Treatment Of Primary Angle-closure Glaucoma Research Articles

The questionnaire survey on glaucoma diagnosis and treatment in China (2016)

Objective: To investigate the present situation of diagnosis and treatment for primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) and awareness of the relevant progress among Chinese ophthalmologists. Methods: This study was a cross-sectional, non-randomized sampling survey. Participants were ophthalmologists who attended the 11st Chinese Glaucoma Society Congress during November 11 to 12, 2016. They were invited to fill out a questionnaire. The questionnaire included participants' basic information and their knowledge about glaucoma diagnosis and treatment. The data collected through questionnaire were analyzed with SAS9.4. Results: A total of 450 questionnaires were distributed and 372 valid questionnaires were retrieved, with a response rate of 82. 7%(372/450). ISGEO classification system was adopted by 58.9% (219/372) of the participants as the diagnostic criteria for PACG. Of the respondents, 48.1% (179/372) of the participants believed that "anterior chamber angle closure mechanism-based PACG classification system" was more instructive for treatment, the percentage was higher than ISGEO classification system (42.2%, 157/372). Most (72.3%, 269/372) of the participants knew the 3-minute dark room prone test, but only 27.7%(103/372) of them applied it in clinical practice. A total of 83.4%(310/372) of the participants believed that low cerebrospinal fluid pressure is a risk factor for POAG. In all, 71.8% (267/372) of the participants reported that their institutes had applied compound trabeculectomy with adjustable suture, with 76.9%(286/372) of the participants agreeing that the adjustable suture reduced the rate of complications after trabeculectomy. Conclusions: Currently, both ISGEO classification system and anterior chamber angle closure mechanism-based PACG classification system were adopted in the diagnosis and treatment of glaucoma. Low cerebrospinal fluid pressure as new risk factors for POAG has been widely acknowledged and given attentions by Chinese ophthalmologists. The 3-minute darkroom prone test and compound trabeculectomy with adjustable suture still need to be promoted. (Chin J Ophthalmol, 2017, 53: 115-120).

Efficacy of neodymium-doped yttrium aluminum garnet laser iridotomies in primary angle-closure diseases: superior peripheral iridotomy versus inferior peripheral iridotomy

Purpose: To evaluate the efficacy and safety of superior peripheral iridotomy versus inferior peripheral iridotomy in the treatment of primary angle-closure glaucoma (PACG) in phakic patients.Methods: In this randomized, prospective, paired-eye comparative study, patients with primary angle closure or primary angle-closure suspects were recruited and randomized to receive neodymium-doped yttrium aluminum garnet (Nd:YAG) laser peripheral iridotomy (LPI) superiorly in one eye and inferiorly in the other eye. Patients were masked to the location of treatment in each eye. The main outcome measures were patency of iridotomy, intraocular pressure (IOP), complications and visual symptoms at each postoperative visit during a 1 year follow-up.Results: A total of 164 patients were recruited, of whom 150 (91.46%) completed the study. The mean age was 58.85 ± 6.4 years. Average IOP measurements before LPI was 22.85 ± 7.53 and 23.62 ± 8.32 in superior LPI and inferior LPI eyes respectively. After LPI, average IOP was 25.14 ± 2.73 and 20.97 ± 2.72 in superior LPI and inferior LPI eyes respectively. Inferior LPIs required less use of mean total laser energy to perforate the tissue (p = .05) and resulted in a significantly lower incidence of iris bleeding at the time of treatment (p = .004), lower IOP elevation following treatment (p = .002), lower incidence of focal corneal damage (p = .002) and a lower post-laser iritis (p = .04). All the 300 iridotomies were patent at 12 month follow up.Conclusion: The inferior LPI appeared to be an efficient method of preventing pupil block with fewer complications. Visual symptoms following inferior LPI are similar to superior LPI.

Laser Peripheral Iridotomy versus Trabeculectomy as an Initial Treatment for Primary Angle-Closure Glaucoma.

