lens & angle closure - cybersight.org · lp!: 18. study 1. vn
TRANSCRIPT
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Siddharth Dikshit, DNB, FLVPEI, FICO
VST Center for Glaucoma CareL V Prasad Eye Institute
Lens & Angle Closure
THE OBVIOUS, THE KNOWN, THE FUTURE & THE UNEXPLORED
Objectives
• To understand the role of lens in angle closure disease
• To understand the measurable parameters of the lens
• To understand the impact of lens removal in angle closure disease
• Special consideration: Plateau iris
• Considerations for cataract surgery
• Decision between cataract and combined surgery
No conflict of interestNo financial implications
Importance of Lensin Angle Closure Glaucoma
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a) Mapstone’s hypothesis explains the importance of lens
b) Maximal in mid-dilated position of pupil
c) Intraocular lens in sulcus is a risk factor
d) IOP rise may occur in PACG by mechanisms other than relative pupillary block
True about relative pupillary block is ALL EXCEPT
Question 1
a) Mapstone’s hypothesis explains the importance of lens
b) Maximal in mid-dilated position of pupil
c) Intraocular lens in sulcus is a risk factor
d) IOP rise may occur in PACG by mechanisms other than relative pupillary block
True about relative pupillary block is ALL EXCEPT
Question 1
Mapstone R. Br J Ophthalmol. 1968 Jan;52(1):19-25.
Sphincter pupillae
Dilator pupillae
Mapstone’s Hypothesis
Relative Pupillary Block
Mapstone’s Hypothesis
Relative Pupillary Block
Sphincter pupillae
Dilator pupillae
Mapstone R. Br J Ophthalmol. 1968 Jan;52(1):19-25.
Ritch R, et al. Br J Ophthalmol. 1995 Mar;79(3):300.
Mapstone’s Hypothesis
Peripheral Iris-bombe
Iridolenticular contact
Aqueous
Relative Pupillary Block
The Obvious••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Pseudophakes cannot have PRIMARY acute angle closure
The ParametersASOCT
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Angle Parameters on ASOCT
Smith SD, et al. Ophthalmology. 2013 Oct;120(10):1985-97.
Lens Parameters on ASOCT
Baek S, et al. Invest OphthalmolVis Sci. 2013 Jan 30;54(1):848-53.
Spectrum of Disease
Lens Parameters on ASOCT
Guzman CP, et al. Invest OphthalmolVis Sci. 2013 Aug 7;54(8):5281-6.
Spectrum of Disease
Lens Parameters on ASOCT
Moghimi S, et al. Am J Ophthalmol. 2013 Apr;155(4):664-673, 673.
Angle Closure Glaucoma
Changes after Cataract Surgery
Kim M, et al. Korean J Ophthalmol 2012;26(2):97-103.
n=11
Impact of Cataract Surgeryin Angle Closure Glaucoma
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a) Acute primary angle closure
b) Primary open angle glaucoma
c) Pseudoexfoliation glaucoma
d) Pigmentary glaucoma
Phacoemulsification reduces the IOP maximally in
Question 2
a) Acute primary angle closure
b) Primary open angle glaucoma
c) Pseudoexfoliation glaucoma
d) Pigmentary glaucoma
Phacoemulsification reduces the IOP maximally in
Question 2
Type of Glaucoma
IOP Reduction & Cataract Surgery
Masis M, et al. Surv Ophthalmol. 2018 Sep - Oct;63(5):700-710.
