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Editors Selection IGR 14-3

Surgical Treatment: Chronic angle-closure glaucoma

Comment by Thomas Samuelson on:

51285 Phacoemulsification versus Trabeculectomy in Medically Uncontrolled Chronic Angle-Closure Glaucoma without Cataract, Tham CC; Kwong YY; Baig N et al., Ophthalmology, 2013; 120: 62-67

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This important article compares two treatment options for medically uncontrolled, chronic angle-closure glaucoma (CACG). Fifty patients with CACG not controlled with peripheral laser iridotomy (LPI) and medical therapy were randomized to receive either trabeculectomy with MMC or phacoemulsification (PE). To be included in the study, visual acuity of 20/40 or better was required, thus excluding patients with advanced lens opacity. The average age at enrollment was 65 years for the PE group and 66 for the trabeculectomy group. All surgical procedures were performed by the same surgeon. Two-year follow up is reported for all 50 patients enrolled in the study. Preoperative clinical and demographic data were not statistically different between groups (p > 0.05).

Both groups had a significant reduction in IOP and in medications. PE alone reduced the mean IOP from 24.1 to 15.9 mmHg (a 34% reduction) and trabeculectomy with MMC reduced the IOP from 24.8 to 15.8 mmHg (a 36% reduction). In addition, the number of medications was significantly reduced in each group. In the PE group the median number of medications was four preoperatively and one at 24 months. In the trabeculectomy group the median number of medications was reduced from 3.5 to 0. While the percentage of patients that remained medication free at two years was higher in the trabeculectomy group (46% vs. 27%), the difference was not statistically significant. Importantly, eight of the 24 patients in the trabeculectomy group (33%) had of progression of cataract and five of these eight patients had cataract removal during the 24-month follow-up period. In the PE group, three eyes (12%) required trabeculectomy during the follow-up period. Another two eyes in the PE group had medically uncontrolled IOP but had not had surgical intervention by the end of the two-year follow up. Complications were considerably higher in the trabeculectomy group than in the PE group (46% and 4% respectively, P = 0.001) although the complications did not have an adverse effect on visual outcomes.

This study demonstrates that both PE and trabeculectomy are very effective at lowering IOP in medically uncontrolled CACG. That phacoemulsification lowered IOP by 34%, and median medications from four preoperatively to one at 24 months, in this patient population that had previously had LPI is very impactful. It is evident from this study, as well as other recent studies, that removal of the native lens in patients with CACG more favorably influences the functional anatomy of the angle than does laser iridotomy. This study demonstrates that PE is a viable treatment option for IOP reduction in CACG not controlled by medication and laser iridotomy, with significantly fewer surgical complications than trabeculectomy.

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