CATARACT AND PRIMARY ANGLE CLOSURE

GLAUCOMA :
PHACO OR COMBINED SURGERY ?

ANDIKA P GANDASUBRATA
PADJADJARAN UNIVERSITY / CICENDO EYE HOSPITAL
BANDUNG
 INTRODUCTION

• GLAUCOMA IS THE WORLD LEADING CAUSE OF IRREVERSIBLE BLINDNESS

• HALF OF ALL CASES BLINDED BY GLAUCOMA ARE AFFECTED BY PRIMARY
ANGLE CLOSURE
• THE MAJORITY OF CASES OF ANGLE-CLOSURE GLAUCOMA ARE
ASYMPTOMATIC AND ‘CHRONIC’
• IN PRIMARY ANGLE-CLOSURE GLAUCOMA (PACG):
• GON OCCURS AS A DIRECT CONSEQUENCE OF ELEVATED IOP CAUSE BY :
• PHYSICAL OBSTRUCTION OF AQUEOUS OUTFLOW OR DEGNERATIVE CHANGES
IN TRABECULAR MESHWORK , RESULTING FROM IRIDOTRABECULAR CONTACT
(ITC)

Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020.Br J Ophthalmol.2006;90: 262-7
 ANGLE
CLOSURE

Primary angle closure Secondary angle closure

Relative pupillary block Other than relative pupillary block alone

Peripheral iris to move forward Closure of the entire or

Obstruct aqueous access to TM Portion of the AC angle
circumference

Directly or indirectly to cause

the peripheral iris to obstruct
Risk factors : the TM
Demographic factor: older age, female, Asians
Ocular biometric : thicker lens, a more anteriorly lens, a shorter axial lenght
Amerasinghe N, Zhang J, Thalamutu A, et al. The heritability and sibling risk of angle closure in Asians.Ophthalmology 2011; 118:480-5
Lowe R. Primary angle closure glaucoma: a review of ocular biometry. Austral J Ophthalmol 1977;5:9-17
 DEFINITION AND CLASSIFICATION
Conceptual Stages in the Natural History of
Primary Angle-Closure Glaucoma

Stage Definition
Primary angle-closure suspect Iridotrabecular contact (ITC) with normal
optic disc and visual field
IOP is normal and PAS are absent
Symptoms are absent

Primary angle-closure ITC + either raised IOP, PAS, or typical

symptoms
Primary angle-closure glaucoma ITC + structural glaucomatous changes in the
optic nerve or glaucomatous visual field loss

Foster PJ,Aung T, Nolan WP, et al. Defining ‘occludable’ angles in population surveys: drainage angle width, peripheral anteriorsynechiae,
And glaucomatous optic neuropathy in East Asia people.Br J Ophthalmol 2004;88:486-90
 ETIOLOGY AND MECHANISM

• IN PRIMARY ANGLE CLOSURE , THERE ARE AT LEAST 3 MECHANISM

CAUSING ELEVATED IOP ;
1. TOTAL ITC PRODUCING ‘SYMPTOMATIC’ ANGLE CLOSURE WILL
RAPIDLY CAUSE THE IOP RISE
2. PROLONGED APPOSITIONAL ITC OR AN EPISODE OF ANTERIOR
SEGMENT INFLAMMATION
3. ITC CAUSES FRICTIONAL CONTACT BETWEEN THE IRIS AND
TRABECULAR MESHWORK OVER PROLONGED PERIODES PROBABLY
DEGRADES TRABECULAR MESHWORK ARCHITECTURE AND FUNCTION

Thomas R, George R, Parikh R, et al. Five year risk of progression of primary anle closure suspect to primary angle closure: a population based study.Br J Ophthalmpl 2003;87;450-4
 • THE MECHANISMS THAT CAUSE ITC :
• PUPILARY BLOCK (THE MAJOR MECHANISM)
• ANTERIOR NON-PUPIL BLOCK (PLATEU IRIS)
• LENS-INDUCED : SECONDARY PROCESS AS THE RESULT OF CHANGES IN
SIZE OR POSITION OF THE LENS
• RETROLENTICULAR FORCES : AS A RESULT OF POSTERIOR MASS EFFECT
(LARGE VITREOUS HEMORRHAGE, GAS TAMPONADE

Mapstone R. Provocative tests in angle-closure glaucoma.Br J Ophthalmol 1976;60:115-19

 SURGICAL MANAGEMENT

• THE 3 MAIN CHALLENGES IN THE MANAGEMENT OF PACG :

1. TO PREVENT PROGRESSION OF THE ANGLE CLOSURE
2. TO PREVENT PROGRESSION OF THE GLAUCOMATOUS OPTIC
NEUROPATHY BY CONTROLLING IOP
3. REOPENING OF THE CLOSED ANGLE
 Various surgical procedures have
different roles in meeting these
challenges
• SURGICAL IRIDECTOMY OR LASER IRIDOTOMY
• TRABECULECTOMY
• LENS EXTRACTION-ALONE OR IN COMBINATION WITH TRABECULECTOMY
• GONIOSYNECHIALYSIS WITH/ WITHOUT LENS EXTRACTION
• CYCLODESTRUCTIVE PROCEDURES
 SURGICAL IRIDECTOMY / LASER
IRIDOTOMY
• TO PREVENT PROGRESSION OF ANGLE CLOSURE
• ALL EYES WITH ANGLE CLOSURE OR VERY NARROW DRAINAGE ANGLE
SHOULD UNDERGO IRIDECTOMY / IRIDOTOMY TO ELLIMINATE PUPILLARY
BLOCK
• LASER IRIDOTOMY IS NONINVASIVE, NO RISK OF ENDOPHTHALMITIS AND
WOUND COMPLICATION
• IRIDOTOMY RESULT IN A WIDENING OF THE IRIDOTRABECULAR ANGLE ,
ALTHOUGH 20-25% STILL HAVE RESIDUAL APPOSITIONAL ANGLE CLOSURE
• IRIDOTOMY IS NOT EFFECTIVE IN REVERSING SYNECHIAL ANGLE CLOSURE
• INDICATION FOR SURGICAL IRIDECTOMY :
• IN PATIENTS WITH SIGNIFICANT CORNEAL OPACITY
• IN NON-COOPERATE PATIENTS

Godel V, Stein R, Feiler-Ofry V. Angle-closure glaucoma: following peripheral iridectomy and mydriasis.Am J Ophthalmol.1968 Apr 65(4): 555-60
Gieser DK, Wilensky JT. Laser iridectomy in the management of chronic angle-closure glaucoma. Am J Ophthalmol 1984Oct 15.98($): 446-50
 TRABECULECTOMY

• TRABECULECTOMY IS EFFECTIVE FOR PACG AND HAS BEEN SHOWN TO

HAVE AN OVERALL SUCCESS RATE OF 68% IN CONTROLLING IOP
• TRABECULECTOMY IN PACG IS ASSOCIATED WITH A HIGHER RISK OF :
• FILTRATION FAILURE
• SHALLOW ANTERIOR CHAMBER
• MALIGNANT GLAUCOMA / AQUEOUS MISDIRECTION

• TRABECULECTOMY INCREASES THE RATE OF CATARACT PROGRESSION 

WILL SOON NEED CATARACT EXTRATION

Sihota R, Gupta V, Agarwal HC. Long-term evaluation of trabeculectomy in primary open angle glaucoma and chronic primary angle closure glaucoma in an Asian population.
Clin Experiment Ophthalmol. 2004 Feb. 32 (1):23-8
Ritch R. The treatment of chronic angle-closure glaucoma. Ann Ophthalmol. 1981 Jan. 13 (1):21-3
 TRABECULECTOMY

• ADJUNCTIVE ANTIMETABOLITE SHOULD BE USED WITH TRABECULECTOMY

EYES WITH HIGH RISK OF FILTRATION FAILURE OR IN A PATIENTS NEEDS A
LOW TARGET IOP
• THE RISK FATORS FOR FILTRATION FAILURE AND THE TARGET PRESSURE IN
ANGLE-CLOSURE GLAUCOMA HAVE NOT YET BEEN CLEARY DEFINED
• TRABECULECTOMY IS ASSOCIATED WITH VARIOUS COMPLICATIONS :
EARLY AND LATE BLEB LEAKS, BLEB-RELATED INFECTIONS (INCREASED BY
ADJUNCTIVE ANTIMETABOLITE)
• FUTURE CATARACT EXTRACTION MAY RESULT IN LOSS OF THE
FUNCTIONING FILTER

