AC & ACG Instruction Course Surgical Treatments for PACG

Transcription

1 AC & ACG Instruction Course Surgical Treatments for PACG Presented by APGS Clement C.Y. THAM Professor, The Chinese University of Hong Kong Chief of Service, Hong Kong Eye Hospital Deputy Secretary-General, APAO AAO-APAO 2012 Chicago

2 Financial Disclosure Aeon Astron Corporation - S Alcon Laboratories, Inc. C,L,S,T Allergan, Inc. C,T Icare Finland - S Merck & Co., Inc. C,L,T Pfizer, Inc. C,L,S,T Santen Pharmaceutical Co., Ltd. C,S,T C = Consultant / Advisor L = Lecture Fees S = Grant Support T = Travel Support

3 General Principles in PACG Open up all appositionally closed portions of angle If IOP still uncontrolled, start topical medications If IOP not controlled by maximally tolerated medications, proceed to further surgery

4 General Principles in PACG Open up all appositionally closed portions of angle Laser peripheral iridotomy Argon laser peripheral iridoplasty (ALPI) to open residual appositionally closed segments Lower threshold for lens extraction

5 General Principles in PACG Laser iridotomy Eliminates pupil block Eliminates appositional AC in 75-80% of eyes Gazzard G et al, He MG et al, No effect on PAS

6 General Principles in PACG PACG after Laser iridotomy: Majority of eyes still require topical IOPlowering drugs >50% require filtration or other IOPlowering surgery Worse prognosis if previous APAC Alsagoff Z et al, 2000.

7 General Principles in PACG Laser iridoplasty Opens up residual appositionally-closed portions of angle due to: Plateau iris Ritch R, Tham C, Lam D, Iris crowding Lens? No effect on PAS

8 General Principles in PACG May consider skipping iridotomy & iridoplasty if very extensive (approaching 360 ) PAS

9 General Principles in PACG Open up all appositionally closed portions of angle If IOP still uncontrolled, start topical medications Choice of medications similar to POAG PGAs of increasing importance

10 Role of IOP-lowering drugs Pilocarpine Less commonly used due to side effects Effective in opening up appositional AC if iridotomy / iridoplasty not possible Kobayashi H et al, 1999.

11 Role of IOP-lowering drugs At presentation if high IOP posing immediate danger, or acute presentation May be needed after angle-opening procedures if IOP still not safe

12 General Principles in PACG Open up all appositionally closed portions of angle If IOP still uncontrolled, start topical medications If IOP not controlled by maximally tolerated medications, proceed to further surgery

13 Further Surgery for Medically- Uncontrolled PACG - Synopsis Trabeculectomy Cataract / Lens Extraction GSL Deep sclerectomy Trabeculotomy GDD, e.g. Ahmed Implant DLTSC using G-probe Combined surgery

14 Importance of Surgery ~ 35 % of PACG eyes need surgical intervention for IOP control in 6-year FU. Acta Ophthalmol Scand

15 An Overview of Surgical Management in PACG

16 PACG Eliminate appositional closure (laser iridotomy +/- iridoplasty +/- lens extraction) Inadequate IOP control despite maximum drugs Adequate IOP control with / without drugs Minimal PAS Long duration of closure Extensive PAS Short duration of closure Not for advanced glaucoma (wipe out phenomenon) GSL (+/- Phaco) Phaco and / or TBx Failed IOP control w drugs Glaucoma implant (for good visual potential cases) Failed IOP control Failed IOP control Cyclodestruction (laser / cryo) (for poor visual potential cases)

17 Surgical Options in PACG Phaco alone? Combined phaco-trabeculectomy (PhacoTBx) Trabeculectomy alone?? (TBx)

18 TBx alone inferior to PhacoTBx? Comparable success rate at 3 years 54% vs. 56% (p = 0.903) Comparable mean IOP & #drugs Comparable complication rates (p = 0.232) But required significantly more subsequent surgery 54% vs. 0% (p<0.001) Tsai HY, et al. BJO 2009.

