Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma

Abstract

Primary angle closure glaucoma (PACG) is more blinding (1 in 4 cases) than primary open angle glaucoma (1 in 10 cases). Cataract surgery is an effective initial treatment for majority of cases of PACG. However, cataract surgery alone may not be enough to control intraocular pressure (IOP) in cases with extensive synechial angle closure glaucoma. It is reported that glaucoma drainage surgery is needed in 12% of PACG cases after cataract surgery. Some experts combine cataract surgery with either goniosynechialysis (GSL) or endocyclophotocoagulation (ECP) to enhance IOP control. However, neither combination ensures complete success. We report three subjects with extensive synechia! angle closure in whom we facilitated a technique that combines lens extraction with ECP and endoscopic—GSL (PIECES). We demonstrated that this combined technique was a more effective and efficient method of achieving lower IOP in the presence of extensive synechial PACG. We believe that it addresses both the inflow and outflow of the aqueous humor simultaneously. Two out of three patients had good IOP control without medication and one patient needed one drop after a minimum 12 months of follow up. Furthermore, it may reduce the need for medical therapy and future more invasive glaucoma drainage surgery.How to cite this article: Alaghband P, Rodrigues IAS, Goyal S. Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma. J Curr Glaucoma Pract 2018;12(1):45-49.

Primary Outcomes of Patients with Chronic Angle-Closure Glaucoma Treated with Combined Phacoemulsification, Viscogoniosynechialysis, and Endocyclophotocoagulation

“…Their report includes 3 patients with CACG and PAS ≥270°; the IOP was preoperatively 26, 45, and 40 mmHg, and postoperative reduction of IOP was 18, 10, and 10, respectively, at 12 months. In our study, mean preoperative IOP was 18.2 ± 6.6 and at 6 months, postoperative IOP was 12.8 ± 3.0 [9].…”

“…ECP is a complementary treatment to phacoemulsification and VGSL in patients with CACG and cataract to reduce aqueous humor production to control IOP [9, 14]. It has an acceptable safety profile compared with traditionally filtering surgery, and it could be considered a second-line treatment when iridotomy and glaucoma medications fail to control IOP [9]. In this study, we found a significant reduction in IOP and glaucoma medications; 44.8% patients did not need any glaucoma medication at 6 months after surgery.…”

“…ECP was first suggested by Thorpe in 1934 and developed by Uram in 1992. Its effectiveness and safety concerns to lower IOP have been demonstrated [9]. It uses an endolaser diode energy probe with an endoscope that directly visualizes and precisely photocoagulate ciliary processes, with the aim to reduce production of aqueous humor.…”

<p>MicroPulse Transscleral Laser Therapy with Kahook Dual Blade Excisional Goniotomy and Goniosynechialysis Combined with Phacoemulsification for Angle-Closure Glaucoma: A Case Report</p>

“…[5][6][7][8] However, cataract extraction alone cannot address the synechial angle closure, and various studies have indicated that phacoemulsification combined with goniosynechialysis (GSL) and excisional goniotomy in PACG is a safe and more effective treatment for IOP reduction than cataract surgery alone. 9 GSL is a surgical technique that aims to strip the peripheral anterior synechia (PAS) from the angle, exposing the TM in an attempt to restore the normal aqueous outflow. The inclusion of excisional goniotomy, which involves TM strip excision using the Kahook Dual Blade (KDB, New World Medical, Rancho Cucamonga, CA) can adequately address the trabecular dysfunction caused by chronic synechiae and scarring of outflow channels.…”

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“…Three quarters of cases occur in female subjects. There are 1.60 million people in Europe and 581,000 people in the USA with PACG [2].…”