|Early phaco/IOL in the management of APAC glaucoma|
|Monday, 04 March 2013|
Husain R, Gazzard G, Aung T, et al. Initial management of acute primary angle closure: A randomised trial comparing phacoemulsification with laser peripheral iridotom. Ophthalmology 2012; 119: 2274-81.
In a nutshell
For the phaco /IOL group, miotic drops were stopped on the morning of surgery; intravenous mannitol 20% was given two hours before the start of surgery if IOP was >21mmHg. A visco-elastic agent was injected 360° circumferentially in the angle to deepen the anterior chamber but removed at the end of the procedure.
The mean IOP after medical treatment was 14.5mmHg. There were significantly more failures at two years in the LPI group (7/18 – 38.9%) compared with the phaco/IOL group (2/19 – 10.5%). Failures in the LPI group underwent phacotrabeculectomy with Mitomycin-C. The two failures in the phaco/IOL group required topical IOP-lowering medication.
Six subjects in the LPI group which had been categorised as having achieved complete success in terms of IOP control underwent subsequent cataract surgery due to increased lens opacities and loss of visual acuity. All procedures which failed did so in the first six months.
A decrease in the amount of PAS in both groups is surprising; the injection of viscoelastic circumferentially may have contributed to the breaking of PAS. Phaco/IOL results in a deeper anterior chamber and better IOP control.
Endothelial cell count reduced by 2% compared to 8% after standard uncomplicated phaco/IOL despite the fact that surgery was carried out on ‘hot’ eyes.
Statistical analysis would have been more meaningful if a sample size of 70 as initially targeted was completed; but the study had to stop due to expiry of research funding.
To provide a clearer picture of the longer term effects of cataract extraction on angle closure glaucoma, a multicentre (23 in the UK, seven in Asia and one in Australia) EAGLE study is under way to establish if clear lens extraction can be justified.
Joseph A Coleiro