Moderate Primary Angle Closure Glaucoma Research Articles

Long-Term Efficacy of Selective Laser Trabeculoplasty in Primary Angle-Closure Disease After Laser Peripheral Iridotomy

ABSTRACT Purpose To evaluate the long-term efficacy of selective laser trabeculoplasty (SLT) in eyes with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) following a laser peripheral iridotomy (LPI). Method In this prospective cross-sectional study, 45 eyes of 34 patients with PAC/PACG diagnosis, uncontrolled intraocular pressure (IOP), and visible pigmented trabecular-meshwork (TM) at least 180° on gonioscopy following a LPI were recruited. Following a detailed baseline ophthalmic evaluation, all eligible eyes underwent SLT, and the patients were examined on day1, at 1 week, 1-, 3-, and 6-months, and 1-, 2-, 3-, 4-, and 5-year subsequently. The main outcomes measured were IOP, number of IOP-lowering agents, and complications. Results The mean age of the cohort was 57.80 ± 6.44 years, the male–female ratio was 8:26, and 17 eyes were PACG, and 28 were PAC. The baseline IOP was 23.81 ± 1.78 mm Hg, and was significantly declined at all follow-ups (p < .0001). The cumulative probability of overall success was 91% and 84% at 2-, and 5-year, respectively. At 5-year SLT provided drug-freedom in 80% of PAC and 23% of PACG eyes. Six eyes had IOP spike at 1-week and two patients underwent repeat SLT after 1-year. No other complications, such as pain/discomfort, inflammation, an increase in peripheral anterior synechiae and cystoid-macular-edema, were noted. Conclusions SLT appears a safe and cost-effective procedure in PAC/mild- moderate PACG eyes with uncontrolled IOP after laser iridotomy. The long-term effectiveness of SLT as adjuvant treatment was good, but need large sized randomized studies for more validation.

Correlation Between Anterior Chamber Angle Status and Limbal Stem Cell Deficiency in Primary Angle-Closure Glaucoma

PurposeTo investigate the correlation between the opening and closing states of anterior chamber angle (ACA) and the density of limbal epithelial basal cells (LEBCs) in subjects with primary angle-closure glaucoma (PACG). DesignCross-sectional observational study. MethodsA total of 54 eyes of 29 patients diagnosed with PACG were included in the study. 54 eyes from normal subjects were included as control. Automatic evaluation system for ultrasound biomicroscopy images of anterior chamber angle was used to assist ophthalmologists in identifying the opening or closing state of ACA, and the in vivo confocal microscopy (IVCM) was used to evaluate the density of LEBCs in different directions. Results1. The average density of LEBCs in the superior, inferior, nasal and temporal limbus of the eyes in the PACG group was lower than that in the control group, and this pattern did not align with the density distribution observed in the control group.2. In the early, moderate and advanced PACG, the density of LEBCs corresponding to the closed angle was lower than that in the control group (P<0.05). Compared with the density of LEBCs corresponding to the closed angle and the open angle, the closed angle of PACG in the early, moderate and advanced stages was less than that in the open angle (P<0.05 in the early and moderate stages; advanced stage P>0.05).3. The basal cell density was processed by dimensionless analysis. In the data calculated by averaging and minimizing, both closed angle dimensionless values were smaller than the open angle (P<0.05).4. Comparative analysis was conducted among the normal, open-angle, and closed-angle conditions in the superior, inferior, nasal, and temporal limbus. In the early stage of PACG, significant differences were observed in 4 limbal regions (P<0.05), while in the moderate PACG stage, this difference was noted in 3 limbal regions (P<0.05). In advanced PACG, 2 limbal regions exhibited significant differences (P<0.05). These findings suggest that during the early PACG stage, angle closure is the predominant influencing factor on LEBCs density, while in the advanced stage, the decrease in density is attributed to a combination of angle closure and the natural progression of the disease. ConclusionThere is a significant correlation between anterior chamber angle status and LEBCs. Advanced PACG and angle closure should be highly suspected of the occurrence of limbal stem cell deficiency (LSCD).

Structural measurements and vessel density of spectral-domain optic coherence tomography in early, moderate, and severe primary angle-closure glaucoma.

To compare the macular ganglion cell-inner plexiform layer (GCIPL) thickness, retinal nerve fiber layer (RNFL) thickness, optic nerve head (ONH) parameters, and retinal vessel density (VD) measured by spectral-domain optical coherence tomography (SD-OCT) and analyze the correlations between them in the early, moderate, severe primary angle-closure glaucoma (PACG) and normal eyes. Totally 70 PACG eyes and 20 normal eyes were recruited for this retrospective analysis. PACG eyes were further separated into early, moderate, or severe PACG eyes using the Enhanced Glaucoma Staging System (GSS2). The GCIPL thickness, RNFL thickness, ONH parameters, and retinal VD were measured by SD-OCT, differences among the groups and correlations within the same group were calculated. The inferior and superotemporal sectors of the GCIPL thickness, rim area of ONH, average and inferior sector of the retinal VD were significantly reduced (all P<0.05) in the early PACG eyes compared to the normal and the optic disc area, cup to disc ratio (C/D), and cup volume were significantly higher (all P<0.05); but the RNFL was not significant changes in early and moderate PACG. In severe group, the GCIPL and RNFL thickness were obvious thinning with retinal VD were decreasing as well as C/D and cup volume increasing than other three groups (all P<0.01). In the early PACG subgroup, there were significant positive correlations between retinal VD and GCIPL thickness (except superonasal and inferonasal sectors, r=0.573 to 0.641, all P<0.05), superior sectors of RNFL thickness (r=0.055, P=0.049). More obvious significant positive correlations were existed in moderate PACG eyes between retinal VD and superior sectors of RNFL thickness (r=0.650, P=0.022), and temporal sectors of RNFL thickness (r=0.740, P=0.006). In the severe PACG eyes, neither GCIPL nor RNFL thickness was associated with retinal VD. The ONH damage and retinal VD loss appears earlier than RNFL thickness loss in PACG eyes. As the PACG disease progressed from the early to the moderate stage, the correlations between the retinal VD and RNFL thickness increases.

Rationale for early lens extraction in the treatment of primary angle closure disease

PURPOSE. To demonstrate the advisability of early lens extraction in the treatment of primary angle closure disease in clinical practice.METHODS. The study presents three clinical cases with patients at different stages of primary angle closure disease (PACD). The first one is related to the development of a bilateral acute attack of primary angle closure (PAC) that happened in the intensive care unit during treatment for acute respiratory distress syndrome (ARDS) associated with COVID-19 pneumonia in a patient with a previously undiagnosed PACD. The second case demonstrates the progression of glaucomatous optic neuropathy (GON) in early primary angle-closure glaucoma (PACG) after laser peripheral iridotomy (LPI) and delayed selective laser trabeculoplasty (SLT) in a patient with increased lens thickness. The third example illustrates the progression of advanced PACG in the right eye (OD) and moderate PACG in the left eye (OS) due to formation of goniosynechiae after bilateral LPI, which required transscleral diode cyclophotocoagulation (TSCP) in OD and trabeculectomy in OS. Subsequently, bilateral cataract phacoemulsification with intraocular lens implantation (CPE+IOL) and SLT were performed.RESULTS. In the first clinical case, advanced PACG developed in both eyes within 2 months. After bilateral LPI, trabeculectomy, compensation of intraocular pressure (IOP) was achieved, visual functions stabilized. In the second clinical case, 5.5 years after LPI and SLT, an increase in the thickness of the lens was revealed (in OD by 0.2 mm, in OS by 0.48 mm). GON did not progress in OD (thinning rate of the retinal nerve fiber layer was 0.94 µm/year, p=0.32) and the progression rate in OS was -1.04 µm/year (p=0.018). Taking into account the lens-involved mechanism of PACD progression, bilateral CPE+IOL was recommended. In the third clinical example, IOP remained elevated after bilateral LPI, TSCP in OD and trabeculectomy in OS as a result of goniosinechiogenesis, and therefore CPE+IOL also did not lead to its decrease. After bilateral SLT, compensation of IOP was achieved without local hypotensive therapy (IOP measured by Icare: OD 18.0 mm Hg, OS 15 mm Hg).CONCLUSION. In order to preserve visual functions, CPE+IOL is highly recommended at the very beginning of PACD, before the formation of GON and goniosynechiae. This is dictated by the dominant role of the lens-involved mechanism in PACD formation, as demonstrated in the described clinical examples.

Changing patterns in treatment of angle closure glaucoma.

Angle closure glaucoma is a leading cause of blindness globally and trends of how best to treat this disease are evolving. The advent of anterior segment imaging aids our understanding of pathogenesis and allows more robust and objective measurement of treatment modalities. We will also review recent literature regarding the role of laser and surgical interventions for the treatment of primary angle closure disease. Recent studies evaluating the efficacy of laser peripheral iridotomy (LPI) in primary angle closure suspects (PACs) show that while it is a safe intervention and initially anterior chamber angle widens following the laser treatment, the effect is lost with time. Only a small minority of PACs patients develop primary angle closure (PAC) or primary angle closure glaucoma (PACG). Trials evaluating argon laser peripheral iridoplasty (ALPI) have failed to show a substantial clinical benefit. In patients with early or moderate PACG and those with PAC with IOP over 30 mmHg, clear lens extraction is associated with better clinical and quality of life outcomes than LPI. Recent evidence supports initial clear lens extraction in the context of PACG or primary angle closure with IOP more than 30 mmHg.

Clear lens extraction for primary angle closure: how clear are we?

Azuara-Blanco et al . (1) in their multicentric “EAGLE” study have done a remarkable work in comparing efficacy of clear lens extraction (CLE) vs . laser peripheral iridotomy (LPI) in 155 eyes having newly diagnosed primary angle closure (PAC) with ocular hypertension (IOP ≥30 mmHg) and 263 eyes with early to moderate primary angle closure glaucoma (PACG). The authors reported better quality of life scores and a mean intraocular pressure lower by 1 mmHg in eyes which underwent CLE as compared to LPI at 36 months follow-up. The conclusion of the study was that CLE has a greater efficacy and is more cost effective as compared to the current standard of care (LPI followed by topical therapy) and should therefore be considered as the first line therapy in management of PAC disease (PAC and PACG).

Role of lens extraction and laser peripheral iridotomy in treatment of glaucoma.

Lens extraction in people with coexisting cataract and open angle glaucoma is associated with a reduction in intraocular pressure (IOP). In primary angle-closure glaucoma (PACG), lens extraction and laser peripheral iridotomy (LPI) can be used to open the anterior chamber angle, increase the outflow through the trabecular meshwork and reduce the IOP. The present review will summarize the recent available literature regarding the role of both interventions for the treatment of glaucoma. Recent articles have confirmed the effect of cataract surgery as an IOP-lowering procedure in people with coexisting cataract and glaucoma, and highlight that the most important predictor for a greater decrease is a higher preoperative IOP. The probability for achieving a significant IOP reduction is highest in PACG and pseudoexfoliation glaucoma. Clear lens extraction (CLE) is associated with better clinical and quality of life outcomes than laser peripheral iridotomy (LPI) in patients with early or moderate PACG and those with primary angle closure and IOP over 30 mmHg. There is no high-quality evidence to support LPI in the treatment of pigmentary glaucoma. Evidence from the assessed period supports the IOP-lowering effect of cataract surgery in people with coexisting cataract and glaucoma. CLE is an option in the initial treatment of some patients with PACG as its superiority has been demonstrated against LPI.

The diagnostic value of white blood cell, neutrophil, neutrophil-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio in patients with primary angle closure glaucoma.

ObjectiveInflammatory mechanisms may have a role in the pathogenesis of primary angle closure glaucoma (PACG). The objective of this study was to investigate the diagnostic value of white blood cell (WBC), neutrophil, neutrophil to lymphocyte ratio (NLR), and lymphocyte to monocyte ratio (LMR) in patients with PACG and its association with glaucoma severity.MethodThe study was retrospectively assessed in 771 consecutive PACG patients and 770 control subjects, laboratory parameters and clinical parameters were obtained from a medical data platform. Patients were divided into three groups with different severity based on perimetry, i.e. mild (mean deviation (MD) ≤6.00 dB), moderate (12 dB≥ MD>6 dB) and severe (MD>12 dB). We developed a nomogram to specifically identify individual patient’s risk.ResultsThe mean levels of neutrophil, NLR and WBC was higher in PACG than control group, and lowest in the mild PACG group, followed by moderate PACG and severe PACG (p<0.05). The AUROC value of NLR and LMR was found to be 0.719, 0.699, respectively. Multiple linear regressions showed that there was a significant correlation between WBC and MD (B=0.151, p<0.001), neutrophil and MD (B=0.143, p=0.003), NLR and MD (B=0.144, p=0.001), LMR and MD (B=-0.100, p=0.034). Logistic regression analyses revealed that WBC (OR=1.208, 95%CI=1.179-1.238), neutrophil (OR=1.598, 95%CI=1.541-1.656), NLR (OR=2.313, 95%CI=2.200-2.431), and LMR (OR=0.682, 95%CI=0.666-0.699) were associated with PACG.ConclusionOur study suggested that WBC, neutrophil, NLR, and LMR was related with PACG, and NLR and LMR may be useful as biomarkers.

