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glaucom
Open Angle Primary Glaucoma
Surgery is indicated when glaucomatous optic neuropathy worsens (or is
expected to worsen) at any given level of IOP and the patient is on maximum
tolerated medical therapy (MTMT).
MTMT varies considerably between individuals, and it may consist of
medicines from 1 or several classes (including a beta-adrenergic antagonist,
a prostaglandin agent, an alpha-agonist, and a topical carbonic anhydrase
inhibitor). Some patients are observed to progress simply because
compliance with the medical regimen becomes too difficult because of the
following: high drug costs, inability to remember the schedule of multiple
medications, inability to instill them in the eyes properly secondary to
arthritis or other incapacitation (especially common among elderly patients
or those with other chronic systemic conditions), or intolerable ocular and
systemic adverse effects.
A brief mention of surgical options is listed below. Detailed information on
surgical procedures, indications, and postoperative care is beyond the scope
of this chapter.
Argon laser trabeculoplasty
See the list below:
Argon laser trabeculoplasty (ALT) uses a laser beam focused through a
goniolens to treat at the border between anterior and posterior
trabecular meshwork. A full treatment consists of 100 spots placed
over the entire 360 degrees of the trabecular meshwork. This may be
divided between 2 sessions consisting of 50 spots over 180 degrees.
Aqueous outflow improves after the procedure.
The specific mechanism of this improved outflow is unknown, but one
hypothesis is up-regulation of trabecular endothelial cells.
IOP reduction obtained is usually in the 7-10 mm Hg range, and it may
last up to 3-5 years following ALT.
A study by Heijl et al studied patients with low IOP levels before ALT.
The study found that IOP before ALT significantly influenced the IOP
reduction produced by ALT, in that a much larger decrease was
observed in eyes with higher IOP before ALT. [19]
Unfortunately, the decrease in IOP is not usually permanent.
Approximately 10% of treated patients will return to pretreatment IOP
for each year following treatment.
Complications include a brief, but potentially significant, increase in
IOP after the procedure (therefore, alpha-agonists often are used either
preoperatively or postoperatively for prophylaxis of this occurrence);
transient iritis or corneal opacities; peripheral anterior synechiae; and
hyphema.
ALT usually is pursued after MTMT has been reached, but it may be
performed sooner in the treatment algorithm if pseudoexfoliation or
pigmentary glaucoma is present, or if the patient is of black ethnicity,
because laser therapy may be most effective in these individuals.
1

Selective laser trabeculoplasty

See the list below:
Selective laser trabeculoplasty (SLT) uses a Q-switched 532 Nd:YAG
laser to selectively target pigmented cells of the trabecular meshwork
in a nonthermal manner, increasing fluid outflow and thereby lowering
IOP.
The 3-nanosecond high-energy specific wavelength of light used
induces the same cell replacement mechanism as traditional ALT but
without the destructive burning and obliteration of structural support
tissue in the meshwork. The short pulse of the laser does not allow
time for heat to spread to other cells. SLT delivers just enough energy
to the trabecular meshwork to target specific melanin-rich cells,
without incurring collateral thermal damage and scarring to adjacent
nonpigmented trabecular meshwork cells and underlying trabecular
beams. When treated with SLT, a primarily biologic response is induced
in the trabecular meshwork that involves the release of cytokines that
trigger macrophage recruitment as well as other changes leading to
IOP reduction.
The laser beam bypasses surrounding tissue leaving it undamaged by
light. Unlike ALT, SLT can be repeated several times. Whereas patients
treated with ALT can receive only 2 treatments in their lifetime,
patients treated with SLT can receive 2 treatments a year.
SLT requires a specially designed laser, as follows:
o A short pulse to allow for thermal relaxation
o Precise wavelength for optimal melanin absorption
o Sufficient energy to heat melanin to the point that it releases
cytokines
o Sufficient spot size to ensure full coverage at the trabecular
meshwork
Trabeculectomy
See the list below:
Trabeculectomy surgery usually is performed after MTMT and ALT have
failed to control IOP adequately. If IOP is so high that ALT and SLT are
likely to be ineffective in reaching target IOP, then proceeding from
MTMT to penetrating surgery may be indicated.
A superficial flap of sclera is dissected anteriorly to the trabecular
meshwork, and a section of trabecular meshwork is removed
underneath the flap.
This alternate outflow pathway is created to increase passage of
aqueous from the anterior chamber to the subconjunctival space,
creating a filtering bleb and, thereby, lowering IOP.
Either releasable sutures or laser suture-lysis may be used to control
aqueous drainage and corresponding IOP postoperative. Alternatively,
to maximize surgical success, antimetabolites (eg, 5-fluorouracil,
mitomycin C) may be applied during or after surgery to decrease
fibroblast proliferation and scar formation.
Risks and complications of filtering surgery include the following:
hypotony,
blebitis/endophthalmitis,
hyphema,
suprachoroidal
2

hemorrhage or effusions, encapsulation of the bleb with resultant

transient IOP elevation, loss of 1 or more lines of visual acuity, and
increased risk of cataract formation.
With the risk of severe complications from trabeculectomy and the
need for frequent postoperative follow-up care (ie, usually weekly for 2
months, initially), some patients with transportation, financial, or longdistance issues concerning postoperative follow-up care may be better
served by tube shunt surgery instead. See the Tube versus
Trabeculectomy Study below.
Vision loss may be a serious complication after trabeculectomy, with
severe and ongoing unexplained loss ("snuff-out") experienced by as
many as 2% of patients. Attendant risk factors such as split fixation on
visual fields prior to surgery, preoperative number of quadrants with
split fixation, and postoperative choroidal effusions with eventual
resolution are possible. [20]

