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Laser Peripheral Iridotomy Versus Trabeculectomy As an Initial Treatment for Primary Angle-Closure Glaucoma

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Laser Peripheral Iridotomy Versus Trabeculectomy As an Initial Treatment for Primary Angle-Closure Glaucoma Laser Peripheral Iridotomy versus Trabeculectomy as an Initial Treatment for Primary Angle-Closure Glaucoma The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Chen, Yan Yun, Su Jie Fan, Yuan Bo Liang, Shi Song Rong, Hai Lin Meng, Xing Wang, Ravi Thomas, and Ning Li Wang. 2017. “Laser Peripheral Iridotomy versus Trabeculectomy as an Initial Treatment for Primary Angle-Closure Glaucoma.” Journal of Ophthalmology 2017 (1): 2761301. doi:10.1155/2017/2761301. http:// dx.doi.org/10.1155/2017/2761301. Published Version doi:10.1155/2017/2761301 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:34492316 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Hindawi Journal of Ophthalmology Volume 2017, Article ID 2761301, 6 pages https://doi.org/10.1155/2017/2761301 Research Article Laser Peripheral Iridotomy versus Trabeculectomy as an Initial Treatment for Primary Angle-Closure Glaucoma 1 2 3,4 5 6 7 Yan Yun Chen, Su Jie Fan, Yuan Bo Liang, Shi Song Rong, Hai Lin Meng, Xing Wang, 8,9 1,10 Ravi Thomas, and Ning Li Wang 1Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China 2Handan Eye Hospital, Handan, Hebei Province, China 3The Affiliated Eye Hospital, School of Optometry and Ophthalmology, Wenzhou Medical University, China 4School of Medicine, Dentistry and Biomedical Sciences Public Health, Health Services and Primary Care, Queen’s University, Belfast, UK 5Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA 6Anyang Eye Hospital, Anyang, Henan Province, China 7Fushun Eye Hospital, Fushun, Liaoning Province, China 8Queensland Eye Institute, Brisbane, Queensland, Australia 9University of Queensland, Brisbane, Queensland, Australia 10Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China Correspondence should be addressed to Yuan Bo Liang; [email protected] Received 19 November 2016; Revised 28 May 2017; Accepted 13 June 2017; Published 1 September 2017 Academic Editor: Jesús Pintor Copyright © 2017 Yan Yun Chen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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 =0000). 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. 1. Introduction primary angle closure (PAC) and PACG, the PPP recom- mends laser peripheral iridotomy (LPI) to eliminate pupil- Primary angle-closure glaucoma (PACG) is the major type of lary block followed by a treatment strategy “similar to that primary glaucoma in China [1–4]. The management of for POAG” [8]. Accordingly, LPI is used as the first-line PACG in China is different from the recommendations of treatment for all patients with PAC or PACG, medication is the American Academy of Ophthalmology Preferred Practice added as needed, and surgery is considered when the intraoc- Patterns (PPP) and other published guidelines [5–7]. For ular pressure (IOP) cannot be controlled with maximum 2 Journal of Ophthalmology tolerated medications. In China, however, trabeculectomy is refraction, Goldmann applanation tonometry, static and considered a primary option for PACG and is generally dynamic gonioscopy (manipulation) using a one-mirror undertaken if peripheral anterior synechiae (PAS) are greater Goldmann gonioscope [14, 15], slit-lamp examination, fun- than 6 clock hours [9, 10]. To the best of our knowledge, dus examination, and automated perimetry (Humphrey Field there is no comparative study of LPI versus primary trabecu- Analyzer 750i, Carl Zeiss Meditec; Sita Fast strategy; and 24–2 lectomy in PACG to support such an approach. Using data threshold test). These examinations were performed at base- from patients enrolled in two separate randomized con- line and at postoperative visits scheduled at month 1, month trolled trials [11, 12], we compared the IOP-lowering efficacy 3, month 6, month 12, and month 18. Postoperative visits and safety of LPI versus trabeculectomy as an initial treat- were scheduled on day 1, day 3, week 1, week 2, month 1, ment for PACG with PAS ≥ 6 clock hours. month 3, month 6, month 12, and month 18 following the LPI or trabeculectomy. 