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Editors Selection IGR 8-4

Angle closure glaucoma

Comment by Tec Kuan Paul Chew on:

13368 To compare argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure: mid-term results, Lai JS; Tham CC; Chua JK et al., Eye, 2006; 20: 309-314

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Lai et al. (156) addressed two approaches in acute angle closure management prior to laser peripheral iridotomy, medical versus laser iridoplasty. It is true that medical practice is geared towards evidence-based system and randomized controlled trials are important, but application of randomized trials to day to day practice must be dealt with caution. As in this case, if this research paper is rigidly followed, one might end up overtreating or undertreating acute angle closure patients with laser iridoplasty. Consider also that immediate response to either treatment (laser or medical) is directly related to the severity and duration of the attack. Attempt is made to discuss the role of immediate ALPI in reducing chance of CACG conversion by decreasing the duration of iris-trabecular meshwork contact and subsequently PAS formation but still severity and duration of attack at initial presentation are potential relevant factors to the possible progression to chronic angle closure glaucoma of the 19.5% eyes in the immediate ALPI and 31.6% in the medical treatment requiring medical treatment to control IOP. Systematic presentation of methodology is commendable. In multicenter trials like this, it would be very difficult to draw conclusions regarding peripheral anterior synechiae formation between the two groups in relation to subsequent progression to chronic angle closure glaucoma because of the subjective nature of gonioscopy findings performed by multiple investigators, although the authors acknowledged this as part of the inherent limitation of standardizing outcome measure documentation and quantification in the discussion part of the article.

The mid term results presented, affirm the usefulness of laser iridoplasty and/or medical treatment as part of the initial approach to break acute angle closure attack, but there is nothing new with the concepts presented because previous researches on angle closure has tackled and reported about the said concepts

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