP and/or PAS Glaucomatousoptic neuropathy

DISEASESTAGING

+++

-

++

-

-+Optic nerve damage

TM dysfunction

TM at risk

PACSPrimary Angle Closure

Suspect

PACPrimary Angle Closure

PACGPrimary Angle Closure

Glaucoma

RISK OF DISEASE PROGRESSION

TM at risk22% in 5 years

TM dysfunction28% in 5 years

Optic nerve damage

PPUUSSHH

AQUEOUSAQUEOUS

LENSLENS

IRISIRIS

NOT MUTUALLY EXCLUSIVE !

VITREOUSVITREOUS

CILIARYCILIARYBODYBODY

CHOROIDCHOROID

DISEASEMECHANISM

STRUCTURE

Narrow angle

Irido-trabecular contactAppositional(reversible)

Irido-trabecular contactSynechial

(irreversible)

FUNCTION

TM normalIOP normal

TM dysfunctionIOP Elevated

TM blockageIOP Elevated

TIME

PupillaryBlock

Lens

IRISABNORMALITY

- Intrinsic- Insertion

We need an OHTS equivalentWe need an OHTS equivalentfor narrow angles!for narrow angles!

IOP > 21 mm Hg

We need “PACTS”! We need “PACTS”!

Primary Angle Closure

Angle Closure Glaucoma

The Effectiveness in Angle-closure The Effectiveness in Angle-closure Glaucoma of Lens Extraction (EAGLE) Glaucoma of Lens Extraction (EAGLE)

Study GroupStudy Group• Prospective multicenter randomized controlled trial• Lens extraction vs. LPI in newly diagnosed PAC or

PACG• Primary outcomes: IOP, QOL, cost-effectiveness at 3

years

Azuara-Blanco A, Burr JM, Cochran C, et al. The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): study protocol for a randomized controlled trial. Trials 2011; 12:133.

Effect of Lens on CB PositionStrenk & Strenk Eye World Sept. 2007

74 y/o Male Paired Eyes74 y/o Male Paired Eyes

PhakicPhakic PseudophakicPseudophakic

(Slide courtesy of Murray Johnstone, MD)(Slide courtesy of Murray Johnstone, MD)

Apical Portion of CB Moves Anteriorly With Age Apical Portion of CB Moves Anteriorly With Age Apical Portion of CB Moves Backward With Lens RemovalApical Portion of CB Moves Backward With Lens Removal

There is little clinical evidence to There is little clinical evidence to support support anyany surgical treatment for surgical treatment for

PACS or PACPACS or PAC

What is an acceptable number needed to What is an acceptable number needed to treat (NNT) to prevent progression from treat (NNT) to prevent progression from

PACS to PAC or PACG?PACS to PAC or PACG?

NNT = 50?NNT = 5?NNT = 1?

Laser iridotomy is not without Laser iridotomy is not without risks.....risks.....

Glare (location-dependent?)More rapid cataract progressionCorneal endothelial lossIritisElevated IOPHyphemaPosterior synechiae

Cataract surgery is not without Cataract surgery is not without risks.....risks.....

Suprachoroidal hemorrhageEndophthalmitisRetinal detachmentCystoid macular edemaElevated IOPCorneal endothelial lossDysphtopsiaIncorrect IOL power

When should I perform lens When should I perform lens extraction alone?extraction alone?

When the patient has a “visually significant” cataract!

When can I justify a When can I justify a clear lensectomy clear lensectomy after a after a patent iridotomy?patent iridotomy?

Development of PACTM dysfunction = elevated IOP or

PASSpecial circumstances unique to the patient:

Symptoms suggestive of intermittent angle closureSystemic medications that may precipitate angle closureNeed for repeat dilated exams (diabetes, retinal disease)Unreliable access to eye care

• “In a country where an aggressive cataract surgical programme is likely to catch up with the patient, do we need to intervene with the laser at all?”

• R. Thomas BJO 2003, 87:453

When should I perform lens When should I perform lens extraction alone?extraction alone?

General approach: ANGLEGeneral approach: ANGLE

Assign stage: PACS, PAC, PACGKNow the mechanismGonio after treatment

Look at the whole patient, not just the angleEvidence-based treatment guidelines – stay tuned!