Association of Plasma Complement C3 Levels With Primary Angle-Closure Glaucoma in Older Women.

The plasma complement component (C)3 concentration and clinical characteristics of primary angle-closure glaucoma (PACG) subjects were analyzed to evaluate whether C3 levels were correlated with PACG severity. Peripheral blood samples from subjects with PACG (n = 237) and normal controls (n = 158) were collected. The plasma levels of C3 were measured by immunoturbidimetry. The assessments of intraocular pressure; vertical cup/disc ratio (VCDR); central corneal thickness; axial length; anterior chamber depth; visual field-derived mean deviation; and mean sensitivity were performed by glaucoma specialists. Based on their sex and age, the PACG subjects were categorized into female (0-49 years, 50-59 years, 60-70 years, and 70+ years) and male (0-49 years, 50-59 years, 60-70 years, and 70+ years) subgroups. The mean plasma levels of C3 (101.71 ± 21.17 mg/dL) were significantly lower (P < 0.001) in PACG subjects compared with controls (110.68 ± 17.63 mg/dL). Plasma C3 concentrations were significantly lower (P < 0.001) in female subjects with PACG (100.74 ± 19.83 mg/dL) compared with controls (113.58 ± 18.80 mg/dL). A similar result was observed when plasma levels of C3 were compared between the PACG and control groups with respect to age (≥50 years). The mean plasma levels of C3 were lowest in the severe PACG group followed by moderate PACG and mild PACG, and the differences were significant (P = 0.003). Multivariable regression analyses showed that there was a significant correlation between C3 levels and VCDR (B = -0.310, P = 0.047). Older women with PACG have lower plasma C3 levels, which were further demonstrated to be negatively associated with PACG severity. These findings suggest the involvement of C3 in the pathomechanisms of PACG in older women.

Lack of Association Between Corneal Hysteresis and Corneal Resistance Factor With Glaucoma Severity in Primary Angle Closure Glaucoma.

We investigated the association between corneal hysteresis (CH) and corneal resistance factor (CRF) with glaucoma severity in primary angle closure glaucoma (PACG). We recruited 204 subjects with PACG. Each subject underwent CH and CRF measurements using the Ocular Response Analyzer (ORA), optic nerve head topography measurement using scanning laser ophthalmoscopy, and visual field assessment. Glaucoma severity was based on the visual field mean deviation (MD) and classified as mild (71), moderate (55), and severe (78). The mean age ± SD of study subjects was 68.7 ± 8.9 years, with most being Chinese (n = 186; 91.2%). Corneal hysteresis and CRF were lowest in the severe PACG group (9.32 ± 1.86 and 9.50 ± 1.67 mm Hg) followed by moderate PACG (9.38 ± 1.88 and 9.73 ± 1.88 mm Hg) and mild PACG (9.47 ± 1.90 and 9.85 ± 1.75 mm Hg) respectively, but the differences were not significant (P = 0.89 and P = 0.46, respectively). There was a significant positive correlation between CH and central corneal thickness (CCT; correlation coefficient [r] = 0.26, P < 0.001), CRF and CCT (r = 0.43, P < 0.001), and negative correlation between CRF and vertical cup-disc ratio (VCDR; r = -0.20, P = 0.004), and CRF with cup-disc area (r = -0.14, P = 0.04). Corneal hysteresis and CRF were not correlated with MD (r = 0.01 for CH, r = 0.1 for CRF). After multivariate analyses, adjusting for age, sex, CCT, axial length, intraocular pressure, and number of glaucoma medication, no significant associations were noted between CH and CRF with MD, VCDR, disc area, rim area, or cup area. Corneal biomechanical parameters measured by the ORA are not associated with severity of glaucoma in PACG.