Posterior segment complications of refractive surgery
PACS lens AGS 2014 final
1. SURGICAL MANAGEMENT OFSURGICAL MANAGEMENT OF
CHRONIC ANGLE CLOSURECHRONIC ANGLE CLOSURE
H. George Tanaka, MDH. George Tanaka, MD
Assistant Clinical ProfessorAssistant Clinical Professor
California Pacific Medical CenterCalifornia Pacific Medical Center
San Francisco, CASan Francisco, CA
3. When should I perform lensWhen should I perform lens
extraction alone?extraction alone?
4. Take out the cataract!Take out the cataract!
Patient is a presbyopic hyperope = good candidate for
multifocal IOL
Laser-assisted cataract surgery (LACS)
Treat corneal astigmatism with arcuate incisions
“Kill FIVE birds with one stone”
Cataract surgery will deepen the angle
9. We need an OHTS equivalentWe need an OHTS equivalent
for narrow angles!for narrow angles!
IOP > 21 mm Hg
10. We need “PACTS”!We need “PACTS”!
Primary Angle Closure
Angle Closure Glaucoma
11. The Effectiveness in Angle-closureThe Effectiveness in Angle-closure
Glaucoma of Lens Extraction (EAGLE)Glaucoma of Lens Extraction (EAGLE)
Study GroupStudy Group
• Prospective multicenter randomized controlled trial
• Lens extraction vs. LPI in newly diagnosed PAC or PACG
• Primary outcomes: IOP, QOL, cost-effectiveness at 3 years
Azuara-Blanco A, Burr JM, Cochran C, 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; 12:133.
12. Effect of Lens on CB Position
Strenk & Strenk Eye World Sept. 2007
74 y/o Male Paired Eyes74 y/o Male Paired Eyes
PhakicPhakic PseudophakicPseudophakic
(Slide courtesy of Murray Johnstone, MD)(Slide courtesy of Murray Johnstone, MD)
Apical Portion of CB Moves Anteriorly With AgeApical Portion of CB Moves Anteriorly With Age
Apical Portion of CB Moves Backward With Lens RemovalApical Portion of CB Moves Backward With Lens Removal
13. There is little clinical evidence toThere is little clinical evidence to
supportsupport anyany surgical treatment forsurgical treatment for
PACS or PACPACS or PAC
14. What is an acceptable number needed toWhat is an acceptable number needed to
treat (NNT) to prevent progression fromtreat (NNT) to prevent progression from
PACS to PAC or PACG?PACS to PAC or PACG?
NNT = 50?
NNT = 5?
NNT = 1?
15. Laser iridotomy is not withoutLaser iridotomy is not without
risks.....risks.....
Glare (location-dependent?)
More rapid cataract progression
Corneal endothelial loss
Iritis
Elevated IOP
Hyphema
Posterior synechiae
16. Cataract surgery is not withoutCataract surgery is not without
risks.....risks.....
Suprachoroidal hemorrhage
Endophthalmitis
Retinal detachment
Cystoid macular edema
Elevated IOP
Corneal endothelial loss
Dysphtopsia
Incorrect IOL power
17. When should I perform lensWhen should I perform lens
extraction alone?extraction alone?
When the patient has a “visually significant” cataract!
18. When can I justify aWhen can I justify a clear lensectomyclear lensectomy after aafter a
patent iridotomy?patent iridotomy?
Development of PAC
TM dysfunction = elevated IOP or PAS
Special circumstances unique to the patient:
Symptoms suggestive of intermittent angle closure
Systemic medications that may precipitate angle closure
Need for repeat dilated exams (diabetes, retinal disease)
Unreliable access to eye care
19. • “In a country where an aggressive cataract surgical
programme is likely to catch up with the patient, do
we need to intervene with the laser at all?”
• R. Thomas BJO 2003, 87:453
When should I perform lensWhen should I perform lens
extraction alone?extraction alone?
20. General approach: ANGLEGeneral approach: ANGLE
Assign stage: PACS, PAC, PACG
KNow the mechanism
Gonio after treatment
Look at the whole patient, not just the angle
Evidence-based treatment guidelines – stay tuned!
Editor's Notes
She’ll trade in her glare for halos at night, but she can throw away those reading glasses....
Different mechanisms drive this disease process from stage to stage
While there is a natural progression to this disease process, We should also be aware that this disease process is probably reversible – up until a certain point.
The patient is predisposed to develop angle closure through an iris abnormality – poor deturgesence or an anterior insertion
With time and the development of pupillary block and lens swelling, appositional closure develops, leading to trabecular dysfunction and elevated pressure. If we don’t intervene at this point permanent synechial closure may develop and the eye pressures can increase dramatically as the trabecular meshwork is obstructed on a macroscopic level.
We know this now because of the OHTS study. We learned that certain ocular hypertensive patients with thin corneas or abnormal optic nerve imaging studies were at greater risk of converting to glaucoma.
Well, we need a similar study for our patients with narrow angles.......
We need to identify static structural features, or even better, dynamic structural responses that predict which patients will develop trabecular dysfunction. We need a high tech 21st century version of the provocative test.
Well are we there yet? The answer is NO:
Just as medical treatment of ocular hypertension has a down side, surgery, even laser surgery, is not entirely benign -- David has mentioned the risks of iridotomy.....
And cataract surgery, while doing great things to the angle, certainly has risks as well, several of which are potentially much more serious than laser iridotomy
Do cataract surgery when the patient has a cataract
EAGLE study will help us choose between iridotomy and lens removal as the initial treamtnet of PAC. Until then I think most of us would perform an iridotomy first in a patient who is 20/20 with no significant cataract. Well what do we do when the iridotomy DOESN’T open the angle? The more difficult question is when do we take out a clear lens in treating the spectrum of angle closure disease. I believe it should be considered when trabecular dysfunction manifests functionally as a rise in IOP OR structurally with the formation of PAS. Beyond that, the decision for lensectomy should be considered on a case by case basis taking into factors such as clinical symptomology suggestive of intermittent angle closure episodes, systemic medications the patient is taking which may precipitate angle closure, the need for frequent dilated exams as dictated by any co-existing retinal disease, or difficulties in obtaining prompt medical attention should an acute angle closure attack occur.
Do cataract surgery when the patient has a cataract
