goniosynechialysis combined with phacoemulsification in ...egscopenaghen2012/posters/june... ·...
TRANSCRIPT
The purpose of this study was to compare the effectiveness of
goniosynechialysis combined with phacoemulsification in patients with
acute primary angle closure (APAC) and chronic primary angle closure
glaucoma (CPACG) and to investigate the possible differences in the
outcome between the 2 groups.
Materials and Methods
Nine eyes of 9 patients with APAC and 18 eyes of 18 patients with
CPACG were enrolled between January 2010 and September 2011. The
surgical procedure and probable outcomes were explained in detail to
the patients and informed consent was obtained from all patients. The
present clinical study was approved by institutional review board.
The criteria used to define APAC included
(1) an eye with an occludable drainage angle (in which more than 270
degrees of the posterior trabecular meshwork cannot be seen on static
gonioscopy) and features indicating that trabecular obstruction by the
peripheral iris has occurred, such as PAS,
(2) presence of at least 2 typical symptoms (ocular pain, nausea,
vomiting, and antecedent history of intermittent blurring of vision with
halo effect),
(3) presence of at least 2 signs (conjunctival injection, corneal
epithelial edema, mid-dilated pupil),
(4) shallow anterior chamber depth;
(5) elevated IOP (>21mmHg), and
(6) no glaucomatous optic neuropathy.
The criteria used to define CPACG included
(1) an eye with an occludable drainage angle and features indicating
that trabecular obstruction by the peripheral iris has occurred, such as
PAS,
(2) elevated IOP (>21mmHg), and
(3) glaucomatous damage to optic disc and visual field.
On the basis of definitions of APAC and CPACG, individuals with:
(1) uncontrolled IOP (>21mmHg) despite medical therapy, laser
iridotomy and argon laser peripheral iridoplasty;
(2) synechial angle closure of 180 degrees or more confirmed by
indentation gonioscopy by Sussman goniolens;
(3) concurrent cataract with best corrected visual acuity (BCVA)≤0.5
(4) no history of acute attack or acute attack having occurred greater
than 6 months previously for CPACG group were included in the study.
Patients with secondary glaucoma, or those who had undergone any
incisional surgery were excluded from the study.
Surgical Technique
A standard clear-cornea phacoemulsification was performed, with
implantation of a foldable intraocular lens.
After lens implantation, the patient’s head was tilted to the side
opposite a chosen paracentesis track to orient the iris surface parallel to
the optical axis of the microscope.
Intraoperative direct gonioscopy was performed with a Swan-Jacob
goinolens.
Goniosynechialysis through clear cornea incision and three separate
paracenteses evenly spaced 90 degrees apart was performed for 360
degrees with the anterior chamber formed with viscoelastic.
A blunt iris spatula was pressed against the most peripheral edges of
the iris next to the points of angle adhesion.
After applying pressure toward the posterior of the iris, the trabecular
meshwork was exposed. Statistical Analysis
Snellen BCVAs were converted to the logarithm of the minimum angle
of resolution (logMAR) for statistical analysis.
Continuous and categorical variables were compared by using Mann-
Whitney U test and Fisher’s exact test.
Variables between preoperative and postoperative IOP in each group
were compared using Wilcoxon signed-rank test.
Analysis of covariance was performed to determine the difference in
postoperative IOP between the APAC and CPACG groups because of
an initially different preoperative IOP. Preoperative IOP had been
adjusted.
All statistical assessments were 2-sided, and the 0.05 level was
considered statistically significant. Statistical analyses were performed
using SPSS 18.0K statistics software (SPSS Inc, Chicago, IL).
Table 1. Descriptive and clinical characteristics of the study groups
Conclusion
Goniosynechialysis combined with phacoemulsification in patients with uncontrolled acute primary angle closure and
chronic primary angle-closure glaucoma
Ji Woong Lee1, Eun Ah Kim2, Seong Jae Kim3
1Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea
2Department of Ophthalmology, Daegu Fatima Hospital, Deagu, Korea
3Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
Purpose
Results
Figure 1. (A) Intraoperative gonioscopy shows angle remains closed by PAS
despite phacoemulsification and injection of viscoelastic near the angle.
(B) The synechiae are stripped from the angle wall at the point of adhesion and
trabecular meshwork are exposed.
(A) (B)
Total
(n=27)
APAC
(n = 9)
CPACG
(n = 18)
P between
two groups
Age (years) 68.33±7.81 66.11±8.81 69.44±7.26 0.587
Follow-up (months) 10.3±4.59
(range, 4-27)
9.33±3.50
(range, 5-15)
10.78±5.07
(range, 4-27) 0.587
OD/OS 17/10 5/4 12/6 0.683
Male/female 5/22 1/8 4/14 0.447
ACD (mm) 1.63±0.21 1.52±0.20 1.68±0.19 0.080
Lens thickness (mm) 5.24±0.34 5.33±0.43 5.19±0.28 0.519
Axial length (mm) 22.40±0.77 22.62±0.78 22.29±0.77 0.280
Table 2. Preoperative and postoperative IOP (mmHg) in study groups
Values are means±SD.
*ANCOVA is performed because of an imbalance of baseline IOP.
†Adjusted P value. Adjusted for preoperative IOP.
ANCOVA, analysis of covariance; IOP, intraocular pressure; Preop., preoperative; Postop.,
postoperative.
Table 3. Preoperative and postoperative BCVA (log MAR) in study
groups
Table 4. Preoperative and postoperative number of anti-glaucoma
medications in study groups
APAC
(n = 9)
CPACG
(n = 18)
P between
two groups
Preop. no. of medications 3.56±0.53 2.61±0.50 0.001
Postop. no. of medications* 0.67±0.50 0.56±0.62 0.722†
P between preop. and postop.
no. of medications 0.007 0.000
No. of medication reduction* -2.89±0.78 -2.06±0.64 0.722†
*ANCOVA is performed because of an imbalance of baseline number of medications.
†Adjusted P value. Adjusted for preoperative number of medications.
Table 5. Preoperative and postoperative gonioscopic findings
in study groups
*ANCOVA is performed because of an imbalance of baseline PAS.
†Adjusted P value. Adjusted for preoperative PAS.
Goniosynechialysis combined with phacoemulsification is effective
in reducing PAS and IOP and improving visual acuity in patients with
uncontrolled APAC and CPACG.
(A) (B)
Figure 2. (A) Ultrasound biomicroscopy (UBM) shows synechial angle closure at the 9-o’clock
position (nasal) in an eye with acute primary angle closure before surgery. (B) UBM at the same 9-
o’clock position reveals that the angle is now open after phacoemulsification, intraocular lens
implantation and goniosynechialysis.