- Email: [email protected]
Primary phacoemulsification for uncontrolled angle-closure glaucoma1
Primary phacoemulsification for uncontrolled angle-closure glaucoma Timothy V. Roberts, FRACO, FRACS, Ian C. Francis, FRACS, FRACO, FASOPRS, Sam Lertusumitkul, FRACS, FRACO, MPH, Medduma B. Kappagoda, FRACS, FRACO, FRCS, FRCOphth, Minas T. Coroneo, MSc, MD, MS, FRACS, FRACO ABSTRACT Purpose: To report the results of primary phacoemulsification to treat uncontrolled angleclosure glaucoma. Setting: Private practice and teaching hospital department. Methods: This retrospective interventional case series assessed 3 patients having phacoemulsification and posterior chamber intraocular lens implantation for uncontrolled intraocular pressure (IOP) after acute primary angle-closure glaucoma. Results: Intraocular pressure control was achieved in all patients postoperatively. Conclusion: Primary phacoemulsification with the option of future trabeculectomy should be considered in selected patients with persistent appositional angle closure and uncontrolled IOP after angle-closure glaucoma. J Cataract Refract Surg 2000; 26: 1012–1016 © 2000 ASCRS and ESCRS
T
he management of primary angle-closure glaucoma (PACG) with peripheral iridectomy is directed toward relieving the pupillary block that precipitates the cascade of anatomic angle closure. Predisposing factors for PACG include a shallow anterior chamber, small corneal diameter and radius of curvature, increased lens thickness, and an anterior lens–iris diaphragm.1,2 Persisting angle closure after peripheral iridotomy suggests a major contribution of the lens component.3 Surgical intervention to manage uncontrolled glaucoma after peripheral iridotomy should be directed toward restoring a normal iridocorneal anatomic relationship. Phacoemulsification induces favorable Accepted for publication January 14, 2000. Reprint requests to Dr. Tim Roberts, The Eye Institute, Level 3, 270 Victoria Avenue, Chatswood NSW 2067, Australia. E-mail: [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
changes in the anterior chamber configuration4 without inducing the trabecular meshwork hypoperfusion that occurs after drainage surgery.5 We report the outcome of primary phacoemulsification in 3 patients with uncontrolled intraocular pressure (IOP) after PACG.
Patients and Methods Case 1 A previously asymptomatic 64-year-old white woman presented with a 12 hour history of pain in the right eye. The episode began as the typical sudden onset of a progressively painful red eye that woke the patient at 2 AM. Examination showed an IOP of 70 mm Hg in the right eye and 20 mm Hg in the left eye. The right pupil was fixed and mid-dilated. The right cornea was edem0886-3350/00/$–see front matter PII S0886-3350(00)00358-8
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atous. The anterior chamber angle was closed in the right eye and narrow in the left (grade 1). Visual acuity was counting fingers in the right eye and 6/6 in the left eye with a correction of ⫹5.00 diopters (D) in the right eye and ⫹5.25 D in the left eye. Fundoscopy showed a healthy optic disc with a cup-to-disc ratio of 0.2 in both eyes. The patient was initially treated with acetazolamide 250 mg 4 times a day, timolol 0.5% eyedrops twice a day in the right eye, pilocarpine 1% eyedrops 4 times a day in both eyes, and dexamethasone acetate 0.1% eyedrops 4 times a day in the right eye. With medication, IOP in the right eye was 52 mm Hg after a further 12 hours. The patient was admitted to hospital, where the above medications were continued, and mannitol 100 g was given intravenously (IV) over 1 hour. Intraocular pressure decreased to 30 mm Hg in the right eye and 12 mm Hg in the left eye. The cornea cleared, but the pupil remained immobile. Thirty-six hours after the initial attack, IOP was 36 mm Hg in the right eye. A further 100 g mannitol IV was administered, and a large neodymium:YAG (Nd: YAG) laser peripheral iridotomy was performed at 10 o’clock with minimal bleeding. The anterior chamber deepened slightly, but gonioscopy showed a persistently closed angle. Two days later, IOP was 50 mm Hg; however, visual acuity had improved to 6/18. The pupil remained immobile, and the iridotomy was clearly patent. The right optic disc showed inferior cupping, and spontaneous pulsation of the central retinal artery was noted. A further 100 g mannitol IV reduced IOP to 28 mm Hg. Primary phacoemulsification was performed through a scleral tunnel.6 A 3-piece foldable intraocular lens (IOL) (SI-40NB, Allergan Medical Optics) was implanted in the capsular bag. Viscoelastic material, injected specifically into the angle region in a circumferential fashion, was used to deepen the angle in an attempt to separate peripheral iris from trabecular meshwork. One day postoperatively, IOP was 10 mm Hg in the right eye. The cornea had cleared, and the IOL was centered in the bag. Gonioscopy showed an open angle, grade 2, with no anterior synechias. An endothelial cell count and pachymetry were performed using the fellow eye as a control. Cell counts (Noncon Robo Specular Microscope, Konan) were