19 Possible clinical scenarios in PACG PACG w co-existing cataract IOP controlled w drugs IOP uncontrolled w drugs PACG w NO cataract IOP controlled w drugs IOP uncontrolled w drugs

20 Possible clinical scenarios in PACG PACG w co-existing cataract IOP controlled w drugs IOP uncontrolled w drugs PACG w NO cataract IOP controlled w drugs IOP uncontrolled w drugs

21 PACG and Cataract PACG increases with age Therefore, majority of PACG co-existing with cataract Cataract may also contribute to pathogenesis of PACG

22 Biometric Characteristics of PACG eyes Shallower anterior chamber Narrower drainage angle Thicker lens -> steeper anterior lens surface Lens more anteriorly positioned Lowe RF, 1972; Lowe RF et al, Tomlinson A, et al, Lowe RF, Lee DA. et al, 1984.

23 Known Effects of Cataract Extraction on Anatomy of PACG Eyes Substantially deepens AC (average increase by 2 mm or 1.37 times) Drainage angle more widely open (average open up by 17 o or 1.57 times) Hayashi K et al. Ophthalmology Kurimoto Y. Am J Ophthalmol 1997.

24 Known Effects of Cataract Extraction on Anatomy of PACG Eyes Mean ACD Pre-op = / mm Post-op = / mm AC angle widened significantly in all 4 quadrants Yang CH, et al. J Cataract Refract Surg

25 Known Effects of Cataract Extraction Alone on IOP Control in Uncontrolled PACG Eyes Success rate (IOP control): 68% - 100% Drugs reduced: 91% Mean IOP: from 31 to 16 mmhg Gunning FP, et al. Int Ophthalmol Yang CH, et al. J Cataract Refract Surg Greve EL. Int Ophthalmol Gunning FP, et al. J Cataract Refract Surg.1998.

26 Known Effects of Cataract Extraction on IOP Control in PACG Eyes 20 consecutive PACG eyes received cataract extraction 84% maintained or decreased their glaucoma medications during 6-month FU Yang CH, et al. J Cataract Refract Surg

27 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs IOP uncontrolled w drugs PACG with NO cataract IOP controlled w drugs IOP uncontrolled w drugs

28 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs IOP uncontrolled w drugs

29 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs

30 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs Phaco or TBx?

31 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs Phaco or TBx?

32 Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology Subgroup Analysis Controlled and Uncontrolled Definitions: IOP Controlled : IOP <=21 mmhg, with 3 or fewer topical drugs (Combinations counted as 2 drugs) IOP UNControlled : IOP > 21 mmhg with maximally tolerated medications, or requiring > 3 topical drugs Group 1: IOP-controlled 35 phaco vs. 37 phaco-tbx (n = 72) Group 2: IOP-uncontrolled 27 phaco vs. 24 phaco-tbx (n = 51)

33 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs IOP uncontrolled w drugs

34 PACG + Cataract (IOP-controlled) Phaco vs. PhacoTBx Mean IOP / mmhg Pre-op Follow-up Duration / months Phaco Group Phaco-trabeculectomy Group Phaco-trabeculectomy with 7 hypotony cases excluded Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2008.

35 PACG + Cataract (IOP-controlled) Phaco vs. PhacoTBx 2.5 Mean Number of Topical Glaucoma Drugs Pre-op Follow-up Duration / months Phaco Group Phaco-trabeculectomy Group Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2008.

36 Phaco alone: 9.82% IOP reduction (p = 0.01) 59.2% drug reduction (p < 0.001) PhacoTBx additional benefits in IOP control IOP: 1.67 mmhg < phaco alone (p = 0.01) Drugs: 0.80 < phaco alone (p < 0.001) But PhacoTBx significantly more complications

37 PACG + Cataract (IOP-controlled) Phaco vs. PhacoTBx Phaco alone - significant reduction in drug requirement in PACG PhacoTBx additional improvements in IOP control IOP advantage only at 1 & 3 months (p < 0.05) 0.80 fewer drugs over 24-month FU (p < 0.001) Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2008.