Drainage implant (ie, seton/tube/shunt) surgery

See the list below:
Generally, this procedure is performed after multiple attempts at
successful trabeculectomy have failed.
A tube is placed in the anterior chamber to shunt aqueous to an
equatorial reservoir, and then posteriorly to be absorbed in the
subconjunctival space.
Types of implants include Molteno, Baerveldt, Ahmed, and Krupin.
o Most shunts function by allowing passive drainage of aqueous
from the anterior chamber.
o The Molteno implant consists of a silicone drainage tube, which is
connected to 1 or 2 acrylic plates that are sutured to the sclera.
o The Baerveldt implant is available with larger plates with
increased reservoir size. The seton (tube) connected to the
reservoir usually is tied off with an absorbable suture, allowing
flow to initiate 4-6 weeks postoperative once some conjunctival
wound remodeling has taken place, thereby reducing the risk of
immediate postoperative hypotony.
o The Ahmed and Krupin implants have 1-way valves, which are
designed to maintain pressure above 8 mm Hg. These implants
may reduce the risk of hypotony, a complication of nonvalved
shunts in the early postoperative period.
Because of less numerous postoperative visits, tube shunts may be
indicated as primary surgery when patients are unable to come as
frequently for follow-up care (because of transportation, financial, or
long-distance issues). This can be a particular concern in rural areas
that cover large distances.
A valved shunt may also be indicated as primary surgery if a patient
has a strenuous job or other activities that require strenuous exertion.
Severe exertion may cause a significant Valsalva maneuver,
significantly increasing venous pressure postoperatively, which could
result in a delayed suprachoroidal hemorrhage and possible severe
loss of vision.
3

The Tube versus Trabeculectomy Study has been undertaken to see if

glaucoma tube shunt surgery may actually be a viable first-line
alternative to (or even surpass) trabeculectomy surgery. Some training
programs have removed trabeculectomy training from their residency
program curricula, with only fellows performing trabeculectomy (not a
general trend).
One-year data have shown nonvalved tube shunt surgery was more
likely to maintain IOP control and to avoid persistent hypotony or
reoperation for glaucoma than trabeculectomy at 1 year, although
both procedures produced similar IOP reduction.
Less supplemental medical therapy has been needed so far in the
trabeculectomy group.
The incidence of postoperative complications at 1 year was higher in
the trabeculectomy group.
Serious complications resulting in reoperation and/or vision loss
occurred with similar frequency in both groups at 1 year.

Ciliary body ablation

See the list below:
Postoperative pain and inflammation are common complaints. Loss of 1
or more lines of visual acuity has been reported. Phthisis is a concern
after this procedure, although it has not been reported as of yet after
the diode laser method of cycloablation.
This procedure is indicated as a last resort for patients who have failed
medical management and other surgeries or for those patients who
have limited visual potential (often 20/200 or less).
By destroying a portion of the nonpigmented ciliary epithelium,
aqueous humor production is limited.
The ciliary body epithelium can be destroyed by cyclocryotherapy,
diathermy, ultrasound, transscleral Nd:YAG or diode laser (known as
cyclophotocoagulation), or a newer endoscopic laser (EndoOptiks,
Inc). [21]
Several of the newer surgical procedures are promising, but many ideas have
been tried before and few have stood the test of time. Generally, the less
complications, the less effective in lowering IOP. There is the possibility that
visual loss can be better prevented, with fewer complications, and treatment
can be tailored to the individual patient. If simple, safe procedures become
available, surgery could be performed earlier in the disease process and
adherence to medications could become less problematic.
The ideal glaucoma procedure would use the healthy portions of the outflow
system and bypass the diseased portions; control IOP without infection and
other risks of a thin-walled bleb; reduce the risk of hypotony during the
perioperative period, with less postoperative care management and
complications, as compared with trabeculectomy and setons; and provide
adequate IOP control for the life of the patient.
Many innovative glaucoma surgical techniques and devices are on the
horizon. Interest in this new frontier is because of the lack of an existing,
ideal glaucoma procedure despite decades of research. Many devices are not
yet approved by the FDA for use in the United States.
4

Newer techniques
See the list below:
Deep sclerectomy/viscocanalostomy/with or without collagen implant
This is probably not as effective as trabeculectomy and is technically
more difficult, but it is associated with less complications.
360-degree suture canaloplasty (iScience) This is a useful alternative
in infants (with congenital glaucoma or juvenile glaucoma) to
trabeculotomy. In adults, suture under tension left in the Schlemm
canal to further open the trabecular meshwork (similar mechanism to
miotics).
New devices
See the list below:
ExPress shunt (Optonol)
o Erosion problems if used without scleral flap
o Now mainly used underneath trabeculectomy flap to better
regulate flow through sclerostomy
o Easy to learn, appears effective, and otherwise has low
complication rate
o Awaiting long-term trials
o May be especially useful for the ophthalmologist who only
occasionally does glaucoma surgery
iStent (Glaukos)
o Shunt device from the anterior chamber into the Schlemm canal
o Internal placement approach
o May need multiple devices placed
o Still undergoing continuing research
Eyepass
o Shunt device from the anterior chamber into the Schlemm canal
o External placement approach
o Inactive technology
o Poor long-term IOP control
Solx gold suprachoroidal space microshunt (OccuLogix)
o Shunts fluid from the anterior chamber into the suprachoroidal
space via gold microchannels
o External placement approach
o Possibly titratable effect with titanium-sapphire laser to modify
microchannel size
o Needs further published series data
Trabectome (NeoMedix)
o FDA approved
o Ablates all of the trabecular meshwork for 90 degrees to 180
degrees via electrocautery and aspiration of the internal wall of
the Schlemm canal
o Similar idea to goniotomy but prevents rescarring of the
Schlemm canal edges, as all tissue is removed
o May have a place between trabeculoplasty and anterior filtering
operations
5