1332 cells/mm2 centrally in the left eye and 750 cells/mm2 in the right eye. Cell morphology was normal, with no evidence of localized endothelial damage near the incision site. Pachymetry (Corneo-Gauge Plus 2, Sonogage) was 546 m centrally and 605 m peripherally in the right eye and 551 and 645 m, respectively, in the left eye. Three years postoperatively, IOP remained at 14 mm Hg with visual acuity of 6/4 and a clear cornea. Case 2 A 45-year-old Asian man presented with a 3 day history of pain in the left eye that had increased during the preceding 24 hours. Examination revealed acute angle-closure glaucoma with an IOP of 65 mm Hg in the left eye and 24 mm Hg in the right eye. Angle closure was confirmed by gonioscopy. Visual acuity was 2/60 in the left eye and 6/5 in the right eye with respective corrections of 0 ⫹0.50 ⫻ 45 and 0 ⫹1.50 ⫻ 10. The left pupil was mid-dilated and nonreactive. The right optic disc was normal, although corneal edema prevented adequate assessment of the left disc. Acetazolamide 500 mg was given immediately. In addition, the patient received pilocarpine 2% drops 4 times a day in both eyes and timolol 0.5% drops 2 times a day in the left eye. An Nd:YAG laser peripheral iridotomy was unsuccessful because of corneal edema and an inflamed iris. The patient was admitted to the hospital and, in addition to the above treatment, was administered mannitol IV and prednisolone phosphate 0.5% drops. Intraocular pressure in the left eye fell from 42 to 17 mm Hg. The cornea cleared, but the pupil remained immobile. The patient was discharged and prescribed acetazolamide drops 250 mg 4 times a day, pilocarpine drops 25 mg 4 times a day in both eyes, timolol 0.5% 2 times a day in the left eye, and prednisolone phosphate 0.5% drops 4 times a day in the left eye. Four days later, the patient presented with angleclosure glaucoma and an IOP of 40 mm Hg in the left eye. He was admitted and treated medically with mannitol 20%, 500 mL IV, and glycerol 50% orally in addition to the ongoing topical medications. His IOP remained elevated despite maximal medical treatment. Phacoemulsification through a scleral tunnel with implantation of a 3-piece foldable IOL (SI-30NB, AMO) was performed. One day postoperatively, visual acuity was 6/12 and IOP, 15 mm Hg.
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Twelve months later, best corrected visual acuity was 6/6, the eye was quiet, and IOP was 19 mm Hg. The pupil remained fixed in the mid-dilated position, and gonioscopy revealed an open grade 2 angle. The discs remained healthy, with a cup-to-disc ratio of 0.3 in both eyes. Prophylactic laser iridotomy was performed in the right eye. An endothelial cell count and pachymetry were performed, with the fellow eye as a control, using the same measuring devices as in Case 1. Cell counts were 3258 cells/mm2 centrally in the right eye and 2705 cells/mm2 in the left eye. Cell morphology was normal, and there was no evidence of localized endothelial damage near the incision site. Pachymetry readings were 556 m centrally and 624 m peripherally in the right eye and 570 and 672 m, respectively, in the left eye, indicating normal endothelial cell function with no corneal edema. Case 3 A 44-year-old woman presented in May 1995 with acute glaucoma in the left eye. Intraocular pressure was 28 mm Hg in the right eye and 50 mm Hg in the left eye. Gonioscopy revealed a narrow, slit-like angle in the right eye and complete angle closure in the left eye. Initial medical treatment was successful, and bilateral Nd:YAG laser peripheral iridotomies were performed. Six months later, the patient had a trabeculectomy in her left eye for uncontrolled IOP. A shallow anterior chamber complicated the postoperative course, and multiple subconjunctival injections of 5-fluorouracil were given. In April 1997, the patient had phacoemulsification and IOL implantation in the left eye. Her IOP remained stable for 10 months, at which time she had needle sweep of the bleb. Gonioscopy revealed extensive peripheral anterior synechias throughout most of the angle. The IOP in the right eye remained elevated at 48 mm Hg, despite maximum medical therapy. Gonioscopy revealed a shallow anterior chamber with progressive appositional closure. In view of the complicated course after trabeculectomy in the left eye, primary IOL implantation was suggested. In June 1988, the patient had phacoemulsification and IOL implantation in the right eye. Postoperatively, the eye was quiet. Final visual acuity was 6/6 in the right eye and 6/12 in the left eye. 1014
Intraocular pressure was 18 and 19 mm Hg, respectively, with timolol 0.25% drops twice a day and latanoprost at night in both eyes.
