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Siddharth Dikshit, DNB, FLVPEI, FICO

VST Center for Glaucoma CareL V Prasad Eye Institute

Lens & Angle Closure

THE OBVIOUS, THE KNOWN, THE FUTURE & THE UNEXPLORED

Objectives

• To understand the role of lens in angle closure disease

• To understand the measurable parameters of the lens

• To understand the impact of lens removal in angle closure disease

• Special consideration: Plateau iris

• Considerations for cataract surgery

• Decision between cataract and combined surgery

No conflict of interestNo financial implications

Importance of Lensin Angle Closure Glaucoma

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a) Mapstone’s hypothesis explains the importance of lens

b) Maximal in mid-dilated position of pupil

c) Intraocular lens in sulcus is a risk factor

d) IOP rise may occur in PACG by mechanisms other than relative pupillary block

True about relative pupillary block is ALL EXCEPT

Question 1

a) Mapstone’s hypothesis explains the importance of lens

b) Maximal in mid-dilated position of pupil

c) Intraocular lens in sulcus is a risk factor

d) IOP rise may occur in PACG by mechanisms other than relative pupillary block

True about relative pupillary block is ALL EXCEPT

Question 1

Mapstone R. Br J Ophthalmol. 1968 Jan;52(1):19-25.

Sphincter pupillae

Dilator pupillae

Mapstone’s Hypothesis

Relative Pupillary Block

Mapstone’s Hypothesis

Relative Pupillary Block

Sphincter pupillae

Dilator pupillae

Mapstone R. Br J Ophthalmol. 1968 Jan;52(1):19-25.

Ritch R, et al. Br J Ophthalmol. 1995 Mar;79(3):300.

Mapstone’s Hypothesis

Peripheral Iris-bombe

Iridolenticular contact

Aqueous

Relative Pupillary Block

The Obvious••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Pseudophakes cannot have PRIMARY acute angle closure

The ParametersASOCT

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Angle Parameters on ASOCT

Smith SD, et al. Ophthalmology. 2013 Oct;120(10):1985-97.

Lens Parameters on ASOCT

Baek S, et al. Invest OphthalmolVis Sci. 2013 Jan 30;54(1):848-53.

Spectrum of Disease

Lens Parameters on ASOCT

Guzman CP, et al. Invest OphthalmolVis Sci. 2013 Aug 7;54(8):5281-6.

Spectrum of Disease

Lens Parameters on ASOCT

Moghimi S, et al. Am J Ophthalmol. 2013 Apr;155(4):664-673, 673.

Angle Closure Glaucoma

Changes after Cataract Surgery

Kim M, et al. Korean J Ophthalmol 2012;26(2):97-103.

n=11

Impact of Cataract Surgeryin Angle Closure Glaucoma

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a) Acute primary angle closure

b) Primary open angle glaucoma

c) Pseudoexfoliation glaucoma

d) Pigmentary glaucoma

Phacoemulsification reduces the IOP maximally in

Question 2

a) Acute primary angle closure

b) Primary open angle glaucoma

c) Pseudoexfoliation glaucoma

d) Pigmentary glaucoma

Phacoemulsification reduces the IOP maximally in

Question 2

Type of Glaucoma

IOP Reduction & Cataract Surgery

Masis M, et al. Surv Ophthalmol. 2018 Sep - Oct;63(5):700-710.

a) Laser iridotomy with Argon laser

b) Cataract extraction immediately

c) Laser iridoplasty

d) Intracameral Pilocarpine

A patient with acute angle closure has been on maximal medicatations for 3 days. The IOP is still 58 mm Hg with dense corneal edema. Evidence suggests that the best next step is:

Question 3

a) Laser iridotomy with Argon laser

b) Cataract extraction immediately

c) Laser iridoplasty

d) Intracameral Pilocarpine

A patient with acute angle closure has been on maximal medicatations for 3 days. The IOP is still 58 mm Hg with dense corneal edema. Evidence suggests that the best next step is:

Question 3

Nature of Study No. of eyes Absolute Complications

Prospective, Consecutive 1 18 100%

Details NA NA

Retrospective, Non-consecutive 2 10 100%

Relative: 3/10Fibrin: 4

Transient IOP ↑: 2

Retrospective, Non-consecutive 3 14

IOP: 10.70±2.80

Meds: 0.13±0.34

Transient IOP ↑: 4

Phaco in Acute PAC

IOP Reduction & Cataract Surgery

1. Ming Zhi Z, et al. Am J Ophthalmol. 2003 Apr;135(4):534-6.2. Yoon JY, et al. Korean J Ophthalmol. 2003 Dec;17(2):122-6.3. Su WW, et al. PLoS One. 2011;6(5):e20056.

Nature of Study No. of eyes Absolute Complications FU Case Selection VA >20/40

Prospective, Consecutive 1 18 100%

Details NA NA 7 weeksPre-op IOP

>31 mm Hg in 3 eyes

NA

Retrospective, Non-consecutive 2 10 100%

Relative: 3/10Fibrin: 4

Transient IOP ↑: 2 NA 7/10 IOP >31 mm Hg

4 patients VA >20/40

Retrospective, Non-consecutive 3 14

IOP: 10.70±2.80

Meds: 0.13±0.34

Transient IOP ↑: 4 3mPre-Op IOP

not mentioned

0.73 ± 0.53

Phaco in Acute PAC

IOP Reduction & Cataract Surgery

1. Ming Zhi Z, et al. Am J Ophthalmol. 2003 Apr;135(4):534-6.2. Yoon JY, et al. Korean J Ophthalmol. 2003 Dec;17(2):122-6.3. Su WW, et al. PLoS One. 2011;6(5):e20056.

Phaco in Acute PAC

IOP Reduction & Cataract Surgery

1. Husain R, et al. Ophthalmology. 2012 Nov;119(11):2274-81.2. Lam DS, et al. Ophthalmology. 2008 Jul;115(7):1134-40.

No. of Eyes Criteria IOP Outcomes Complications FU Vision

LP!: 18Study 1

Vn <6/15Vn

IOP <30 within 24 hours

Comp: 9/18Qual: 2/18

Hyphema: 3Corneal burn: 1

2 years0.34±0.35

Phaco: 19 Comp: 13/18Qual: 4/18 CE: 1 0.37±0.51

Phaco: 31Study 2

IOP <21 after medications

12.6±1.90.90±1.14 meds

3.2% Failures

Corneal edema: 12, PCR: 1, Hyphema, Fibrin: 7, PCO: 5

18m

0.28±0.24

LPI: 3115.0±3.4

0.03±0.18 meds46.7% Failures

Add PI: 4 0.38±0.29

Tarongoy P, et al. Surv Ophthalmol 54:211--225, 2009.

ECCE

IOP Reduction in PACG

Phaco

IOP Reduction in PACG

Tarongoy P, et al. Surv Ophthalmol 54:211--225, 2009.

Controlled PACG Eyes

Fluctuation of IOP

Özyol P, et al. Acta Ophthalmol. 2016 Nov;94(7):e528-e533.

• 39 subjects, Consecutive• PACG S/P YAG PI• IOPs at 8am, 12noon & 4pm, 3 months after surgery • Correlated with increase in ACD• 3 eyes had increase in IOP, unchanged in 1eye

PGAs were resumed after 1 week of surgery

The Known••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Cataract extraction will reduced IOP & its fluctuations deepen anterior chamber; in proportion to increase in depth

after surgery

Plateau-Iris

Changes after Cataract Surgery

Tran HV, et al. Am J Ophthalmol. 2003 Jan;135(1):40-3.

Plateau-Iris

Changes after Cataract Surgery

Tran HV, et al. Am J Ophthalmol. 2003 Jan;135(1):40-3.

Plateau-Iris

Changes after Cataract Surgery

Nonaka A, et al. Ophthalmology. 2005 Jun;112(6):974-9.

Plateau-Iris

Changes after Cataract Surgery

Nonaka A, et al. Ophthalmology. 2005 Jun;112(6):974-9.