Tham CC, Lai JS, Poon AS, Lai TY, Lam DS. Results of trabeculectomy with adjunctive intraoperative mitomycin C in Chinese patients with glaucoma. Ophthalmic Surg Lasers Imaging. 2006 Jan-Feb. 37 (1):33-41
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH
TRABECULECTOMY
• LENS POSITION AND THICKNESS BOTH PLAY IMPORTANT ROLE IN THE
ETIOLOGY OF ANGLE-CLOSURE GLAUCOMA
• THE LENS MAY NARROW THE ANGLE BY PUSHING THE PERIPHERAL
IRIS ANTERIORLY AND WILL BE MARKED IF THE LENS IS CATARACTOUS

Tarongoy P, Ho CL, Walton DS. Angle-closure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment> Surv Ophthalmol.2009; 54(@) : 211-25
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH
TRABECULECTOMY
• THE DEPTH OF ANTERIOR CHAMBER AND THE WIDTH OF THE ANGLE
WILL INCREASE SIGNIFICANTLY AND ALSO DECREASE THE IOP AFTER
CATARACT EXTRACTION AND IOL IMPLANTATION
• DURING PHACO, THE IRRIGATION FLUID FLUSHES CELLULAR DEBRIS
FROM THE TRABECULAR MESHWORK, DECREASING RESISTANCE TO
AQUEOUS OUTFFLOW

Tarongoy P, Ho CL, Walton DS. Angle-closure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment> Surv Ophthalmol.2009; 54(@) : 211-25
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH TRABECULECTOMY

• THAM ET AL : COMPARE PHACO VS PHACO-TRABECULECTOMY IN PACG EYES

WITH COEXISTING CATARACT :
• PACG WITH ADEQUATE CONTROLLED BY GLAUCOMA DRUGS BEFORE SURGERY
• PACG WITH MEDICALLY UNCONTROLLED
• THE RESULT :
• PHACO ALONE COULD SIGNIFICANTLY REDUCED IOP, REQUIRE GLAUCOMA DRUGS,
FOR AT LEAST 2 YEARS AFTER SURGERY
• COMBINED PHACO-TRABECULECTOMY RESULTED IN EVEN GREATER IOP AND DRUG
REDUCTIONS, BUT ASSOSIATED WITH MORE COMPLICATIONS AND ADDITIONAL
SURGERY TO MANAGE THE COMPLICATIONS
• CONCLUSION :
• IN MEDICALLY CONTROLLED PACG WITH CATARACT , PHACO ALONE MAY BE
CONSIDERED AS INITIAL TREATMENT
• IN MEDICALLY UNCONTROLLED PACG WITH CATARACT, EITHER PHACO ALONE OR
COMBINED PHACO-TRABECULECTOMY MAY BE CONSIDERED, DEPENDING ON PATIENT
FACTORS
Tham CC, Kwong YY, Leung DY, Lam SW, Li FC, Chiu TY, et al. Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract.
Ophthalmology. 2008 Dec. 115 (12):2167-2173
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH
TRABECULECTOMY
• THAM ET AL. COMPARE PHACO VS TRABECULECTOMY ALONE IN MEDICALLY
UNCONTROLLED PACG COEXISTED WITH AN OPTICALLY CLEAR LENS
• THE RESULT :
• BOTH PHACO AND TRABECULECTOMY REDUCED IOP BY OVER 30% AT 24 MONTHS AFTER
SURGERY
• PHACO REDUCED THE REQUIREMENT FOR GLAUCOMA DRUG BY 60% VS 89% BY
TRABECULECTOMY AT 24 MONTH AFTER SURGERY
• CLEAR LENS EXTRACTION RESULT IN SIGNIFICANT REDUCTION IN SYNECHIAL ANGLE CLOSURE
AND AC ANGLE WIDTH, AC DEPTH IN PACG EYES WITHOUT CATARACT

• CONCLUSION :
• EITHER SURGERY COULD BE CONSIDERED FOR MEDICALLY UNCONTROLLED PACG EYES
WITHOUT CATARACT, DEPENDING ON PATIENT FACTORS

Tham CC, Kwong YY, Baig N, Leung DY, Li FC, Lam DS. Phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle-closure glaucoma without cataract. Ophthalmology. 2013 Jan. 120 (1):62-7
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH
TRABECULECTOMY
• THE IOP- LOWERING EFFECT OF LENS EXTRACTION MAY BE LESS
PRONOUNCED IN PACG CASES WITH PAS COVERING ¾ OR MORE OF
THE ANGLE
• LENS EXTRACTION ALONE MAY HAVE A ROLE IN IMPROVING IOP
CONTROL IN PACG ESPECIALLY IN LESS EXTENSIVE PAS AND THE IOP
IS NOT OUT OF CONTROL
• LENS EXTRACTION SHOULD BE CONSIDERED IN PATIENTS WITH PACG,
ESPECIALLY WITH HYPEROPIA OR THICK AND ANTERIORLY VAULTED
LENS