o Safer than trabeculectomy or tube shunt but may be less

effective
o Needs more long-term data on complication rate and persistence
of effect
Primary Angle-Closure Glaucoma
The two main challenges in the management of PACG are, firstly, to prevent
progression of the angle closure and, secondly, to prevent progression of the
glaucomatous optic neuropathy by controlling IOP. Various surgical
procedures have different roles in meeting these challenges.
The diminishing role of surgical iridectomy
To prevent progression of the angle closure, all eyes with angle closure or
very narrow drainage angles should undergo iridectomy or iridotomy to
eliminate pupillary block. Nowadays, laser iridotomy has largely succeeded
surgical iridectomy, except in exceptional circumstances.[39, 40]
Laser iridotomy has many advantages over surgical iridectomy. Laser
iridotomy is noninvasive, so there is no inherent risk of endophthalmitis and
wound complications, such as wound leak. With sequential laser techniques,
the wound edge of the iridotomy is well coagulated and the risk of
hemorrhage from iris tissue is much reduced. The movement of fluid when
the iris is penetrated is a good sign of iris penetration, and the chance of an
incomplete iridotomy is minimal. Furthermore, as no ocular incision is
required, there is no risk of further shallowing of the anterior chamber and
causing iridocorneal adhesion and damage, PAS and permanent closed
angle, or precipitating malignant glaucoma. Laser iridotomy can also be
conveniently performed on an outpatient basis, and it does not require
operating room facilities.
As laser equipment and expertise have become widely available, the role of
surgical iridectomy in the management of angle-closure glaucoma is now
limited to situations in which laser iridotomy is not possible or effective, for
example, in patients with significant corneal opacity. The inability of patients
to cooperate may also be a relative indication for surgical iridectomy, which
can be performed under sedation or even general anesthesia. Severe
anterior chamber inflammation may repeatedly occlude a laser iridotomy,
while the relatively larger iridectomy created by surgery is much more likely
to remain open under such circumstances.
Trabeculectomy
Trabeculectomy is effective for PACG.[41, 42, 43, 44, 45] Trabeculectomy has been
shown to have an overall success rate of 68% in controlling IOP. However,
compared to primary open-angle glaucoma (POAG), any aqueous-draining
procedure in an eye with a shallow anterior chamber and a chronic closed
angle poses the risk of further shallowing the anterior chamber or
precipitating malignant glaucoma. Trabeculectomy in PACG is associated with
a higher risk of filtration failure, shallow anterior chamber, and malignant
glaucoma/aqueous misdirection. As the incidence of PACG increases with
age, many patients with PACG have co-existing cataract. Trabeculectomy
increases the rate of cataract progression, and a significant proportion of
patients will soon need cataract extraction after trabeculectomy.
6

Furthermore, future cataract extraction may result in loss of the functioning

filter. It has been reported that 30-100% of previously functioning blebs
required antiglaucoma medications to control IOP after extracapsular
cataract extraction (ECCE). Therefore, trabeculectomy alone is not the ideal
surgical option in medically uncontrolled PACG.
In theory, adjunctive antimetabolite should be used with trabeculectomy
when performed in eyes with a high risk of filtration failure or when a very
low target pressure needs to be attained. However, the risk factors for
filtration failure specific to angle-closure glaucoma and the target pressure in
angle-closure glaucoma have not yet been clearly defined. Trabeculectomy is
associated with various complications, both early and late, including bleb
leaks and bleb-related infections. These risks are further increased by
adjunctive antimetabolite.
Lens extractionalone or in combination with trabeculectomy
Lens position and thickness both play important roles in the etiology of
angle-closure glaucoma.[46] Lens extraction significantly increases anterior
chamber depth and width of the drainage angle. Lens extraction has been
actively studied and reported in recent years in the treatment of PACG. The
lens may narrow the angle by pushing the peripheral iris anteriorly, and this
effect will be more marked if the lens is cataractous. Both traditional
extracapsular cataract extraction and phacoemulsification have been
reported to lower IOP in PACG. Phacoemulsification alone has also been
shown to normalize IOP in PACG.
Hayashi has shown that the depth of the anterior chamber and the width of
the drainage angle in eyes with angle-closure glaucoma increased
significantly after cataract extraction and intraocular lens implantation,
which may lead to the decrease in IOP seen in the postoperative period. It
has been postulated that removal of a large cataractous lens from an eye
with a crowded anterior segment may improve aqueous outflow. It has also
been postulated that during phacoemulsification, the irrigating fluid flushes
cellular debris from the trabecular meshwork, decreasing resistance to
aqueous outflow.
A multicenter, randomized controlled clinical trial comparing lens extraction
versus laser iridotomy in patients with newly diagnosed PAC or PACG is being
conducted by The Effectiveness in Angle-closure Glaucoma of Lens
Extraction (EAGLE) Study Group. [47] This ongoing study is aimed at evaluating
the effect of cataract extraction with regards to IOP, quality of life, and cost
in angle-closure glaucoma at 3 years.
Randomized controlled surgical trials by Tham et al in Hong Kong directly
compared cataract extraction alone by phacoemulsification against
combined phaco-trabeculectomy in PACG eyes with coexisting cataract. Their
first study focused on PACG eyes that were adequately controlled by
glaucoma drugs before surgery,[48] while their second study focused on PACG
eyes that were medically uncontrolled.[49] In both clinical scenarios, it was
demonstrated that phacoemulsification alone could significantly reduce IOP,
as well as the requirement for glaucoma drugs, for at least two years after
surgery. Combined phacotrabeculectomy resulted in even greater IOP and
drug reductions, but was associated with more complications and additional
surgery to manage the complications.[50] Based on these initial results, the
authors concluded that in medically controlled PACG with cataract,
7

