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March 2012 Clear lens exchange proving viable to treat angle closure by Michelle Dalton EyeWorld Contributing Editor Evidence is emerging to support early lens extraction L ens extraction—for patients with and without cataract —may be a viable option in cases of angle-closure. Al- though more expensive initially than a traditional laser pe- ripheral iridotomy (LPI), lens extrac- tion "can be competitive with LPI from a cost-effectiveness standpoint in certain patients," said Qi Cui, M.D., University of Rochester School of Medicine and Dentistry, N.Y. Dr. Cui and colleagues initially pre- sented their findings last May at the 2011 Association for Research in Vi- sion and Ophthalmology conference in Fort Lauderdale, Fla. "Intraocular pressures com- monly drop even more in angle- closure cases than they do in open- angle cases after cataract removal," said Steven Vold, M.D., in private practice, Rogers, Ark. "When you perform an LPI in phakic patients, the angle often does not open as much as after cataract surgery alone. In my experience, LPI may not lower IOP as effectively as cataract sur- gery." In patients with plateau iris syndrome, they may have another acute angle-closure attack despite having an iridotomy. Although laser iridoplasty is certainly a viable option in these patients, cataract surgery avoids the potentially disfiguring iris effects of iridoplasty. Several studies out of Asia "have all shown clear lens exchange is su- perior to LPI," said Douglas J. Rhee, M.D., assistant professor, Massachu- setts Eye and Ear Infirmary, Harvard Medical School, Boston, adding that the subject is still evolving. "I generally still do the PI first rather than taking them to the OR," he said. "In acute cases, I want to break the attack first, medically if I can. Then I'll do a laser iridotomy and schedule the lens extraction for 3-4 weeks later." He also counsels patients that because the risk of developing angle-closure in the con- tralateral eye is 50% at 6 months and 75% at 1 year, he recommends lens extraction in the fellow eye. "This is certainly more contro- versial, but it's where we're head- ing," he said. For people in their 30s and 40s "who still have good accommoda- tion, I don't necessarily want to make them pseudophakic and take away their accommodation," Dr. Vold countered. "Presbyopic IOLs certainly should be considered in this population." Outcomes and pearls In angle-closure patients with visu- ally significant cataracts, "cataract surgery is my first-line treatment," Dr. Vold said. "A lot of these patients are hyperopic, so I'm correcting their hyperopia and addressing their glau- coma issues all at once," he said. "It is a home-run, over-the-fence deal." In his hands, Dr. Vold prefers cataract surgery to PIs "especially in cases of dark or brown irides." With PI, surgeons run the risk of introduc- ing additional inflammation that can predispose patients to peripheral anterior synechiae, especially in dark-colored irides. In eyes with EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews