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

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

METHODS. The study presents three clinical cases with patients 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) that happened in the intensive care unit during 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) in a patient with 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) due to formation of goniosynechiae after bilateral LPI, which required transscleral diode cyclophotocoagulation (TSCP) in OD and trabeculectomy in OS. Subsequently, bilateral cataract phacoemulsification with intraocular lens implantation (CPE+IOL) and SLT were 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 stabilized. In the second clinical case, 5.5 years after LPI and SLT, an increase in the thickness of the lens was revealed (in OD by 0.2 mm, in OS by 0.48 mm). GON did not progress in OD (thinning rate 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-involved mechanism of PACD progression, bilateral CPE+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 CPE+IOL also did not lead to its decrease. After bilateral SLT, compensation of IOP was achieved without local hypotensive therapy (IOP measured by Icare: OD 18.0 mm Hg, OS 15 mm Hg).

CONCLUSION. In order to preserve visual functions, CPE+IOL is highly recommended at the very beginning of PACD, before the formation of GON and goniosynechiae. This is dictated by the dominant role of the lens-involved mechanism in PACD formation, as demonstrated in the described clinical examples.

1. Foster P.J., Buhrmann R., Quigley H.A., Johnson G.J. The definition and classification of glaucoma in prevalence surveys. Br J Ophthalmol 2002; 86(2):238-242. https://doi.org/10.1136/bjo.86.2.238

2. Kurysheva N.I., Sharova G.A. The Role of Optical Coherence Tomography in the Diagnosis of Angle Closed Diseases of the Anterior Chamber. Part 1: Visualization of the Anterior Segment of the Eye. Ophthalmology in Russia 2021; 18(2):208-215. (In Russ.) https://doi.org/10.18008/1816-5095-2021-2-208-215

3. Quigley H.A. Long-term follow-up of laser iridotomy. Ophthalmology 1981; 88(3):218-224. https://doi.org/10.1016/s0161-6420(81)35038-6

4. Sihota R, Rishi K, Srinivasan G, Gupta V, Dada T, Singh K. Functional evaluation of an iridotomy in primary angle closure eyes. Graefe’s Arch Clin Exp Ophthalmol = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2016; 254(6):1141–9. https://doi.org/10.1007/s00417-016-3298-x

5. Kurysheva N.I., Lepeshkina L.V., Shatalova E.O. Predictors of outcome in selective laser trabeculoplasty: a long-term observation study in primary angle-closure glaucoma after laser peripheral iridotomy compared with primary open-angle glaucoma. J Glaucoma 2018; 27(10):880-886. https://doi.org/10.1097/IJG.0000000000001048

6. Kurysheva N.I., Sharova G.A. Comparative study of retinal microcirculation in primary angle closure disease and early primary open-angle glaucoma. Vestnik oftal’mologii 2022; 138(1):44-51. (In Russ.) https://doi.org/10.17116/oftalma202213801144

7. Azuara-Blanco A., Burr J., Ramsay C., et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet 2016; 388(10052): 1389-1397. https://doi.org/10.1016/S0140-6736(16)30956-4

8. Nongpiur M.E., Sakata L.M., Friedman D.S., et al. Novel association of smaller anterior chamber width with angle closure in Singaporeans. Ophthalmology 2010; 117(10):1967-1973. https://doi.org/10.1016/j.ophtha.2010.02.007

9. Marchenko AN, Sorokin EL, Pashentcev YaE. Effectiveness of the system for predicting the risk of developing an acute angle closure glaucoma attack. Vestnik oftal’mologii 2019; 135(1):47-52. (In Russ.) https://doi.org/10.17116/oftalma201913501147

10. Ghelichkhani P, Esmaeili M. Prone position in management of COVID-19 patients; a Commentary. Arch Acad Emerg Med 2020; 8(1):e48.

11. Kurysheva NI. COVID-19 i porazheniya organa zreniya: Monografiya [COVID-19 and eye impairment]. Moscow, Largo Publ., 2021. 80 p.

12. Sanghi P., Malik M., Hossain I.T., Manzouri B. Ocular Complications in the Prone Position in the Critical Care Setting: The COVID-19 Pandemic. J Intensive Care Med 2021; 36(3):361-372. https://doi.org/10.1177/0885066620959031

13. Sano R., Kurokawa T., Kurimoto Y., Miyazawa D., Yoshimura N. Comparison between the anterior chamber configuration in the supine position and that in the prone position in patients with narrow angle. Nippon Ganka Gakkai Zasshi 2001; 105(6):388-393.

14. Kim T.W., Park K.H., Hong C. Dark-room prone-position test for intermittent angle closure. Korean J Ophthalmol 2007; 21(3):151-154. https://doi.org/10.3341/kjo.2007.21.3.151

15. Yamada R., Hirose F., Matsuki T., Kameda T., Kurimoto Y. Comparison of mydriatic provocative and dark room prone provocative tests for anterior chamber angle configuration. J Glaucoma 2016; 25(6):482-486. https://doi.org/10.1097/IJG.0000000000000310

16. Anderson A.P., Babu G., Swan J.G., et al. Ocular changes over 60 min in supine and prone postures. J Appl Physiol (1985). 2017; 123(2): 415-423. https://doi.org/10.1152/japplphysiol.00687.2016

17. Harris L.S., Galin M.A. Prone provocative testing for narrow angle glaucoma. Arch Ophthalmol 1972; 87(5):493-496. https://doi:10.1001/archopht.1972.01000020495001

18. Ostroumova O.D., Shikh E.V., Rebrova E.V., Ryazanova Ayu, Moshetova L.K. Drug-induced glaucoma. Vestnik oftal’mologii 2020; 136(2):107-116. (In Russ.) https://doi.org/10.17116/oftalma2020136021107

19. Sokolovskaya T.V., Yashina V.N., Mahno N.A. Angle-closure glaucoma, iris-lens contact, ciliochoroidal effusion, and transient myopia induced by topiramate. Fyodorov Journal of Ophthalmic Surgery. 2021;1:57-62. (In Russ.) https://doi.org/10.25276/0235-4160-2021-1-57-62

20. Kurysheva N.I., Sharova G.A. The Role of Optical Coherence Tomography in the Diagnosis of Angle Closed Diseases of the Anterior Chamber. Part 2: Visualization of the Posterior Segment of the Eye. Ophthalmology in Russia 2021; 18(3):381-388. (In Russ.) https://doi.org/10.18008/1816-5095-2021-3-381-388

21. Nerlikar R.R., Palsule A.C., Vadke S. Bilateral Acute Angle Closure Glaucoma After Prone Position Ventilation for COVID-19 Pneumonia. J Glaucoma 2021; 30(8):e364-e366. https://doi.org/10.1097/IJG.0000000000001864

22. Barosco G., Morbio R., Chemello F., Tosi R., Marchini G. Bilateral angleclosure during hospitalization for coronavirus disease-19 (COVID-19): A case report. Eur J Ophthalmol 2021; 11206721211012197. https://doi.org/10.1177/11206721211012197

23. Tanaka H.G. The Asymptomatic PAC Suspect: LPI or No LPI? Review ophthalmology 2018. Available at: https://www.reviewofophthalmology.com/article/the-asymptomaticpac-suspect-lpi-or-no-lpi (date of access: 11.03.2022)

24. He M., Jiang Y., Huang S., Chang D.S., Munoz B., Aung T., Foster P.J., Friedman D.S. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, Randomized controlled trial. Lancet 2019; 20;393(10181):1609-1618. https://doi.org/10.1016/S0140-6736(18)32607-2