Plateau-Iris

Changes after Cataract Surgery

Nonaka A, et al. Ophthalmology. 2006 Mar;113(3):437-41.

The Unknown••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Impact on Plateau-Iris

Challenges in Cataract Surgeryin Angle Closure Glaucoma

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• Shallow AC

• Large lens

• Small pupil

• Pro-inflammatory PGA/Pilocarpine

• IOL Power calculation

• Intraocular pressure control

Challenges

Cataract Surgery in ACG

Cataract vs Combined

Complications

Zhang ML, et al. Cochrane Database Syst Rev. 2015 Jul 14;(7):CD008671.

Intra-op ShallowingCorneal edemaCorneal decompensationIritisCMEAqueous misdirectionSteroid-response

Pre-Operative Preparation••••••••••••••••••••••••••••••••••

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a) In absence of a pre-existing laser iridotomy, a surgical PI must be made

b) Post-operative acetazolamide reduces the chances of IOP spike

c) Corneal endothelial decompensation after cataract surgery is 5 times more common in patients with PACG

d) Prostaglandin analogues and Pilocarpine can be used till the day of surgery, but should be discontinued thereafter

True about post-operative management of a PACG patient after a routine Phacoemulsification is

Question 4

a) In absence of a pre-existing laser iridotomy, a surgical PI must be made

b) Post-operative acetazolamide reduces the chances of IOP spike

c) Corneal endothelial decompensation after cataract surgery is 5 times more common in patients with PACG

d) Prostaglandin analogues and Pilocarpine can be used till the day of surgery, but should be discontinued thereafter

True about post-operative management of a PACG patient after a routine Phacoemulsification is

Question 4

To Discontinue

Glaucoma Medications

• Pilocarpine: 1-2 weeks ahead• Replace with Acetazolamide

• PG Analogues: After surgery• Resume beyond 8-12 weeks• Used Topical NSAID for 6 weeks

• Best possible IOP control pre-op

a) SRK II

b) SRK/T

c) Hoffer Q

d) Haigis

e) None

The IOL Calculation formula with >95% accuracy of residual refractive error of <0.25D is

Question 5

a) SRK II

b) SRK/T

c) Hoffer Q

d) Haigis

e) None

The IOL Calculation formula with >95% accuracy of residual refractive error of <0.25D is

Question 5

SRKII

IOL Power

• 42 eyes with controlled PACG• 45 eyes with open angles

Kang SY, et al. Yonsei Med J 50(2):206-210, 2009

SRKII

IOL Power

Kang SY, et al. Yonsei Med J 50(2):206-210, 2009

SRK/T, Haigis, Hoffer Q

IOL Power

• 63 eyes with controlled PACG• 93 eyes of normal subjects

Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379

SRK/T, Haigis, Hoffer Q

IOL Power

Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379

EAGLE Trial

IOL Power

Day AC, et al. Br J Ophthalmol. 2018 Dec;102(12):1658-1662.

Recommendations

IOL Power

• Aim myopic if using older formulae

• Modern formulae: Barett’s

• Avoid multifocals

• Toric: Inform about future impact of Trab, if one is needed

Joo J, et al. Korean J Ophthalmol 2011;25(6):375-379

Intraocular Pressure

Pre-Op Mannitol

• Advanced Glaucoma• Patients with Plateau-iris syndrome

• At least 1 hour prior to surgery

Deepening of AC

Pre-Op Mannitol

Hwang HS, et al. Curr Eye Res. 2016 Sep;41(9):1161-5.