38 PACG + Cataract (IOP-controlled) Phaco vs. PhacoTBx No significant difference in VA or glaucomatous progression But what price to pay for additional drug reduction? Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2008.

39 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco or PhacoTBx? IOP uncontrolled w drugs Phaco or PhacoTBx? PACG with NO cataract IOP controlled w drugs IOP uncontrolled w drugs

40 PACG + Cataract (IOP-uncontrolled) Phaco vs. PhacoTBx Mean IOP / mmhg Pre-op Follow-up Duration / months Phaco Group Phaco-trabeculectomy Group Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2009.

41 PACG + Cataract (IOP-uncontrolled) 3.5 Phaco vs. PhacoTBx Mean Number of Topical Glaucoma Drugs Pre-op Follow-up Duration / months Phaco Group Phaco-trabeculectomy Group Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2009.

42 Phaco alone: 34.4% IOP reduction (p < 0.001) 52.4% drug reduction (p < 0.001) PhacoTBx additional benefits in IOP control IOP: 1.97 mmhg < phaco alone (p = 0.02) Drugs: 1.25 < phaco alone (p < 0.001) But PhacoTBx significantly more complications

43 PACG + Cataract (IOP-uncontrolled) Phaco vs. PhacoTBx PhacoTBx - better IOP control than phaco over 24 months: lower IOP at 3, 15, and 18 months after surgery (p < 0.05) 1.25 fewer drugs (p < 0.001) No significant difference in VA or glaucomatous progression Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2009.

44 PACG + Cataract Phaco vs. PhacoTBx Main advantage of PhacoTBx over Phaco alone: fewer IOP-lowering drugs 0.80 fewer drugs if pre-op medically controlled 1.25 fewer drugs if pre-op medically uncontrolled But what is the price to pay for this advantage? Tham CC, Kwong YY, Leung DY, et al. Ophthalmology Tham CC, Kwong YY, Leung DY, et al. Ophthalmology 2009.

45 PACG + Cataract Phaco vs. PhacoTBx Pooling all cases from both studies (medically controlled & uncontrolled) to compare: Complications Intra-operative Post-operative Additional surgical interventions To manage complications To maintain filtration / control IOP Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

46 PACG + Cataract Phaco vs. PhacoTBx - Complications Phaco group 5 of the 62 CACG eyes (8.1%) had a total of 5 surgical complications PhacoTBx group 16 of the 61 CACG eyes (26.2%) had a total of 19 surgical complications p = 0.007, Pearson Chi-square test Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

47 Complications - Intraoperative Phacoemulsification group (n = 62) Combined Phacotrabeculectomy with Adjunctive Mitomycin C Group (n = 61) Posterior capsular rupture 2 (3.2%) 2 (3.3%) Retrobulbar hemorrhage secondary to anesthetic injection Zonular dehiscence Total number of intraoperative complications Total number of eyes with 1 or more intra-operative complications (p = 0.714, Pearson Chi-square test) 1 (1.6%) 0 1 (1.6%) (does not require capsular tension ring implantation) 1 (1.6%) (requires capsular tension ring implantation) (6.5%) 3 (4.9%) Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

48 Complications Post-operative Phacoemulsific ation group (n = 62) Combined Phaco-trabeculectomy with Adjunctive Mitomycin C Group (n = 61) Anterior chamber shallowing requiring anterior chamber reformation Conjunctival wound leak healed with conservative measures Conjunctival wound leak requiring suturing 0 3 (4.9%) 0 2 (3.3%) 0 2 (3.3%) Giant symptomatic bleb requiring surgery 0 1 (1.6%) Hyphema 0 4 (6.6%) Over-drainage with choroidal detachment 0 1 (1.6%) Posterior capsular opacity requiring YAG capsulotomy Total number of post-operative complications Total number of eyes with 1 or more post-operative complications (p < 0.001, Pearson Chi-square test) 1 (1.6%) 1 (1.6%) (1.6%) 15 (24.6%) Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

