PHACOEMUSLIFICATION AS A TREATMENT OPTION IN CHRONIC ANGLE CLOSURE GLAUCOMA B. Kozomara, E. Potkonjak, R. Lazic, N. Gabric Eye Clinic “Svjetlost” Banja Luka University Eye Hospital “Svjetlost” Zagreb, Croatia

Authors have no financial interest. Financial disclosure Authors have no financial interest.

Introduction By definition, angle closure in glaucoma can be divided into primary (acute) and secondary - gradual (chronic) Secondary angle closure glaucoma in often insidious eye condition mostly caused by thickening of the crystalline lens in elderly patients, as well as their specific ocular anatomy, subsequently closing the angle and rising intraocular pressure Usually bilateral but asymmetric condition, affecting more woman than men, particularly hypermetropes Good clinical evaluation of suspected patients in crucial for early detection and good therapeutic planning (gonioscopy, anterior segment OCT, good follow up) Mostly used treatment options so far included non invasive or partially invasive procedures (topical therapy and YAG laser iridotomy)

Introduction Surgical treatment options were based on the same procedures as for the primary angle closure glaucoma (trabeculectomy, shunt and valve surgery) Phacoemulsification arose as a treatment option in recent years from the fact that it stabilized intraocular pressure (IOP) in some patients with angle closure and cataract.

Purpose To show our results and effect of phacoemulsification and IOP stabilization in candidates for cataract surgery with chronic angle closure glaucoma

Materials and methods Preoperative and postoperative data of patients with cataract and chronic angle closure glaucoma were analyzed All patients were on double anti-glaucoma therapy and all underwent unilateral or simultaneous bilateral phacoemulsification with intraocular lens (IOL) implantation from January 2014 until February 2015. Regarding refraction, 14 patients were hypermetropes and 10 were emmetropic

Materials and methods Preoperative evaluation included: Uncorrected and best spectacle corrected distance visual acuity (UNDVA, BSCDVA) Intraocular pressure measurement Gonioscopy Slit lamp examination of the anterior and posterior eye segments Oculus Pentacam evaluation of the angle and cataract gradation

Materials and methods All patients underwent standard and uncomplicated topical phacoemulsification with three piece IOL implantation in the capsular bag Postoperative follow up included: UNDVA and BSCDVA IOP evaluation Anterior chamber debt IOL position within capsular bag Visual field testing (4 months postoperatively) All follow-ups were at first and seventh postoperative day, as well as after 1, 2 and 4 months.

Results We have evaluated 24 patients (42 eyes) that had separate unilateral or same day simultaneous bilateral phacoemulsification with IOL implantation

Demographics of evaluated patients Results Demographics of evaluated patients Gender (female/male) 18/6 Age (F/M) 71.2±1.14 / 69.7±3.48 Mean preoperative UNDVA (F/M) 0.11±3.14 / 0.28±2.89 Mean preoperative BSCDVA (F/M) 0.42±2.34 / 0.63±1.69 Mean preoperative IOP (F/M) 25.4±4.10 / 26.9±3.45 Mean preoperative ACD (F/M) 1.86±4.14 / 2.03±1.12 Cataract grade, F/M 2.50±1.14 / 1.50±3.87

Postoperative Visual Acuity Postoperative follow-up Results Postoperative Visual Acuity Postoperative follow-up Better No change Worse 1st postoperative day 24 7th postoperative day 17 (2 Snellen lines) 7 1 month postoperatively 2 months postoperatively 4 months postoperatively

Postoperative IOP values Postoperative follow-up Results Postoperative IOP values Postoperative follow-up Better No Change Worse 1st postoperative day 24 7th postoperative day 5 (17.2±4.13) 21 (24.0±2.13) 1 month postoperatively 14 (19.7±2.81) 7 (given previous topical therapy) 3 (filtration surgery advised) 2 months postoperatively 17 (15.6±3.45) 4 4 months postoperatively (16.7±1.88)

Postoperative ACD values Postoperative follow-up Results Postoperative ACD values Postoperative follow-up Better No Change Worse 1st postoperative day 24 7th postoperative day 17 7 1 month postoperatively 2 months postoperatively 4 months postoperatively (3.14±2.59 / 2.98±1.97)

Results

Results

Results There was no dislocation of the IOL within the capsular bag All examined patients had no changes in their visual fields Gonioscopy was inconclusive and it wasn’t listned in the results section

Discussion For many years now, phacoemulsification has become a standard procedure not only for the cataract removal It has its very important role today in refractive surgery, mainly in refractive lens exchange and monofocal/multifocal IOL implantation Many surgeons worldwide are now more considering a role of phacoemulsification chronic angle closure glaucoma treatment

Discussion Visual acuity improvement can be expected due to angle widening and better trabecular flow, but also because of cataract removal.¹ In our study, 17 patients (70.83%) had better postoperative VA from 7th postoperative day until the end of follow up for 2 Snellen lines VA improvement also depends on the glaucoma stage and the damage to the optical nerve. ¹Brown RH, Zhong L, Lynch MG. Lens-based glaucoma surgery: using cataract surgery to reduce intraocular pressure. J Cataract Refract Surg 2014;40:1255-62.

Discussion Majority of patients had better postoperative intraocular pressure (17 patients -70.83%) at the end of the follow up, with main IOP level of 16.7±1.88. In some other studies, the level of improvement was much better, but in the same time the follow up period was longer than ours.² We believe that in those cases where there was no improvement there were much more anatomical problems in the trabecular meshwork than anticipated. ²Moghimi S, et al. Phacoemulsification Versus Combined Phacoemulsification and Viscogonioplasty in Primary Angle-Closure Glaucoma: A Randomized Clinical Trial. J Glaucoma 2014; [ahead of print, online preview available at PubMed.com].

Discussion Deepening of anterior chamber can be expected, and all patients in our study had deepening of the anterior chamber (1.86±4.14 / 2.03±1.12; 3.14±2.59 / 2.98±1.97). Anterior chamber debt also depends on the irido-capsular bag anatomy, but also on the type on intraocular lens implanted³, especially on the position of the IOL within the bag Visual field remained the same during the follow up in our study, as it could be expected. ³Bhandari S, Pandyal I, Khanal SP, Thapa SS. Effect of phacoemulsification surgery on various parameters in patients with glaucoma. Nepal J Ophthalmol 2014;6:46-55.

Conclusion Phacoemulsification can be considered as on of the treatment options for chronic angle closure glaucoma. More than 70% of patients had satisfactory postoperative IOP without any additional treatments, which can be attributed to good anatomical structures in the irido-corneal angle. Future studies on the larger sample are needed to confirm these findings, as well as to investigate if the same results can be expected with one-piece intraocular lenses.

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