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Eye (1989) 3, 70712

Extracapsular Cataract Extraction and Posteror

Chamber Lens Impantation in Patents wth PrmaryChronic Ange-Closure Glaucoma: Effect onIntraocuar Pressure Conro

P K WISHAR, P L AKINSNiv

Summary'enty-hree eyes of consecutive patients with primary chronic ange-cosuregaucoma (PCACG) undergoing extracapsuar cataract extraction (ECCE) withintraocuar ens IOL) impantation were studied prospectvey to assess the effect ofECCE on ntracuar pessure (lP) contro For comparisn, a group of eyeswith open ange gaucoma. (OAG) wich had undergone ECCE were reviewed retrospectivey The PCACG grop had a ow incidence of acue post-operative lOP eevations 9, and ong-term the majority 65achieved an lOP

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MY CONC GCOS GCOM

with a shallow anterior chamber and peripheral anterior snechiae PAS) of te anteriorchamber angle demonstrated b Zeiss fourmirror indentation gonioscop All ees adpreviousl had a peripheral iridectom 2

ees) or laser iridotom four ees) performed and all were receiving topical and isome cases sstemic anti-glaucomamedications

Al patients nderwent initial slit-lamp eeeamination including Goldmann applanation tonometr, anterior chamber deptmeasurement using a Haag-Streit pachmeter, gonioscop using a Zeiss four mirrorindentation gonioscope b one author (PKW)to assess the etent of peripheral anterior sn

echiae PAS), and where possible fundoscopand disc assessment Pre-operative P wastaken as the mean of the last three recordedmeasurements prior to surger

Ees wit long-standing PCACG and cataract in which pre-operaive indentation gonioscop showed near total snechial closure ofthe anterior chamber angle with PAS etending to Schwalbes line, and medicall uncontrollable P, were eclded from the stdas it was felt that for these ees ECCE com

bined with trabeculectom was indicatedEtracapsular cataract etraction with

implantation of a posterior chamber L wasperformed in all cases, under general aaesthetic in all but one case A corneal sectiowas emploed in all cases Posterior snechiaewere broken down using Healonid and an irisspatula, and sphincterotomies performedwhere necessar Healonid was sed in allcases and was washed out at the end of eachoperation he section was closed with /

nlon either as a continuous or interruptedsutures

Post-operativel, P was recorded for therst wo das and if satisfactor the patientdischarged home off glaucoma treatment andusing topical deamethasone or betametasone four times a da and a mdriaticPatients were followed up regularl in the outpatient clinic and glaucoma therap recommenced if felt clinicall necessar

At the end of the stud period all patients

had repeat indentation gonioscop PKW)and optic disc assessment b slit-lampbiomicroscop

For comparison, the notes of 2 patients 2ees) with chronic simple glaucoma CSG)who had undergone etracapsuar cataractsurger were reviewed retrospctivel Nineteen ees were diagnosed as suffering from

AG while we classied two ees as suferingfrom narrow angle glaucoma NAG) heselatter two ees had shallow anterior chambers25 mm) but no PAS as demonstrated bZeiss four mirror indentation gonioscopEcept in one ee with AG who had had afailed trabeculectom, no patient had undergone previous surger or laser treatment, andall ad normal Ps controlled with medicaltreatment A posterior chamber L wasimplanted in cases, the rmaining four

patients receiving no L

ResutsPCACG Gupf te 23 patients in the CACG group, 22patients 23 ees) completed follow up nepatient, who had originall presented withsubacute angle-closure glaucoma, suffered acentral retinal vein occlusion two weeks postoperativel and developed rubeotic glaucoma his patient is ecluded from the fol

lowing analsishe CACG group consisted of nine maleand 3 female patients, mean age 5 earsstandard deviation SD .), range 2ears

Mean anterior chamber depth was 5 mmSD 2), range 325 mm

Mean post-operative follow up was 112months SD .), range 2 months

Mean pre-operative P was 1 mmHgSD 3), rage 325 mmHg

Post-operativel, at te end of the studperiod, the mean P was 5 mmHgSD 33), range 225 mmHg

n 5 ees te P was controlled

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P. K WISHART AND P L. ATKINSON

ion of 125 mg er day aceazolamide In islae case he osoeraive P was20 mmHg on e original medicaions eera medicaion eing added in an effor oreduce e P sill furer in an eye wi

severe glaucomaous damage Tale I sowse numer of gaucoma medicaions in usere and osoeraively

