pacs lens ags 2014 final
TRANSCRIPT
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SURGICAL MANAGEMENT OF SURGICAL MANAGEMENT OF CHRONIC ANGLE CLOSURE CHRONIC ANGLE CLOSURE
H. George Tanaka, MD H. George Tanaka, MD
Assistant Clinical ProfessorAssistant Clinical ProfessorCalifornia Pacific Medical CenterCalifornia Pacific Medical Center
San Francisco, CASan Francisco, CA
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Financial DisclosuresFinancial Disclosures
• Alcon• Allergan• Merck• iScience
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When should I perform lens When should I perform lens extraction alone?extraction alone?
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Take out the cataract!Take out the cataract!
Patient is a presbyopic hyperope = good candidate for multifocal IOLLaser-assisted cataract surgery (LACS)Treat corneal astigmatism with arcuate incisions“Kill FIVE birds with one stone”Cataract surgery will deepen the angle
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PACSPrimary Angle Closure
Suspect
PACPrimary Angle Closure
PACGPrimary Angle Closure
Glaucoma
≥180° ITC IOP and/or PAS Glaucomatousoptic neuropathy
DISEASESTAGING
+++
-
++
-
-+Optic nerve damage
TM dysfunction
TM at risk
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PACSPrimary Angle Closure
Suspect
PACPrimary Angle Closure
PACGPrimary Angle Closure
Glaucoma
RISK OF DISEASE PROGRESSION
TM at risk22% in 5 years
TM dysfunction28% in 5 years
Optic nerve damage
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PPUUSSHH
AQUEOUSAQUEOUS
LENSLENS
IRISIRIS
NOT MUTUALLY EXCLUSIVE !
VITREOUSVITREOUS
CILIARYCILIARYBODYBODY
CHOROIDCHOROID
DISEASEMECHANISM
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STRUCTURE
Narrow angle
Irido-trabecular contactAppositional(reversible)
Irido-trabecular contactSynechial
(irreversible)
FUNCTION
TM normalIOP normal
TM dysfunctionIOP Elevated
TM blockageIOP Elevated
TIME
PupillaryBlock
Lens
IRISABNORMALITY
- Intrinsic- Insertion
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We need an OHTS equivalentWe need an OHTS equivalentfor narrow angles!for narrow angles!
IOP > 21 mm Hg
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We need “PACTS”! We need “PACTS”!
Primary Angle Closure
Angle Closure Glaucoma
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The Effectiveness in Angle-closure The Effectiveness in Angle-closure Glaucoma of Lens Extraction (EAGLE) Glaucoma of Lens Extraction (EAGLE)
Study GroupStudy Group• Prospective multicenter randomized controlled trial• Lens extraction vs. LPI in newly diagnosed PAC or
PACG• Primary outcomes: IOP, QOL, cost-effectiveness at 3
years
Azuara-Blanco A, Burr JM, Cochran C, et al. The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): study protocol for a randomized controlled trial. Trials 2011; 12:133.
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Effect of Lens on CB PositionStrenk & Strenk Eye World Sept. 2007
74 y/o Male Paired Eyes74 y/o Male Paired Eyes
PhakicPhakic PseudophakicPseudophakic
(Slide courtesy of Murray Johnstone, MD)(Slide courtesy of Murray Johnstone, MD)
Apical Portion of CB Moves Anteriorly With Age Apical Portion of CB Moves Anteriorly With Age Apical Portion of CB Moves Backward With Lens RemovalApical Portion of CB Moves Backward With Lens Removal
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There is little clinical evidence to There is little clinical evidence to support support anyany surgical treatment for surgical treatment for
PACS or PACPACS or PAC
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What is an acceptable number needed to What is an acceptable number needed to treat (NNT) to prevent progression from treat (NNT) to prevent progression from
PACS to PAC or PACG?PACS to PAC or PACG?
NNT = 50?NNT = 5?NNT = 1?
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Laser iridotomy is not without Laser iridotomy is not without risks.....risks.....
Glare (location-dependent?)More rapid cataract progressionCorneal endothelial lossIritisElevated IOPHyphemaPosterior synechiae
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Cataract surgery is not without Cataract surgery is not without risks.....risks.....
Suprachoroidal hemorrhageEndophthalmitisRetinal detachmentCystoid macular edemaElevated IOPCorneal endothelial lossDysphtopsiaIncorrect IOL power
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When should I perform lens When should I perform lens extraction alone?extraction alone?
When the patient has a “visually significant” cataract!
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When can I justify a When can I justify a clear lensectomy clear lensectomy after a after a patent iridotomy?patent iridotomy?
Development of PACTM dysfunction = elevated IOP or
PASSpecial circumstances unique to the patient:
Symptoms suggestive of intermittent angle closureSystemic medications that may precipitate angle closureNeed for repeat dilated exams (diabetes, retinal disease)Unreliable access to eye care
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• “In a country where an aggressive cataract surgical programme is likely to catch up with the patient, do we need to intervene with the laser at all?”
• R. Thomas BJO 2003, 87:453
When should I perform lens When should I perform lens extraction alone?extraction alone?
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General approach: ANGLEGeneral approach: ANGLE
Assign stage: PACS, PAC, PACGKNow the mechanismGonio after treatment
Look at the whole patient, not just the angleEvidence-based treatment guidelines – stay tuned!