Discussion The role of iridolenticular apposition leading to relative pupillary block has been well documented as a pathophysiological mechanism in PACG.1 Anterior chamber depth and axial length are the biometric parameters used to identify high-risk individuals. One study confirmed that ethnic groups with a higher rate of PACG do not differ on a population basis from other ethnic groups in many of the biometric risk factors known to predispose to PACG.7 Thus, other unidentified risk factors for PACG exist. The role of the crystalline lens in the pathogenesis of PACG has not been fully elucidated. In 1963, Lowe saw cases of angle-closure glaucoma without cataract resolved by complete dislocation of the lens into the vitreous (Ronald Lowe, personal communication, 1997). Guyton8 suggested in 1945 that cataract extraction might be effective in controlling IOP in PACG. In the past 2 decades, the number of cataract extractions has increased, with a corresponding decrease in the incidence of angle-closure glaucoma. This may be a result of the decrease in the proportion of patients with large lenses and iris bombe in the angle-closure population and provides anecdotal evidence of the role of the crystalline lens in the pathogenesis of PACG.9 The progressive enlargement of the lens throughout life has important consequences in eyes with short axial lengths and shallow anterior chambers. A subgroup of these eyes, with an as yet undefined additional risk factor, develops angle closure resulting from increased iridolenticular apposition, increased posterior chamber aqueous pressure, and closure of the angle by peripheral iris. To our knowledge, reports of primary IOL implantation for PACG have only described extracapsular cataract extraction (ECCE). Phacoemulsification offers the advantages of a small self-sealing incision, better maintenance of the anterior chamber intraoperatively, less risk of iris prolapse, and less iris manipulation. Phacoemulsification through a 3.0 to 4.0 mm selfsealing corneal incision significantly deepens the anterior chamber and widens the angle. Kurimoto and coauthors4 found the chamber was 1.37 times deeper
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and the angle 1.57 times wider after surgery. The more shallow the preoperative anterior chamber, the greater the postoperative change in the chamber depth. The more narrow the preoperative angle, the greater the postoperative change in the angle. These findings suggest that cataract extraction with IOL implantation is an effective therapeutic treatment for patients with PACG or for eyes with a narrow angle. Yang and Hung10prospectively studied 20 consecutive eyes with chronic PACG before and after ECCE. Mean anterior chamber depth was 2.04 mm ⫾ 0.29 (SD) preoperatively and 3.44 ⫾ 0.16 mm postoperatively. All eyes maintained an IOP under 21 mm Hg during the 6 month follow-up. Gunning and Greve11 compared the long-term effects of extraction of incipient cataracts or clear lenses with filtering surgery on glaucoma control in patients with PACG. Glaucoma control was achieved in 68% of eyes in both groups. Filtration surgery was associated with multiple surgical interventions and deterioration in visual function. After filtration surgery, aqueous flows preferentially through the surgical sclerostomy site, bypassing the remaining trabecular meshwork. This results in underperfusion of the trabecular meshwork by aqueous and induces degenerative changes in the meshwork similar to those seen in chronic open-angle glaucoma.12 The incidence of cataract reported after filtration surgery is 15% to 60%,10,13 and other complications such as shallow anterior chamber, hypotony, and choroidal effusion or hemorrhage are known to occur. Other options to treat angle-closure glaucoma include argon laser peripheral iridoplasty (ALPI), which can be used to open an appositionally closed angle in cases of angle closure unresponsive to medical therapy and in which laser iridotomy cannot be performed.14 –16 Definitive treatment with iridotomy is still required once the corneal edema has resolved or the anterior chamber deepened sufficiently to allow laser iridotomy to be safely performed. Approximately 10% of patients with PACG have an underlying mechanism other than pupillary block and do not respond to iridotomy. Other techniques such as surgical goniosynechialysis and chamber-deepening procedures have been described. Goniosynechialysis17 has been successful in reducing pressure in cases of chronic angle closure complicated by synechial closure. The technique is only effective if the synechias have been present for less than 1 year and it is