a) Laser iridotomy with Argon laser
b) Cataract extraction immediately
c) Laser iridoplasty
d) Intracameral Pilocarpine
A patient with acute angle closure has been on maximal medicatations for 3 days. The IOP is still 58 mm Hg with dense corneal edema. Evidence suggests that the best next step is:
Question 3
a) Laser iridotomy with Argon laser
b) Cataract extraction immediately
c) Laser iridoplasty
d) Intracameral Pilocarpine
A patient with acute angle closure has been on maximal medicatations for 3 days. The IOP is still 58 mm Hg with dense corneal edema. Evidence suggests that the best next step is:
Question 3
Nature of Study No. of eyes Absolute Complications
Prospective, Consecutive 1 18 100%
Details NA NA
Retrospective, Non-consecutive 2 10 100%
Relative: 3/10Fibrin: 4
Transient IOP ↑: 2
Retrospective, Non-consecutive 3 14
IOP: 10.70±2.80
Meds: 0.13±0.34
Transient IOP ↑: 4
Phaco in Acute PAC
IOP Reduction & Cataract Surgery
1. Ming Zhi Z, et al. Am J Ophthalmol. 2003 Apr;135(4):534-6.2. Yoon JY, et al. Korean J Ophthalmol. 2003 Dec;17(2):122-6.3. Su WW, et al. PLoS One. 2011;6(5):e20056.
Nature of Study No. of eyes Absolute Complications FU Case Selection VA >20/40
Prospective, Consecutive 1 18 100%
Details NA NA 7 weeksPre-op IOP
>31 mm Hg in 3 eyes
NA
Retrospective, Non-consecutive 2 10 100%
Relative: 3/10Fibrin: 4
Transient IOP ↑: 2 NA 7/10 IOP >31 mm Hg
4 patients VA >20/40
Retrospective, Non-consecutive 3 14
IOP: 10.70±2.80
Meds: 0.13±0.34
Transient IOP ↑: 4 3mPre-Op IOP
not mentioned
0.73 ± 0.53
Phaco in Acute PAC
IOP Reduction & Cataract Surgery
1. Ming Zhi Z, et al. Am J Ophthalmol. 2003 Apr;135(4):534-6.2. Yoon JY, et al. Korean J Ophthalmol. 2003 Dec;17(2):122-6.3. Su WW, et al. PLoS One. 2011;6(5):e20056.
Phaco in Acute PAC
IOP Reduction & Cataract Surgery
1. Husain R, et al. Ophthalmology. 2012 Nov;119(11):2274-81.2. Lam DS, et al. Ophthalmology. 2008 Jul;115(7):1134-40.
No. of Eyes Criteria IOP Outcomes Complications FU Vision
LP!: 18Study 1
Vn <6/15Vn
IOP <30 within 24 hours
Comp: 9/18Qual: 2/18
Hyphema: 3Corneal burn: 1
2 years0.34±0.35
Phaco: 19 Comp: 13/18Qual: 4/18 CE: 1 0.37±0.51
Phaco: 31Study 2
IOP <21 after medications
12.6±1.90.90±1.14 meds
3.2% Failures
Corneal edema: 12, PCR: 1, Hyphema, Fibrin: 7, PCO: 5
18m
0.28±0.24
LPI: 3115.0±3.4
0.03±0.18 meds46.7% Failures
Add PI: 4 0.38±0.29
Tarongoy P, et al. Surv Ophthalmol 54:211--225, 2009.
ECCE
IOP Reduction in PACG
Phaco
IOP Reduction in PACG
Tarongoy P, et al. Surv Ophthalmol 54:211--225, 2009.
Controlled PACG Eyes
Fluctuation of IOP
Özyol P, et al. Acta Ophthalmol. 2016 Nov;94(7):e528-e533.
• 39 subjects, Consecutive• PACG S/P YAG PI• IOPs at 8am, 12noon & 4pm, 3 months after surgery • Correlated with increase in ACD• 3 eyes had increase in IOP, unchanged in 1eye
PGAs were resumed after 1 week of surgery
The Known••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Cataract extraction will reduced IOP & its fluctuations deepen anterior chamber; in proportion to increase in depth
after surgery
Plateau-Iris
Changes after Cataract Surgery
Tran HV, et al. Am J Ophthalmol. 2003 Jan;135(1):40-3.
Plateau-Iris
Changes after Cataract Surgery
Tran HV, et al. Am J Ophthalmol. 2003 Jan;135(1):40-3.
Plateau-Iris
Changes after Cataract Surgery
Nonaka A, et al. Ophthalmology. 2005 Jun;112(6):974-9.
