The traditional treatment for closed-angle glaucoma is periradicular iridotomy or filtration surgery, but postoperative complications often include accelerated cataract formation, shallow anterior chamber, filter bubble scarring, and poor IOP control. Cataract simple ultrasound emulsion aspiration (Phaco) combined with artificial lens (IOL) implantation can reduce IOP in the operated eye. The procedure can also be combined with atrial angle separation (GSL) to achieve better results. In this study, we investigated the effectiveness of cataract ultrasound emulsion aspiration combined with atrial angle separation in the treatment of closed-angle glaucoma. The results are reported as follows.
Data and methods 1. Clinical data: 36 patients (38 eyes) with inpatient closed-angle glaucoma, 12 men (14 eyes) and 24 women (24 eyes), aged 69.9-6.7 years, were collected consecutively from January 2006 to December 2006, of which 20 eyes were primary acute closed-angle glaucoma (hereinafter referred to as acute closure) and 18 eyes were primary chronic closed-angle glaucoma (hereinafter referred to as slow closure). The patients had preoperative visual acuity in front of the manual eye to 0.8. All had varying degrees of lens clouding and were graded according to the Locs II classification. The follow-up period was 3 to 18 months, with a mean of (8.5sh3.5) months.
2.Preoperative preparation: Different measures were taken to lower the IOP according to the patient’s IOP at the time of admission. The drugs mainly included: pupil constrictor (1% trigonelline ophthalmic solution), β-blocker (0.5% thimerosal ophthalmic solution), carbonic anhydrase inhibitor (vincristine tablets) and hypertonic agent (20% mannitol injection) to control the preoperative IOP within 35 mmHg.
3.Surgical method: 30 minutes before surgery 5% neuflex + 0.25% tropicamide eye solution to dilate the pupil. 2% lidocaine + 0.75% bupivacaine drops into the conjunctival sac 2 to 3 times surface anesthesia. Superior clear corneal incision. An auxiliary incision is made at the 3:00 orientation clear corneal margin with an anterior chamber puncture knife. After injection of viscoelastic into the anterior chamber, a continuous circular tear capsule of approximately 5.5 mm in diameter was made. Adequate subcapsular water separation was performed. Using a German Geuder ultrasonic emulsifier with a power setting of 40% to 50% and a negative pressure suction of 150 to 200 mmHg, intracapsular lens nucleus emulsification was performed, and the nucleus fragmentation method was used in situ and aspirated in pieces. The average postoperative energy and time were:40% and 21 seconds for class I nuclei, 40-50% and 41 seconds for class II nuclei, and 50% and 1 minute and 14 seconds for class III nuclei. The automated perfusion/suction system removed the residual lens cortex. The anterior chamber and capsular bag were filled with viscoelastic, and a SensarAR40e IOL with an optical diameter of 6.0 mm was implanted in the capsular bag. Camicoline was used to shrink the pupil, and the viscoelastic injection and aspiration needle was used to gently press the iris root and bluntly separate the anterior chamber angle at 360°. After surgery, wrap the single eye.
4. Observation items: observe intraoperative and postoperative complications. Postoperative visual acuity, intraocular pressure, atrial angle opening, A ultrasound measurement of anterior chamber depth, inflammatory reaction and IOL in situ, and medication use.
5. Statistical processing: The data were analyzed by statistical processing using SPSS 11.0 statistical package, and P < 0.05 was considered statistically significant. Results 1. IOP: In the 20 eyes of the acute closed group that received Phaco ten GSL, the mean IOP was (19.6 Shi 5.9) mmHg before surgery and (10.9 Shi 2.3) mmHg after drug control, t=6.1442, P<0.01; in the 18 eyes of the slow closed group, the mean IOP was (19.9 Shi 4.1) mmHg before surgery and (15.1 Shi 3.8) mmHg after surgery. The postoperative IOP in both groups was significantly lower than that in the preoperative group, and the difference was significant. 2. Comparison of medications before and after surgery: 19 eyes (95.0%) in the acute closed group and 15 eyes (83.3%) in the slow closed group did not use any IOP-lowering drugs after surgery, and the IOP was controlled normally. 3. Anterior chamber depth (ACD): The ACD was measured by Sine Scan ophthalmic ultrasound instrument manufactured by Phototaxx, France, and was (2.07 Shi 0.23) mm in the acute closed group before surgery and increased to (3.62 Shi 0.36) mm after surgery, t=16.2261, P<0.01; in the slow closed group, it was (2.36 Shi 0.36) mm before surgery and increased to (4.03 Shi 0.46) mm after surgery. (0.46) mm, t=14.0907, P<0.01, there were significant differences between the two groups before and after surgery. 4, atrial angle examination: the anterior atrial angle was wider in both groups after surgery than before surgery, the quadrant where the atrial angle was closed before surgery had different degrees of opening, and the scope of peripheral anterior adhesions became smaller or disappeared. In the acute closure group, 20 eyes were completely opened (100.0%); in the slow closure group, 13 eyes were completely opened (72.2%) and 5 eyes were partially opened (27.8%). The difference between the two groups was significant,χ2=6.3973, P<0.05. The degree of opening of the acute closed atrial angle was better than that of the slow closed. 5, visual acuity: 32 eyes (84.2%) had improved best corrected visual acuity after primary angle-closure glaucoma in 38 eyes, 19 eyes (50.0%) had corrected visual acuity >0. 5, 6 eyes (15.8%) had no improvement in corrected visual acuity after surgery, and different degrees of glaucomatous optic nerve damage were found.
