Lens extraction for uncontrolled angle-closure glaucoma: long-term follow-up. A randomized study of trabeculectomy and subconjunctival administration of fluorouracil in primary glaucomas.
To evaluate the long-term effects of extraction of incipient cataracts or clear lenses on glaucoma control in patients with subacute or chronic angle-closure glaucoma.
                Department of Ophthalmology, University of Amsterdam, The Netherlands.
                This retrospective analysis comprised 22 extracapsular lens extractions with implantation of a posterior chamber intraocular lens in 18 patients with chronic or subacute angle-closure glaucoma (Group 1). The effect of glaucoma control was evaluated using visual field examination, diurnal intraocular pressure (IOP) curves, gonioscopic appearance, and number of antiglaucoma medications. The results were compared with those in 25 eyes of 19 patients with chronic angle-closure glaucoma in whom a filtering procedure was performed (Group 2).
                Glaucoma control was achieved in 15 eyes (68%) in Group 1 and in 17 eyes (68%) in Group 2. Mean preoperative IOP was 27.9 mm Hg +/- 8.1 (SD) and 29.0 +/- 7.7 mm Hg, respectively. Mean postoperative IOP was 17.1 +/- 2.9 mm Hg (Group 1) and 14.8 +/- 6.6 mm Hg (Group 2) after a mean follow-up of 52.6 and 58.9 months, respectively. Mean number of ocular hypotensive medications preoperatively was 2.3 +/- 0.8 in Group 1 and 2.2 +/- 0.8 in Group 2 and at last follow-up, 1.3 +/- 0.7 and 0.52 +/- 0.8, respectively. Twenty eyes (91%) in Group 1 had the same or better final visual acuity than before surgery. In Group 2, the final visual acuity was unchanged or better in 13 eyes (52%) and worse in 12 eyes (48%); subsequent cataract surgery was performed in 9 (75%) of these 12 eyes. Additional incisional surgery was done or recommended in 6 eyes (27%) in Group 1 and 20 eyes in Group 2 (80%).
                Drainage surgery in patients with angle-closure glaucoma proved to be associated with multiple surgical interventions and deterioration in visual function. The choice of first a cataract procedure with the option of a future trabeculectomy may be a more attractive approach in patients with subacute or chronic angle-closure glaucoma than trabeculectomy followed by an optional cataract procedure. Forty-one adult patients with primary open angle glaucoma and nine adult patients with chronic angle closure glaucoma underwent trabeculectomy in one eye each. Twenty-one eyes with primary open angle glaucoma and four with chronic angle closure glaucoma were randomly assigned to receive four to six subconjunctival injections of fluorouracil for 10 days after surgery. Twenty-five control eyes did not receive fluorouracil. Intraocular pressure was 20 mm Hg or lower in 24 eyes (96%) in the treatment group after mean follow-up of 17.8 months and in 19 control eyes (76%) after mean follow-up of 17.5 months (P less than .05). Encapsulated bleb developed in three (12%) of the fluorouracil-treated eyes vs two (8%) of the control eyes. A few injections of fluorouracil adequately inhibited scarring. This might be explained by its toxic effect on existing fibroblasts. Overall, trabeculectomy with injection of fluorouracil was found to be efficacious and relatively safe. Further studies regarding late complications are required.
There is no evidence from good quality randomized trials or non-randomized studies of the effectiveness of lens extraction for chronic primary angle-closure glaucoma.