Plateau-Iris
Changes after Cataract Surgery
Nonaka A, et al. Ophthalmology. 2005 Jun;112(6):974-9.
Plateau-Iris
Changes after Cataract Surgery
Nonaka A, et al. Ophthalmology. 2006 Mar;113(3):437-41.
The Unknown••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Impact on Plateau-Iris
Challenges in Cataract Surgeryin Angle Closure Glaucoma
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• Shallow AC
• Large lens
• Small pupil
• Pro-inflammatory PGA/Pilocarpine
• IOL Power calculation
• Intraocular pressure control
Challenges
Cataract Surgery in ACG
Cataract vs Combined
Complications
Zhang ML, et al. Cochrane Database Syst Rev. 2015 Jul 14;(7):CD008671.
Intra-op ShallowingCorneal edemaCorneal decompensationIritisCMEAqueous misdirectionSteroid-response
Pre-Operative Preparation••••••••••••••••••••••••••••••••••
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a) In absence of a pre-existing laser iridotomy, a surgical PI must be made
b) Post-operative acetazolamide reduces the chances of IOP spike
c) Corneal endothelial decompensation after cataract surgery is 5 times more common in patients with PACG
d) Prostaglandin analogues and Pilocarpine can be used till the day of surgery, but should be discontinued thereafter
True about post-operative management of a PACG patient after a routine Phacoemulsification is
Question 4
a) In absence of a pre-existing laser iridotomy, a surgical PI must be made
b) Post-operative acetazolamide reduces the chances of IOP spike
c) Corneal endothelial decompensation after cataract surgery is 5 times more common in patients with PACG
d) Prostaglandin analogues and Pilocarpine can be used till the day of surgery, but should be discontinued thereafter
True about post-operative management of a PACG patient after a routine Phacoemulsification is
Question 4
To Discontinue
Glaucoma Medications
• Pilocarpine: 1-2 weeks ahead• Replace with Acetazolamide
• PG Analogues: After surgery• Resume beyond 8-12 weeks• Used Topical NSAID for 6 weeks
• Best possible IOP control pre-op
a) SRK II
b) SRK/T
c) Hoffer Q
d) Haigis
e) None
The IOL Calculation formula with >95% accuracy of residual refractive error of <0.25D is
Question 5
a) SRK II
b) SRK/T
c) Hoffer Q
d) Haigis
e) None
The IOL Calculation formula with >95% accuracy of residual refractive error of <0.25D is
Question 5
SRKII
IOL Power
• 42 eyes with controlled PACG• 45 eyes with open angles
Kang SY, et al. Yonsei Med J 50(2):206-210, 2009
SRKII
IOL Power
Kang SY, et al. Yonsei Med J 50(2):206-210, 2009
SRK/T, Haigis, Hoffer Q
IOL Power
• 63 eyes with controlled PACG• 93 eyes of normal subjects
Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379
SRK/T, Haigis, Hoffer Q
IOL Power
Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379
EAGLE Trial
IOL Power
Day AC, et al. Br J Ophthalmol. 2018 Dec;102(12):1658-1662.
Recommendations
IOL Power
• Aim myopic if using older formulae
• Modern formulae: Barett’s
• Avoid multifocals
• Toric: Inform about future impact of Trab, if one is needed
Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379
Intraocular Pressure
Pre-Op Mannitol
• Advanced Glaucoma• Patients with Plateau-iris syndrome
• At least 1 hour prior to surgery
Deepening of AC
Pre-Op Mannitol
Hwang HS, et al. Curr Eye Res. 2016 Sep;41(9):1161-5.
