EyeWorld Asia-Pacific September 2014 Issue

September 2014 18 EWAP GLAUCOMA continued on page 20 Making the case for cataract surgery in angle closure glaucoma patients by Vanessa Caceres EyeWorld Contributing Writer Procedure is simpler than glaucoma surgery, helps to lower IOP C ataract surgery for angle closure glaucoma (ACG) patients is coming into its heyday. A mere 8 years ago, authors of a Cochrane Review paper made the following conclusion: “There is no evidence from good quality randomized trials or non-randomized studies of the effectiveness of lens extraction for chronic primary angle-closure glaucoma.” 1 Fast forward to 2014, and a paper in Current Opinion in Ophthalmology in March stated that data suggest that cataract extraction in those with angle closure may be more effective for controlling IOP than laser or incisional glaucoma procedures. 2 Of course, the increasing use of cataract surgery to treat ACG doesn’t come from just one published paper. Clinicians base that decision on a variety of research and clinical experience. “This is a changing area of clinical care,” said David S. Friedman, MD , PhD , Alfred Sommer professor, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Md., U.S.— and co-author of the 2006 review paper mentioned above. “There will be more and more evidence about how to treat angle closure glaucoma, and several clinical trials are nearing completion.” Dr. Friedman pointed to the large EAGLE trial underway in England and Asia to evaluate the cost- effectiveness and clinical outcomes of early lens extraction in ACG. Results are expected in the next year or two. When to use cataract surgery Glaucoma surgeons consider a few factors when deciding to perform cataract extraction in patients with ACG. One consideration is how much the procedure will lower IOP. “If patients have a hyperopic eye with a crowded angle, then removing the lens will typically lower the pressure at least a few millimeters,” said Nicholas P. Bell, MD , director of the glaucoma service, Robert Cizik Eye Clinic, and A.G. McNeese Jr. clinical associate professor, Ruiz Department of Ophthalmology & Visual Science, UTHealth, Houston, Texas, U.S. “The reason to remove the lens is to treat primary angle closure by deepening the angle. The decrease in IOP is a result of successful alteration of the anterior chamber anatomy. Patients with narrower angles may get even greater pressure lowering than we typically expect from cataract surgery.” Another consideration is whether cataract surgery can help patients avoid more complex glaucoma surgery. For instance, Reay H. Brown, MD , founding partner, Atlanta Ophthalmology Associates, said he performed cataract surgery in 83 eyes with ACG, and the average pressure reduction was 5.3 mmHg in patients with a preop IOP of 20 or higher. The pressure was reduced in 100% of eyes with preop IOP of 18 or above. “It’s not something you can bet the ranch on, but when you can do the cataract surgery by itself, I think you should. You have the chance to help the patient and do it without the risk of glaucoma surgery,” he said. A greyer area is when to perform clear lens extraction in these patients. “Clear lens extraction has its own negatives, and there’s a small risk of retinal detachment and macular edema. When you make people pseudophakic, you can use multifocal lenses, but that leaves many people with presbyopia and they don’t like it. If a patient has a dangerously high pressure, I think it’s reasonable to take out the lens,” Dr. Friedman said. AT A GLANCE • Cataract surgery is a growing treatment option in patients with angle closure glaucoma. • In qualified candidates, surgeons are finding that clear lens extraction helps to widen the anterior chamber angle and lower IOP in angle closure glaucoma. • There is no clear evidence about the value of goniosynechialysis, but the procedure seems to be most effective if the synechiae recently developed. • Trabeculectomy is a more common treatment approach when patients have advanced ACG. An eye with a cataract and elevated IOP Source: Pekka Virtanen