Al aiens in e PCACG grou a adegree of glaucomaous oic disc damage fe wo aiens wo required more medicaions osoeraively o ad endsageglaucomaous disc cuing; owever of eve aiens wi endsage cuing reeaiens ad imroved conrolosoeraively

In e rs ours posoeraively woaiens were recorded as aving a signicanP rise (> mmHg over reoeraiveIPaving pressures of 0 mmHg on dayone and 30 mmHG on day wo resecively

A osoeraive P rise wic was considered o e a seroid resons was seen in 2of e 23 aiens e P normalising on cessaion of e seroids

ne aien from is grou develoed cysoid macular oedema osoeraively reduc

ing he nal visual acuiy o /1 Anoeraien developed severe anerior uveiis siwees osoeraively wic resonded oreamen wi oical seroids

Te glaucomaous damage o e oicdiscs was classifed ino ree groups Good'moderaely damaged and ad In ePCACG aiens e discs were assessed asve good eig moderae and en adlydamaged

CSG GroupTis grou consised of 21 eyes of 20 aiens

Tbl Preoperative versus Pstopetivemedications for the PCAG group

PAG GroupNo. ofMedications

1

23

Mean NoMedcaons

Number of Eyes N=Preoperative Potoperative

11 48)10()2 9)

1.61

15 (65)4(17)3 (13)1 4)

057

ve male and 15 female Mean age was years (SO = 11.3) range 553 years

Mean osoeraive follow u was 1.mons (SO = 11.5) range monhs

Mean reoperaive P was 1. mmHg

(SO = 3.2) range 12 mmHgMean osoeraive P a e end of efollow u eriod was 1. mmHg (SO = 3.)range 12 mmHg

In one eye e P was conrolled(

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PRIMARY CHRONIC ANGLE-C LOSURE GLAUCOMA

Tbl Preoperive versus Posoperiveedicions for he SG group

SG GroupNo ofMedicions

234

Mean No.Medicaions

Nuber(%) of Eyes N=Preoperive Posoperive

o4 7

24

.29

2

29

43

were open pre-and post-operatively, with noforward bowing of the iris. Post-operativey,

there was some increase in peripheral anteriorchamber depth as assessed with the slitlamp,and the anterior chamber angle remainedopen.

In the PCACG group, in 22 of te 23 eyes,there was a marked attening of the forwardconvexity of the peripheral iris and deepeningof the anterior chamber anglepost-operatively.

Table IV summarises the relationshipsbetween post-operative medications, PAS,

and pre-operative anterior chamber depth.Despite patent peripheral iridectomies/

lase iridotomies in all eyes, preoperativegonioscopy was difcult in some cases d toextreme narrowness f the anterior chamberangle. Accurate assessment was impossible ineight eyes, but seven eyes were judged to haveno PAS pre-operatively, two eyes to have limited PAS, and six eyes o have extensive PAS.

Post-operative assessment at six monthsfollow-up was much easier in that the periph

eral anterior chamber deepened considerably

Tbl oprion of lOP conro beween hePAG nd SG groups

Eary lOP riseSeroid responselOP

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P K WISHA AND P L AKINSON

the previous surgical iridectomies the cataract surgery in the PCACG group wasgenerally more complicated resulting inmore intraocular manipulation and pigmentrelease.

Notwithstanding the above considerationsthe PCACG group had a low incidence ofearly post-operative P rises (%). Thiscompares to 1% in the CSG group and is lowcompared with other studies on patients withCSG.4

The incidence of post-operative steroidresponders was % and 5% in the PCACGand CSG groups respectively. This is asexpected from the reported high incidence ofsteroid response in both CSG67 and angle

closure glaucoma.8In the long-term ECCE with IL implantation had a benecial effect on the P contro of patients in the PCACG group with amean P reduction of .5 mmHg (p

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IMAY CHONIC ANGECOSUE GACOMA

risk of per-operative compications and Simmons et aL report ony a 5% ong-term contro of gaucoma o medications with thisprocedure.