used in association with phacoemulsification in the management of uncontrolled chronic angle-closure glaucoma after acute angle-closure glaucoma.18 Early intervention with phacoemulsification and IOL implantation prevents synechia formation and eliminates lens-induced angle narrowing. Surgery can be performed acutely or days to weeks after ALPI if the eye is considered too inflamed. In our cases, the angle was opened using viscoelastic material without mechanical synechialysis. Although concerns regarding damage to corneal endothelium during phacoemulsification are documented, cataract surgery with IOL implantation has been successfully performed in eyes with acute angleclosure glaucoma. Endothelial cell damage after acute angle closure is well documented,19 –23 with mean decreases in cell density of up to 33% reported. The duration of elevated IOP correlates with the number of corneal endothelial cells lost. High IOP lasting 3 days or more lowers the central endothelial count, whereas a rise in pressure lasting from only a few hours to 2 days does not affect the cell count. The change in the endothelial cell count in our patients is consistent with the episode of angle closure and does not suggest an increased risk after phacoemulsification. Both our patients with endothelial cell counts showed a difference in endothelial cell density between the operated and nonoperated eye, but with normal cell morphology and no clinical or pachymetric evidence of corneal decompensation. The results in our 3 patients were satisfactory; we were surprised as surgery in patients with PACG has traditionally been thought to be risky, in particular in terms of corneal and iris trauma. All our patients regained good vision, and none developed cystoid macular edema or corneal decompensation. We ensured that each patient had low IOP at surgery by the judicious use of mannitol and by performing each step of the surgery with extreme care.
Conclusion Glaucoma filtering surgery is associated with more postoperative complications and deterioration in vision than primary phacoemulsification surgery. Multiple surgeries are often required. Degenerative changes induced in the trabecular meshwork resemble those in chronic open-angle glaucoma, and the eye becomes rel-
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atively dependent on bleb drainage. Phacoemulsification is safer in eyes with a shallow anterior chamber and high vitreous pressure. The superior limbus and conjunctiva are preserved, and visual rehabilitation is excellent with a predictable postoperative course. Favorable changes are seen in the anterior chamber configuration, with a subsequent decrease in IOP. Primary phacoemulsification with the option of future trabeculectomy should be considered in patients with persistent appositional angle closure and uncontrolled IOP after angle-closure glaucoma.
References
13.
14.
15.
1. Lowe RF. Aetiology of the anatomical basis for primary angle-closure glaucoma; biometrical comparisons between normal eyes and eyes with primary angle-closure glaucoma. Br J Ophthalmol 1970; 54:161–169 2. Lowe RF. Primary angle closure glaucoma: a review of ocular biometry. Aust NZ J Ophthalmol 1977; 5:9 –17 3. Ritch R. Glaucoma secondary to lens intumescence and dislocation. In: Ritch R, Shields MB, eds, The Secondary Glaucomas. St Louis, MO, CV Mosby Co, 1982:131– 149 4. Kurimoto Y, Park M, Sakaue H, Kondo T. Changes in the anterior chamber configuration after small-incision cataract surgery with posterior chamber intraocular lens implantation. Am J Ophthalmol 1997; 124:775–780 5. Kaufman PL. Pressure-dependent outflow. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas, 2nd ed. St Louis, MO, Mosby, 1996; 307–335 6. Francis IC, Irvine S, O’Brien DPB, et al. Prospective evaluation of one surgeon’s first 100 cases of endocapsular phacoemulsification cataract surgery. Aust NZ J Ophthalmol 1993; 21:147–152 7. Congdon NG, Youlin Q, Quigley H, et al. Biometry and primary angle-closure glaucoma among Chinese, white, and black populations. Ophthalmology 1997; 104:1489 –1495 8. Guyton JS. Choice of operation in eyes with primary glaucoma and cataracts. Trans Am Acad Ophthalmol Otolaryngol 1945; 49:216 –224 9. Ritch R, Lowe RF. Angle-closure glaucoma: mechanisms and epidemiology. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas, 2nd ed. St Louis, MO, Mosby, 1996; 805 10. Yang C-H, Hung P-T. Intraocular lens position and anterior chamber angle changes after cataract extraction in eyes with primary angle-closure glaucoma. J Cataract Refract Surg 1997; 23:1109 –1113 11. Gunning FP, Greve EL. Lens extraction for uncontrolled
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angle-closure glaucoma: long-term follow-up. J Cataract Refract Surg 1998; 24:1347–1356; citation correction 1999; 25:446 Lu¨tjen-Drecoll E, Ba´ra´ny EH. Functional and electron microscopic changes in the trabecular meshwork remaining after trabeculectomy in cynomolgus monkeys. Invest Ophthalmol 1974; 13:511–524 D’Ermo F, Bonomi L, Doro D. A critical analysis of the long-term results of trabeculectomy. Am J Ophthalmol 1979; 88:829 – 835 Ritch R, Liebmann JM. Laser iridotomy and peripheral iridoplasty. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas, 2nd ed. St Louis, MO, Mosby, 1996; 1564 – 1568 Lai JSM, Tham CCY, Lam DSC. Limited argon laser peripheral iridoplasty as immediate treatment for an acute attack of primary angle closure glaucoma: a preliminary study. Eye 1999; 13:26 –30 Ritch R. Argon laser peripheral iridoplasty: an overview. J Glaucoma 1992; 1:206 –213 Campbell DG, Vela A. Modern goniosynechialysis for the treatment of synechial angle-closure glaucoma. Ophthalmology 1984; 91:1052–1060 Teekhasaenee C, Ritch R. Combined phacoemulsification and goniosynechialysis for uncontrolled chronic angle-closure glaucoma after acute angle-closure glaucoma. Ophthalmology 1999; 106:669 – 674; discussion by EL Greve, FP Gunning, 674 – 675 Olsen T. The endothelial cell damage in acute glaucoma. On the corneal thickness response to intraocular pressure. Acta Ophthalmol 1980; 58:257–266 Se¨ta¨la K. Corneal endothelial cell density after an attack of acute glaucoma. Acta Ophthalmol 1979; 57:1004 – 1013 Markowitz SN, Morin JD. The endothelium in primary angle-closure glaucoma. Am J Ophthalmol 1984; 98:103–104 Malaise-Stals J, Collignon-Brach J, Weekers J-F. Corneal endothelial cell density in acute angle-closure glaucoma. Ophthalmologica 1984; 189:104 –109 Bigar F, Witmer R. Corneal endothelial changes in primary acute angle-closure glaucoma Ophthalmology 1982; 89:596 –599
From The Eye Institute (Roberts), Chatswood (Francis), and the Departments of Ophthalmology, Liverpool Hospital (Lertusumitkul), University of Sydney (Kappagoda), and University of NSW, Prince of Wales Hospital, Randwick (Coroneo), Sydney, Australia. Presented at the Australian and New Zealand Glaucoma Club Conference, Sydney, Australia, February 1999. None of the authors has a financial or proprietary interest in any material or method mentioned.
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he management of primary angle-closure glaucoma (PACG) with peripheral iridectomy is directed toward relieving the pupillary block that precipitates the cascade of anatomic angle closure. Predisposing factors for PACG include a shallow anterior chamber, small corneal diameter and radius of curvature, increased lens thickness, and an anterior lens–iris diaphragm.1,2 Persisting angle closure after peripheral iridotomy suggests a major contribution of the lens component.3 Surgical intervention to manage uncontrolled glaucoma after peripheral iridotomy should be directed toward restoring a normal iridocorneal anatomic relationship. Phacoemulsification induces favorable Accepted for publication January 14, 2000. Reprint requests to Dr. Tim Roberts, The Eye Institute, Level 3, 270 Victoria Avenue, Chatswood NSW 2067, Australia. E-mail: [email protected]. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
changes in the anterior chamber configuration4 without inducing the trabecular meshwork hypoperfusion that occurs after drainage surgery.5 We report the outcome of primary phacoemulsification in 3 patients with uncontrolled intraocular pressure (IOP) after PACG.