Trikha S, Perera SA, Husain R, Aung T. The role of lens extraction in the current management of primary angle-closure glaucoma. Curr Opin Ophthalmol. 2015 Mar. 26 (2):128-34
 LENS EXTRACTION – ALONE OR IN
COMBINATION WITH
TRABECULECTOMY
• EAGLE ( EFFECTIVENESS IN ANGLE-CLOSURE GLAUCOMA OF LENS
EXTRACTION) STUDY GROUP :
• COMPARE LENS EXTRACTION VS LASER IRIDOTOMY IN PATIENTS WITH
NEWLY DIAGNOSED PAC OR PACG
• THE AIM : TO EVALUATE THE EFFECT OF CATARACT EXTRACTION WITH
REGARDS TO IOP, QUALITY OF LIFE, AND COST IN ANGLE-CLOSURE
GLAUCOMA AT 3 YEARS

Azuara-Blanco A, Burr JM, Cochran C, Ramsay C, Vale L, Foster P, et al. The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma
(EAGLE): study protocol for a randomized controlled trial. Trials. 2011 May 23. 12:133
• CLEAR LENS EXTRACTION FOR THE MANAGEMENT OF PRIMARY ANGLE CLOSURE GLAUCOMA: SURGICAL
TECHNIQUE AND REFRACTIVE OUTCOMES IN THE EAGLE COHORT.

• DAY AC1, COOPER D2, BURR J3, FOSTER PJ1, FRIEDMAN DS4, GAZZARD G1, CHE-HAMZAH J5, AUNG T6, RAMSAY
CR2, AZUARA-BLANCO A7.

• AUTHOR INFORMATION

• ABSTRACT

• BACKGROUND:

• TO DESCRIBE THE SURGICAL TECHNIQUE AND REFRACTIVE OUTCOMES FOLLOWING CLEAR LENS EXTRACTION (CLE) IN
THE EFFECTIVENESS, IN ANGLE-CLOSURE GLAUCOMA, OF LENS EXTRACTION TRIAL.

• METHODS:

• REVIEW OF PROSPECTIVELY COLLECTED DATA FROM A MULTICENTRE, RANDOMISED CONTROLLED TRIAL COMPARING
CLE AND LASER PERIPHERAL IRIDOTOMY. ELIGIBLE PARTICIPANTS WERE ≥50 YEARS OLD AND NEWLY DIAGNOSED WITH
(1) PRIMARY ANGLE CLOSURE (PAC) WITH INTRAOCULAR PRESSURE ABOVE 30 MM HG OR (2) PAC GLAUCOMA. WE
REPORT THE POSTOPERATIVE CORRECTED DISTANCE VISUAL ACUITY (CDVA) AND REFRACTIVE OUTCOMES AT 12 AND 36
MONTHS POSTOPERATIVELY FOR THOSE WHO UNDERWENT CLE.

• RESULTS:

• OF THE 419 PARTICIPANTS, 208 WERE RANDOMISED TO CLE. MEAN BASELINE CDVA WAS 77.9 (SD 12.4) LETTERS AND
DID NOT CHANGE SIGNIFICANTLY AT 36 MONTHS WHEN MEAN CDVA WAS 79.9 (SD 10.9) LETTERS. MEAN
PREOPERATIVE SPHERICAL EQUIVALENTS WERE +1.7 (SD 2.3) AND +0.08 (SD 0.95) DIOPTERS (D) AT 36 MONTHS. FIFTY-
NINE PER CENT AND 85% EYES WERE WITHIN ±0.5D AND ±1.0D OF PREDICTED REFRACTION, RESPECTIVELY, AT 36
MONTHS.

