Peripheral iridotomy helps many patients with angle-closure glaucoma, effectively reducing the risk of closure. However, surgeons may question what the best option is when iridotomy does not work. The answer depends on the patient’s disease state, lifestyle, and other needs, and these factors mean that selection of the right therapy is best determined through careful consideration and discussion. The following case will present an example of a patient with angle-closure glaucoma and describe the course taken to help the patient.

A Case With Complex Needs

A 41-year-old man was referred 1 year after diagnosis of angle-closure glaucoma. The referring ophthalmologist had performed a peripheral iridotomy a year earlier, but the patient’s pressure remained elevated at 23 mmHg on maximum tolerated medical therapy. In addition, he was still experiencing symptoms of angle closure.

Plateau Iris Configuration

Appositional angle closure was apparent in both eyes on gonioscopy and anterior-segment optical coherence tomography (OCT). Ultrasound biomicroscopy showed a typical plateau iris configuration (Figure 1). Not only did the patient have an anteriorly vaulted lens with appositional angle closure, but he also had large anteriorly rotated ciliary processes. The nature of the closure was primary angle closure with a plateau iris component, as well as a phakomorphic component with some anterior lens vault.

Good Optic Nerve and Clear Vision

The patient’s cup-to-disc ratio was 0.3, so no damage had yet occurred to the optic nerve. He also had excellent 20/15 uncorrected vision. We needed to open up the angles and bring down his pressure. Glaucoma medications were not preferred by the patient because he had poor tolerance for those he had used previously.

Pilocarpine Intolerance

In addition to lowering the pressure, it was almost equally important to alleviate the patient’s very symptomatic pilocarpine intolerance. He was dependent on pilocarpine to prevent symptoms of intermittent angle closure, but he had developed intolerance to the drug that severely affected his vision — the induced myopia was so severe that he could not see clearly for 3 to 4 hours after using pilocarpine. He also suffered from allergy and asthma symptoms because he could not take his usual over-the-counter allergy and asthma medications, which exacerbate the risk of angle closure.

Clear Lens Extraction With ECP and ECPL

We had a long discussion about the patient’s treatment options. Lower-dose pilocarpine was not on the table because of his intolerance to 1.0%. Laser iridoplasty was a reasonable choice, but he disliked the temporary nature of the procedure and probable continued limitations on allergy medications. Iridoplasty would likely prove effective for only a few years, and it would not open up the plateau iris, so it would still be risky to take allergy and asthma medications.

We discussed clear lens extraction with laser treatment of the ciliary processes, which appealed to him because it would provide results with better longevity. I tried to talk him out of this approach because his vision was 20/15, and I could not guarantee that his vision would be as good after the procedure. He insisted on taking this approach, however, because he wanted a more permanent treatment option that alleviated both his symptoms and his medication worries.

I performed clear lens extraction with endoscopic cyclophotocoagulation (ECP) and endocycloplasty (ECPL) (Endo Optiks E2 laser and endoscopy system; BVI) to shrink the processes, anatomically change the plateau iris problem, and also lower the intraocular pressure (IOP).

When performing the procedure, I dilate the eye for surgery, extract the lens, implant the intraocular lens (IOL), and then perform ECP and ECPL. In ECP, we treat the processes and areas between them (Figure 2). The ECPL procedure shrinks the large processes and pulls them posteriorly away from the iris, reversing the anatomic cause of plateau iris syndrome, as well as the angle closure.¹ For both procedures, I typically treat 3 quadrants. From a temporal approach, I treat the superior, inferior, and nasal quadrants and leave the temporal quadrant untreated, so I do not need to make a second incision. I find it works quite well, both anatomically and in terms of the pressure reduction that is achieved.

Outcomes of the Procedures

The patient had excellent results (Figure 3). The angles were opened, and the patient is off pilocarpine. His pressure was reduced to the mid-teens, so he does not need glaucoma medications. The patient can also take allergy medications when he needs them without worrying about his pupils dilating and raising the risk of angle closure.

The concern that his vision might be 20/20 or 20/25 after surgery was allayed; fortuitously, his vision remains 20/15. He chose a monofocal distance lens (Tecnis Monofocal 1-Piece IOL; Johnson & Johnson Vision) after a long discussion about monofocal distance and multifocal IOLs. He did not want to risk the potential for glare and halos associated with multifocal lenses, and he had already begun wearing reading glasses and was content to continue using them.

The patient is very happy. He has clear vision and comfortable eyes, and his allergies and asthma are under control. He feels he has the freedom to stop worrying about his angles and eye drops and just live his life. I continue to follow him like any other glaucoma suspect.

An Anatomic Solution

The combination of ECP and ECPL is an elegant solution that changes not only the physiology to lower IOP but also the anatomy. For this young patient, it provided the permanence and freedom he wanted so he can live a lifestyle that is more to his liking, with excellent vision and no more limitations — a lifestyle virtually identical to that of other healthy 41-year-old individuals.

Reference

1. Francis BA, Pouw A, Jenkins D, et al. Endoscopic cycloplasty (ECPL) and lens extraction in the treatment of severe plateau iris syndrome. J Glaucoma. 2016;25(3):e128-e133. doi: 10.1097/IJG.0000000000000156.