Lens extraction for uncontrolled angle-closure glaucoma: long-term follow-up. A randomized study of trabeculectomy and subconjunctival administration of fluorouracil in primary glaucomas. Laser peripheral iridotomy with and without iridoplasty for primary angle-closure glaucoma: 1-year results of a randomized pilot study. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Randomised controlled trial of anterior-chamber intraocular lenses. Long-term functional outcome after early surgery compared with laser and medicine in open-angle glaucoma. Phacoemulsification and intraocular lens implantation for angle closure glaucoma after the relief of pupillary block. Ocular hypertension: correlation of anterior chamber angle width and risk of progression to glaucoma. Early trabeculectomy versus conventional management in primary open angle glaucoma.
To evaluate the long-term effects of extraction of incipient cataracts or clear lenses on glaucoma control in patients with subacute or chronic angle-closure glaucoma.
                Department of Ophthalmology, University of Amsterdam, The Netherlands.
                This retrospective analysis comprised 22 extracapsular lens extractions with implantation of a posterior chamber intraocular lens in 18 patients with chronic or subacute angle-closure glaucoma (Group 1). The effect of glaucoma control was evaluated using visual field examination, diurnal intraocular pressure (IOP) curves, gonioscopic appearance, and number of antiglaucoma medications. The results were compared with those in 25 eyes of 19 patients with chronic angle-closure glaucoma in whom a filtering procedure was performed (Group 2).
                Glaucoma control was achieved in 15 eyes (68%) in Group 1 and in 17 eyes (68%) in Group 2. Mean preoperative IOP was 27.9 mm Hg +/- 8.1 (SD) and 29.0 +/- 7.7 mm Hg, respectively. Mean postoperative IOP was 17.1 +/- 2.9 mm Hg (Group 1) and 14.8 +/- 6.6 mm Hg (Group 2) after a mean follow-up of 52.6 and 58.9 months, respectively. Mean number of ocular hypotensive medications preoperatively was 2.3 +/- 0.8 in Group 1 and 2.2 +/- 0.8 in Group 2 and at last follow-up, 1.3 +/- 0.7 and 0.52 +/- 0.8, respectively. Twenty eyes (91%) in Group 1 had the same or better final visual acuity than before surgery. In Group 2, the final visual acuity was unchanged or better in 13 eyes (52%) and worse in 12 eyes (48%); subsequent cataract surgery was performed in 9 (75%) of these 12 eyes. Additional incisional surgery was done or recommended in 6 eyes (27%) in Group 1 and 20 eyes in Group 2 (80%).
                Drainage surgery in patients with angle-closure glaucoma proved to be associated with multiple surgical interventions and deterioration in visual function. The choice of first a cataract procedure with the option of a future trabeculectomy may be a more attractive approach in patients with subacute or chronic angle-closure glaucoma than trabeculectomy followed by an optional cataract procedure. Forty-one adult patients with primary open angle glaucoma and nine adult patients with chronic angle closure glaucoma underwent trabeculectomy in one eye each. Twenty-one eyes with primary open angle glaucoma and four with chronic angle closure glaucoma were randomly assigned to receive four to six subconjunctival injections of fluorouracil for 10 days after surgery. Twenty-five control eyes did not receive fluorouracil. Intraocular pressure was 20 mm Hg or lower in 24 eyes (96%) in the treatment group after mean follow-up of 17.8 months and in 19 control eyes (76%) after mean follow-up of 17.5 months (P less than .05). Encapsulated bleb developed in three (12%) of the fluorouracil-treated eyes vs two (8%) of the control eyes. A few injections of fluorouracil adequately inhibited scarring. This might be explained by its toxic effect on existing fibroblasts. Overall, trabeculectomy with injection of fluorouracil was found to be efficacious and relatively safe. Further studies regarding late complications are required. To compare the efficacy and safety of laser peripheral iridotomy with or without laser peripheral iridoplasty in the treatment of eyes with synechial primary angle-closure or primary angle-closure glaucoma.
                Randomized, controlled clinical trial.
                Consecutive patients older than 40 years with synechial primary angle-closure or primary angle closure glaucoma were recruited. Eligible patients were randomized to 1 of 2 treatment options, iridotomy or iridotomy plus iridoplasty, and were followed up for 1 year. Main outcome measures were intraocular pressure (IOP), peripheral anterior synechiae, corneal endothelial cell count, and complications.