• 38 eyes undergoing cataract surgery• Measurements 1 hour after mannitol
a) Initiated not more than 15-20 minutes of surgery
b) Use a rapidly acting mydriatic in combination with long-acting on
c) Accompanied by cycloplegic to deepen the anterior chamber
d) Intra-operative pilocarpine will reduce chances of floppy iris
All the following are true EXCEPT ONE. Pre-Operative dilatation, before a Phacoemulsification, in a patient with plateau-iris syndrome should be:
Question 6
a) Initiated not more than 15-20 minutes of surgery
b) Use a rapidly acting mydriatic in combination with long-acting on
c) Accompanied by cycloplegic to deepen the anterior chamber
d) Intra-operative pilocarpine will reduce chances of floppy iris
All the following are true EXCEPT ONE. Pre-Operative dilatation, before a Phacoemulsification, in a patient with plateau-iris syndrome should be:
Question 6
Timing
Dilatation
Mapstone R. Br J Ophthalmol. 1974 Jan; 58(1): 46–54.
• Just before block/shifting
• Rise of IOP happens after 40-50 minutes of instillation of mydriatic in susceptible eyes
• Strong, rapidly acting mydriatic
Cycloplegia along with Mydriasis
Dilatation
Nuzzi R,et al. Open Ophthalmol J. 2018 Mar 30;12:34-40.
• Along with mydriatic
• Will help in deepening the AC
• Prevention of Aqueous misdirection
• Additional protection against Floppy Iris
Nil / Minimal Block
Anesthesia
Huber KK, et al. Br J Ophthalmol. 2005 Jun; 89(6): 719–723.
• Peribulbar anesthesia reduces ONH blood flow
No Compression
Anesthesia
Chang B, et al. Br J Ophthalmol. 2000 Nov; 84(11): 1260–1263.
Recommendations
Anesthesia
Huber KK, et al. Br J Ophthalmol. 2005 Jun; 89(6): 719–723.
• Topical preferable
• Posterior sub-tenon, subconjunctival: Alternatives
• 2ml Injection inferotemporally
• Wait for eye to be soft, no compression
• Limit total volume
Control the Controlables
Avoid Positive Vitreous Pressure
Chronopoulos A, et al. Surv Ophthalmol. 2017 Mar - Apr;62(2):127-133.
• Bathroom break prior to surgery • Specially if Mannitol was
administered
• Light-weight (Titanium) self-retaining speculum
• Open to moderate extent
Clear-Corneal
Incision
• Clear corneal phaco
• Temporal SICS (Leave one quadrant untouched)
• Clear corneal ECCE
Post-Operative Management••••••••••••••••••••••••••••••••••
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Do Not Forget IOP, Other Eye
Post-Op Regimen
• Steroid, Antibiotic
• Immediate Oral Acetazolamide
• Replace with alternative agents
• Used Topical NSAID for 6 weeks
Managing Spikes
Post-Op Regimen
• Oral Acetazolamide
• Can use ½ TID dose with Potassium supplementation
• Control of inflammation
• Syrup Glycerol
Managing Glaucoma
Post-Op Regimen
• Can resume PGA after 3 months
• Prescription should always contain AGM
• Repeat fields at 2-3 months: Fresh baseline
Combined vs Cataract••••••••••••••••••••••••••••••••••
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Cataract vs Combined
Complications
Zhang ML, et al. Cochrane Database Syst Rev. 2015 Jul 14;(7):CD008671.
Combined in Certain Situations
Combined vs Cataract
Tham CC, et al. Ophthalmology. 2009 Apr;116(4):725-31, 731.e1-3.Tham CC, et al. Ophthalmology. 2013 Jan;120(1):62-7.
Combined in Certain Situations
Combined vs Cataract
• Advanced glaucoma on 2 or more medications
• Moderate glaucoma on 3 or more medications
• Progressive Glaucoma
• Economic burden
• Difficulty in Follow-up
• Lens factor insignificant
Summary
• Lens is an essential component of relative pupillary block
• Cataract extraction benefits PACD patients
• Not all patients are benefitted (equally)
• Phacoemlusification is a good option for non-severe acute angle closure
• Careful pre,- intra-, and, post-op management
The Future & The Unexplored••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Dynamic properties of the lensCauses of persistent occludability
Factors to predict impactIOL calculation
A Multifactorial Disease
Beyond Pupillary Block
Goniosynechiae
Plateau-Iris
Iris Properties Choroidal Expansion
TM Damage
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