49 Additional surgery to manage complications Phaco Group (n = 62) Combined Phaco-trabeculectomy with Adjunctive Mitomycin C Group (n = 61) Suturing for conjunctival wound leak 0 2 (3.3%) Anterior chamber reformation with viscoelastic agent for mild overdrainage Trabeculectomy revision for significant overdrainage Conjunctival suturing for symptomatic giant filtration bleb YAG capulotomy for posterior capsular opacification Total number of additional surgical interventions to manage complications Total number of eyes requiring 1 or more additional surgical interventions to manage complications (p = 0.01, Chi-square test) 0 3 (4.9%) 0 1 (1.6%) 0 1 (1.6%) 1 (1.6%) 1 (1.6%) (1.6%) 8 (13.1%) Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

50 Additional surgery to control IOP Phaco Group (n = 62) Combined Phaco-trabeculectomy with Adjunctive Mitomycin C Group (n = 61) Post-operative subconjunctival 5-fluorouracil injection Laser suturelysis for early post-operative underdrainage Needling revision of trabeculectomy with adjunctive subconjunctival 5-fluorouracil injection for late post-operative underdrainage Subsequent trabeculectomy with adjunctive mitomycin C chemotherapy for IOP control Total number of additional surgical interventions to control IOP Total number of eyes requiring 1 or more additional surgical interventions to control IOP (p = 0.050, Chi-square test) 0 2 (3.3%) 0 5 (8.2%) 1 (1.6%) 5 (6.6%) 4 (6.5%) (6.5%) 11 (18.0%) Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

51 PACG + Cataract Phaco vs. PhacoTBx Additional Surgery 4 phaco-alone eyes (6.5%) required TBx for IOP control during 24-month FU 11 PhacoTBx eyes (18%) required additional procedures to maintain filtration Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

52 Summary Complications & Interventions PhacoTBx - more complications than phaco 26.2% vs 8.1%. (P = 0.007) PhacoTBx more additional surgery to manage complications 13.1% vs 1.6% (p = 0.01) Tham CC, Kwong YY, Leung DY, et al. Archives of Ophthalmology 2010.

53 Summary Complications & Interventions No significant differences in: additional surgery to control IOP pre-op & final BCVA progression in GON progression in GVFL Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

54 Is phaco alone sufficient to protect ON in more advanced CACG cases? Median PSD for all 52 cases in pre-op. medically-uncontrolled study = 4.13 db All CACG eyes with pre-op PSD > 4.13 db then defined as Advanced Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

55 Is phaco alone sufficient to protect ON in more advanced CACG cases? VF progression amongst Advanced cases Phaco group - 5 of 13 eyes (38.5%) PhacoTBx group - 4 of the 10 eyes (40%) P = 0.94, Chi-square test Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

56 Is phaco alone sufficient to protect ON in more advanced CACG cases? Phacoemulsification alone did not appear to result in a greater risk of visual field progression amongst the more advanced CACG cases Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

57 Conclusions PACG with Cataract Trabeculectomy alone limited role in PACG because: Cataract common in PACG eyes Known pathogenic role of cataract in PACG Some peri-operative risks / complications of trabeculectomy reduced / avoided when combined with lens extraction Rate of cataract progression may increase after TBx Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

58 Conclusions PACG with Cataract If medically-controlled: Benefits of PhacoTBx probably not sufficient to justify risk of complications and additional interventions 1.67 mmhg lower IOP & 0.80 fewer drugs Therefore, may consider Phaco alone Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

59 Conclusions PACG with Cataract If medically-uncontrolled: Greater benefits of PhacoTBx may / may not justify risk of complications and additional interventions 1.97 mmhg lower IOP & 1.25 fewer drugs Either approach may be adopted, depending on patient factors Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

60 Conclusions PACG with Cataract If medically-uncontrolled: May consider Phaco alone if, for example: Patient more prone to risk of TBx complications, e.g. NLDO, blepharitis The eye may not tolerate / survive greater trauma of combined surgery, e.g. near-terminal glaucoma or poor corneal endothelium Patient cannot accept higher risk of complications Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

