Eyeworld

59 EW RESIDENTS July 2015 2. Tham, YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 2014;121(11)2081–90. 3. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90(3):262–267. 4. Sihota R, Rao A, Gupta V, Srinivasan G, Sharma A. Progression in primary angle clo- sure eyes. J Glaucoma 2010;19(9):632–636. 5. Thomas R, Arun T, Muliyil J, George R. Out- come of laser peripheral iridotomy in chronic primary angle closure glaucoma. Ophthalmic Surg Lasers 1999;30(7): 547–553. 6. Thomas R, Parikh R, Muliyil J, Kumar RS. Five-year risk of progression of primary angle closure to primary angle closure glaucoma: a population-based study. Acta Ophthalmol Scand 2003;81(5);480–485. 7. Azuara-Blanco A, Burr JM, Cochran C, Ramsay C, Vale L, Foster P, et al. Effectiveness in Angle-closure Glaucoma of Lens Extraction Study Group. The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): study protocol for a ran- domized controlled trial. Trials 2011;12:133. 8. Tarongoy P, Ho CL, Walton, DS. Angle-clo- sure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment. Surv Ophthalmol 2009:54(2):211–225. 9. Thomas R, Walland MJ, Parikh RS. Clear lens extraction in angle closure glaucoma. Curr Opin Ophthalmol 2011;22(2):110–114. 10. Walland M, Thomas R. Role of clear lens extraction in adult angle closure disease: a review. Clin Experiment Ophthalmol 2011;39(1):61–64. Contact information Mian: smian@med.umich.edu mitis, retinal detachment, additional surgery, suprachoroidal hemorrhage, bullous keratopathy, and vision loss. To address this important clinical question, we await the results of a multicenter, random- ized controlled trial in the U.K. and East Asia designed to investigate the role CLE in patients with newly diagnosed PAC and PACG. 7 This study will report on 3 outcomes: a patient-centered quality of life assessment, a clinical outcome of lower IOP, and an economic out- come comparing the CLE approach to standard of care. Of great interest is the intervention arm that will have a CLE performed even prior to the standard-of-care laser peripheral iridotomy. In conclusion, Dada et al have published intriguing data on the role of CLE in patients with PAC. The primary outcome of reducing IOP is simple and straightforward. From the results of this study, it is reason- able to consider CLE as part of our armamentarium in achieving low IOP in patients with PAC disease, as long as we are cognizant of the risks of this elective procedure. Acknowledgements The authors would like to thank residents and faculty in helping prepare this review. EW References 1. Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of glaucoma in prevalence surveys. Br J Ophthalmol 2002;86(2):238–242. the "adjusted" multivariate analysis, the authors did not indicate what adjustment variables were included. Since ACD only became statistical- ly significant after adjustment, it is difficult to understand why that might be without knowing what ad- justments were made. Finally, since axial length has previously been associated with angle crowding, axial length could have been used in univariate and multivariate analysis to determine whether it is a risk fac- tor for intraocular pressure control and angle anatomy after surgery. 8 Dada et al's results provide the opportunity for a global dialogue to assess which patient, with anatom- ically narrow angles, benefits from surgical risks of CLE to prevent glaucoma. In other words, "Does the inconvenience of applying eye drops or the side effects of topical ocular hypotensive medications warrant the tangible risk of surgical com- plications?" As Dada et al excluded PAC suspects, Thomas et al also did not recommend using CLE in patients who are PAC suspects and caution against widespread use in patients with PAC and PACG. 9 Wal- land et al recommended restricting the use of incisional surgery to pa- tients where the benefits exceed the risks with glaucoma or a high prob- ability of developing the problem. 10 This study emphasizes that although it is important to prevent glaucoma and its progression, every patient with PAC disease does not need to have a CLE due to its inherent surgical risks, including endophthal- prior to performing a trabeculecto- my. The authors acknowledge the limitations include a short follow-up period, a lack of a control group with IOP controlled by medications or with a trabeculectomy, and no gonioscopic analysis to evaluate the extent of synechial closure postop- eratively. In addition, the study is a non-randomized, single location, single surgeon study that may lead to surgeon and geographic bias. The authors report limited patient demographic data. Thus, there is an assumption that the patients are homogenous with no significant comorbidities that may impact the reported primary and secondary outcomes. Finally, the total number of patients screened for enrollment in the study and specific indications for exclusion are not noted, which would have been helpful given the small sample size and long recruit- ment period of 2.5 years. There were several questions on the statistical analysis. On the anal- ysis of the change in uncorrected near visual acuity, statistical anal- ysis did not need to be performed, and when it was, a McNemar's chi-square test would have been appropriate to evaluate pre- and postoperative change. The univar- iate analysis tables present many contrasts of preoperative values with 12-month postoperative values and correlations among variables. One could quibble regarding the lack of attention to trends over time and the need to adjust p-values for the multiple comparisons problem. In The residents of the Kellogg Eye Center, University of Michigan Source: University of Michigan

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