                Seventy-seven eyes (77 patients) were randomized to the iridotomy group, and 81 eyes (81 patients) were randomized to the iridotomy plus iridoplasty group. Sixty-one patients (79.2%) in the iridotomy and 65 patients (80.2%) from the iridotomy plus iridoplasty groups completed 1 year of follow-up. There were no significant differences between the groups in the baseline data. IOP was reduced from 24.66 +/- 13.76 mm Hg to 19.03 +/- 6.21 mm Hg in the iridotomy group (P < .001) and from 27.96 +/- 13.06 mm Hg to 20.45 +/- 7.26 mm Hg in the iridotomy plus iridoplasty group (P < .001). Extent of peripheral anterior synechiae was decreased by 1 more clock-hour after iridoplasty compared with that after iridotomy in the iridotomy plus iridoplasty group (P < .001). There was no significant difference in IOP, medications, need for surgery, or visual function between groups at the 1-year visit.
                In eyes with synechial primary angle-closure or primary angle-closure glaucoma, both iridotomy alone or combined with iridoplasty provide a significant and equivalent reduction in IOP. There is also a possible reduction in peripheral anterior synechiae, more so in the iridoplasty group.
                2010 Elsevier Inc. All rights reserved. To report interim outcome data, using all available follow-up through 5 years after treatment initiation, in the Collaborative Initial Glaucoma Treatment Study (CIGTS).
                Randomized clinical trial.
                Six hundred seven newly diagnosed glaucoma patients.
                In a randomized clinical trial, 607 patients with newly diagnosed open-angle glaucoma were initially treated with either medication or trabeculectomy (with or without 5-fluorouracil). After treatment onset and early follow-up, patients were evaluated clinically at 6-month intervals. In addition, quality of life telephone interviews were conducted at similar frequency to the clinical visits. Patients in both arms of CIGTS were treated aggressively in an effort to reduce intraocular pressure (IOP) to a level at or below a predetermined target pressure specific for each individual eye. Visual field (VF) scores were analyzed by time-specific comparisons and by repeated measures models.
                VF loss was the primary outcome variable in CIGTS. Secondary outcomes of visual acuity (VA), IOP, and cataract were also studied.
                On the basis of completed follow-up through 4 years and partially completed through 5 years, VF loss did not differ significantly by initial treatment. Over the entire period of follow-up, surgical patients had a greater risk of substantial VA loss compared with medical patients. However, by 4 years after treatment, the average VA in the two groups was about equal. Over the course of follow-up, IOP in the medicine group has averaged 17 to 18 mmHg, whereas that in the surgery group averaged 14 to 15 mmHg. The rate of cataract requiring removal was greater in the surgically treated group.
                Both initial medical or initial surgical therapy result in about the same VF outcome after up to 5 years of follow-up. VA loss was greater in the surgery group, but the differences between groups seem to be converging as follow-up continues. When aggressive treatment aimed at substantial reduction in IOP from baseline is used, loss of VF can be seen to be minimal in general. Because 4 to 5 years of follow-up in a chronic disease is not adequate to draw treatment conclusions, these interim CIGTS outcomes do not support altering current treatment approaches to open-angle glaucoma. There are an estimated 16 million people blind in both eyes with cataracts. Most live in rural areas of developing countries where surgical resources are scarce. There is no consensus on the most appropriate type of intraocular lens in situations where high-volume low-cost surgery is required. This study was undertaken to evaluate the safety of multiflex open-loop anterior-chamber lenses (ACIOLs).
                2000 people attending Lahan Eye Hospital, southern Nepal, with bilateral cataracts reducing vision to 6/36 or less were randomly allocated to receive standard surgery--intracapsular extraction (ICCE) with aphakic correction--or ICCE with an ACIOL in their first operated eye. The primary outcome was a visual acuity of less than 6/60 in the operated eye at 1 year follow-up. Visual acuity was measured for 91% of the cohort at 1 year. The sample size was estimated to detect a doubling in poor visual outcome from an estimated rate of 4% in the standard surgery (control) group.
                The median (range) time taken to do the surgery was 6.0 (3.0-17.2) min for the ACIOL group and 4.1 (2.4-10.3) min for the control group. 1 year after surgery, 5.0% of the ACIOL group and 5.4% of controls had functional vision less than 6/60 (OR 0.93 [0.60-1.43], p = 0.71). The causes of poor vision in the ACIOL and control groups were: correctable refractive error (22 and 29), uveitis/secondary glaucoma (13 and two), endophthalmitis (four and seven), pre-existing eye disease (four and five), retinal detachment (none and four), cystoid macular oedema (two and none), corneal ulcer (one and one), and corneal decompensation (none and one).
                This study provides evidence that, in rural areas of developing countries, multiflex open-loop ACIOLs can be implanted safely by experienced ophthalmologists after routine ICCE, avoiding the disadvantages of aphakic spectacle correction. Further follow-up is planned. This randomly allocated prospective clinical study was designed to assess the relative efficacy of laser trabeculoplasty, medical therapy, and trabeculectomy used as the primary treatment in open-angle glaucoma, with particular regard to the level of intraocular pressure control and the amount of visual field decay. No patient had received any antiglaucoma treatment before entry into the trial.