61 Conclusions PACG with Cataract If medically-uncontrolled: May consider PhacoTBx if, for example: Known poor compliance with drugs Drug allergy No long-term access to drugs / follow up? Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

62 Lens Extraction in PACG Preliminary Conclusions: PACG with co-existing cataract IOP controlled w drugs Phaco IOP uncontrolled w drugs Phaco or PhacoTBx PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs

63 Lens Extraction in PACG Preliminary Conclusions: PACG with co-existing cataract IOP controlled w drugs Phaco IOP uncontrolled w drugs Phaco or PhacoTBx PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs Phaco or TBx?

64 Possible clinical scenarios in PACG PACG with co-existing cataract IOP controlled w drugs Phaco IOP uncontrolled w drugs Phaco or PhacoTBx PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs Phaco or TBx? Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

65 Uncontrolled PACG w No Cataract RCT comparing Clear Lens Extraction vs. TBx Definition of IOP UNControlled : IOP > 21 mmhg with maximally tolerated medications, or requiring > 3 topical drugs Tham CC, et al. Manuscript in preparation 2012.

66 Recruitment Criteria Diagnostic criteria for PACG: 180º of angle closure obliterating pigmented part of TM, whether synechial or appositional, segmented or continuous, in the presence of a patent PI; Requiring IOP-lowering drugs, or IOP of above 21 mmhg without IOP-lowering drugs; GVFL and / or GON. Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

67 Recruitment Criteria Definitions of IOP Control: IOP Controlled : IOP <=21 mmhg, with 3 or fewer topical drugs (Combinations counted as 2 drugs) IOP UNControlled : IOP > 21 mmhg with maximally tolerated medications, or requiring > 3 topical drugs Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

68 Recruitment Criteria Diagnostic criteria for NO cataract : Best corrected visual acuity (BCVA) better than or equal to 20/40, and NOT affecting activities of daily living. Tham CC, et al. Manuscript in preparation 2012.

69 Exclusion Criteria Single functional eye; Patients refusing either lens extraction or trabeculectomy; Previous intraocular surgery, with the exception of laser peripheral iridotomy & ALPI. Tham CC, et al. Ophthalmology Tham CC, et al. Ophthalmology Tham CC, et al. Archives of Ophthalmology 2010.

70 Comparison of Studies Tham et al 2011 vs. EAGLE Study Tham et al 2012 EAGLE Study Study Design Target Patients Randomized controlled interventional trial Uncontrolled PACG eyes with prior PI but NO cataract Randomized controlled interventional trial Newly diagnosed PACG eyes before PI with NO cataract Interventions Compared Phaco vs. Trabeculectomy Phaco vs. PI

71 Uncontrolled PACG w No Cataract Results 26 phaco vs. 24 TBx All surgery by single surgeon (CT) FU: 3-monthly, up to 24 months Tham CC, et al. Manuscript in revision 2012.

72 Uncontrolled PACG + No Cataract Phaco vs. TBx IOP / mmhg Phacoemulsification Group Trabeculectomy Group Pre-op Time in relation to surgery / months

73 Uncontrolled PACG + No Cataract Phaco vs. TBx 4.0 Mean Number of Glaucoma Drugs Phacoemulsification Group Trabeculectomy Group 0.0 Pre-op Time in relation to surgery / months

74 Uncontrolled PACG + No Cataract Phaco vs. TBx Tham CC, et al. Manuscript in revision 2012.

75 Uncontrolled PACG + No Cataract Phaco vs. TBx Tham CC, et al. Manuscript in revision 2012.

76 Uncontrolled PACG + No Cataract Phaco vs. TBx Tham CC, et al. Manuscript in revision 2012.

77 Uncontrolled PACG + No Cataract Phaco vs. TBx Phaco. Trabeculectomy IOP Reduction at 24 months 34.0% 36.3% Drug Reduction at 24 months 59.5% 88.6% Over first 24 months, trabeculectomy was associated with: IOP of 0.75 mmhg lower (p = 0.94) 1.06 fewer drugs (p < 0.001) than phacoemulsification. Tham CC, et al. Manuscript in revision 2012.

