9/25/2017 CASE. 67 years old On 2 topical meds since 3 years. Rx: +3.0 RE LE

Transcription

1 CASE 67 years old On 2 topical meds since 3 years Rx: +3.0 /-0.5@65 RE +2.5/-0.5@115 LE IOP : 17 RE 19 LE CD: 0.5 RE 0.6 LE 1

2 67 years old On 2 topical meds since 3 years Rx: +3.0 /-0.5@65 RE +2.5/-0.5@115 LE IOP : 17 RE 19 LE CD: 0.5 RE 0.6 LE BCVA: 0.7 OU 2

3 1. Peripheral Iridotomy 2. Lens extraction Please vote 3

4 Peripheral Iridotomy vs Lens Extraction in PAC Yasmine El Sayed MD, MRCSEd Assist. Professor of Ophthalmology Cairo University PACS 180 of Iridotrabecular Contact (ITC) - On non compressive gonioscopy - In primary gaze No PAS Normal IOP 4

5 PAC 180 of Iridotrabecular Contact (ITC) - On non compressive gonioscopy - In primary gaze Elevated IOP and/or PAS PACG 180 of Iridotrabecular Contact (ITC) - On non compressive gonioscopy - In primary gaze Elevated IOP and/or PAS Glaucomatous optic neuropathy 5

6 Characteristic of eyes with PAC: Hallmark: - shallow AC - narrow angle. Mean ACD in PAC eyes is 1.8 mm. Angle closure becomes a rarity when anterior chamber depth exceeds 2.5 mm Characteristic of eyes with PAC: Small AC volume Small corneal diameter Short axial length 6

7 The AC shallowing is mostly related to the age-related increase in lens thickness and more anterior position of the lens. The axial lens thickness is greater than in normal subjects, and the thicker lenses are significantly more anteriorly positioned than in normal eyes. Current Surgical Treatment Options for PAC 7

8 Trabeculectomy Higher risk of failure Postoperative AC shallowing Malignant glaucoma Cataract Because the anterior chamber anatomy is a predisposing condition in the PAC spectrum, a surgical treatment to deepen the anterior chamber for these eyes may prevent progression of the disease. 8

9 LASER PERIPHERAL IRIDOTOMY (LPI) LPI 9

10 LPI LENS EXTRACTION 10

11 Lens Extraction The potential importance of this definitive procedure to correct persistent pupillary-block and angle crowding in both the treatment and prevention of acute and chronic angle closure glaucoma cannot be overestimated. IOP reduction not observed to the same extent in POAG eyes Some studies found that IOP control in POAG eyes are largely unaffected by cataract surgery Others found a reduction in IOP that is smaller, and less sustained than that seen in PACG eyes. The mechanism for IOP reduction in POAG eyes is unclear. 11

12 Lens extraction in PAC Deepens the AC Opens the angle Decreases diurnal IOP fluctuations * Improves facility of outflow ** Liu, C., Cheng, C., Wu, C. et al. Factors predicting intraocular pressure control after phacoemulsification in angle closure glaucoma. Arch Ophthalmol. 2006; 124: **Meyer, M.A., Savitt, M.C., and Kopitas, E. The effect of phacoemulsification on aqueous outflow facility. Ophthalmology. 1997; 104: Effect of Phacoemulsification on Chronic PACG 12

13 PAS after surgery Residual open angle does NOT guarantee successful IOP control Factors associated with Lower IOP after Phacoemulsification 13

14 Preoperative IOP Higher Iancu, R. and Corbu, C. Intraocular pressure after phacoemulsification in patients with uncontrolled primary open angle glaucoma. J Med Life. 2014; 7: Liu, C.J., Cheng, C.Y., Ko, Y.C., and Lau, L.I. Determinants of long-term intraocular pressure after phacoemulsification in primary angle-closure glaucoma. J Glaucoma. 2011; 20: Yudhasompop, N. and Wangsupadilok, B. Effects of phacoemulsification and intraocular lens implantation on intraocular pressure in primary angle closure glaucoma (PACG) patients. J Med Assoc Thai. 2012; 95: Shams, P.N. and Foster, P.J. Clinical outcomes after lens extraction for visually significant cataract in eyes with primary angle closure. J Glaucoma. 2012; 21: Moghimi S, Latifi G, ZandVakil N, et al. Phacoemulsification versus combined phacoemulsification and viscogonioplasty in primary angle-closure glaucoma: a randomized clinical trial. J Glaucoma 2014 Nov 12 Jacobi, P.C., Dietlein, T.S., Luke, C. et al. Primary phacoemulsification and intraocular lens implantation for acute angle-closure glaucoma. Ophthalmology. 2002; 109: Preoperative IOP Lower Hayashi, K., Hayashi, H., Nakao, F., and Hayashi, F. Effect of cataract surgery on intraocular pressure control in glaucoma patients. J Cataract Refract Surg. 2001; 27:

15 AC depth Liu, C.J., Cheng, C.Y., Ko, Y.C., and Lau, L.I. Determinants of long-term intraocular pressure after phacoemulsification in primary angle-closure glaucoma. J Glaucoma. 2011; 20: Shallower preoperative AC depth was associated with more IOP reduction. Jacobi, P.C., Dietlein, T.S., Luke, C. et al. Primary phacoemulsification and intraocular lens implantation for acute angle-closure glaucoma. Ophthalmology. 2002; 109: : Change in AC depth was associated with more IOP reduction Yudhasompop, N. and Wangsupadilok, B. Effects of phacoemulsification and intraocular lens implantation on intraocular pressure in primary angle closure glaucoma (PACG) patients. J Med Assoc Thai. 2012; 95: IOP reduction not related to AC depth or lens thickness PAS Shams, P.N. and Foster, P.J. Clinical outcomes after lens extraction for visually significant cataract in eyes with primary angle closure. J Glaucoma. 2012; 21: IOP reduction associated with more than 180 of PAS and a narrower angle width before surgery by gonioscopy. Pachimkul, P. and Intajak, Y. Effect of lens extraction on primary angle closure in a Thai population. J Med Assoc Thai. 2008; 91: IOP reduction unrelated to PAS extent Liu, C.J., Cheng, C.Y., Ko, Y.C., and Lau, L.I. Determinants of long-term intraocular pressure after phacoemulsification in primary angleclosure glaucoma. J Glaucoma.2011; 20: IOP reduction unrelated to preoperative gonioscopy 15

16 Others.. Moghimi S, Latifi G, ZandVakil N, et al. Phacoemulsification versus combined phacoemulsification and viscogonioplasty in primary angle-closure glaucoma: a randomized clinical trial. J Glaucoma 2014 Nov 12 Female gender associated with more IOP reduction after phacoemulsification EAGLE Eye Study The Effectiveness Of Early Lens Extraction With Intraocular Lens Implantation For The Treatment Of Primary Angle-closure Glaucoma (EAGLE) 16

17 Clear lens extraction in PAC and PACG First trial to assess early (clear) lens extraction as the primary treatment for chronic primary angle-closure glaucoma 50 years old 1. Newly diagnosed PAC with IOP 30 mm Hg 2. Newly diagnosed PACG with IOP > 21 mmhg on at least one occasion 17

18 Exclusion criteria: Symptomatic cataract Advanced glaucoma (mean deviation worse than 15 db or cup-to-disc ratio 0 9) Previous acute angle-closure attack Previous laser or ocular surgery National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) Glaucoma Utility Index, which provides a descriptive profile in six dimensions: central and near vision, lighting and glare, mobility, activities of daily living, eye discomfort, and other effects of glaucoma and its treatment VA IOP Meds VF Complications Further interventions 18

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