In patients with PCACG, either foowing

an acute or subacute attack, or with creepingange cosure, assessment of the degree ofgaucomatous dmage may be difcut. Foowing a surgica periphera iridectomy/aseriridotomy and ong term miotic treatmentoptic dsc assessent and visua e anaysisis hindered by miosis, posterior synechae ofthe pupi, and coexsting cataract. n eyes withPCACG, if cataract extraction is performedwithout simutaneous tration surgery theremight be expected to be risk of P eevat

ion in the post-operative period, causing considerabe damage to an aready compromisedoptic dsc.4

he resuts of our study indicate that ECCEwith I impantation aone wi benet theP contro in the majrity of patients withPCACG. he reason for this eect is uncear.Removing a cataract in an eye with AGwoud be unikey to affect ongterm gaucoma contro and most studies reect thisview. In our study, eyes with AG under

going ECCE with I impantation aone didnot have improved P contro postoperativey. Yet there was a cear improvement inP contro in the majority of patients withPCACG undergoing ECCE with I impantation, with 5% of eyes reuiring no medications postoperativey. here was aso anunexpectedy ow incidence of eary postoperative P rises considering the extent ogaucomatous damage most of these eyes hadsuffered.

Pupi bock had previousy been reieved inthese eyes and therefore this coud not be afactor in the iproved post-operative Pcontro. It may be postuated that a arge cataractous ens in an eye with a reativey smaanterior segment somehow advrsey affectsthe outow of aueous from the eye. In thePCACG group, the ow incidence of earypostoperative P eevations suggests animmediate benecia effect on aueous outow. In the majority of cases the anterior

chamber ange widened and the peripheraanterior chamber deepened postoperativey,and it may be that this change in the cong-

uration of the anterior chamber ange wasresponsibe for an improvement in the function of the trabecuar meshwork, perhaps byreieving physica compression of the trabecuar ameae. However, other factors such as

an increase in uveoscera outow may beimpicated.

he benecia effect of ECCE and Iimpantation in these eyes with PCACGraises the uestion, shoud this procedure beconsidered in eyes with PCACG, uncontroed P, and a cear ens? Greve certainybeieves this to be the case as tering surgeryin such eyes may subseuety cause the ensto opacfy, and he beieves that ens extractionremoves the underying cause of the condi

tionnamey a arge ens.9Might, therefore, ECCE and I impan

tation be benecia to eyes with uncontroedP and narrow ange gaucoma? A study ofargon aser trabecuopasy (A) in eyes withnarrow ange gaucoma showed that foowingreief of pupi bock the anterior chamberange widened sufcienty to permit A inthe maority of eyes. However, combinedperiphera iridectomy/aser iridotomy pusA faed to improve P contro in 5% of

eyes treated. It shoud be noted, however,that of the 23 eyes (%) in our PCACGgroup had previousy sufered an attack ofacute or subacute ange-cosure gaucoma andthe other ve had chonic ange-cosure gaucoma with signicant cosure of the anteriorchmber ange by PAS. In the NAG studythe majority of eyes were hypertensive eyeswith narrow anges and those with PAScosure were of the insidious creeping osurevariety. It is therefore ikey that many eyes in

the NAG group were suffering from chronicsimpe gaucoma coincident with a narrowanterior chamber ange and some degree ofappositona cosure eading to PA. his mayexpain why periphera iridectomy/aser iridotomy aone dd not iprove signicanty Pcontro, as pupi bock was not contributing tothe raised P. Reanaysis of the resuts ofthis NAG study presented at the 3rd Congressof the European Gaucoma Socety, showed acose correation between faiure of P con

tro and extension of PAS, probaby reatedto the A. In our study, we found noimprovement in P contro in eyes with CSG

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P K WISHART AND P L. ATKINSON

following ECCE and IL implantation, andtherefore as CSG ma be the underlingmechanism for the P elevation in mancases of NAG the authors would not recom

mend lens extraction as a therapeutic procedure in NAG ees.

ConcusionIn ees with cataract and primar chronicangle-closure glaucoma under reasonablemedical control we recommend ECCE wihIL implantation as a rst procedure ratherthan cataract extraction combined with ltering surger.

We are indebted to Mrs Owen for her administra

tive and technica hep

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