phacoemulsification alone may be considered as an initial treatment. In PACG

eyes with cataract, higher preoperative IOP and increased requirement for
glaucoma drugs correlate with failure to control IOP after phacoemulsification
or phacotrabeculectomy. In medically uncontrolled PACG with cataract, either
phacoemulsification alone or combined phacotrabeculectomy may be
considered, depending on patient factors.[48, 49, 50, 51]
In situations where medically uncontrolled PACG coexisted with an optically
clear lens, a third randomized controlled trial by Tham et al compared the
outcomes of clear lens extraction by phacoemulsification versus
trabeculectomy alone.[52] In this study, both phacoemulsification and
trabeculectomy reduced IOP by over 30% at 24 months after surgery.
Phacoemulsification reduced the requirement for glaucoma drugs by 60%
and trabeculectomy by 89% at 24 months after surgery. Trabeculectomy was
associated with more complications. Compared to trabeculectomy, clear lens
extraction resulted in a significant reduction in synechial angle closure and
an increase in anterior chamber angle width and anterior chamber depth in
PACG eyes without cataract.[53] The authors concluded that, with available
data, either surgery could be considered for medically uncontrolled PACG
eyes without cataract, depending on patient factors.
One study suggested that the IOP-lowering effect of lens extraction may be
less pronounced in PACG cases with PAS covering three fourths or more of
the angle. Therefore, lens extraction alone may have a role in improving IOP
control in PACG, especially in cases with less extensive PAS and when the IOP
is not grossly out of control. Good long-term IOP control has been found
following lens extraction for PACG, and lens extraction should be considered
in patients with PACG, especially those with hyperopia or a thick and
anteriorly vaulted lens.[54]
Goniosynechialysis with/without lens extraction
Goniosynechialysis (GSL) is a surgical technique performed to strip the PAS
from the trabecular surface in the angle and provide aqueous renewed
access to the trabecular meshwork.[55, 56, 57] In eyes with minimal PAS,
trabeculectomy is preferred because trabecular function in these eyes is
expected to be poor and a fistula procedure would be more appropriate. On
the other hand, there may be spikes of raised IOP during and after the GSL
procedure leading to loss of vision. GSL is more suitable for eyes with a
minimal to moderate degree of neuronal damage.
In the past, ophthalmologists have tried to sweep open a closed angle
without direct visualization. This often failed because accurate instrument
placement could not be achieved. In 1984, Campbell and Vela introduced a
technique using direct intraoperative visualization of the angle and anterior
chamber deepening with viscoelastic agents. [58] Visualization has been
further improved with the use of the Swan-Jacob lens. This speciallydesigned lens has a handle attached to a small diameter prism so that it will
not obstruct the spatula from entering the anterior chamber at the limbus.
When PAS has been present for less than 1 year, the overall success rate in
terms of IOP control is approximately 80%. Irreversible damage to the
meshwork may occur in areas of synechial closure, with proliferation of iris or
fibrous tissue into the intertrabecular space. This may explain why GSL
appeared to be less effective in closed angle of longer duration.
8

In order for GSL to be effective, it must be performed before there is

irreversible histological change in the meshwork. The mechanisms causing
the angle closure should also be eliminated by performing peripheral
iridotomy, laser peripheral iridoplasty, or lens extraction, either alone or in
combination, to minimize the possibility of recurrent closure. Tanihara et al
reported success in using GSL followed by argon laser peripheral iridoplasty.
[59]

The most common complication of GSL is intraoperative hemorrhage. Other

complications include iridodialysis, cyclodialysis, and lens damage.
Teekhasaenee and Ritch have reported success with phacoemulsification
combined with GSL, and Lai et al were successful with combined
phacoemulsification and limited GSL, followed by diode laser peripheral
iridoplasty, for PACG.[60] The authors demonstrated with ultrasound
biomicroscopy that lens removal in PACG would only deepen the peripheral
anterior chamber, without actually opening up the angle, while GSL opened
up the angle and allowed aqueous access to the trabeculum.
Nevertheless, both lens extraction and GSL performed alone have been
shown to lower the IOP, although the mechanisms are uncertain and may or
may not be common to both procedures. Combining GSL with lens extraction
has the advantages of noticeable visual improvement after surgery, and the
combined IOP-lowering effect of the two procedures. Furthermore, removal of
the lens may decrease the possibility of recurrent angle closure. It has been
shown that eyes undergoing combined phacoemulsification with GSL have a
greater reduction in circumferential iridotrabecular contact area than eyes
undergoing phacoemulsification alone.[61] A 2015 prospective study, however,
demonstrated that IOP-lowering effects of phacoemulsification and GSL do
not differ significantly from those of phacoemulsification alone in medically
well-controlled PACG with cataract.[62]
Cyclodestructive procedures
In 1950, Bietti introduced cyclocryotherapy. A temperature of -80C was
applied with a cryoprobe to destroy the ciliary body epithelium, stroma, and
vasculature. The clinical usefulness of cyclocryodestruction is limited by its
complications, which include hypotony, phthisis, hyphema, choroidal
detachment, and retinal detachment.
In the past 10 years, transscleral diode laser cyclophotocoagulation (TSCPC)
using the G-probe is becoming more popular and is used to treat many
different types of glaucoma.[63, 64] The semiconductor diode laser emits light
of wavelength 810 nm, near the infrared spectrum. It is transmitted through
the sclera and absorbed by melanin. The success rates of cyclodestruction
vary among the different procedures and the types of glaucoma. Diode
TSCPC was reported effective in controlling IOP to less than 21 mm Hg in 7081% of pediatric and adult refractory glaucoma. However, there has been no
large-scale study on its efficacy in the treatment of PACG. Since it decreases
IOP by destroying the ciliary epithelium and reducing aqueous production, it
should, theoretically, be effective even in eyes with complete synechial
closed angle closure.
In a recent study, adjunctive diode TSCPC was effective in lowering IOP in 4
cases of PACG that were uncontrolled despite a glaucoma aqueous tube
shunt and multiple medications. In another study, diode TSCPC appeared to
9