78 Phaco vs. TBx No significant differences in BCVA Progression in glaucomatous optic neuropathy Progression in visual field losses But study NOT powered / long enough to evaluate progression Tham CC, et al. Manuscript in revision 2012.

79 Uncontrolled PACG + No Cataract Phaco vs. TBx - Complications Phaco group 1 eye (3.8%) had zonular dehiscence with capsular tension ring implanted No PCR / other complications TBx group 11 eyes (45.8%) had a total of 13 complications 8 eyes (33.3%) had cataract 2 eyes with overdrainage & mild choroidal detachment -resolved with conservative measures 2 eyes with conjunctival wound leak resolved with aqueous suppression & eye patching 1 eye with overdrainage requiring AC reformation and subsequent revision of Tbx

80 Uncontrolled PACG + No Cataract Phaco vs. TBx Subsequent Sx Phaco group 5 eyes (19.2%) indicated for TBx within 24 months 3 eyes (11.5%) actually had TBx within 24 months TBx group 6 eyes (25.0%) required a total of 10 additional surgical interventions 5 eyes (20.8%) had phaco for progressive lens opacity 2 eyes require 3 needling revisions 1 eye had anterior chamber reformation, and subsequent revision of Tbx Difference NOT statistically significant (p = 0.22)

81 Discussion Phaco effective in improving IOP control, reducing IOP by 34.0% and the requirement for glaucoma drugs by 59.5% at 24 months after surgery Phaco has low rate of complication (3.8%) Phaco can avoid potential complications of Tbx After phaco, dependence on glaucoma drugs remain significant Tham CC, et al. Manuscript in revision 2012.

82 Discussion Trabeculectomy: More effective in reducing drug dependency More surgical complications Tham CC, et al. Manuscript in revision 2012.

83 Conclusions Phaco may be an appropriate alternative to Tbx as an initial surgical option in medically uncontrolled CACG eyes without cataract Phaco may be more favourable in patients who are prone to, or cannot accept, the complications of Tbx In situation where drug reduction is a high priority, Tbx may be more suitable Tham CC, et al. Manuscript in revision 2012.

84 Combined Phacotrabeculectomy? Role in uncontrolled PACG without cataract remains to be evaluated Key facts: After phaco, 19.2% became / remained medically uncontrolled in 2 years increase with longer FU? After TBx, 33.3% developed cataract in 2 years will increase with longer FU Tham CC, et al. Manuscript in revision 2012.

85 Lens Extraction in PACG Preliminary Conclusions: PACG with co-existing cataract IOP controlled w drugs Phaco IOP uncontrolled w drugs Phaco or PhacoTBx PACG with NO cataract IOP controlled w drugs - Drugs IOP uncontrolled w drugs Phaco or TBx

86 Other Roles of Lens Extraction In combination with other IOP-lower procedures, e.g.: Goniosynechialysis (GSL) Glaucoma Drainage Device (GDD) implantation Cyclophotocoagulation in PACG Transscleral or endoscopic

87 Other Roles of Lens Extraction Advantages of combining with other IOPlower procedures: Visual improvement Deepened AC in PACG Allowing better exposure / access Reducing risk of complications Avoiding need for subsequent cataract extraction

88 Further Reading Lens Extraction in ACG 1. Tham CC, et al. Archives of Ophthalmology Tham CC, et al. J Glaucoma Tham CC, et al. Ophthalmology Tham CC, et al. Eye Tham CC, et al. Ophthalmology Lam DS, et al. Ophthalmology Lai JS, et al. J Glaucoma Correspondence: clemtham@cuhk.edu.hk

89 Thank You!!

90

91 AC & ACG Instruction Course Surgical Treatments for PACG Presented by APGS Clement C.Y. THAM Professor, The Chinese University of Hong Kong Chief of Service, Hong Kong Eye Hospital Deputy Secretary-General, APAO AAO-APAO 2012 Chicago