Purpose To compare laser peripheral iridotomy (LPI) with trabeculectomy as an initial treatment for primary angle-closure glaucoma (PACG) with peripheral anterior synechiae (PAS) ≥ 6 clock hours. Methods Patients were drawn from two randomized controlled trials. 38 eyes of 38 patients (PAS ≥ 6 clock hours) were treated with LPI (group 1) while 111 eyes of 111 PACG patients (PAS ≥ 6 clock hours) underwent primary trabeculectomy (group 2). All patients underwent a comprehensive ophthalmic examination at baseline and at postoperative visits and were followed up for a minimum of one year. Results Group 2 had higher baseline IOP (45.7 ± 14.8 mmHg versus 34.3 ± 14.3 mmHg) than group 1 and more clock hours of PAS (10.4 ± 1.9 versus 9.0 ± 2.2). IOPs at all postoperative visits were significantly lower in group 2 than in group 1 (p = 0.000). Five eyes in group 1 required trabeculectomy. 17 of the 38 eyes in group 1 (44.7%) required IOP-lowering medications as compared to seven of the 111 eyes in group 2 (6.3%). Cataract progression was documented in 2 eyes (5.3%) in group 1 and 16 eyes (14.4%) in group 2. Conclusions Primary trabeculectomy for PACG (PAS ≥ 6 clock hours) is more effective than LPI in lowering IOP.

Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial

Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment. From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607. Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015-0·088, p=0·005) and mean intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI -1·99 to -0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events. 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. Medical Research Council.

Role of Lens Extraction In Glaucoma – A Review

Primary angle closure glaucoma (PACG) is a multifactorial disease with ethnicity, gender, ocular anatomy, iris configuration, lens volume and angle pathology all contributing to its genesis. The frequency of this disease is maximal in Asia where 85% of patients with PACG reside. The magnitude of this disease, primarily asymptomatic coupled with late presentation, where merely laser iridotomy does not suffice to arrest its progression makes surgical treatment by trabeculectomy a necessity to control glaucoma related blindness. However since trabeculectomy in the best of scenarios and best of hands is a surgery with limited functional longevity, more viable and robust surgical treatments for blinding glaucoma have long been explored. Of these new strategies, lens removal is one such modality which has been in the forefront of many recent debates. Lens removal surgery has always been known to be been associated with reduction of intraocular pressure in patients with normotensive states as well as ocular hypertensive states and performing lens extraction as primary treatment modality to control PACG has been advocated in the past. The soaring popularity of more elegant, less tissue destructive phacoemulsification procedure over manual extracapsular cataract surgery (ECCE) over the last two decades has led to a phenomenal increase in reports confirming increasing utility of lens extraction as a viable method for treatment of PACG. Post phacoemulsification, there is a notable increase in the angle opening distance (AOD500), as seen on various angle imaging modalities, which corresponds positively with improvement in other anterior chamber biometric parameters. But can this anatomical widening of crowded angle and reduction in IOP be extrapolated to the entire spectrum of glaucoma cases? Can primary phacoemulsification be promoted as the first treatment for PACG in the current scenario? Does documented widening of angle by imaging translate into persistent IOP control leading to reduced requirement of other means of glaucoma treatment? This article attempts to answer these questions by literature review of articles and studies pertaining to role of lens extraction in open angle as well as angle closure glaucoma eyes, in those with acute angle closure attack and the new buzzword ‘clear lens extraction’.

Phacoemulsification versus combined phacotrabeculectomy in the treatment of primary angle-closure glaucoma with cataract: a Meta-analysis.