be an effective and safe primary surgical treatment of medically-uncontrolled

PACG, with IOP-lowering effect persisting up to two years.
The efficacy and relative safety, the portability of the equipment, the ease of
learning, and the short duration required for performing this technique make
diode TSCPC a potential primary or secondary surgical procedure in the
future treatment of PACG. However, TSCPC is associated with some rare but
potentially serious complications, and these should be balanced against its
many advantages. Potential complications include uveitis, pupillary
distortion, conjunctival burns, hyphema, chronic hypotony, cystoid macular
edema, retinal detachment, phthisis bulbi, and scleral perforations.
An alternative to TSCPC is endoscopic cyclophotocoagulation (ECP), which
involves laser treatment of the ciliary processes under direct visualization
and is most commonly performed in combination with lens extraction in
refractory cases. Endoscopic laser allows a more precise application of laser
to the targeted ciliary tissue. An animal study has also shown that TSCPC is
associated with a more persistent poor perfusion of the ciliary processes and
therefore a higher risk of hypotony and phthisis.[65] In an earlier retrospective
study, it was reported to be able to achieve an IOP of less than 21 mm Hg in
90% of refractory glaucoma, including PACG eyes.[66] Although hypotony and
phthisical change were not reported in this series, reported complications of
ECP included uveitis, hyphema, cystoid macular edema, visual loss, choroidal
detachment and malignant glaucoma.
A more recent randomized prospective study has tried to compare the safety
between combined cataract surgery with ECP and combined cataract surgery
with trabeculectomy.[67] With a mean follow up period of 2 years, 30% of ECP
eyes achieved an IOP of less than 19 mm Hg without medication and 52%
with medication. The authors suggested that combined cataract surgery with
ECP to be a reasonably safe and effective alternative surgical option.
Glaucoma implants in primary angle-closure glaucoma
The use of a glaucoma implant for difficult-to-treat glaucoma is not new.
There is a wide variety of such glaucoma drainage devices, from the early
Molteno implant to the currently popular valve-equipped variety, such as the
Ahmed implant. Overall, the success rates for controlling IOP for complicated
cases range from 70-90%. However, because it is technically more difficult
than trabeculectomy, and potentially serious complications can occur, the
use of a glaucoma implant for PACG has been mainly confined to those
patients in whom one or more previous filtering procedures have failed.
Among the studies that included PACG, the proportion of patients with PACG
ranged from 1.7-9%. Aside from the small number of patients, another major
problem with these studies is that only two published the results of the
subgroup with PACG. One had only a single non-Asian patient with angleclosure glaucoma, who ended up with no light perception at 6 months, while
the other included 10 patients of unspecified race, 7 of whom had successful
surgery.
A more recent randomized study evaluated non-valved tube shunt surgery
against trabeculectomy in patients with glaucoma who had previously failed
trabeculectomy and/or cataract extraction with intraocular lens implantation.
In this study, there were 18 eyes with PACG, with 7 randomized to the
implant group and 11 to the trabeculectomy group. In the former study,
there were 15 eyes (23%) with the diagnosis of PACG, iridocorneal
10

endotheliopathy, and juvenile open-angle glaucoma treated with the 350

mm2 Baerveldt glaucoma implant. The immediate-term failure rate in this
subgroup was 47%, compared with 19% in the group with POAG. Although
this study did not provide a subgroup analysis for patients with PACG, the 1year results found a higher success rate in the tube group compared to the
trabeculectomy group. These results suggest a possible expanded role for
the use of implants in eyes with previous ocular surgery.
REFERENCES:
1. Lowe RF, Ritch R. Angle-closure glaucoma: clinical types. Ritch R,
Shields, Krupin T, eds. The Glaucomas. St Louis: CV Mosby Co; 1989.
839-853.
2. Foulds WS, Phillips CI. Some observations on chronic closed-angle
glaucoma. Br J Ophthalmol. 1957. 41:208-213.
3. Sihota R, Dada T, Gupta R, Lakshminarayan P, Pandey RM. Ultrasound
biomicroscopy in the subtypes of primary angle closure glaucoma. J
Glaucoma. 2005 Oct. 14(5):387-91. [Medline].
4. Lowe RF. Primary angle-closure glaucoma investigations after surgery
for pupillary block. Am J Ophthalmol. 1964. 57:931.
5. Lowe RF. Primary angle-closure glaucoma. Postoperative acute
glaucoma after phenylephrine eyedrops.Am J Ophthalmol. 1968 Apr.
65(4):552-4. [Medline].
6. Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and
classification of glaucoma in prevalence surveys. Br J Ophthalmol. 2002
Feb. 86 (2):238-42. [Medline].
7. Aung T, Lim MC, Chan YH, Rojanapongpun P, Chew PT, EXACT Study
Group. Configuration of the drainage angle, intraocular pressure, and
optic disc cupping in subjects with chronic angle-closure
glaucoma. Ophthalmology. 2005 Jan. 112 (1):28-32. [Medline].
8. Lowe RF. Primary creeping angle-closure glaucoma. Br J Ophthalmol.
1964. 48:544.
9. Ritch R. Exfoliation syndrome and occludable angles. Trans Am
Ophthalmol Soc. 1994. 92:845-944.[Medline].
10.
Lowe RF. Plateau iris. Aust J Ophthalmol. 1981 Feb. 9(1):713. [Medline].
11.
Ward M, Grant WM, Simmons RJ, et al. Plateau iris
syndrome. Trans Am Acad Ophthalmol Otol. 1977. 83:122.
11