• CONCLUSIONS:

• MEAN CDVA IN PATIENTS UNDERGOING CLE FOR ANGLE-CLOSURE GLAUCOMA APPEARED STABLE OVER THE 3-YEAR
STUDY PERIOD. REFRACTIVE ERROR WAS SIGNIFICANTLY REDUCED WITH SURGERY BUT REFRACTIVE PREDICTABILITY WAS
SUBOPTIMAL.
Br J Ophthalmol. 2018 Feb 16. pii: bjophthalmol-2017-311447. doi:
• TRIAL REGISTRATION NUMBER: ISRCTN44464607.
10.1136/bjophthalmol-2017-311447. [Epub ahead of print]
 GONIOSYNECHIALYSIS WITH/
WITHOUT LENS EXTRACTION

• GONIOSYNECHIALYSIS (GSL) IS A SURGICAL

TECHNIQUE PERFORMED TO STRIP THE PAS FROM
TRABECULAR SURFACE IN THE ANGLE AND
PROVIDE AQUEOUS RENEWED ACCESS TO THE
TRABECULAR MESHWORK
• WHEN PAS HAS BEEN PRESENT FOR LESS THAN 1
YEAR, THE SUCCESS RATE OF IOP CONTROL IS
80%
• IRREVERSIBLE DAMAGE TO THE MESHWORK MAY
OCCUR IN AREAS OF SYNECHIAL CLOSURE
• GSL MUST BE PERFORMED BEFORE IRREVERSIBLE
HISTOLOGICAL CHANGE IN THE MESHWORK

Campbell DG, Vela A. Modern goniosynechialysis for the treatment of synechial angle-closure glaucoma.
Ophthalmology. 1984 Sep. 91 (9):1052-60

Moster MR,Hue WD. Goniosynechialysis and chronic angle-closure glaucoma.Glaucoma Today.April 2015
 GONIOSYNECHIALYSIS WITH/
WITHOUT LENS EXTRACTION
• THE MOST COMMON COMPLICATION OF GSL : INTRAOPERATIVE
HEMMORRHAGE, IRIDODIALYSIS, CYCLODIALYSIS, LENS DAMAGE
• THE SUCCESS REPORT OF GSL IN PACG :
• PHACO COMBINED WITH GSL
• PHACO COMBINED WITH LIMITED GSL FOLLOWED BY DIODE LASER
PERIPHERAL IRIDOPLASTY

• IOP-LOWERING EFFECT OF PHACO AND GSL DO NOT DIFFER

SIGNIFICANTLY FROM PHACO ALONE IN MEDICALLY WELL-CONTROLLED
PACG WITH CATARACT

Tanihara H, Nishiwaki K, Nagata M. Surgical results and complications of goniosynechialysis. Graefes Arch Clin Exp Ophthalmol. 1992. 230 (4):309-13
 COMPARISON OF INTRAOCULAR PRESSURE REDUCTION AFTER
TRABECULECTOMY AND COMBINED SURGERY IN PRIMARY OPEN
AND ANGLE CLOSURE GLAUCOMA IN CICENDO EYE HOSPITAL
Mona SR, Gandasubrata AP, Gustianty E.
Dept Ophthalmology of Padjadjaran University/Cicendo Eye Hospital

• OBJECTIVE: TO COMPARE THE INTRAOCULAR PRESSURE (IOP) REDUCTION

AFTER TRABECULECTOMY, TRABECULECTOMY WITH ADJUNCTIVE
MITOMYCIN C (MMC) AND COMBINED SURGERY IN PATIENTS WITH
PRIMARY OPEN AND ANGLE CLOSURE GLAUCOMA.
• METHODS: IN THIS RETROSPECTIVE REVIEW (FROM JANUARY 2010 TO
DECEMBER 2011), 43 EYES UNDERWENT TRABECULECTOMY COMPARED
WITH 19 EYES UNDERWENT TRABECULECTOMY WITH ADJUNCTIVE MMC
AND 16 EYES UNDERWENT COMBINED SURGERY (PHACO-
TRABECULECCTOMY).
INTRAOCULAR PRESSURE AND ITS REDUCTION, NUMBER OF GLAUCOMA MEDICATIONS,
AND VISUAL ACUITY BETWEEN THE THREE GROUPS WERE ANALYZED IN 1 WEEK, 1
MONTH, 2 MONTHS, AND 3 MONTHS POSTOPERATIVELY. KRUSKAL WALLIS TEST WAS
USED TO ANALYZE THE REDUCTION OF IOP BETWEEN THE THREE GROUPS.
 The
TIO mean IOP before
Antar Waktu and after surgery
Pengamatan
untuk Ketiga Jenis Tindakan

fako+trabek+iol trabek trabek+mmc

45.00
39.10
40.00 36.79
35.00
(mmHg)

28.00
30.00
TIO(mmHg)