6. Postoperative complications: all patients did not have intraoperative posterior capsule rupture, and a total of 5 eyes (13.2%) had mild corneal endothelial edema, all of which recovered after 2-3 days of conservative treatment; all patients did not have serious complications such as corneal endothelial loss and retinal detachment after surgery.
In 1979, Simmons [4] used atrial angle separation to treat acute closed glaucoma after retinal detachment surgery, and Teekhasaenee and Ritch reported a high success rate of using ultrasound emulsification combined with atrial angle separation to treat early closed angle glaucoma. The success rate was high.
The feasibility of cataract ultrasonic emulsion aspiration combined with viscoelastic atrial angle separation for the treatment of closed-angle glaucoma lies in the following: (1) The intraoperative replacement of the approximately 5.5 mm thick human lens with an artificial lens less than 1.0 mm thick removes the lens factor, and the postoperative central and peripheral anterior chamber depths are significantly deepened, and the pupillary margin and lens contact plane are posteriorly shifted, thus resolving the pupillary block state. (2) When the IOL was implanted into the capsular bag, the crystal formed a pulling force on the bag, pulling the suspensory ligament, increasing the space, which was conducive to the drainage of atrial fluid and lowering the IOP. (3) The intraoperative incision is airtight, which can achieve high perfusion pressure effect. (4) Blunt separation of the entire circumference of the iris root using viscoelastic allows for varying degrees of widening or reopening of the adherent atrial angle. (5) In cases with partial posterior iris adhesions, we use an I/A aspiration tip to perform traction aspiration in the central direction of the iris pupillary margin to release the posterior iris adhesions by mechanical action on the one hand, and to induce the release of some inflammatory mediators such as interleukins [7] and prostaglandins [8] in the atrial fluid, which have the effect of promoting the degradation of the extracellular matrix of the trabecular meshwork, thus increasing the ease of atrial fluid flow. (6) Ultrasound itself can cause a decrease in ciliary secretion, reduce atrial aqueous secretion, and treat glaucoma.
This study focused on the comparison of surgical efficacy between acute closure and slow closure, and the results showed that: (1) IOP decreased significantly after both acute closure and slow closure, and the level of IOP was lower and decreased more after acute closure than slow closure. (2) The number of cases using anti-glaucoma drugs after acute closure and slow closure was significantly reduced, and the number of cases using drugs after acute closure was even less. In the slow-closure group, there were three cases of gradual increase in IOP after six months after surgery, and examination of the atrial angle did not reveal any significant difference from those with controlled IOP. (3) The degree of postoperative acute closure of the atrial angle opening was better than that of slow closure. Therefore, the surgical results of cataract ultrasound emulsion aspiration combined with atrial angle separation for acute closure were better than those for slow closure. Possible reasons for the difference in efficacy: (1) The pupillary block factor plays a key role in the pathogenesis of acute occlusion, and the surgery released the relative pupillary block caused by the lens, allowing the atrial angle to reopen. In contrast, the development process of slow-closure atrial angle adhesions is slow and gradual, and their atrial angle morphology is not changed by cataract surgery. (2) In acute occlusion, the duration of the disease is short, the atrial angle adhesions are not firm, or the atrial angle closure is only contact closure. Slowly closed atrial horns have mostly formed adhesions, and although they are opened by atrial horn separation, the trabecular function has been progressively damaged.
Atrial angle dissection is effective in reducing pressure in closed-angle glaucoma and can be more effective when combined with cataract extraction. The order of atrial angle separation and cataract ultrasound aspiration can be arbitrary, but in all cases we studied, cataract ultrasound aspiration followed by atrial angle separation was performed. The shallow anterior chamber and the raised anterior surface of the iris are difficult and skillful for atrial angle dissection. Otherwise, more intraoperative complications may occur, such as iris root dissection, anterior chamber hemorrhage, postoperative transient IOP elevation, and failure to prevent atrial angle re-adhesion. In addition, the choice of a clear corneal incision is necessary to protect the superior bulbar conjunctiva to allow space for possible future trabecular surgery. In conclusion, cataract ultrasonic lens implantation combined with anterior chamber angle separation for the treatment of closed-angle glaucoma with combined cataract has a synergistic effect with superimposed effects, good control of IOP, rapid improvement of visual acuity, and safe and simple operation. However, there is still no definite conclusion on the applicable evidence of using ultrasound alone or combined with atrial angle separation, which deserves further study and comparison.