Patients and Methods Case 1 A previously asymptomatic 64-year-old white woman presented with a 12 hour history of pain in the right eye. The episode began as the typical sudden onset of a progressively painful red eye that woke the patient at 2 AM. Examination showed an IOP of 70 mm Hg in the right eye and 20 mm Hg in the left eye. The right pupil was fixed and mid-dilated. The right cornea was edem0886-3350/00/$–see front matter PII S0886-3350(00)00358-8
PHACOEMULSIFICATION FOR UNCONTROLLED ANGLE-CLOSURE GLAUCOMA
atous. The anterior chamber angle was closed in the right eye and narrow in the left (grade 1). Visual acuity was counting fingers in the right eye and 6/6 in the left eye with a correction of ⫹5.00 diopters (D) in the right eye and ⫹5.25 D in the left eye. Fundoscopy showed a healthy optic disc with a cup-to-disc ratio of 0.2 in both eyes. The patient was initially treated with acetazolamide 250 mg 4 times a day, timolol 0.5% eyedrops twice a day in the right eye, pilocarpine 1% eyedrops 4 times a day in both eyes, and dexamethasone acetate 0.1% eyedrops 4 times a day in the right eye. With medication, IOP in the right eye was 52 mm Hg after a further 12 hours. The patient was admitted to hospital, where the above medications were continued, and mannitol 100 g was given intravenously (IV) over 1 hour. Intraocular pressure decreased to 30 mm Hg in the right eye and 12 mm Hg in the left eye. The cornea cleared, but the pupil remained immobile. Thirty-six hours after the initial attack, IOP was 36 mm Hg in the right eye. A further 100 g mannitol IV was administered, and a large neodymium:YAG (Nd: YAG) laser peripheral iridotomy was performed at 10 o’clock with minimal bleeding. The anterior chamber deepened slightly, but gonioscopy showed a persistently closed angle. Two days later, IOP was 50 mm Hg; however, visual acuity had improved to 6/18. The pupil remained immobile, and the iridotomy was clearly patent. The right optic disc showed inferior cupping, and spontaneous pulsation of the central retinal artery was noted. A further 100 g mannitol IV reduced IOP to 28 mm Hg. Primary phacoemulsification was performed through a scleral tunnel.6 A 3-piece foldable intraocular lens (IOL) (SI-40NB, Allergan Medical Optics) was implanted in the capsular bag. Viscoelastic material, injected specifically into the angle region in a circumferential fashion, was used to deepen the angle in an attempt to separate peripheral iris from trabecular meshwork. One day postoperatively, IOP was 10 mm Hg in the right eye. The cornea had cleared, and the IOL was centered in the bag. Gonioscopy showed an open angle, grade 2, with no anterior synechias. An endothelial cell count and pachymetry were performed using the fellow eye as a control. Cell counts (Noncon Robo Specular Microscope, Konan) were
1332 cells/mm2 centrally in the left eye and 750 cells/mm2 in the right eye. Cell morphology was normal, with no evidence of localized endothelial damage near the incision site. Pachymetry (Corneo-Gauge Plus 2, Sonogage) was 546 m centrally and 605 m peripherally in the right eye and 551 and 645 m, respectively, in the left eye. Three years postoperatively, IOP remained at 14 mm Hg with visual acuity of 6/4 and a clear cornea. Case 2 A 45-year-old Asian man presented with a 3 day history of pain in the left eye that had increased during the preceding 24 hours. Examination revealed acute angle-closure glaucoma with an IOP of 65 mm Hg in the left eye and 24 mm Hg in the right eye. Angle closure was confirmed by gonioscopy. Visual acuity was 2/60 in the left eye and 6/5 in the right eye with respective corrections of 0 ⫹0.50 ⫻ 45 and 0 ⫹1.50 ⫻ 10. The left pupil was mid-dilated and nonreactive. The right optic disc was normal, although corneal edema prevented adequate assessment of the left disc. Acetazolamide 500 mg was given immediately. In addition, the patient received pilocarpine 2% drops 4 times a day in both eyes and timolol 0.5% drops 2 times a day in the left eye. An Nd:YAG laser peripheral iridotomy was unsuccessful because of corneal edema and an inflamed iris. The patient was admitted to the hospital and, in addition to the above treatment, was administered mannitol IV and prednisolone phosphate 0.5% drops. Intraocular pressure in the left eye fell from 42 to 17 mm Hg. The cornea cleared, but the pupil remained immobile. The patient was discharged and prescribed acetazolamide drops 250 mg 4 times a day, pilocarpine drops 25 mg 4 times a day in both eyes, timolol 0.5% 2 times a day in the left eye, and prednisolone phosphate 0.5% drops 4 times a day in the left eye. Four days later, the patient presented with angleclosure glaucoma and an IOP of 40 mm Hg in the left eye. He was admitted and treated medically with mannitol 20%, 500 mL IV, and glycerol 50% orally in addition to the ongoing topical medications. His IOP remained elevated despite maximal medical treatment. Phacoemulsification through a scleral tunnel with implantation of a 3-piece foldable IOL (SI-30NB, AMO) was performed. One day postoperatively, visual acuity was 6/12 and IOP, 15 mm Hg.