25.00
20.00 16.67
15.17 15.13 16.00
13.62 12.80 14.54
12.70 13.50 14.13 14.00 13.83 14.85
IOP

15.00 12.45 12.00

10.00
5.00
0.00
Pre-op
Pra Bedah 11Minggu
week 11Bulan
month 22months
Bulan 3 months
3 Bulan 1 year
1 Tahun
Waktu
FollowPengamatan
up

• CONCLUSION: IOP REDUCTION UNTIL 1 MONTH POSTOPERATIVELY WAS FOUND BETTER WITH
TRABECULECTOMY WITH ADJUNCTIVE MMC COMPARED WITH TRABECULECTOMY AND COMBINED
SURGERY IN PATIENTS WITH PRIMARY OPEN AND ANGLE CLOSURE GLAUCOMA.
 • TRABECULECTOMY IS THE STANDARD SURGICAL PROCEDURE FOR MANAGING
UNCONTROLLED GLAUCOMA PATIENTS

• THE ASSOCIATED COMPLICATIONS SUCH AS SHALLOW CHAMBER, BLEB LEAKS, BLEB

INFECTIONS, AND BLEB DYSESTHESIA HAVE LED TO INCREASE IN USE OF TUBE SHUNTS OR
GLAUCOMA DRAINAGE DEVICES AS AN ALTERNATIVE TO TRABECULECTOMY

• GLAUCOMA DRAINAGE DEVICES (GDD) HAVE BEEN CONVENTIONALLY USED AS SECONDARY

PROCEDURES IN CASES WITH PRIOR FAILED GLAUCOMA FILTRATION SURGERIES

• IN REFRACTORY GLAUCOMAS LIKE NEOVASCULAR OR POST UVEITIC GLAUCOMA, WHERE

THE CHANCES OF FAILURE OF TRABECULECTOMY ARE HIGH, THESE DEVICES HAVE BEEN
IMPLANTED AS A PRIMARY PROCEDURE

Chen PP, Yamamoto T, Sawada A, Parrish RK 2nd, Kitazawa Y. Use of antifibrosis agents and glaucoma drainage devices in the American and Japanese Glaucoma Societies. J Glaucoma 1997; 6:192-6.

.
Joshi AB, Parrish RK 2nd, Feuer WF. 2002 survey of the American Glaucoma Society: practice preferences for glaucoma surgery and antifibrotic use. J Glaucoma 2005; 14:172-4
 PROGNOSIS

• THE PROGNOSIS OF ANGLE-CLOSURE GLAUCOMA VARIES ACCORDING

TO THE STAGE OF THE DISEASE
• UNTREATED ANGLE CLOSURE GLAUCOMA CAUSES BLINDNESS IN AT
LEAST ONE EYE OF 33-75% (VS 11-27% IN OPEN-ANGLE GLAUCOMA)
• IN EARLY STAGES DISEASES 75-80% CAN BE EFFECTIVELY TREATED BY
LASER IRIDOTOMY
• IN PRIMARY ANGLE-CLOSURE GLAUCOMA, LASER IRIDOTOMY IS NOT
USUALLY EFFECTIVE FOR LONG-TERM IOP CONTROL, AND OVER HALF
REQUIRED TRABECULECTOMY

Alsagoff Z, Aung T, Ang LP, et al. Long-term clinical course of primary angle-closure glaucoma in Asian population.Ophthalmology 2000;107:2300-4
Ang LP, Aung T,Chew PT. Acute primary angle closure in an Asian population : long term outcome of the fellow eyeAfter prophylactic laser peripheral iridotomy. Ophthalmology
2000; 107:2092-6
 SUMMARY

• PACG IS A MORE VISUALLY DESTRUCTIVE FORM OF DISEASE THAN PRIMARY OPEN-ANGLE

GLAUCOMA
• MOST ANGLE CLOSURE IS ASYMPTOMATIC
• TRABECULECTOMY IS AN EFFECTIVE PROCEDURE FOR PACG
• TRABECULECTOMY IN PACG IS ASSOCIATED WITH A HIGHER RISK OF FILTRATION FAILURE,
SHALLOW ANTERIOR CHAMBER AND MALIGNANT GLAUCOMA

• IN MEDICALLY UNCONTROLLED PACG WITH CATARACT, EITHER

PHACO ALONE OR COMBINED PHACO-TRABECULECTOMY
MAY BE CONSIDERED, DEPENDING ON PATIENT FACTORS
THANK YOU