12.
Shukla S, Damji KF, Harasymowycz P, et al. Clinical features
distinguishing angle closure from pseudoplateau versus plateau iris. Br
J Ophthalmol. 2008 Mar. 92(3):340-4. [Medline].
13.
Tornquist R. Angle-closure glaucoma in an eye with a plateau
type of iris. Acta Ophthalmol. 1958. 36:413.
14.
Ritch R. Plateau iris is caused by abnormally positioned ciliary
processes. J Glaucoma. 1992. 1:23-26.
15.
Wand M, Pavlin CJ, Foster FS. Plateau iris syndrome: ultrasound
biomicroscopic and histologic study.Ophthalmic Surg. 1993 Feb.
24(2):129-31. [Medline].
16.
Orgul SI, Daicker B, Buchi ER. The diameter of the ciliary sulcus: a
morphometric study. Graefes Arch Clin Exp Ophthalmol. 1993 Aug.
231(8):487-90. [Medline].
17.
Gorin G. Angle-closure glaucoma induced by miotics. Am J
Ophthalmol. 1966 Dec. 62(6):1063-7.[Medline].
18.
Merritt JC. Malignant glaucoma induced by miotics
postoperatively in open-angle glaucoma. Arch Ophthalmol. 1977 Nov.
95(11):1988-9. [Medline].
19.
Levene R. A new concept of malignant glaucoma. Arch
Ophthalmol. 1972 May. 87(5):497-506. [Medline].
20.
Rieser JC, Schwartz B. Miotic-induced malignant glaucoma. Arch
Ophthalmol. 1972 Jun. 87(6):706-12.[Medline].
21.
Quigley HA, Broman AT. The number of people with glaucoma
worldwide in 2010 and 2020. Br J Ophthalmol. 2006 Mar. 90(3):2627. [Medline].
22.
Day AC, Baio G, Gazzard G, Bunce C, Azuara-Blanco A, Munoz B,
et al. The prevalence of primary angle closure glaucoma in European
derived populations: a systematic review. Br J Ophthalmol. 2012 Sep.
96 (9):1162-7. [Medline].
23.
Cheng JW, Zong Y, Zeng YY, Wei RL. The prevalence of primary
angle closure glaucoma in adult Asians: a systematic review and metaanalysis. PLoS One. 2014. 9 (7):e103222. [Medline].
24.
Leung CK, Yu M, Weinreb RN, Lai G, Xu G, Lam DS. Retinal nerve
fiber layer imaging with spectral-domain optical coherence
tomography: patterns of retinal nerve fiber layer
progression. Ophthalmology. 2012 Sep. 119 (9):1858-66. [Medline].
12

25.
Lau LI, Liu CJ, Chou JC, Hsu WM, Liu JH. Patterns of visual field
defects in chronic angle-closure glaucoma with different disease
severity. Ophthalmology. 2003 Oct. 110 (10):1890-4. [Medline].
26.
Augsburger JJ, Affel LL, Benarosh DA. Ultrasound biomicroscopy of
cystic lesions of the iris and ciliary body. Trans Am Ophthalmol Soc.
1996. 94:259-71; discussion 271-4. [Medline].
27.
Pavlin CJ, Ritch R, Foster FS. Ultrasound biomicroscopy in plateau
iris syndrome. Am J Ophthalmol. 1992 Apr 15. 113 (4):390-5. [Medline].
28.
Baskaran M, Iyer JV, Narayanaswamy AK, He Y, Sakata LM, Wu R,
et al. Anterior Segment Imaging Predicts Incident Gonioscopic Angle
Closure. Ophthalmology. 2015 Dec. 122 (12):2380-4. [Medline].
29.
Ritch R, Liebmann J, Solomon IS. Laser iridectomy and iridoplasty.
Ritch R, Shields MB, and Krupin T, eds. The Glaucomas. St Louis: CV
Mosby Co; 1989. 581-603.
30.
Ritch R. Techniques of argon laser iridectomy and iridoplasty.
Palo Alto, Calif: Coherent Medical Press; 1983.
31.
Tham CC, Kwong YK, Ritch R, et al. Argon laser peripheral
iridoplasty (ALPI). Techniques in Ophthalmology. 2005. 3(4):176-81.
32.
Ritch R, Solomon LD. Argon laser peripheral iridoplasty for angleclosure glaucoma in siblings with Weill-Marchesani syndrome. J
Glaucoma. 1992. 1:243-7.
33.
Ritch R, Liebmann JM. Argon laser peripheral
iridoplasty. Ophthalmic Surg Lasers. 1996 Apr. 27 (4):289300. [Medline].
34.
Ritch R, Tham CC, Lam DS. Long-term success of argon laser
peripheral iridoplasty in the management of plateau iris
syndrome. Ophthalmology. 2004 Jan. 111 (1):104-8. [Medline].
35.
Wishart PK, Nagasubramanian S, Hitchings RA. Argon laser
trabeculoplasty in narrow angle glaucoma.Eye (Lond). 1987. 1 ( Pt
5):567-76. [Medline].
36.
Shirakashi M, Iwata K, Nakayama T. Argon laser trabeculoplasty
for chronic angle-closure glaucoma uncontrolled by iridotomy. Acta
Ophthalmol (Copenh). 1989 Jun. 67 (3):265-70. [Medline].
37.
Ho CL, JSM Lai, MV Aquino. Selective laser trabeculoplasty for
primary angle-closure with persistently elevated intraocular pressure
after iridotomy. J Glaucoma. 2009. 18:563-6.
13

