EBM Case Discussion Supervisor Dr Speaker R 1

EBM Case Discussion Supervisor: Dr. 蘇蔚文 Speaker: R 1 林子瑜

Case n name: 顧劉x桃 No. : 20992840 age: 73 F

Chief complaint (99. 8. 25) n Blurred vision OU. Glaucoma was diagnosed 2 months ago, cosopt use.

Past history n n n OPH history: OP (-), trauma (-) Right middle cerebral artery territory infarction with left hemiplegia, dysphagia and neurogenic bladder (since 99. 2. 11 ) Left leg deep vein thrombosis (under warfarin therapy )

Examination of eye n n VA: OD: L-S(+), OS: HM/100 CM PT : OD: 28. 3 mm. Hg , OS: 21. 9 mm. Hg Eyelid : clear OU conea: clear OU anterior chamber: shallow OU Lens: OD NS (+++) CO (+++) OS NS (+++) CO (+++) Fundus disc OD pale, C/D 0. 8 x 0. 9 inferior no rim OS pinkish, C/D 0. 7 x 0. 7

Course and treatment(99. 8 -100. 3) n drug n 1: cosopt 3: cosopt , alphagan, xalatan 4: cosopt , alphagan, xalatan, diamox n OP day

2011. 1. 18 phacoemulsification and of intraocular lens implantation(OU) n 2011. 1. 27 VA : OD: CF/60 cm, OS: 0. 04 n

Impression 1. Chronic angle closure glaucoma, OU 2. Senile cataract , OU post phacoemulsification and of intraocular lens implantation

Discussion lens extraction in chronic angle closure glaucoma

Mechanisms in Angle-closure Glaucoma n n pupillary block mechanism angle crowding: plateau iris configuration

Pathogenesis of Angle-closure Glaucoma and the Role of the Lens Mean anterior chamber depth in PAC eyes is approximately 1. 8 mm. n factor related to angle closure - lens thickness - anterior position of the lens n

Change after cataract surgery n n n anterior chamber depth angle opening distance at points 500 µm from the scleral spur trabecular–ciliary process distance attenuate anterior positioning of the ciliary processes widen of the angle Ophthalmology 2006; 113: 437– 441 c 2006 by the American Academy of Ophthalmology

Intraocular pressure reduction with cataract surgery n No evidence to suggest that more efficient removal of lens material have had any significant impact on the postoperative IOP. Current Opinion in Ophthalmology 2010, 21: 118– 122

In glaucoma patients n n vary with glaucoma diagnosis which related to preoperative angle anatomy Chronic angle closure glaucoma - Hayashi et al. in 2001, larger percentage of patients with CACG (40. 0%) did not require glaucoma medications postoperatively relative to those with POAG (19. 1%). - Lam and Hata in 2008 demonstrated 2. 4 - 2. 8 mm. Hg additional decreases in IOP for cataract surgery patients as compared with those undergoing LPI alone.

the effect of post cataract surgery - increase postoperative aqueous outflow facility - trabecular meshwork cells release interleukins and tumor necrosis factors, which increase synthesis of matrix metalloproteinases n

Clinical studies lens extraction for angle closure glaucoma (1988 -2007)

Survey of ophthalmology March to April 2009

pros title setting Number/time Result conclusion Phacoemulsification Treatment of Subjects With Acute Primary Angle Closure and Chronic Primary Angle-closure Glaucoma Prospective, crosssectional study 23(13, 10) / 6 months The IOP of subjects in the APAC group dropped to 12. 9 ± 7. 6 mm Hg compared with 15. 8 ± 7. 4 mm Hg in the CPACG group. (53. 25 ± 18. 78 mm Hg vs. 32. 00 ± 6. 00 mm Hg, P = 0. 015) phacoemulsification performed to provide short-term control of IOP is more efficacious in patients with APAC than in those with CPACG No randomized trial, retrospective study 59/52. 4 months Compare with two group of ECCE+ PCIOL with limbal-based trabeculectomy. No enough evidence of superiority of lens extraction to control IOP , visual field. No evidence from good quality trials studies of the effectiveness of lens extraction for chronic primary angle closure glaucoma. (J Glaucoma 2009; 18: 646– 651) cons Lens extraction for chronic angle closure glaucoma (Cochrane Database of Review, 2006)

Conclusion n n Lensectomy and PCIOL implantation for ACG patients may offer successful IOP control, and maintenance of improved vision. There is no evidence from good quality randomized trials of the effectiveness of lens extraction for CACG.

n Thanks for listening!!