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Twelve months later, best corrected visual acuity was 6/6, the eye was quiet, and IOP was 19 mm Hg. The pupil remained fixed in the mid-dilated position, and gonioscopy revealed an open grade 2 angle. The discs remained healthy, with a cup-to-disc ratio of 0.3 in both eyes. Prophylactic laser iridotomy was performed in the right eye. An endothelial cell count and pachymetry were performed, with the fellow eye as a control, using the same measuring devices as in Case 1. Cell counts were 3258 cells/mm2 centrally in the right eye and 2705 cells/mm2 in the left eye. Cell morphology was normal, and there was no evidence of localized endothelial damage near the incision site. Pachymetry readings were 556 m centrally and 624 m peripherally in the right eye and 570 and 672 m, respectively, in the left eye, indicating normal endothelial cell function with no corneal edema. Case 3 A 44-year-old woman presented in May 1995 with acute glaucoma in the left eye. Intraocular pressure was 28 mm Hg in the right eye and 50 mm Hg in the left eye. Gonioscopy revealed a narrow, slit-like angle in the right eye and complete angle closure in the left eye. Initial medical treatment was successful, and bilateral Nd:YAG laser peripheral iridotomies were performed. Six months later, the patient had a trabeculectomy in her left eye for uncontrolled IOP. A shallow anterior chamber complicated the postoperative course, and multiple subconjunctival injections of 5-fluorouracil were given. In April 1997, the patient had phacoemulsification and IOL implantation in the left eye. Her IOP remained stable for 10 months, at which time she had needle sweep of the bleb. Gonioscopy revealed extensive peripheral anterior synechias throughout most of the angle. The IOP in the right eye remained elevated at 48 mm Hg, despite maximum medical therapy. Gonioscopy revealed a shallow anterior chamber with progressive appositional closure. In view of the complicated course after trabeculectomy in the left eye, primary IOL implantation was suggested. In June 1988, the patient had phacoemulsification and IOL implantation in the right eye. Postoperatively, the eye was quiet. Final visual acuity was 6/6 in the right eye and 6/12 in the left eye. 1014
Intraocular pressure was 18 and 19 mm Hg, respectively, with timolol 0.25% drops twice a day and latanoprost at night in both eyes.
Discussion The role of iridolenticular apposition leading to relative pupillary block has been well documented as a pathophysiological mechanism in PACG.1 Anterior chamber depth and axial length are the biometric parameters used to identify high-risk individuals. One study confirmed that ethnic groups with a higher rate of PACG do not differ on a population basis from other ethnic groups in many of the biometric risk factors known to predispose to PACG.7 Thus, other unidentified risk factors for PACG exist. The role of the crystalline lens in the pathogenesis of PACG has not been fully elucidated. In 1963, Lowe saw cases of angle-closure glaucoma without cataract resolved by complete dislocation of the lens into the vitreous (Ronald Lowe, personal communication, 1997). Guyton8 suggested in 1945 that cataract extraction might be effective in controlling IOP in PACG. In the past 2 decades, the number of cataract extractions has increased, with a corresponding decrease in the incidence of angle-closure glaucoma. This may be a result of the decrease in the proportion of patients with large lenses and iris bombe in the angle-closure population and provides anecdotal evidence of the role of the crystalline lens in the pathogenesis of PACG.9 The progressive enlargement of the lens throughout life has important consequences in eyes with short axial lengths and shallow anterior chambers. A subgroup of these eyes, with an as yet undefined additional risk factor, develops angle closure resulting from increased iridolenticular apposition, increased posterior chamber aqueous pressure, and closure of the angle by peripheral iris. To our knowledge, reports of primary IOL implantation for PACG have only described extracapsular cataract extraction (ECCE). Phacoemulsification offers the advantages of a small self-sealing incision, better maintenance of the anterior chamber intraoperatively, less risk of iris prolapse, and less iris manipulation. Phacoemulsification through a 3.0 to 4.0 mm selfsealing corneal incision significantly deepens the anterior chamber and widens the angle. Kurimoto and coauthors4 found the chamber was 1.37 times deeper
