EyeWorld Asia-Pacific September 2014 Issue

20 EWAP GLAUCOMA September 2014 “You have to talk to the patients about it,” Dr. Bell said. “As an alternative to laser iridotomy for the initial treatment of primary angle closure, I offer it to higher hyperopes who have functional visual complaints related to cataract even if their visual acuity may not be worse than 20/40.” “These aren’t patients who are saying they can’t see the golf ball or a road sign,” said Dr. Brown. “The trigger for doing something is that they have angle closure and their pressures are too high despite maximal medical therapy. You can do a trabeculectomy, a tube shunt, or cataract [surgery]. If you can solve the problem with a cataract surgery, you’ve done the patient an incredible service.” It’s important to make sure the patient has an apparent medical need for clear lens extraction, said Dr. Brown. For example, a patient with no elevated pressure using only one glaucoma drop would not be an ideal clear lens extraction candidate; a patient on 3 to 4 medications with continuing pressure elevation is a stronger candidate. How about goniosynechialy- sis? When should a goniosynechialysis be done along with cataract surgery? Dr. Friedman believes if the synechiae are there a long time, it is not clear whether or not just removing them will be of benefit. “If they are relatively acute, there may be a good argument for breaking those with surgery. A month or two out, you might have synechiae that have already damaged the trabecular meshwork,” he added. It is difficult to show the exact benefit of goniosynechialysis as there likely will never be a trial to compare patients who have had that procedure against those who have not, Dr. Brown said. Instead, glaucoma surgeons must rely on inconsistent evidence from the literature and their clinical experience. “I’ll do goniosynechialysis if there’s no more than 180 degrees, and if I get any bleeding, I stop,” he said. In his hands, Dr. Bell finds that the procedure can help if it is done within the first 6 to 12 months after peripheral anterior synechiae develop. “Once the angle has scar tissue present for too long, even if you can physically peel back the scar tissue, the trabecular meshwork may not be functioning properly,” he said. Moving on to trabeculectomy Despite efforts to do cataract surgery and provide ACG patients relief, there are always going to be times when trabeculectomy is necessary. “If the anterior angle is synechially closed for more than 270 degrees, removing the lens may be insufficient to control the IOP and prevent glaucomatous progression,” Dr. Bell said. A trabeculectomy may do a better job of controlling the IOP in those patients, he said, adding that if done in a phakic eye, it should be done with an iridectomy. “You want to perform that as well to remove the pupillary block component of angle closure. Otherwise, you’ll make a hole in the sclera and the patient is still going to be at risk of an acute attack,” he said. Dr. Brown said that ACG patients with particularly high pressures may need a trabeculectomy but even then, he usually tries cataract surgery first. It goes back to tempering patient expectations, he explained. “You have to tell the patient there’s a chance the cataract surgery might not work and that you’ll have to do a trabeculectomy next week. You can’t tell patients that the cataract surgery will always work. You have to say this is something that may help, but if it doesn’t, we have a next step and we’ll have to do it quickly,” he said. EWAP References 1. Friedman DS, Vedula SS. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev. 2006;19:CD005555. 2. Emanuel, ME, Parrish RK II, Gedde SJ. Evidence-based management of primary angle closure glaucoma. Curr Opin Ophthalmol . 2014;25:89–92. Editors’ note: The physicians have no financial interests related to their comments. Contact information Bell: nbell@cizikeye.org Brown: reaymary@comcast.net Friedman: friedman@jhu.edu Making - from page 18 Index to Advertisers Carl Zeiss Southeast Asia Page: 23 www.zeiss.com.sg Carl Zeiss Meditec Page: 49, 61 www.meditec.zeiss.com Haag-Streit Page: 53 www.haag-streit.com Moria Page: 32 , 47 www.moria-surgical.com OCULUS Optikgeräte Page: 17 www.oculus.de Rayner Intraocular Lenses Page: 31 www.rayner.com Shanghai Mediworks Page : 2 www.mediworks.com.cn Singapore National Eye Centre Page: 68 www.snec.com.sg Topcon Corporation Page: 15 www.topcon.co.jp ASCRS Page: 14, 26, 62 , 67 www.ascrs.org APACRS Page : 5 , 7, 27 , 57 www.apacrs.org