Glaucoma is an irreversible blinding eye disease, and the last thing we want to see in our clinical work is that the patient comes to us with advanced glaucoma, which is very difficult to treat, but we can’t just watch the patient go blind, and as a doctor facing this situation, we will be very torn. In clinical work, we have met some patients with advanced closed-angle glaucoma and achieved good results in treatment. Case: Male, 78 years old, blurred vision in the left eye for 1 year. In early 2010, physical examination suggested increased crystal density in both eyes. In August 2010, he was seen at Anzhen Hospital, and his IOP was 38 mmHg in the left eye. The left eye was treated with Mogrozanine, Meclaren, Alfagen, and Pyridoxine, and the pressure in the left eye was 35-38 mmHg. Ophthalmologic examination in 2011: visual acuity of the left eye was 0.6, peripheral anterior chamber was slit-like, central anterior chamber was shallow, crystal density was increased, and there was no significant clouding. Atrial angle (left eye): N4 in all quadrants, but light misalignment , iris root bulge, angle of incidence less than 10 degrees Endothelium (left eye): 1421 (significantly lower than normal) Visual field: canal vision Fundus: pale optic papilla in left eye, cup-to-disc ratio 1.0 Preoperative anterior segment and preoperative visual field The patient consulted in many hospitals and concluded that the left eye could only be controlled by medication, poor visual field, low endothelial count, high surgical risk, and unclear results. Blindness is unavoidable and the focus should be on follow-up and treatment of the contralateral eye to avoid the same situation. The situation in this patient’s left eye is indeed very pessimistic, and the first question for the physician is whether to treat or not to treat. The outcome of no treatment is obvious, with complete blindness in the left eye expected within a year; the risks of treatment are also obvious, with the likelihood of no light from posterior bulbar anesthesia, violent choroidal hemorrhage, and corneal loss significantly higher for this patient than for others, any of which could result in immediate loss of vision. Faced with such a patient with advanced glaucoma whose vision was still 0.6, I decided that it was treatment. However, I gave the patient a detailed analysis in terms of risks and benefits, and hoped that the patient would think carefully about it. Finally, the patient asked for treatment after careful consideration. In terms of treatment, the surgical options available to us included trabeculectomy alone, clear lens extraction + trabeculectomy, clear lens extraction + atrial angle separation, and ciliary laser photocoagulation. After careful analysis of the patient’s data and consideration of the number of complications associated with the different surgical procedures, I chose to perform clear lens extraction + IOL implantation + atrial angle separation on this patient, with appropriate treatment for high intraocular pressure, shallow anterior chamber, and low endothelial count. The patient’s surgery went well, and the IOP dropped to 10 mmHg on the second day after surgery without corneal edema, and the corrected visual acuity reached 1.0. Since then, all IOP-lowering medications were stopped, and the IOP was maintained between 10-13 mmHg, and the patient has been followed up for more than 9 months. With the patient’s IOP maintained at this level, I believe that the existing visual function will hopefully stay with him for the rest of his life. The patient’s anterior segment on the first postoperative day, with significant anterior chamber deepening: In dealing with similar patients, my experience is that clear lens removal + atrial angle separation is very effective for early, intermediate, and late primary angle-closure glaucoma where neither medications nor laser can control IOP, but there are some issues to keep in mind during this process: 1. Pay attention to communication with the patient: patients with glaucoma have a unique psychology. It is important to respect the patient’s choice when the risks and benefits are made clear. This patient’s ability to be treated at the edge of darkness depends more on his own determination to demand treatment. The physician’s confidence in the face of high-risk surgery comes from the patient’s determination. If the patient is hesitant, the physician will be apprehensive, and ultimately the patient will lose the opportunity for treatment and slowly slide into darkness. 2. Choosing the right surgery is crucial: Patients with advanced glaucoma usually have only one chance to be treated and cannot afford to choose another surgery after one has failed. Therefore, it is very important to carefully analyze the patient’s situation before surgery and choose a suitable treatment plan. 3. Clear lens removal for advanced angle-closure glaucoma is a test of the surgeon’s surgical skills: handling this type of patient is more difficult than handling simple cataracts, and only on the basis of proficiency and precision in general cataract surgery can one attempt to handle such a patient. Although these patients are at high risk and have poor visual fields, their central vision is usually very good. The surgery must not only avoid serious complications and solve the glaucoma problem, but also make the patient’s vision as close to or even higher than the vision before the surgery.