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Editors Selection IGR 26-1

Surgical Treatment: Combined SPI + goniosynechialysis + goniotomy for advanced PACG: 2-year data

Comment by Bryan Ang on:

125218 Two-year outcomes of combined surgical peripheral iridectomy, goniosynechialysis, and goniotomy for advanced primary angle-closure glaucoma without cataract: A multicenter study, Lin F; Li L; Lu P et al., Asia-Pacific journal of ophthalmology (Philadelphia, Pa.), 2025; 0: 100166

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Primary angle-closure glaucoma (PACG) remains one of the leading causes of irreversible blindness, particularly in Asia. Conventional trabeculectomy is effective in managing advanced PACG but requires intensive post-operative care and possesses surgical risks, including hypotony, malignant glaucoma, endophthalmitis and bleb-related complications. Alternative approaches, such as surgical peripheral iridectomy (SPI) or standalone lens extraction alone, may be insufficient in advanced disease.

This was a multi-centre, prospective observational study which evaluated, in 63 eyes of 51 Chinese subjects, outcomes of single-session SPI, goniosynechialysis (GSL) and Tanito microhook-assisted 120-degree goniotomy (GT), in eyes with advanced PACG (mean visual field (VF) mean deviation of -19.8 dB) without cataract. This combined procedure targets multiple mechanisms of PACG – the SPI relieves pupillary block, the GSL releases peripheral anterior synechiae (PAS) and GT incises the trabecular meshwork to improve aqueous outflow. With prior 6- and 12-month studies reporting promising results1,2, this present study, with an extended follow-up to 24 months, successfully demonstrated sustained intraocular pressure (IOP) reduction from a baseline of 28.8 mmHg to 15.8 mmHg (reduction of 42.6%), with a concomitant decrease from 1.9 to 0.8 medication types per eye, with over half of eyes remaining medication-free by 24 months. 58.7% and 87.3% of eyes achieved complete and qualified success, respectively. Regression analysis found that older age was associated with higher complete and qualified success (OR 1.05 and 1.08 per year, respectively). Complications were mild and transient, consisting of primarily IOP spikes (14.2%), hyphema (11.1%), and shallow anterior chambers (4.8%).

These findings are valuable as they confirm the efficacy of a safe, angle-based procedure in advanced PACG, without the contributory effect of lens extraction. Data on this is scarce, with most previous studies reporting outcomes of GSL/GT only in combination with phacoemulsification3,4. This study suggests that a standalone “all-in-one” angle procedure, even without cataract extraction, may achieve near trabeculectomy-like IOP reductions5, and without bleb-related risks. Comparative evidence, in the context of SPI-GSL+GT combined with phacoemulsification, has also helped to support the efficacy of SPI+GSL+GT in angle closure disease. A recently-concluded randomized controlled trial (RCT) demonstrated that IOP reduction following phaco-goniotomy was noninferior to phaco-trabeculectomy at 2 years, suggesting phaco-goniotomy as a viable alternative for patients with advanced PACG6.

Limitations of this study include its limited generalizability, with all subjects being of Chinese ethnicity. Longer-term outcomes may be limited by progressive angle closure, expected due to cataract formation and lens thickening in phakic patients. Indeed, PAS recurrence was already observed over this study’s 2-year follow-up duration. As a single-arm design study, the absence of a comparator group may also limit its findings in real-life practice, as well as on conclusions on the relative efficacy of SPI+GSL+GT compared to trabeculectomy and lens extraction with GSL. An RCT directly comparing SPI+GSL+GT with trabeculectomy is currently ongoing (NCT05163951)7.

Overall, while current guidelines prioritize trabeculectomy for advanced PACG, studies such as this provide valuable data on outcomes of angle-based procedures as alternatives to trabeculectomy. There is growing evidence that SPI+GSL+GT, as a bleb-less procedure with few post-operative risks, may be a viable surgical option in advanced PACG, particularly in populations where post-operative adherence and access to intensive follow-up may be challenging.

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