The authors of this randomized controlled trial compared phacoemulsification alone or in combination with goniosynechialysis (phacoGSL) in patients with primary angle-closure glaucoma (PACG).

Study design

The study included 80 patients with uncontrolled PACG on maximal hypotensive therapy that were randomized into two groups. Group 1 underwent phaco alone and group 2 underwent phaco with goniosynechialysis (phaco-GSL). Patients were examined at baseline and at postop week 1, month 1, month 3 and month 6. The primary outcome measure was IOP reduction; a reduction in IOP of 20% or more from baseline, with or without medications, was considered a success. Secondary outcomes measures included changes in anterior chamber angle parameters measured on swept-source anterior segment OCT, surgical safety, visual acuity and reduction in the number of glaucoma medications.

Outcomes

Group 1 (phaco alone) and 2 (phaco-GSL) had comparable baseline age range (high 50s) and preoperative mean IOPs of about 30 mm Hg. At 6 months of follow-up, mean IOP was about 13 mm Hg in both groups, representing a 55.3% (group 1) and 56.9% (group 2) IOP decrease. There was also a significant widening of the angle parameters compared with baseline values in both groups.

Limitations

Though the study attempted to measure the impact of goniosynechialysis for peripheral anterior synechia (PAS), it did not report preoperative or postoperative extent of PAS. Since long-term success of phaco or phaco-GSL appears to be dependent on the amount of residual PAS, it would be prudent to know the difference in residual PAS between the two groups.

Clinical significance

Lensectomy with or without goniosynechialysis for primary angle closure glaucoma is an effective procedure for lowering IOP and can generally be a sufficient and preferred surgical approach. To ensure long-term success in such patients, the surgeon should assess for residual PAS. If residual PAS is clinically significant (>3 to 4 clock hours) and likely to cause chronic angle-closure, goniosynechiolysis should be considered.