38.
Narayanaswamy A, Leung CK, Istiantoro DV, Perera SA, Ho CL,
Nongpiur ME, et al. Efficacy of selective laser trabeculoplasty in
primary angle-closure glaucoma: a randomized clinical trial. JAMA
Ophthalmol. 2015 Feb. 133 (2):206-12. [Medline].
39.
Godel V, Stein R, Feiler-Ofry V. Angle-closure glaucoma: following
peripheral iridectomy and mydriasis.Am J Ophthalmol. 1968 Apr. 65
(4):555-60. [Medline].
40.
Gieser DK, Wilensky JT. Laser iridectomy in the management of
chronic angle-closure glaucoma. Am J Ophthalmol. 1984 Oct 15. 98
(4):446-50. [Medline].
41.
Sihota R, Gupta V, Agarwal HC. Long-term evaluation of
trabeculectomy in primary open angle glaucoma and chronic primary
angle closure glaucoma in an Asian population. Clin Experiment
Ophthalmol. 2004 Feb. 32 (1):23-8. [Medline].
42.
Tham CC, Lai JS, Poon AS, Lai TY, Lam DS. Results of
trabeculectomy with adjunctive intraoperative mitomycin C in Chinese
patients with glaucoma. Ophthalmic Surg Lasers Imaging. 2006 JanFeb. 37 (1):33-41. [Medline].
43.
Eltz H, Gloor B. [Trabeculectomy in cases of angle closure
glaucoma--successes and failures (author's transl)]. Klin Monbl
Augenheilkd. 1980 Nov. 177 (5):556-61. [Medline].
44.
Lai JS, Tham CC, Lam DS. Incisional surgery for angle closure
glaucoma. Semin Ophthalmol. 2002 Jun. 17 (2):92-9. [Medline].
45.
Ritch R. The treatment of chronic angle-closure glaucoma. Ann
Ophthalmol. 1981 Jan. 13 (1):21-3.[Medline].
46.
Tarongoy P, Ho CL, Walton DS. Angle-closure glaucoma: the role
of the lens in the pathogenesis, prevention, and treatment. Surv
Ophthalmol. 2009 Mar-Apr. 54 (2):211-25. [Medline].
47.
Azuara-Blanco A, Burr JM, Cochran C, Ramsay C, Vale L, Foster P,
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
May 23. 12:133. [Medline].
48.
Tham CC, Kwong YY, Leung DY, Lam SW, Li FC, Chiu TY, et al.
Phacoemulsification versus combined phacotrabeculectomy in
medically controlled chronic angle closure glaucoma with
cataract. Ophthalmology. 2008 Dec. 115 (12):2167-2173.e2. [Medline].
14

49.
Tham CC, Kwong YY, Leung DY, Lam SW, Li FC, Chiu TY, et al.
Phacoemulsification versus combined phacotrabeculectomy in
medically uncontrolled chronic angle closure glaucoma with
cataracts.Ophthalmology. 2009 Apr. 116 (4):725-31, 731.e13. [Medline].
50.
Tham CC, Kwong YY, Leung DY, Lam SW, Li FC, Chiu TY.
Phacoemulsification vs phacotrabeculectomy in primary angle-closure
glaucoma with cataract: complications [corrected]. Arch Ophthalmol.
Mar 2010. 128(3):303-11.
51.
Tham CC, Leung DY, Kwong YY, Liang Y, Peng AY, Li FC, et al.
Factors correlating with failure to control intraocular pressure in
primary angle-closure glaucoma eyes with coexisting cataract treated
by phacoemulsification or combined phacotrabeculectomy. Asia Pac J
Ophthalmol (Phila). 2015 Jan-Feb. 4 (1):56-9. [Medline].
52.
Tham CC, Kwong YY, Baig N, Leung DY, Li FC, Lam DS.
Phacoemulsification versus trabeculectomy in medically uncontrolled
chronic angle-closure glaucoma without cataract. Ophthalmology. 2013
Jan. 120 (1):62-7. [Medline].
53.
Man X, Chan NC, Baig N, Kwong YY, Leung DY, Li FC, et al.
Anatomical effects of clear lens extraction by phacoemulsification
versus trabeculectomy on anterior chamber drainage angle in primary
angle-closure glaucoma (PACG) patients. Graefes Arch Clin Exp
Ophthalmol. 2015 May. 253 (5):773-8. [Medline].
54.
Trikha S, Perera SA, Husain R, Aung T. The role of lens extraction
in the current management of primary angle-closure glaucoma. Curr
Opin Ophthalmol. 2015 Mar. 26 (2):128-34. [Medline].
55.
Ando H, Kitagawa K, Ogino N. Results of goniosynechialysis for
synechial angle-closure glaucoma after pupillary block. 1990. 41:883-6.
56.
Sharpe ED, Thomas JV, Simmons RJ. Goniosynechialysis. Thomas
JV, Belcher CD, and Simmons RJ, eds. Glaucoma Surgery. St Louis: CV
Mosby; 1992.
57.
Nagata M, Nezu N. Goniosynechialysis as a new treatment for
primary angle-closure glaucoma. Jpn J Clin Ophthalmol. 1985;39. 70710.
58.
Campbell DG, Vela A. Modern goniosynechialysis for the
treatment of synechial angle-closure glaucoma.Ophthalmology. 1984
Sep. 91 (9):1052-60. [Medline].