• 38 eyes undergoing cataract surgery• Measurements 1 hour after mannitol

a) Initiated not more than 15-20 minutes of surgery

b) Use a rapidly acting mydriatic in combination with long-acting on

c) Accompanied by cycloplegic to deepen the anterior chamber

d) Intra-operative pilocarpine will reduce chances of floppy iris

All the following are true EXCEPT ONE. Pre-Operative dilatation, before a Phacoemulsification, in a patient with plateau-iris syndrome should be:

Question 6

a) Initiated not more than 15-20 minutes of surgery

b) Use a rapidly acting mydriatic in combination with long-acting on

c) Accompanied by cycloplegic to deepen the anterior chamber

d) Intra-operative pilocarpine will reduce chances of floppy iris

All the following are true EXCEPT ONE. Pre-Operative dilatation, before a Phacoemulsification, in a patient with plateau-iris syndrome should be:

Question 6

Timing

Dilatation

Mapstone R. Br J Ophthalmol. 1974 Jan; 58(1): 46–54.

• Just before block/shifting

• Rise of IOP happens after 40-50 minutes of instillation of mydriatic in susceptible eyes

• Strong, rapidly acting mydriatic

Cycloplegia along with Mydriasis

Dilatation

Nuzzi R,et al. Open Ophthalmol J. 2018 Mar 30;12:34-40.

• Along with mydriatic

• Will help in deepening the AC

• Prevention of Aqueous misdirection

• Additional protection against Floppy Iris

Nil / Minimal Block

Anesthesia

Huber KK, et al. Br J Ophthalmol. 2005 Jun; 89(6): 719–723.

• Peribulbar anesthesia reduces ONH blood flow

No Compression

Anesthesia

Chang B, et al. Br J Ophthalmol. 2000 Nov; 84(11): 1260–1263.

Recommendations

Anesthesia

Huber KK, et al. Br J Ophthalmol. 2005 Jun; 89(6): 719–723.

• Topical preferable

• Posterior sub-tenon, subconjunctival: Alternatives

• 2ml Injection inferotemporally

• Wait for eye to be soft, no compression

• Limit total volume

Control the Controlables

Avoid Positive Vitreous Pressure

Chronopoulos A, et al. Surv Ophthalmol. 2017 Mar - Apr;62(2):127-133.

• Bathroom break prior to surgery • Specially if Mannitol was

administered

• Light-weight (Titanium) self-retaining speculum

• Open to moderate extent

Clear-Corneal

Incision

• Clear corneal phaco

• Temporal SICS (Leave one quadrant untouched)

• Clear corneal ECCE

Post-Operative Management••••••••••••••••••••••••••••••••••

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Do Not Forget IOP, Other Eye

Post-Op Regimen

• Steroid, Antibiotic

• Immediate Oral Acetazolamide

• Replace with alternative agents

• Used Topical NSAID for 6 weeks

Managing Spikes

Post-Op Regimen

• Oral Acetazolamide

• Can use ½ TID dose with Potassium supplementation

• Control of inflammation

• Syrup Glycerol

Managing Glaucoma

Post-Op Regimen

• Can resume PGA after 3 months

• Prescription should always contain AGM

• Repeat fields at 2-3 months: Fresh baseline

Combined vs Cataract••••••••••••••••••••••••••••••••••

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Cataract vs Combined

Complications

Zhang ML, et al. Cochrane Database Syst Rev. 2015 Jul 14;(7):CD008671.

Combined in Certain Situations

Combined vs Cataract

Tham CC, et al. Ophthalmology. 2009 Apr;116(4):725-31, 731.e1-3.Tham CC, et al. Ophthalmology. 2013 Jan;120(1):62-7.

Combined in Certain Situations

Combined vs Cataract

• Advanced glaucoma on 2 or more medications

• Moderate glaucoma on 3 or more medications

• Progressive Glaucoma

• Economic burden

• Difficulty in Follow-up

• Lens factor insignificant

Summary

• Lens is an essential component of relative pupillary block

• Cataract extraction benefits PACD patients

• Not all patients are benefitted (equally)

• Phacoemlusification is a good option for non-severe acute angle closure

• Careful pre,- intra-, and, post-op management

The Future & The Unexplored••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Dynamic properties of the lensCauses of persistent occludability

Factors to predict impactIOL calculation

A Multifactorial Disease

Beyond Pupillary Block

Goniosynechiae

Plateau-Iris

Iris Properties Choroidal Expansion

TM Damage

L V Prasad Eye Institutewww.lvpei.org

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