To compare the efficacy and safety of phacoemulsification (Phaco) against combined phacotrabeculectomy (Phacotrabe) in primary angle-closure glaucoma (PACG) with coexisting cataract. By searching electronically the PubMed, EMBASE, Scientific Citation Index and Cochrane Library published up from inception to January 2014, all randomized controlled trials that matched the predefined criteria were included. The quality of included trials was evaluated according to the guidelines developed by the cochrane collaboration. And the outcomes estimating efficacy and safety of two different surgical treatments were measured and synthesised by RevMan 5.0. Five randomized controlled trials were selected and included in Meta-analysis with a total of 468 patients (468 eyes) with both PACG and cataract. We found that Phacotrabe had a greater intraocular pressure (IOP) lowing effect [preoperative IOP: weighted mean difference (WMD)=0.58, 95% confidence intervals (95% CI, -0.53 to 1.69), P=0.31; postoperative IOP: WMD=1.37, 95% CI (0.45 to 2.28), P=0.003], a lower number of anti-glaucoma medications [ risk ratio (RR) =0.05, 95% CI (0.02 to 0.18), P<0.00001] needed postoperatively and less serious damage of optic nerve [risk ratio (RR)=0.48, 95% CI (0.21 to 1.07), P=0.07], but a higher risk of complications [odds ratio (OR) =0.04, 95% CI (0.01 to 0.16), P<0.00001] compared with Phaco. The rest studies indicated that there had no significantly difference between the two surgical methods for postoperative best-corrected visual acuity (BCVA) [WMD=-0.05, 95% CI (-0.14 to 0.05), P=0.32] and loss of visual field [OR=1.06, 95% CI (0.61 to 1.83), P=0.83]. Phaco alone compared with Phacotrabe had a better effect in IOP reduction, whereas the security decline. Considering the number of sample size, our results remains to be further studied.

Management of Primary Angle-Closure Glaucoma.

Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension caused by closure of the drainage angle. Angle closure is caused by appositional approximation or adhesion between the iris and the trabecular meshwork. The main treatment strategy for PACG lies in the reduction of intraocular pressure, reopening of the closed angle, and possible prevention of further angle closure. There is no universally agreed best surgical treatment for PACG. Trabeculectomy, goniosynechialysis (GSL), glaucoma implant, and cyclodestructive procedures are effective surgical options. Each of them plays an important role in the management of PACG with its own pros and cons. Accumulating evidence is available to show the effectiveness of visually significant and visually nonsignificant cataract extraction in the treatment of PACG. Trabeculectomy and GSL are often combined with cataract extraction, which may offer additional pressure control benefits to patients with PACG. This review article will discuss laser peripheral iridotomy, argon laser peripheral iridoplasty, and surgeries such as GSL, phacoemulsification, and phaco plus glaucoma surgeries that lower intraocular pressure and also alter the anterior segment and/or drainage angle anatomy. Currently, glaucoma implants and cyclodestruction are mainly reserved for PACG patients who have failed previous filtering operations. Their role as initial surgical treatment for PACG will not be discussed.

Mistakes in the diagnosis and treatment of primary angle-closure glaucoma: Case report

Primary angle-closure glaucoma (PACG) is a leading cause of blindness globally. It is a condition that is responsible for nearly half of patients who have a bilateral blindness caused by glaucoma. PACG is highly prevalent in Asian countries, as compared with Primary open-angle glaucoma (POAG), which is reported as the predominant disease among Whites, but prevalence of PACG in Europe has been underestimated previously. Early detection by effective screening and appropriate prophylaxis and treatment may prevent blindness from angle-closure glaucoma. The purpose of this study was to present through the cases of 3 patients with PACG the importance of each phase of glaucoma: diagnosis, treatment and follow-up.

Initial Treatment for Primary Angle-Closure Glaucoma in China.

China has a large burden of primary angle-closure glaucoma (PACG) and the approach to treatment is different from that in most parts of the world. In China, trabeculectomy is a mainstay of initial treatment for PACG and laser peripheral iridotomy is reserved for PAC and PACG with peripheral angle synechiae ≤180 degrees. The greater reduction of and more stable IOP, lower frequency of acute angle closure, decreased progression of peripheral anterior synechia and glaucoma, and the reduction of ocular complications associated with long-term use of glaucoma medications support the use of initial trabeculectomy in PACG without significant lens opacities. Further study is required to determine the indications and effectiveness of initial trabeculectomy for PACG in a developing country setting.

New findings in the diagnosis and treatment of primary angle-closure glaucoma.

