Researchers recently assessed whether phacoemulsification or laser peripheral iridotomy (LPI) resulted in better clinical outcomes for patients with acute primary angle-closure glaucoma (PACG) and found that early phaco was associated with fewer complications and a decreased medication burden.

The team assessed 40 acute PACG patients (19 had phaco and 21 had LPI). None of the participants underwent any additional glaucoma procedures, but the researchers noted that 15 of those who received LPI also had a lens extraction.

The investigators found that the phaco group used significantly fewer medications per eye (0.16 vs. 0.76 bottles) and had less extensive peripheral anterior synechiae (120° vs. 244°) and greater mean Shaffer gonioscopy grading (1.79 vs. 1.40) than the LPI group.

In the LPI group, five eyes had persistent IOP elevation greater than 21mm Hg in two consecutive visits and four eyes had blindness, defined as a BCVA worse than 6/60 and/or a central visual field of less than 20°. None of the eyes in the phaco group experienced any of these complications. The researchers found no significant difference in the mean IOP, BCVA or number of eyes with visual field progression between groups.

They concluded that in the long term, “early phacoemulsification performed shortly after the abortion of acute PACG attack is effective in preventing IOP elevation and blindness with less medication requirement compared with LPI.” Whether early phaco should be the primary procedure or done after LPI depends on the surgeon’s preference, they added. “LPI is still an important primary treatment to consider, especially when early phacoemulsification is difficult (e.g., inflamed eye with cornea edema, poor general health of patient who required general anesthesia). Even after a successful LPI, phacoemulsification should be performed early in order to open the angle, prevent further irreversible damage to the trabecular meshwork, lower the risk of IOP elevation and blindness, reduce medication requirement and improve visual acuity.” The study authors noted that life expectancy and visual function in the fellow eye are also important factors to consider in decision-making.

Chan PP, Fangyao T, Leung DY, et al. Ten-year clinical outcomes of acute primary angle closure randomized to receive early phacoemulsification versus laser peripheral iridotomy. J Glaucoma. February 1, 2021. [Epub ahead of print].