Eyeworld

67 EW FEATURE February 2017 • Glaucoma and the cataract patient and closed angle glaucoma, many of us prefer to stick to our classic treat- ment algorithm when managing glaucoma, instituting medical and laser therapy first and then moving to traditional glaucoma surgery if the intraocular pressure is too high for the degree of disc damage." Dr. Panarelli's first choice for treatment of a narrow angle is a laser iridotomy. If there is elevated intra- ocular pressure, he begins medica- tion and considers iridoplasty, espe- cially in those patients with plateau iris syndrome or nanophthalmos. If these measures do not adequately reduce the IOP, he considers do- ing filtering surgery. He explained, "New study results do not change my practice patterns that quickly. I am always open to the results of new studies, but I think you have to look at each individual patient as the results/conclusions do not apply directly to every patient you see. Not every new study—even with en- couraging results—will impact your clinical practice in a definitive way. In the end, you still need to do what is best in your hands." Looking at the clinical impact of eight landmark glaucoma tri- als, Dr. Panarelli noted substantial differences in the way randomized clinical trials affected actual clinical practices, owing to factors like study timing, design, conduct, and inter- pretation of results. 3 Acknowledging surgery, threatened function of the bleb, and loss of any benefit to the IOP of removing the lens primari- ly. Although Dr. Brown combines goniosynechialysis with clear lens extraction to help to reduce IOP, no studies have compared the risks and benefits of phaco with goniolysis using phaco alone. In his practice, Dr. Brown has seen many cases where pressures have normalized with cataract surgery alone. A classic case in point was a 45-year-old patient with PACG and a clear lens, who had undergone LPI and iridoplasty but still had IOP of more than 30 mm Hg and was on maximum dosages of medications. The patient began showing increased optic nerve cupping, even though the visual field was full. In the absence of cataract, many surgeons would have recommended a trab- eculectomy. However, after many consultations with the patient and another specialist, who recommend- ed a trabeculectomy, the patient opted for clear lens extraction. The 5-year results show normal IOP and the patient is medication-free. Dr. Brown has also performed clear lens extractions for angle closure issues in more than 20 patients who had small fixed pupils from previous pilocarpine use and iris epithelium adherence to the anterior lens surface from repeated laser iridoplasty in unsuccessful attempts to pull the iris out of the angle. The patients were highly hy- peropic (up to +18) with short eyes and very shallow chambers, some requiring pars plana vitrectomy to have enough anterior chamber room for surgery. These risk factors make cataract surgery/clear lens extraction in this group very difficult, and Dr. Brown thinks that performing early lens removal would help avoid unnecessary complications and reduce the future risk from pressure damage. He said, "Predicting which angle closure patients will benefit from lens removal—whether clear or cataractous—remains uncertain. Concerns about clear lens extraction generating high volumes of unneces- sary surgery are unfounded because, in practice, truly clear lenses are not common in patients who have had acute attacks or have chronic glaucoma, and who will usually also have multiple risk factors." Grain of salt As would be expected, there is an- other valid side to this argument. To Dr. Panarelli, cataract surgery is still more of a solution for patients with visual complaints due to cataract and to be considered with caution for PACG patients. He told EyeWorld, "I was trained to perform cata- ract surgery on people with visual complaints that impinge upon their daily activities; early lens extraction as a treatment for glaucoma is a completely new approach for me. Although there have been studies showing that lens removal can re- duce the IOP in patients with open EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put "EW Pulse" in the subject line. Poll size: 154 continued on page 68 Angle closure in eye before (left) and after (right) cataract surgery. The spots on the superior iris are laser iridoplasty scars that were done in an effort to try and deepen the angle and lower the pressure. That treatment did not work, but cataract surgery lowered the pressure to a normal level. Source: Reay Brown, MD

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