Glaucoma is the second cause of blindness worldwide. In the next years, approximately one-fourth of all glaucoma cases will be angle-closure types. Older age, female sex, and Asian ethnicities are described risk factors as well as shorter axial length, shallow anterior chamber depth, lens position, and thickness. New findings suggest iris volume and choroidal thickness to have a key role in the mechanisms of angle closure. Classical clinical conditions are acute, intermittent, and chronic forms. Ultrasound biomicroscopy and anterior segment optical coherence tomography contribute to a better understanding of the mechanisms of angle closure, helping the ophthalmologists in the diagnosis and treatment. The therapy includes laser iridotomy, argon laser peripheral iridoplasty, lens extraction, goniosynechialysis, filtering surgery, drainage implant, and cyclodestruction.

Letter to the Editor Regarding "Comparison of Combined Phacoemulsification, Intraocular Lens Implantation, and Goniosynechialysis With Phacotrabeculectomy in the Treatment of Primary Angle-Closure Glaucoma and Cataract".

Letter to the Editor Regarding "Comparison of Combined Phacoemulsification, Intraocular Lens Implantation, and Goniosynechialysis With Phacotrabeculectomy in the Treatment of Primary Angle-Closure Glaucoma and Cataract".

Comparison of Combined Phacoemulsification, Intraocular Lens Implantation, and Goniosynechialysis With Phacotrabeculectomy in the Treatment of Primary Angle-Closure Glaucoma and Cataract.

This study aimed to compare the efficacy and safety of combined phacoemulsification, intraocular lens implantation, and goniosynechialysis with phacotrabeculectomy in the treatment of primary angle-closure glaucoma (PACG) and cataract. A comparative case series. Sixty-five patients (65 eyes) with PACG and cataract from the Fifth Affiliated Hospital of Sun Yat-Sen University were enrolled for this study between October 2009 and July 2011. Of these, 33 underwent combined phacoemulsification, intraocular lens implantation, and goniosynechialysis (treatment group), and 32 underwent phacotrabeculectomy (control group). The effects on intraocular pressure, best-corrected visual acuity, anterior chamber angle, number of antiglaucoma medications, and complications were evaluated. Both the treatment group and the control group had lowered intraocular pressure, reduced the use of antiglaucoma medications, and improved vision in patients with PACG and cataract. Complications were 8 (24.2%) of 33 in the treatment group and 12 (37.5%) of 32 in the control group. Combined phacoemulsification, intraocular lens implantation, and goniosynechialysis appears to be a preferred method for the treatment of PACG and cataract because it seems to have the same efficacy as phacotrabeculectomy and has much less surgical complications.

The surgical method and effect of angle-closure glaucoma during high intraocular pressure

Objective To study the efficacy and surgical method of angle-closure glaucoma ( ACG)in persistent high intraocular pressure (IOP). Method 42 cases (45 eyes) with ACG accepted trabeculectomy in high IOP.Puncture and release of aqueous were done twice preoperative and intraoperative.Visual acuity,filtering bleb,anterior chamber,IOP and complications were observed after operation.Results All of the 42 cases (45 eyes) underwent surgery successfully. There were no complications of perichoroidal space bleeding or prolapse of vitreous occurred.Conclusion Trabeculectomy is safe and effective for the treatment of primary angle-closure glaucoma in high intraocular pressure with proper treament perioperatively. Key words: Glaucoma,angle-closure,acute; Intraocular pressure,high; Trabeculectomy; Method; Efficiency

Surgical treatment for primary angle closure-glaucoma: a Meta analysis.