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and the angle 1.57 times wider after surgery. The more shallow the preoperative anterior chamber, the greater the postoperative change in the chamber depth. The more narrow the preoperative angle, the greater the postoperative change in the angle. These findings suggest that cataract extraction with IOL implantation is an effective therapeutic treatment for patients with PACG or for eyes with a narrow angle. Yang and Hung10prospectively studied 20 consecutive eyes with chronic PACG before and after ECCE. Mean anterior chamber depth was 2.04 mm ⫾ 0.29 (SD) preoperatively and 3.44 ⫾ 0.16 mm postoperatively. All eyes maintained an IOP under 21 mm Hg during the 6 month follow-up. Gunning and Greve11 compared the long-term effects of extraction of incipient cataracts or clear lenses with filtering surgery on glaucoma control in patients with PACG. Glaucoma control was achieved in 68% of eyes in both groups. Filtration surgery was associated with multiple surgical interventions and deterioration in visual function. After filtration surgery, aqueous flows preferentially through the surgical sclerostomy site, bypassing the remaining trabecular meshwork. This results in underperfusion of the trabecular meshwork by aqueous and induces degenerative changes in the meshwork similar to those seen in chronic open-angle glaucoma.12 The incidence of cataract reported after filtration surgery is 15% to 60%,10,13 and other complications such as shallow anterior chamber, hypotony, and choroidal effusion or hemorrhage are known to occur. Other options to treat angle-closure glaucoma include argon laser peripheral iridoplasty (ALPI), which can be used to open an appositionally closed angle in cases of angle closure unresponsive to medical therapy and in which laser iridotomy cannot be performed.14 –16 Definitive treatment with iridotomy is still required once the corneal edema has resolved or the anterior chamber deepened sufficiently to allow laser iridotomy to be safely performed. Approximately 10% of patients with PACG have an underlying mechanism other than pupillary block and do not respond to iridotomy. Other techniques such as surgical goniosynechialysis and chamber-deepening procedures have been described. Goniosynechialysis17 has been successful in reducing pressure in cases of chronic angle closure complicated by synechial closure. The technique is only effective if the synechias have been present for less than 1 year and it is
used in association with phacoemulsification in the management of uncontrolled chronic angle-closure glaucoma after acute angle-closure glaucoma.18 Early intervention with phacoemulsification and IOL implantation prevents synechia formation and eliminates lens-induced angle narrowing. Surgery can be performed acutely or days to weeks after ALPI if the eye is considered too inflamed. In our cases, the angle was opened using viscoelastic material without mechanical synechialysis. Although concerns regarding damage to corneal endothelium during phacoemulsification are documented, cataract surgery with IOL implantation has been successfully performed in eyes with acute angleclosure glaucoma. Endothelial cell damage after acute angle closure is well documented,19 –23 with mean decreases in cell density of up to 33% reported. The duration of elevated IOP correlates with the number of corneal endothelial cells lost. High IOP lasting 3 days or more lowers the central endothelial count, whereas a rise in pressure lasting from only a few hours to 2 days does not affect the cell count. The change in the endothelial cell count in our patients is consistent with the episode of angle closure and does not suggest an increased risk after phacoemulsification. Both our patients with endothelial cell counts showed a difference in endothelial cell density between the operated and nonoperated eye, but with normal cell morphology and no clinical or pachymetric evidence of corneal decompensation. The results in our 3 patients were satisfactory; we were surprised as surgery in patients with PACG has traditionally been thought to be risky, in particular in terms of corneal and iris trauma. All our patients regained good vision, and none developed cystoid macular edema or corneal decompensation. We ensured that each patient had low IOP at surgery by the judicious use of mannitol and by performing each step of the surgery with extreme care.
Conclusion Glaucoma filtering surgery is associated with more postoperative complications and deterioration in vision than primary phacoemulsification surgery. Multiple surgeries are often required. Degenerative changes induced in the trabecular meshwork resemble those in chronic open-angle glaucoma, and the eye becomes rel-
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atively dependent on bleb drainage. Phacoemulsification is safer in eyes with a shallow anterior chamber and high vitreous pressure. The superior limbus and conjunctiva are preserved, and visual rehabilitation is excellent with a predictable postoperative course. Favorable changes are seen in the anterior chamber configuration, with a subsequent decrease in IOP. Primary phacoemulsification with the option of future trabeculectomy should be considered in patients with persistent appositional angle closure and uncontrolled IOP after angle-closure glaucoma.
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From The Eye Institute (Roberts), Chatswood (Francis), and the Departments of Ophthalmology, Liverpool Hospital (Lertusumitkul), University of Sydney (Kappagoda), and University of NSW, Prince of Wales Hospital, Randwick (Coroneo), Sydney, Australia. Presented at the Australian and New Zealand Glaucoma Club Conference, Sydney, Australia, February 1999. None of the authors has a financial or proprietary interest in any material or method mentioned.
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