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Original Investigation
July 11, 2019

Efficacy of Phacoemulsification Alone vs Phacoemulsification With Goniosynechialysis in Patients With Primary Angle-Closure Disease: A Randomized Clinical Trial

Author Affiliations
  • 1Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
  • 2Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  • 3Vietnam National Institute of Ophthalmology, Hanoi, Vietnam
  • 4Li Ka Shing Faculty of Medicine, University of Hong Kong and Queen Mary’s Hospital, Hong Kong
  • 5Faculty of Medicine, Siriraj Hospital, Mahjidol University, Bangkok, Thailand
  • 6Department of Ophthalmology, Guy’s and St Thomas’ National Health Services Foundation Trust, London, United Kingdom
JAMA Ophthalmol. 2019;137(10):1107-1113. doi:10.1001/jamaophthalmol.2019.2493
Key Points

Question  What is the efficacy of phacoemulsification combined with goniosynechialysis compared with phacoemulsification without goniosynechialysis in lowering of intraocular pressure after 1 year?

Findings  In this randomized clinical trial of 78 patients with synechial primary angle-closure disease, lowering of intraocular pressure of approximately 7 to 8 mm Hg was achieved by both phacoemulsification alone and phacoemulsification with goniosynechialysis after 1 year.

Meaning  This randomized clinical trial was unable to show that goniosynechialysis with phacoemulsification provided additional lowering of the intraocular pressure compared with phacoemulsification without goniosynechialysis.

Abstract

Importance  The effectiveness of intraocular pressure (IOP) lowering phacoemulsification combined with goniosynechialysis (GSL) compared with phacoemulsification without GSL remains unknown.

Objective  To compare the IOP outcome after 1 year in patients with synechial primary angle-closure disease (PACD) and cataract who underwent phacoemulsification with intraocular lens implantation (PEI) alone compared with PEI with GSL (PEI-GSL).

Design, Setting, and Participants  A multicenter randomized clinical trial was conducted from September 29, 2011, to March 16, 2015; data analysis was performed from April 1, 2015, to March 4, 2019. Patients with PACD, defined as primary angle closure or primary angle-closure glaucoma, and at least 90° peripheral anterior synechiae (PAS) with cataract were included. Patients were randomized to undergo PEI alone or PEI-GSL. Patients were followed up for 1 year with standardized evaluations. Intention-to-treat analysis was performed.

Interventions  Phacoemulsification with intraocular lens implantation alone or with GSL.

Main Outcomes and Measures  Successful control of IOP at 12 months, defined as IOP 21 mm Hg or lower without use of topical IOP-lowering medications and a decrease in IOP of 20% or more from baseline IOP.

Results  Data from 78 patients (78 eyes) were analyzed. Of these, 37 patients were Chinese (47.4%) and 54 were women (69.2%); mean (SD) age was 67.7 (8.9) years. Mean deviation (SD) at baseline was −13.5 dB (9.4 dB). Forty patients were randomized to the PEI group and 38 to the PEI-GSL group. The mean (SD) IOP at baseline was 22.3 (8.5) mm Hg for the PEI group and 22.9 (5.3) mm Hg for the PEI-GSL group. At 1 year, the mean IOP was 14.3 (5.0) mm Hg for the PEI group and 15.9 (4.5) mm Hg for the PEI-GSL group. Successful control at 1 year occurred in 21 patients (52.5%) in the PEI group and 22 patients (57.9%) in the PEI-GSL group (mean difference, 5.4%; 95% CI, −18.0% to 28.2%; P = .63). In eyes that achieved successful control, mean IOP at 1 year was 12.5 (2.7) mm Hg (range, 7.0-19.0) for the PEI group and 13.6 (2.4) mm Hg (range, 9.0-18.0) for the PEI-GSL group. The number of medications at baseline and 1 year decreased from a mean of 2.2 (0.8) to 0.5 (0.9) in the PEI group and 1.9 (0.9) to 0.6 (1.2) in the PEI-GSL group (P < .001 for each), with a mean change difference of 0.4% (95% CI, −0.02% to 0.9%; P = .06). There were 3 postoperative complications (7.5%) in the PEI group and 3 (7.9%) in the PEI-GSL group. These included IOP spike (IOP≥30 mm Hg) (n = 3), excessive anterior chamber inflammation (n = 1), and posterior capsule opacification (n = 2).

Conclusions and Relevance  This randomized clinical trial was unable to show that PEI-GSL added additional IOP lowering compared with PEI alone in patients with PACD.

Trial Registration  ClinicalTrials.gov identifier: NCT02376725

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