To evaluate the efficacy and safety of trabeculectomy, phacotrabeculectomy plus intraocular lens implantation(phacotrab+IOL group) and phacoemulsification with IOL(phaco+IOL) in primary angle-closure glaucoma(PACG). It was a systematic review and meta-analysis, randomized controlled trials(RCT) and clinical controlled trials(CCT) were collected through electronic searches of the Cochrane Library, PubMed, EMbase, Wanfang Database online, Chinese journal Full-text Database, Chinese Scientific Journals Full-text Database (from the date of building the database to October 2010) We also checked the bibliographies of retrieved articles. All the related data that matched our standards were abstracted. The quality of included trials was evaluated according to the Dutch Cochrane Centre. RevMan 5.0 software was used for Meta-analysis. A total of 5 RCT and 11 CCT involving 1495 eyes were included. The results of meta-analysis showed that phacotrab+IOL group was superior than trabeculectomy(trab group) (MD -3.93,95%CI [-7.31, -0.54]) which was also superior than phaco+IOL group(MD 0.52,95%CI [0.10, 0.95]) in decreasing Intraocular Pressure(IOP). Phacotrab group(MD -1.45,95%CI [-1.68, -1.22])and phaco group (MD-1.12,95%CI [-1.87, -0.37])are both deeper than trab group in the anterior chamber depth. In increasing the coefficient of outflow facility of aqueous humor(C values) there was no statistical difference in the three groups. And there was no statistical difference between phacotrab groups and phaco groups in visual acuity but phacotrab group was superior than phaco group (MD 1.07, 95%CI [0.73, 1.40])in the use of IOP-lowering drugs. There was no statistical difference among three groups. Current evidence suggests that phacotrab+ IOL group was superior than trab group which was also superior than phaco+IOL group in decreasing IOP. Phacotrab group and phaco group are both deeper than trab group in the anterior chamber depth. Phacotrab group was superior than phaco group in the use of IOP-lowering drugs.

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.

BackgroundGlaucoma is the leading cause of irreversible blindness. Although primary open-angle glaucoma is more common, primary angle-closure glaucoma (PACG) is more likely to result in irreversible blindness. By 2020, 5·3 million people worldwide will be blind because of PACG. The current standard care for PACG is a stepped approach of a combination of laser iridotomy surgery (to open the drainage angle) and medical treatment (to reduce intraocular pressure). If these treatments fail, glaucoma surgery (eg, trabeculectomy) is indicated. It has been proposed that, because the lens of the eye plays a major role in the mechanisms leading to PACG, early clear lens extraction will improve glaucoma control by opening the drainage angle. This procedure might reduce the need for drugs and glaucoma surgery, maintain good visual acuity, and improve quality of life compared with standard care.EAGLE aims to evaluate whether early lens extraction improves patient-reported, clinical outcomes, and cost-effectiveness, compared with standard care.Methods/DesignEAGLE is a multicentre pragmatic randomized trial. All people presenting to the recruitment centres in the UK and east Asia with newly diagnosed PACG and who are at least 50 years old are eligible.The primary outcomes are EQ-5D, intraocular pressure, and incremental cost per quality adjusted life year (QALY) gained. Other outcomes are: vision and glaucoma-specific patient-reported outcomes, visual acuity, visual field, angle closure, number of medications, additional surgery (e.g., trabeculectomy), costs to the health services and patients, and adverse events.A single main analysis will be done at the end of the trial, after three years of follow-up. The analysis will be based on all participants as randomized (intention to treat). 400 participants (200 in each group) will be recruited, to have 90% power at 5% significance level to detect a difference in EQ-5D score between the two groups of 0·05, and a mean difference in intraocular pressure of 1·75 mm Hg. The study will have 80% power to detect a difference of 15% in the glaucoma surgery rate. Trial Registration: ISRCTN44464607.

Clear lens extraction in angle closure glaucoma

Clear lens extraction is being advocated for primary angle closure disease (PACD). It is important that this advocacy should be based on a sound, peer-reviewed evidence base. This review attempts to establish the extent of that evidence and provide some management guidelines. There are only three reports that incorporate clear lens extraction (CLE) for angle closure: numbers are sparse and none compare modern phacoemulsification to alternative treatments for primary angle closure glaucoma or provide enough detail to guide clinical decisions. A Cochrane review in 2006 found that there was no evidence to support lens extraction as treatment for primary angle closure glaucoma (PACG). More recent randomized controlled trials have provided support for cataract extraction--although not specifically for CLE--as treatment for part of the spectrum of PACD. A recent review has attempted to provide guidelines for application of CLE in PACG by extrapolating from this evidence. There are currently no randomized controlled trials supporting the use of CLE as treatment for PACG. A benefit from the procedure is biologically plausible and extrapolation from existing randomized trials to a few specific situations may be possible. Any potential benefit must be carefully weighed against the risks of intervention.