25. Kurysheva N.I., Lepeshkina L.V., Shatalova E.O. Efficacy of selective laser trabeculoplasty in primary angle-closure glaucoma after peripheral iridotomy: a long-term follow-up. Fyodorov Journal of Ophthalmic Surgery 2018; (3):33-40. (In Russ.) https://doi.org/10.25276/0235-4160-2018-3-33-40

26. Raj S., Tigari B., Faisal T.T., et al. Correction: Efficacy of selective laser trabeculoplasty in primary angle closure disease. Eye (Lond) 2021; 35(3):1028. https://doi.org/10.1038/s41433-020-1047-1

27. Kurysheva N.I., Maslova E.V., Zolnikova I.V., Fomin A.V., Lagutin M.B. A comparative study of structural, functional and circulatory parameters in glaucoma diagnostics. PLoS One 2018; 13(8):e0201599. https://doi.org/10.1371/journal.pone.0201599

28. Kurysheva N.I., Lepeshkina L.V. Detection of primary angle closure glaucoma progression by optical coherence tomography. J Glaucoma 2021; 30(5):410-420. https://doi.org/10.1097/IJG.0000000000001829

29. Jiang Y., Chang D.S., Zhu H., et al. Longitudinal changes of angle configuration in primary angle-closure suspects: the Zhongshan AngleClosure Prevention Trial. Ophthalmology 2014; 121(9):1699-1705. https://doi.org/10.1016/j.ophtha.2014.03.039

30. Lee K.S., Sung K.R., Kang S.Y., Cho J.W., Kim D.Y., Kook M.S. Residual anterior chamber angle closure in narrow-angle eyes following laser peripheral iridotomy: anterior segment optical coherence tomography quantitative study. Jpn J Ophthalmol 2011; 55(3):213-219. https://doi.org/10.1007/s10384-011-0009-3

31. Shao T., Hong J., Xu J., Le Q., Wang J., Qian S. Anterior chamber angle assessment by anterior-segment optical coherence tomography after phacoemulsification with or without goniosynechialysis in patients with primary angle closure glaucoma. J Glaucoma 2015; 24(9):647-655. https://doi.org/10.1097/IJG.0000000000000061

32. Ghadamzadeh M., Karimi F., Ghasemi Moghaddam S., Daneshvar R. Anterior chamber angle changes in primary angle-closure glaucoma following phacoemulsification versus phacotrabeculectomy: A prospective randomized clinical trial. J Glaucoma 2022; 31(3):147-155. https://doi.org/10.1097/IJG.0000000000001977

33. Song M.K., Sung K.R., Shin J.W., Jo Y.H., Won H.J. Glaucomatous progression after lens extraction in primary angle closure disease spectrum. J Glaucoma 2020; 29(8):711-717. https://doi.org/10.1097/IJG.0000000000001537

34. Kurysheva N.I., Sharova G.A. Efficacy of laser iridotomy in primary angle closure suspects and primary angle closure glaucoma. The EYE GLAZ. 2022; 24(1):20–33. (In Russ.) https://doi.org/10.33791/2222-4408-2022-1-20-33

35. Sihota R., Goyal A., Kaur J., Gupta V., Nag T.C. Scanning electron microscopy of the trabecular meshwork: understanding the pathogenesis of primary angle closure glaucoma. Indian J Ophthalmol 2012; 60(3):183-188. https://doi.org/10.4103/0301-4738.95868

36. Kurysheva N., Lepeshkina L.V., Kapkova S.G. Factors affecting the corneal endothelium after selective laser trabeculoplasty in primary open angle and angle closure glaucoma. BMJ Open Ophthalmology 2021; 27(6):e000638. https://doi.org/10.1136/bmjophth-2020-000638

37. Chan P.P., Tang F.Y., Leung D.Y., Lam T.C., Baig N., Tham C.C. Tenyear clinical outcomes of acute primary angle closure randomized to receive early phacoemulsification versus laser peripheral iridotomy. J Glaucoma 2021; 30(4):332-339. https://doi.org/10.1097/IJG.0000000000001799