Eyeworld

EW GLAUCOMA 62 October 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer EAGLE is an international mul- ticenter randomized controlled trial that compared standard glaucoma management with lens extraction in patients with primary angle closure/ glaucoma. 1 Eligible patients were more than 50 years of age, did not have visually significant cataracts, and were newly diagnosed with primary angle closure associated with an IOP of at least 30 mm Hg, or with primary angle closure glauco- ma. The 419 enrolled patients broke Removing the crystalline lens with a clear conscience T he experienced cataract and glau- coma surgeon has known for years that certain cases of angle closure are best treated with cataract extraction by phacoemulsification. Particularly if caught early in the process (before significant syn- echiae are formed), the angle opens and the IOP comes down after cataract extraction. In some situations, where the cataract is not as visually significant, it may have been challenging for us to be reimbursed for an "off-label" cataract extraction performed for the purpose of reducing intraocular pres- sure. There was a dilemma. We lamented that we needed better data to demonstrate definitively that cataract surgery could be appropriately performed for uncontrolled angle closure glaucoma. Today is a new era. As you will read in this "Glaucoma editor's corner of the world," that data is here, and it is dramat- ically in favor of clear lens extraction for angle closure in eyes without cataract. Not only do we now have robust data to show that cataract extraction can be effective in angle closure glaucoma, we have evidence that this can be performed in eyes without any cataract, and we have evidence that it is better than the standard of care (laser and medications) for primary angle closure. We now face a new dilemma. Are we ready to make major changes in our practice, to forgo iridotomy and drops, and to take the cataract out first in eyes with chronic angle closure and elevated pressure? Nathan Radcliffe, MD, Glaucoma co-editor continued on page 64 Glaucoma editor's corner of the world down into 155 with primary angle closure and 263 with primary angle closure glaucoma, of which 208 were randomly assigned to have clear lens extraction and 211 to standard care with laser peripheral iridotomy and topical medications. The patients were followed for 3 years. Clear lens extraction showed greater efficacy and higher QoL scores. The mean health status score Long-awaited EAGLE study outcomes provide clinicians with key insights into the treatment of angle closure glaucoma C lear lens extraction deep- ens the anterior chamber and opens up the anterior chamber angle, causing a dramatic reduction in IOP in the eyes of angle closure glaucoma patients. This has led many to wonder whether clear lens extraction should be recommended in angle closure disease. Despite a strong hunch on the part of cli- nicians in favor of this treatment, removing the crystalline lens in the absence of a cataract is controversial and needs to be justified. Clinicians need to ask themselves how well the standard stepped approach of laser peripheral iridotomy, topical medication, and possible trabeculec- tomy measures up against clear lens extraction in the treatment of closed angle glaucoma. EyeWorld spoke with four experts in the field about whether they have any lingering reservations about removing the crystalline lens. The facts speak There is ample evidence that lens extraction benefits IOP, according to Sunee Chansangpetch, MD, visit- ing assistant professor, University of California, San Francisco, who told EyeWorld, "There is growing evi- dence that supports the role of cata- ract surgery in angle closure disease, particularly in eyes with existing visually significant cataracts. Studies have demonstrated substantial effec- tiveness in IOP reduction as well as a decrease in the number of medi- cations after cataract extraction in the various settings of angle closure, including primary angle closure glaucoma (PACG), primary angle closure (PAC), and acute primary angle closure (APAC). For those eyes without cataract, data from the EAGLE study support lens removal for its improvement in IOP, number of medications, and quality of life in PACG and high tension PAC." Phacomorphic angle closure is characterized by a very shallow anterior chamber, elevated IOP, and appositionally closed angle despite a patent iridotomy. Source: George Tanaka, MD

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