Primary Angle closure and Primary Angle closure Glaucoma

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Summary of Evidence

Primary Angle Closure (PAC)

Prophylatic Laser peripheral iridotomy

 

The incidence of Angle closure disease was very low in patients who were primary angle closure suspects. Prophylactic laser PI for PACS is not recommended.(ZAP, 2019) {He M, Jiang Y, Huang S, Chang DS, Munoz B, Aung T, Foster PJ, Friedman DS. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial. Lancet. 2019 Apr 20;393(10181):1609-1618.}

Primary Angle Closure and PACG

Clear lens extraction vs Laser peripheral iridotomy

 

Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment.(EAGLE, 2016) {Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, Scotland G, Javanbakht M, Cochrane C, Norrie J; EAGLE study group. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016 Oct 1;388(10052):1389-1397}

Evidence

1. Primary Angle Closure Suspect

1.1 General principles

Clinical Trial

2019 He et.al. (ZAP)

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2019
Clinical Trial

The incidence of Angle closure disease was very low in patients who were primary angle closure suspects. Prophylactic laser PI for PACS is not recommended. {He M, Jiang Y, Huang S, Chang DS, Munoz B, Aung T, Foster PJ, Friedman DS. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial. Lancet. 2019 Apr 20;393(10181):1609-1618.}

  • Randomized controlled trial of Laser Peripheral Iridotomy vs observation (in fellow eye) in Primary Angle Closure Suspect (889 patients)
  • Findings:
    • The incidence of primary angle closure was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes.
    • PAC occurred in significantly more untreated eyes (36 vs 19), mostly due to development of PAS.

1.2 Risk factors for conversion to PAC or AAC

Clinical Trial

2022 Xu et.al.

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2022
Clinical Trial

Anterior segment OCT measurements of biometric parameters describing the angle and iris are predictive of progression from PACS to PAC or AAC, whereas gonioscopy grades are not.

1.3 PI location

Clinical Trial

2021 Xu et.al. (ZAP)

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2021
Clinical Trial

Superior LPI location results in significantly greater angle widening compared with temporal or nasal locations in a Chinese population with PACS. This supports consideration of superior LPI locations to optimize anatomic changes after LPI. {Xu BY, Friedman DS, Foster PJ, Jiang Y, Pardeshi AA, Jiang Y, Munoz B, Aung T, He M. Anatomic Changes and Predictors of Angle Widening after Laser Peripheral Iridotomy: The Zhongshan Angle Closure Prevention Trial. Ophthalmology. 2021 Aug;128(8):1161-1168.}

  • Analysis on participants of the Zhongshan Angle Closure Prevention (ZAP) Trial who underwent gonioscopy and AS-OCT imaging at baseline and 2 weeks after LPI.
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2. Primary Angle Closure

2.1 Laser Peripheral Iridotomy

Review

2021 Bayliss et.al. (Cochrane)

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2021
Review

Despite a potential positive impact on anterior chamber morphology, the use of laser peripheral iridoplasty as a treatment for chronic angle closure is not supported by the results of trials published to date. {Bayliss JM, Ng WS, Waugh N, Azuara-Blanco A. Laser peripheral iridoplasty for chronic angle closure. Cochrane Database Syst Rev. 2021 Mar 23;3(3):CD006746.}

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2.2 Clear lens extraction

Review

2021 Ong et.al. (Cochrane)

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2021
Review

Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow-up. {Ong AY, Ng SM, Vedula SS, Friedman DS. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev. 2021 Mar 24;3(3):CD005555.}

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Clinical Trial

2016 Azuara-Blanco et.al. (EAGLE)

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2016
Clinical Trial

Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment. {Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, Scotland G, Javanbakht M, Cochrane C, Norrie J; EAGLE study group. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016 Oct 1;388(10052):1389-1397}

  • Randomized controlled trial of Clear lens extraction vs Laser PI in Primary Angle Closure/Primary Angle Closure Glaucoma (419 patients)
  • Findings:
    • Quality of life was higher and mean intraocular pressure lower after CLE compared to laser PI/topical medications (1.18mmHg lower)
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3. Cataract Surgery

3.1 Goniosynechiolysis (at time of phacoemulsification)

Review

2021 Ong et.al. (Cochrane)

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2021
Review

In patients with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. {Ong AY, Ng SM, Vedula SS, Friedman DS. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev. 2021 Mar 24;3(3):CD005555.}

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Review

2016 Liu et.al.

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2016
Review

The capacity of goniosynechialysis for IOP-lowering seems superior to Phaco alone and comparable to Phaco-trabeculectomy/trabeculectomy {Liu Y, Li W, Jiu X, Lei X, Liu L, Yan C, Li X. Systematic Review and Meta-Analysis of Comparing Phacoemulsification Combined with goniosynechialysis to other mainstream procedures in treating patients with angle-closure glaucoma. Medicine (Baltimore). 2019 Oct;98(42):e17654.}

3.2 Trabeculectomy (at time of phacoemulsification)

Review

2021 Ong et.al. (Cochrane)

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2021
Review

Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. {Ong AY, Ng SM, Vedula SS, Friedman DS. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev. 2021 Mar 24;3(3):CD005555.}

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References

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