EyeWorld Asia-Pacific March 2017 Issue

March 2017 28 EWAP SECONDARY FEATURE by Stefanie Petrou Binder, MD EyeWorld Contributing Writer Debating the benefits of lens extraction in PACG Contrasting perspectives prevail despite new evidence in the handling of angle-closure glaucoma G laucoma specialists handle primary angle- closure glaucoma (PACG) on a patient-to- patient basis, as no single avenue of treatment can cover all the scenarios encountered in this disease. Lens extraction using phacoemulsification is a new approach for PACG management, often alleviating high IOP, opening the anterior chamber angle, and improving quality of life. Some glaucoma doctors, however, are less convinced than others about the efficacy of lens extraction—in the absence of cataract—as the best way to reduce IOP in these patients. Reay Brown, MD , founding partner, Atlanta Ophthalmology AT A GLANCE • Pressure-reducing effect elevates lens-based glaucoma surgery to the forefront of glaucoma treatment. • Clear lens extraction shows greater efficacy and cost effectiveness than peripheral laser iridotomy, according to the EAGLE study. • Not all new study results definitively impact physicians’ clinical practice. • Lens removal is effective in eyes with less than 270 degrees of PAS. Associates, Atlanta; Joseph Panarelli, MD , glaucoma fellowship director and associate residency program director, New York Eye and Ear Infirmary of Mount Sinai, New York, and Robert Feldman, MD , clinical professor and chairman, Ruiz Department of Ophthalmology and Visual Science, University of Texas McGovern Medical School, Houston, spoke with EyeWorld about their treatment preferences for PACG. All for it According to Dr. Brown, doctors are now looking at the glaucoma patient in new ways. The role for cataract surgery in angle closure is expanding, and he thinks that the pressure reduction achieved by modern phacoemulsification has elevated lens-based glaucoma surgery to the forefront of glaucoma treatment. As most patients will eventually need cataract surgery, doctors have all the more reason to factor lens removal into their overall treatment plan. “We see patients everyday in our practices from the pre- phacoemulsification era with peripheral anterior synechiae, secondary angle closure, chronic inflammation, and other ongoing problems from extracapsular surgery that contribute to their glaucoma,” Dr. Brown said. “Modern phacoemulsification can help glaucoma patients avoid the worsening of their pressure control caused by these now avoidable complications. Does a diagnosis of glaucoma change the indications for cataract surgery? Clearly, yes. There seem to be few clinical situations in PACG in which lens removal is not beneficial and preferred over laser treatment or a phaco trabeculectomy,” he explained. Dr. Brown’s views coincide with the newest evidence in support of lens extraction from the recently published multicenter, randomized, controlled Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) study. 1 EAGLE investigated the benefits of early clear lens extraction in 419 patients newly diagnosed with primary angle closure and IOPs in excess of 30 mmHg, or with PACG, who underwent either lens extraction or laser iridotomy (LI). It demonstrated the greater efficacy and cost effectiveness of clear lens extraction over peripheral LI and suggested that clear lens extraction be considered as an option for first- line treatment in PACG. Eyes with angle closure will typically present as short eyes with shallow anterior chambers. It is thought that the increasing thickness of the aging lens also contributes to a progressive narrowing of the angle. Meanwhile, LI widens the anterior chamber angle, some degree of iridotrabecular contact persists in most patients, and angle closure may progress despite an iridectomy. Dr. Brown explained, “The anatomy of angle-closure eyes supports a therapeutic role for lens removal. Removal of the lens clearly deepens the chamber and opens the angle. Combining the anatomical evidence with the clinical success of cataract surgery has led to discussions about whether clear lens extraction should be recommended for patients with angle closure. There Angle closure in eye before (left) and after (right) cataract surgery. The spots on the superior iris are laser iridoplasty scars that were done in an effort to try and deepen the angle and lower the pressure. That treatment did not work, but cataract surgery lowered the pressure to a normal level. Source: Reay Brown, MD