Early Phacoemulsification A Superior Option for Patients With Angle Closure

Early phacoemulsification with intraocular lens (IOL) implantation is a more effective way to reduce the need for medication avoid intraocular pressure (IOP) spikes, and prevent blindness for patients with acute primary angle closure (APAC) than other methods, researchers in Hong Kong have concluded. Clinicians should take life expectancy and visual function of the other eye into account when recommending treatment, according to findings published in the Journal of Glaucoma. 

Previously, randomized controlled trials determined that soon after APAC is halted with medications, primary phacoemulsification with IOL implantation is more effective than laser peripheral iridotomy (LPI). Success was defined in this research as maintaining an IOP of lower than 21 mm Hg with fewer glaucoma medications, and achieving a wider angle within the first 2 years. However, outcomes of these patients were not reported beyond 18 months.

The current study aimed to compare the 10-year clinical outcomes of this same group of patients who had been randomized to receive early phacoemulsification or LPI shortly after medically treated APAC. To do this, the team recruited 62 APAC patients who had undergone either early phacoemulsification (phaco group) or LPI (LPI group) in a previous randomized controlled trial for a 10-year assessment. Then, they compared the results of the 2 groups. Researchers examined 40 of 62 patients (64.5%; 19 in the phaco group and 21 from the LPI group). None had any additional glaucoma procedures, but 15 patients in the LPI group (71.4%) received lens extraction before this assessment. The mean follow-up duration was approximately 10.7 years.

The phaco group used fewer medications (0.16 bottles per eye ± 0.37 bottles per eye vs 0.76 bottles per eye ± 1.09 bottles per eye, P =.028), had less extensive anterior synechiae (120.0 ˚±116.12 ˚ vs 244.3 ˚± 139.8 ˚, P =.010), and greater mean Shaffer gonioscopy grading (1.79 ± 0.84 vs 1.40 ± 0.87; P =.021) than the LPI group. Findings reveal that 5 eyes had persistent IOP elevation of greater than 21 mm Hg in 2 consecutive visits, and 4 eyes in the LPI group had blindness (defined as best-corrected visual acuity worse than 6/60 and/or a central visual field of less than 20 ˚) compared with no eyes in the phaco group (P =.022 and P =.045, respectively). Investigators noted no significant difference in the mean IOP, best-corrected visual acuity, and the number of eyes with visual field progression.

This study has several limitations, including that its retrospective design didn’t enable an analysis of the outcome at other time points. Other limitations were that multiple ophthalmologists were involved, its small sample size due to a high dropout rate, that deceased patients’ charts could not be evaluated, and that a high percentage of patients in the LPI group underwent phacoemulsification after the end of the last trial. Lastly, researchers admit that the study could have potential selection bias toward younger, healthier, and more motivated subjects.

Reference

Chan PP, Tong F, Leung DY, et al. Ten-year Clinical Outcomes of Acute Primary Angle Closure Randomized to Receive Early Phacoemulsification versus Laser Peripheral Iridotomy. J Glaucoma. Published online February 1, 2021. doi:10.1097/IJG.0000000000001799