2. Methods 2.2. Laser Peripheral Iridotomy. All laser procedures were Patients included in this study had participated in 2 random- performed by one of two senior glaucoma specialists. 2% ized clinical trials (RCTs) for PACG. Both trials were pilocarpine was applied, and iridotomy was performed under conducted in accordance with the tenets of the Declaration topical anesthesia using a Nd:YAG laser (YL-1600; NIDEK of Helsinki and approved by the ethics committee of the Co. Ltd., Japan) using an Abraham contact lens (Ocular Tongren Eye Centre, Capital Medical University. Written Instruments Inc., Bellevue, USA). A treatment site was informed consent was obtained from all subjects for partici- selected in the superior nasal iris or in a crypt where present. pation in the original trials. The treatment was initiated with a single 4 mJ pulse, the Patients undergoing primary trabeculectomy for PACG power was adjusted, and the treatment was continued to had participated in a multicenter RCT (registration number: obtain a 0.2 mm opening; patency was determined by direct ChiCTR-TCR-00000218) [12]. This RCT was conducted in visualization of the posterior chamber. four clinical collaborative centers of Beijing Tongren Hospi- In accordance with local practice, IOP-lowering medica- tal: Handan 3rd Hospital (Hebei Province, China), Anyang tion was initiated if the IOP was greater than 21 mmHg Eye Hospital (Henan Province, China), Fushun Eye Hospital following laser and confirmed by a repeat reading on the (Liaoning Province, China), and the Chenzhou Eye and same day [11]. Optometry Center (Hunan Province, China). PACG was defined as primary angle closure with glaucomatous optic 2.3. Trabeculectomy. Surgery was performed under topical or neuropathy and corresponding visual field defects, and peribulbar anesthesia using a standard surgical technique. patients were recruited from the four centers between April The eye was prepared using a standard aseptic technique 2006 and November 2007. The primary purpose of the trial and draped to isolate the lashes. A lid speculum was inserted was to report the efficacy and complications of trabeculect- and a 7/0 superior rectus muscle traction suture was placed. omy with or without releasable sutures in PACG. A limbus-based conjunctival flap was created using a Patients who underwent LPI as an initial treatment were 10 mm incision through the conjunctiva and Tenon’s cap- part of another RCT (registration number: ChiCTR-TRC- sule approximately 8–10 mm from the limbus. The flap 00000034, http://www.chictr.org.cn) conducted at the Han- was dissected forwards and hemostasis achieved with dan 3rd Hospital [11]. The purpose of this RCT was to monopolar diathermy. investigate the role of laser iridotomy (with or without A half-thickness 4 × 3mm2 rectangular scleral flap was iridoplasty) in patients with synechial PAC or PACG. The fashioned, and cellulose sponges soaked in MMC (0.3 mg/ definition of PACG was the same as that used in the trial ml) were applied under the scleral flap, conjunctiva, and mentioned above; consecutive cases of PAC and PACG Tenon’s capsule for a duration determined by the surgeon presenting to the hospital between October 1, 2005, and based on an assessment of risk factors. Irrigation with bal- October 31, 2006, were recruited for this trial. anced salt solution was performed to wash out residual MMC solution. A paracentesis was created, a 2 × 1.5 mm 2.1. Patient Selection. The inclusion criteria for the current trabeculectomy block excised, and an iridectomy performed. study were as follows: The scleral flap was sutured with 10-0 monofilament, BSS was injected into the anterior chamber to assess flow, and (1) PACG: defined as primary angle closure with glauco- the conjunctiva was closed with a single running 8/0 vicryl matous optic neuropathy and visual field defects [13] suture [12]. (2) Age 40 years or more Visual acuity was recorded with a decimal chart and converted to the logarithm of minimum angle of resolution ≥ (3) PAS 6 clock hours (LogMAR) format. Finger counting, hand movement, and (4) Minimum follow-up of one year. light perception were recorded as 1.5, 2.0, and 2.5 on the LogMAR scale.
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