                One hundred sixty-eight patients were entered into the trial and randomly allocated into one of the three treatment groups--laser, medicine, or surgery. Follow-up was for a minimum of 5 years. The patients were monitored in the standard way, including intraocular pressure estimations and visual field tests (initially using the Friedmann analyzer and later including Humphrey automated perimetry).
                Despite similar initial composition of the three treatment groups, primary surgery resulted in the lowest mean intraocular pressures. The perimeter Friedmann visual fields were shown to have deteriorated in patients in the medicine-treated group and to a lesser extent in patients in the laser-treated group, but not in patients in the surgery-treated group. Multivariate linear regression analysis showed that the difference in field changes between laser and surgical treatments could be explained entirely by the difference between the intraocular pressure values at 6 months between the two groups. The same was not true for the medicine-treated group.
                Primary trabeculectomy appears to have the desired effect in preserving visual function in patients with high-tension glaucoma. This may be related to laser treatment might be expected to have the same effect. We studied the surgical outcomes of phacoemulsification and intraocular lens (IOL) implantation for cataract and/or uncontrolled intraocular pressure (IOP) in eyes with angle closure glaucoma.
                Department of Ophthalmology, National Nagasaki Medical Center, Nagasaki, Japan.
                Eighteen eyes from 15 patients after laser iridotomy (17 eyes) or peripheral iridectomy (1 eye) had undergone surgery and were studied. We used an iris retractor in 7 eyes due to insufficient mydriasis and a capsular tension ring in 2 eyes due to phacodonesis during the operation. The patients were followed up for at least 6 months (13.8 +/- 7.2 months; range: 6-36 months).
                The mean IOP significantly decreased from 17.4 +/- 8.1 to 13.5 +/- 3.3 mm Hg at 6 months after surgery. The IOP was below 21 mm Hg in all eyes. The visual acuity was not worsened in any eyes and became better than 2 Snellen lines in 14 eyes. The corneal endothelial cell count decreased from 2,365 +/- 517 to 1,960 +/- 661/mm2 (18.3 +/- 17.2%).
                Phacoemulsification and IOL implantation is useful in IOP control for angle closure glaucoma after relief of pupillary block. However, we should take care of operative complications because of a shallow anterior chamber, poor mydriasis and zonular weakness.
                Copyright 2003 S. Karger AG, Basel Twenty five patients with ocular hypertension (OH) and a narrow angle and 34 patients with OH and an open angle were followed for an average of six years. One eye of each patient had been randomly assigned to treatment with topical timolol. A shallow axial anterior chamber depth and a narrow angle (van Herick Grade 2 or less) was associated with the development of angle-closure glaucoma (ACG) in the narrow angle group, but the open angle group developed significantly more visual field loss. Nine patients (36%) in the narrow angle group developed ACG, and nine patients (26.5%) in the open angle group developed glaucomatous discs and field loss. The reduction in intraocular pressure due to topical timolol was equal in the narrow angle and the open angle groups, but topical timolol did not protect against the development of angle-closure glaucoma or visual field loss. The results of a randomised, prospective, multicentre trial of the management of primary open angle glaucoma are presented at up to five years' follow up. Previously undiagnosed cases were selected with intraocular pressure of 26 mmHg or more on two occasions together with field loss characteristic of glaucoma. Analysis was performed on one eye selected at random from each of 99 patients. Conventional medical treatment followed in unsuccessful cases by trabeculectomy (group A) was compared with trabeculectomy at diagnosis followed when necessary by supplementary medical therapy (group B). The life expectancy of these glaucoma patients was found to be similar to that for the local population matched for age and sex. In group A after four years trabeculectomy had been performed in 53% of eyes because medical management had failed to control the disease. The rate of operation was lower in those patients with intraocular pressure less than 31 mmHg and mild relative field loss (17% at three years) than in those with intraocular pressure greater than 30 mmHg and dense scotomas (75% at three years). Early surgery provided much more stable control with fewer changes in treatment than in group A. The group mean intraocular pressure after trabeculectomy was 15.0 mmHg irrespective of the time of operation, and this was significantly lower than the intraocular pressure in those cases thought to be controlled on medical therapy alone at the end of the first year (20.8 mmHg). Early operation provided significantly better protection of visual field, and the extra loss of visual field with delayed operation occurred in the preoperative period. Changes in visual fields were not related to the use of miotics. There was no significant difference in the final visual acuity in the two groups, but six cases in group A lost central fixation because of progressive loss of visual field, and there were no such cases in group B. Cataract occurred in approximately 10% of cases in both groups, but in group A this happened with only half the number of operations and at a shorter postoperative follow-up than in group B. It appears that in cases of primary open angle glaucoma of this severity the risk of delaying operation are significantly greater than those of performing trabeculectomy as the primary treatment.
There is no evidence from good quality randomized trials or non-randomized studies of the effectiveness of lens extraction for chronic primary angle-closure glaucoma.