Clinical study on the treatment of primary angle-closure glaucoma with cataract by phacoemulsification combined with goniosynechialysis

Objective To investigate the clinical effect of phacoemulsification combined with goniosynechialysis on primary angle-closure glaucoma with cataract. Methods It was a retrospective study.There were 20 cases (22 eyes) diagnosed primary angle-closure glaucoma (PACG) with cataract in our hospital from 2007 to 2009. Male, 12 cases (14 eyes) and female, 8 cases (8 eyes). Their age were from 64to 85 years old, mean age is 76.8 gears old. 22 eyes:18 with PACG, 4 with CPACG, were undergone phacoemulsification and IOL implantation, combined with goniosynechialysis. The intraocular pressure (IOP)before and after operation, best corrected visual acuity ( BCVA), peripheral anterior chamber (PAC) and the change of anterior chamber angle were all observed and reported. The time of following up was 3 to 12months. Results preoperative IOP were from 7.8 mmHg to 30 mmHg and mean IOP is 18. 91 + 5.48mmHg. Meanwhile the postoperative IOP were 11.81+2.9 mmHg. The IOP were obviously decreased after operation. The IOP were obviously decreased after operation. There were 7 eyes (31.8%) whose preoperational BCVA were less than 0.1. There were 12 eyes (54.5%) whose postoperative BCVA were more than 0. 5, There were 18 eyes whose preoperative PAC depth were less than 1/2 CT. There were 22 eyes whose postoperative PAC depth were more than one CT. They have smooth iris and disappeared peripheral bulges.The angle-closure can be partly opened and the range of goniosynechia can be decreased after operation. Two cases had anterior chameber angle exudative and iris adhesion. Only one case had posterior capsular rupture.No case had corneal decompensation. Conclusion The treatment of primary angle-closure glaucoma with cataract by phacoemulsification combined with goniosynechialysis phacoemulsification combined with goniosynechialysis is safe and effective. Key words: phacoemulsification; goniosynechialysis; primary angle-closure glaucoma; cataract

Phacotrabeculectomy in treatment of primary angle-closure glaucoma and primary open-angle glaucoma.

To evaluate the surgical outcome of combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy) in patients with primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG). The records of 57 consecutive patients (65 eyes) with PACG or POAG that were treated with phacotrabeculectomy were reviewed retrospectively. There were 31 eyes with PACG and 34 with POAG. The mean follow-up period was 21.0 +/- 8.3 months. The visual acuity, intraocular pressure (IOP), number of medications, and complications were evaluated. The mean IOP and the number of glaucoma medications decreased significantly after phacotrabeculectomy in both groups. The mean IOP reduction was significantly greater in eyes with PACG (P < 0.05). The absolute success rates were 87.1% and 70.6% in PACG and POAG, respectively. The difference in the success rates was not significant (P = 0.297). The early postoperative complication rates were similar in both groups. Phacotrabeculectomy results in greater IOP reduction in eyes with PACG than in those with POAG, but the overall success rates were not significantly different.

Review of recent advancements in the understanding of primary angle-closure glaucoma.

Primary angle-closure glaucoma is a leading cause of blindness worldwide. However, the terminology used for angle-closure in the literature is inconsistent, with inappropriate emphasis on symptomatology. A new nomenclature for primary angle-closure glaucoma focuses on the presence of end-organ damage and limits the use of the term "glaucoma" only for people who have suffered injury to the optic nerve. This review describes the various modalities of treatment for primary angle-closure glaucoma. The role and limitations of laser peripheral iridotomy in the management of the different forms of the disease are summarized. Recent developments have led to improvements in the understanding of the epidemiology, clinical course, and treatment of the condition.

Discussion by Erik L. Greve, MD, PhD, F. P. Gunning, MD

What options do we have for the treatment of primary angle-closure glaucoma (PACG)? We can do phacoemulsification with or without goniosynechialysis (GSL). We can perform a trabeculectomy with or without mitomycin, and we can perform a combined procedure of phacoemulsification and trabeculectomy.