The purpose of this study was to compare the effectiveness of

goniosynechialysis combined with phacoemulsification in patients with

acute primary angle closure (APAC) and chronic primary angle closure

glaucoma (CPACG) and to investigate the possible differences in the

outcome between the 2 groups.

Materials and Methods

Nine eyes of 9 patients with APAC and 18 eyes of 18 patients with

CPACG were enrolled between January 2010 and September 2011. The

surgical procedure and probable outcomes were explained in detail to

the patients and informed consent was obtained from all patients. The

present clinical study was approved by institutional review board.

The criteria used to define APAC included

(1) an eye with an occludable drainage angle (in which more than 270

degrees of the posterior trabecular meshwork cannot be seen on static

gonioscopy) and features indicating that trabecular obstruction by the

peripheral iris has occurred, such as PAS,

(2) presence of at least 2 typical symptoms (ocular pain, nausea,

vomiting, and antecedent history of intermittent blurring of vision with

halo effect),

(3) presence of at least 2 signs (conjunctival injection, corneal

epithelial edema, mid-dilated pupil),

(4) shallow anterior chamber depth;

(5) elevated IOP (>21mmHg), and

(6) no glaucomatous optic neuropathy.

The criteria used to define CPACG included

(1) an eye with an occludable drainage angle and features indicating

that trabecular obstruction by the peripheral iris has occurred, such as

PAS,

(2) elevated IOP (>21mmHg), and

(3) glaucomatous damage to optic disc and visual field.

On the basis of definitions of APAC and CPACG, individuals with:

(1) uncontrolled IOP (>21mmHg) despite medical therapy, laser

iridotomy and argon laser peripheral iridoplasty;

(2) synechial angle closure of 180 degrees or more confirmed by

indentation gonioscopy by Sussman goniolens;

(3) concurrent cataract with best corrected visual acuity (BCVA)≤0.5

(4) no history of acute attack or acute attack having occurred greater

than 6 months previously for CPACG group were included in the study.

Patients with secondary glaucoma, or those who had undergone any

incisional surgery were excluded from the study.

Surgical Technique

A standard clear-cornea phacoemulsification was performed, with

implantation of a foldable intraocular lens.

After lens implantation, the patient’s head was tilted to the side

opposite a chosen paracentesis track to orient the iris surface parallel to

the optical axis of the microscope.

Intraoperative direct gonioscopy was performed with a Swan-Jacob

goinolens.

Goniosynechialysis through clear cornea incision and three separate

paracenteses evenly spaced 90 degrees apart was performed for 360

degrees with the anterior chamber formed with viscoelastic.

A blunt iris spatula was pressed against the most peripheral edges of

the iris next to the points of angle adhesion.

After applying pressure toward the posterior of the iris, the trabecular

meshwork was exposed. Statistical Analysis

Snellen BCVAs were converted to the logarithm of the minimum angle

of resolution (logMAR) for statistical analysis.

Continuous and categorical variables were compared by using Mann-

Whitney U test and Fisher’s exact test.

Variables between preoperative and postoperative IOP in each group

were compared using Wilcoxon signed-rank test.

Analysis of covariance was performed to determine the difference in

postoperative IOP between the APAC and CPACG groups because of

an initially different preoperative IOP. Preoperative IOP had been

adjusted.

All statistical assessments were 2-sided, and the 0.05 level was

considered statistically significant. Statistical analyses were performed

using SPSS 18.0K statistics software (SPSS Inc, Chicago, IL).

Table 1. Descriptive and clinical characteristics of the study groups

Conclusion

Goniosynechialysis combined with phacoemulsification in patients with uncontrolled acute primary angle closure and

chronic primary angle-closure glaucoma

Ji Woong Lee1, Eun Ah Kim2, Seong Jae Kim3

1Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea

2Department of Ophthalmology, Daegu Fatima Hospital, Deagu, Korea

3Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea

Purpose

Results

Figure 1. (A) Intraoperative gonioscopy shows angle remains closed by PAS

despite phacoemulsification and injection of viscoelastic near the angle.

(B) The synechiae are stripped from the angle wall at the point of adhesion and

trabecular meshwork are exposed.

(A) (B)

Total

(n=27)

APAC

(n = 9)

CPACG

(n = 18)

P between

two groups

Age (years) 68.33±7.81 66.11±8.81 69.44±7.26 0.587

Follow-up (months) 10.3±4.59

(range, 4-27)

9.33±3.50

(range, 5-15)

10.78±5.07

(range, 4-27) 0.587

OD/OS 17/10 5/4 12/6 0.683

Male/female 5/22 1/8 4/14 0.447

ACD (mm) 1.63±0.21 1.52±0.20 1.68±0.19 0.080

Lens thickness (mm) 5.24±0.34 5.33±0.43 5.19±0.28 0.519

Axial length (mm) 22.40±0.77 22.62±0.78 22.29±0.77 0.280

Table 2. Preoperative and postoperative IOP (mmHg) in study groups

Values are means±SD.

*ANCOVA is performed because of an imbalance of baseline IOP.

†Adjusted P value. Adjusted for preoperative IOP.

ANCOVA, analysis of covariance; IOP, intraocular pressure; Preop., preoperative; Postop.,

postoperative.

Table 3. Preoperative and postoperative BCVA (log MAR) in study

groups

Table 4. Preoperative and postoperative number of anti-glaucoma

medications in study groups

APAC

(n = 9)

CPACG

(n = 18)

P between

two groups

Preop. no. of medications 3.56±0.53 2.61±0.50 0.001

Postop. no. of medications* 0.67±0.50 0.56±0.62 0.722†

P between preop. and postop.

no. of medications 0.007 0.000

No. of medication reduction* -2.89±0.78 -2.06±0.64 0.722†

*ANCOVA is performed because of an imbalance of baseline number of medications.

†Adjusted P value. Adjusted for preoperative number of medications.

Table 5. Preoperative and postoperative gonioscopic findings

in study groups

*ANCOVA is performed because of an imbalance of baseline PAS.

†Adjusted P value. Adjusted for preoperative PAS.

Goniosynechialysis combined with phacoemulsification is effective

in reducing PAS and IOP and improving visual acuity in patients with

uncontrolled APAC and CPACG.

(A) (B)

Figure 2. (A) Ultrasound biomicroscopy (UBM) shows synechial angle closure at the 9-o’clock

position (nasal) in an eye with acute primary angle closure before surgery. (B) UBM at the same 9-

o’clock position reveals that the angle is now open after phacoemulsification, intraocular lens

implantation and goniosynechialysis.