Eyeworld

65 EW GLAUCOMA October 2017 "Watch and wait" is likely to be a common approach in angle closure glaucoma. EyeWorld spoke to George Tanaka, MD, Pacific Vision Foundation, San Francisco, who said that prior to the green flag from the EAGLE study, his approach was just that. "In my practice, I would wait until the pressure went up, until the cataract became visually significant, or the patients developed peripheral anterior synechiae. At that point, I felt justified by my clinical judgment to proceed to cataract surgery. But what EAGLE has done is confirmed my suspicions of the benefit of taking out a clear lens. This tells me that if I have a patient with angle closure with PAC or early PACG, I don't have to do the iridotomy first, I can go right ahead and do the clear lensectomy and know that it is better for the patient long term," he said. Dr. Tanaka said that not all pa- tients seen in clinical practice meet the inclusion criteria of the EAGLE study: more than 50 years of age and very high IOPs. "Typically the pa- tients we see have normal pressures or mildly elevated pressures. Then the question becomes can I general- ize the results of EAGLE to include these patients? In general, I don't. I usually wait and see how the patient develops, but I know if anything changes, I am on solid ground going ahead and taking out a clear lens. Another difficulty arises in younger patients who fulfill all the criteria of EAGLE, but may be 30 or 40 years of age, and you know when you re- move their lens that they are going to lose their accommodation. A lot of these patients have small eyes and are hyperopic, making them a good candidate for a multifocal lens implant, so that is a saving grace. It is a difficult question, especially in 20/20 eyes," he said. Trabeculectomy alone seems to be losing ground. Dr. Tanaka still considers combining trabe- culectomy with clear lensectomy to achieve a very low target pressure in the framework of severe optic nerve damage. However, choosing a MIGS device would likely super- sede that choice. He explained, "In mild glaucoma you could get away with just the phaco. With moderate nerve damage you would consider phaco with one of the subconjunc- tival MIGS. Most MIGS that require a more intact trabecular meshwork are contraindicated in angle closure disease. But if you have a lot of optic nerve damage and visual field loss, I would combine the phaco with a trab. In acute attacks, cataract surgery has been shown in clinical studies to be better than iridoto- mies," he said. EW References 1. Azuara-Blanco A, et al. The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): Study pro- tocol for a randomized controlled trial. Trials. 2011;12:133. 2. Moghimi S, et al. Changes in anterior segment morphology after laser peripheral iridotomy in acute primary angle closure. Am J Ophthalmol. 2016;166:133–140. 3. Jiang Y, et al. Longitudinal changes of angle configuration in primary angle-closure suspects: the Zhongshan Angle-Closure Pre- vention Trial. Ophthalmology. 2014;121:1699– 1705. 4. Melese E, et al. Comparing laser pe- ripheral iridotomy to cataract extraction in narrow angle eyes using anterior segment optical coherence tomography. PLoS One. 2016;11:e0162283. 5. Brown RH, et al. Lens-based glaucoma surgery: Using cataract surgery to reduce intraocular pressure. J Cataract Refract Surg. 2014;40:1255–62. Editors' note: Drs. Chansangpetch, Lin, Tanaka, and Wallace have no financial interests related to their comments. Contact information Chansangpetch: sunee.ch@chula.ac.th Lin: shan.lin@ucsf.edu Tanaka: ghtanakamd@gmail.com Wallace: danajwallace@gmail.com " What EAGLE has done is confirmed my suspicions of the benefit of taking out a clear lens. " —George Tanaka, MD

• Blank Page
• Blank Page (1)