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Editors Selection IGR 9-1

Surgery: Anterior Chamber Paracentesis in ACG

Comment by Dennis Lam on:

16979 Anterior chamber paracentesis in patients with acute elevation of intraocular pressure, Arnavielle S; Creuzot-Garcher C; Bron AM, Graefe's Archive for Clinical and Experimental Ophthalmology, 2007; 245: 345-350

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In situations of acute severe ocular hypertension, the challenge is to safely and rapidly reduce the intraocular pressure so as to relieve the patient of the very unpleasant symptoms, and at the same time, reduce the amount of ir-reversible damage to ocular tissues. Anterior chamber paracentesis (ACP) has been used by phacoemulsification surgeons to treat the acute ocular hypertension in the early post-operative period. It was shown to be effective and safe in this situation.¹ It is a logical next step to explore the application of ACP in other situations of acute ocular hypertension, such as in acute primary angle closure.

This study by Arnavielle et al. (379) clearly echoed the results from our previous study in Hong Kong² that ACP is potentially an effective and safe adjunctive treatment in acute primary angle closure. We commend the authors for taking the idea one step further: to include other types of acute glaucoma in their prospective case series. Since the efficacy and safety of any treatment protocols may be related to the underlying disease mechanisms, we may need significantly larger sample sizes of each disease to delineate the outcomes of ACP. This study is surely a good starting point, but we agree with the auhtors that its conclusions remain 'preliminary', especially with regard to the secondary glaucomas.

Decompression retinopathy and choroidal hemorrhage or effusion are potential complications after rapid intraocular pressure reduction. It is advisable to perform dilated fundoscopy or ultrasonography (B-scan) if the pupil dilatation is not satisfactory in acute primary angle closure cases treated with ACP once the pupillary block has been eliminated. Our group has performed over 100 ACP in acute primary angle closure so far, and we are happy to report that these complications have not been documented.
ACP, as an adjunctive treatment in acute ocular hypertension, has other advantages too. It does not require round-the-clock availability of laser surgical expertise and equipment. Any cataract surgeons are already experienced in performing paracentesis, albeit in slightly different setting. In our opinion, any ophthalmology resident, after appropriate training can perform ACP independently and safely.

We share Arnavielle and colleagues view that ACP may indeed have a role in the treatment of acute glaucoma, and this role is best to be clearly defined by prospective randomized controlled trials. We believe proper ground work has been laid by Arnavielle et al. and other previous investigators. We are now ready for the litmus test for this procedure.

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