Rationale for early lens extraction in the treatment of primary angle closure disease

PURPOSE. To demonstrate the feasibility of early lens extraction in the treatment of primary angle closure disease in clinical practice.

MATERIAL AND METHODS. Three clinical cases are presented at different stages of primary angle closure disease (PACD). The first one is related to the development of a bilateral acute attack of primary angle closure (PAC) in the intensive care unit during the treatment for acute respiratory distress syndrome (ARDS) associated with COVID-19 pneumonia in a patient with a previously undiagnosed PACD. The second case demonstrates the progression of glaucomatous optic neuropathy (GON) in early primary angle-closure glaucoma (PACG) after laser peripheral iridotomy (LPI) and delayed selective laser trabeculoplasty (SLT) against the background of increased lens thickness. The third example illustrates the progression of advanced PACG in the right eye (OD) and moderate PACG in the left eye (OS), which was due to the formation of goniosynechia after bilateral LPI, which required transscleral diode cyclophotocoagulation (TSCP) in OD and trabeculectomy in OS. Subsequently, bilateral lens extraction with implantation of an intraocular lens (LE+IOL) and SLT was performed.

RESULTS. In the first clinical case, advanced PACG developed in both eyes within 2 months. After bilateral LPI, trabeculectomy, compensation of intraocular pressure (IOP) was achieved, visual functions remained the same. In the second clinical case, 5.5 years after LPI and SLT, an increase in the thickness of the lens was revealed (OD by 0.2 mm, OS 0.48 mm). GON did not progress in OD (the rate of thinning of the retinal nerve fiber layer was 0.94 µm/year, p=0.32 and the progression rate in OS was -1.04 µm/year (p=0.018). Taking into account the lens mechanism of the progression of PACD, bilateral LE+IOL was recommended. In the third clinical example IOP remained elevated after bilateral LPI, TSCP in OD and trabeculectomy in OS as a result of goniosinechiogenesis, and therefore LE+IOL also did not lead to its decrease. After bilateral SLT, compensation of IOP was achieved without local hypotensive therapy (IOP, Icare: OD 18.0 mm Hg, OS 15 mm Hg).

CONCLUSION. For preserving visual functions LE+IOL is highly recommended at the very beginning of PACD in order to prevent the formation of GON and goniosynechia. This is dictated by the dominant role of the lens mechanism in the PACD formation as it is demonstrated in the described clinical examples.

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