15

59.
Tanihara H, Nishiwaki K, Nagata M. Surgical results and
complications of goniosynechialysis. Graefes Arch Clin Exp Ophthalmol.
1992. 230 (4):309-13. [Medline].
60.
Lai JS, Tham CC, Chua JK, Lam DS. Efficacy and safety of inferior
180 degrees goniosynechialysis followed by diode laser peripheral
iridoplasty in the treatment of chronic angle-closure glaucoma. J
Glaucoma. 2000 Oct. 9 (5):388-91. [Medline].
61.
Lee CK, Rho SS, Sung GJ, Kim NR, Yang JY, Lee NE, et al. Effect of
Goniosynechialysis During Phacoemulsification on IOP in Patients With
Medically Well-controlled Chronic Angle-Closure Glaucoma. J Glaucoma.
2015 Aug. 24 (6):405-9. [Medline].
62.
Tun TA, Baskaran M, Perera SA, Htoon HM, Aung T, Husain R.
Swept-source optical coherence tomography assessment of iristrabecular contact after phacoemulsification with or without
goniosynechialysis in eyes with primary angle closure glaucoma. Br J
Ophthalmol. 2015 Jul. 99 (7):927-31.[Medline].
63.
Lai JS, Tham CC, Chan JC, Lam DS. Diode laser transscleral
cyclophotocoagulation as primary surgical treatment for medically
uncontrolled chronic angle closure glaucoma: long-term clinical
outcomes. J Glaucoma. 2005 Apr. 14 (2):114-9. [Medline].
64.
Lai JS, Tham CC, Chan JC, Lam DS. Diode laser transscleral
cyclophotocoagulation in the treatment of chronic angle-closure
glaucoma: a preliminary study. J Glaucoma. 2003 Aug. 12 (4):3604. [Medline].
65.
Lin SC, Chen MJ, Lin MS, Howes E, Stamper RL. Vascular effects
on ciliary tissue from endoscopic versus trans-scleral
cyclophotocoagulation. Br J Ophthalmol. 2006 Apr. 90 (4):496500. [Medline].
66.
Chen J, Cohn RA, Lin SC, Cortes AE, Alvarado JA. Endoscopic
photocoagulation of the ciliary body for treatment of refractory
glaucomas. Am J Ophthalmol. 1997 Dec. 124 (6):787-96. [Medline].
67.
Gayton JL, Van Der Karr M, Sanders V. Combined cataract and
glaucoma surgery: trabeculectomy versus endoscopic laser
cycloablation. J Cataract Refract Surg. 1999 Sep. 25 (9):12149. [Medline].
68.
Sharmini AT, Yin NY, Lee SS, Jackson AL, Stewart WC. Mean target
intraocular pressure and progression rates in chronic angle-closure
glaucoma. J Ocul Pharmacol Ther. 2009 Feb. 25 (1):71-5. [Medline].
16

69.
Lou H, Zong Y, Ge YR, Cheng JW, Wei RL. Efficacy and tolerability
of latanoprost compared with timolol in the treatment of patients with
chronic angle-closure glaucoma. Curr Med Res Opin. 2014 Jul. 30
(7):1367-73. [Medline].
70.
Sihota R, Sood A, Gupta V, Gupta V, Dada T, Agarwal HC. A
prospective longterm study of primary chronic angle closure
glaucoma. Acta Ophthalmol Scand. 2004 Apr. 82 (2):209-13. [Medline].
71.
Tan S, Yu M, Baig N, Chan PP, Tang FY, Tham CC. Circadian
Intraocular Pressure Fluctuation and Disease Progression in Primary
Angle Closure Glaucoma. Invest Ophthalmol Vis Sci. 2015 Jul. 56
(8):4994-5005. [Medline].
72.
Tan HK, Ahmad Tajuddin LS, Lee MY, Ismail S, Wan-Hitam WH. A
Study on the Central Corneal Thickness of Primary Angle Closure and
Primary Angle Closure Glaucoma and Its Effect on Visual Field
Progression. Asia Pac J Ophthalmol (Phila). 2015 May-Jun. 4 (3):1615. [Medline].
73.
Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract
extraction by phacoemulsification in eyes with primary angle-closure
glaucoma (PACG) and co-existing cataract: a prospective case series. J
Glaucoma. 2006 Feb. 15 (1):47-52. [Medline].
74.
Lai JS, Tham CC, Chan JC, Lam DS. Phacotrabeculectomy in
treatment of primary angle-closure glaucoma and primary open-angle
glaucoma. Jpn J Ophthalmol. 2004 Jul-Aug. 48 (4):408-11. [Medline].
75.
Lai JS, Tham CC, Lam DS. The efficacy and safety of combined
phacoemulsification, intraocular lens implantation, and limited
goniosynechialysis, followed by diode laser peripheral iridoplasty, in
the treatment of cataract and chronic angle-closure glaucoma. J
Glaucoma. 2001 Aug. 10 (4):309-15. [Medline].

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