Kataraktoperation mit Hinterkammerlinsenimplantation zur Behandlung des akuten Glaukoms

OBJECTIVE: The aim of this study was to compare phacoemulsification in eyes with angle-closure glaucoma to the partner eyes with or without iridectomy or laser iridotomy, respectively. METHODS: Twelve eyes with an elevated intraocular pressure due to an angle closure that were treated by phacoemulsification and IOL implantation were compared with 12 partner eyes with narrow angle and iridectomy or iridotomy without intraocular pressure elevation and cataract extraction. The average follow-up period was 15.7+/-2.1 months. RESULTS: The average intraocular pressure in eyes with angle-closure glaucoma was 54.1+/-14.7 mmHg and in the partner eyes 22.4+/-8.6 mmHg preoperatively. Follow-up pressure was 19.3+/-2.0 mmHg in eyes with angle-closure glaucoma and 18.8+/-1.5 mmHg in the partner eyes.CONCLUSION: Primary cataract extraction including posterior chamber lens implantation into eyes with angle-closure glaucoma reduced intraocular pressure to normal levels, increased visual acuity, and decreased the number of antiglaucomatous drugs. Eyes with angle-closure glaucoma do not respond differently to phacoemulsification and lens implantation compared to eyes with narrow angle without pressure elevation during and after phacoemulsification.     

激光虹膜切除术治疗早期原发性闭角型青光眼

目的评价激光虹膜切除术治疗早期原发性闭角型青光眼的疗效。方法对62例（112眼）早期原发性闭角型青光眼按不同类型分为3组，分别行激光虹膜切除术，观察术前及术后1h、1周、3月的眼压、前房深度、前房角等变化情况。结果所有病例治疗后中央及周边前房深度都有不同程度加深。暗室试验阳性组治疗后平均眼压（13．71±2．29）mmHg。且房角未出现关闭。原发性急性闭角型青光眼组治疗后平均眼压（14．69±2．43）mmHg，11．9％的眼出现了15。以内的房角关闭。原发性慢性闭角型青光眼组治疗后平均眼压（23．18±5．66）mmHg，房角关闭增加15。以内5只眼，增加300。600的3眼，共占50．00％。结论激光虹膜切除术是预防和治疗早期闭角型青光眼，保护视功能的一种有效手段。但由于慢性闭角型青光眼发病机制复杂，应通过术前病例的合理选择及术后的密切随访，有效控制术后病情的发展。     

Laser peripheral iridoplasty as initial treatment of acute attack of primary angle-closure: a long-term follow-up study

PURPOSE: To study the long-term clinical course and complications of patients with acute primary angle-closure treated with immediate laser peripheral iridoplasty followed by laser peripheral iridotomy. PATIENTS AND METHODS: Consecutive patients with acute primary angle closure treated with immediate laser peripheral iridoplasty, followed by laser peripheral iridotomy, at the Prince of Wales Hospital from July 1997 through January 2000 were followed up to document the clinical course of their disease and any complications from the laser treatment. Visual acuity, intraocular pressure, gonioscopic findings, corneal and lens clarity, iris appearance, pupillary reaction, and progression of glaucomatous optic neuropathy were evaluated. RESULTS: Thirty eyes of 29 Chinese patients with acute primary angle closure treated initially with either argon or diode laser peripheral iridoplasty were recruited. The mean follow-up period was 33.0 +/- 9.3 months. Twenty-one eyes (70%) had no further attack and maintained normal intraocular pressure without medications, and 9 eyes (30%) developed chronic angle-closure glaucoma with peripheral anterior synechiae. All eyes had pigmented laser marks on the peripheral iris, but none had peripheral corneal burn. CONCLUSIONS: Long-term follow-up data indicated that 30% of Chinese eyes with acute primary angle closure successfully treated with immediate laser peripheral iridoplasty followed by laser peripheral iridotomy developed peripheral anterior synechiae and an increase in intraocular pressure. There were minimal long-term complications on the cornea and the lens from the laser treatment.     

Angle-closure Glaucoma: The Role of the Lens in the Pathogenesis, Prevention, and Treatment

Primary angle-closure glaucoma is a major cause of blindness worldwide. It is a disease of ocular anatomy that is related to pupillary-block and angle-crowding mechanisms of filtration angle closure. Eyes at increased risk for primary angle-closure are small with decreased axial length, anterior chamber depth, and filtration angle width, associated with a proportionately large lens. Angle-closure glaucoma afflicts Asian and Eskimo eyes more frequently than eyes in other races with similar predisposing dimensions. The treatment of primary angle closure addresses its causal mechanisms. Laser peripheral iridotomy equalizes the anterior and posterior pressures and widens the filtration angle by reducing the effect of pupillary block. Argon laser peripheral iridoplasty contracts the iris stroma to reduce angle crowding and is helpful for some affected eyes. Lensectomy dramatically widens the angle and eliminates pupillary block. Clinical reports of lensectomy with posterior chamber intraocular lens implantation in the treatment of acute, chronic, and secondary angle-closure glaucoma describe very favorable results. The appropriate role for lensectomy in the management of primary angle closure, however, remains unproven. Prospective, randomized clinical trials are ongoing to determine the value and comparative risks and efficacy of lensectomy versus medical therapy, laser peripheral iridotomy, laser iridoplasty, and filtration procedures for the treatment of acute and chronic primary angle closure and for the prevention of chronic angle-closure glaucoma, both after and in place of laser peripheral iridotomy.     

Experiences with laser therapy in different forms of glaucoma with open and closed chamber angle

Results of laser treatment of open-angle and angle-closure glaucomas are communicated. Argon laser trabeculoplasty was performed in 78 eyes with open-angle glaucoma. The most favorable site for photocoagulation was the gone between the pigmented and nonpigmented trabecular meshwork. Forty-two eyes with angle-closure glaucoma were treated by argon laser gonioplasty. This method proved successful in chronic angle-closure glaucoma and for the prophylactic management of acute angle-closure glaucomas. A combination of argon laser gonioplasty and argon laser trabeculoplasty was used in 16 eyes. Both methods were found to be effective in treating certain forms of juvenile glaucoma. A further 11 eyes with acute angle-closure glaucoma were treated by Nd-YAG laser iridotomy, 9 of them successfully.     

Neodymium-YAG laser iridotomy in angle closure glaucoma: preliminary study.

A prospective short-term preliminary clinical study to evaluate the efficacy and immediate complications of Q-switched Nd-YAG laser iridotomy in the treatment of acute and chronic angle closure glaucoma is described. The follow-up period ranged from four to 10 months. Of 40 eyes treated 36 (90%) required a single lasing session for patency (19, one application; 17, two applications), and four eyes (10%) required two sessions. Closure of the iridotomy site following Nd-YAG lasing due to pigment epithelium proliferation occurred in 10% of eyes, an incidence remarkably lower than that of argon laser iridotomy. Transitory closure or diminution of a prior patent iridotomy during the first hour after lasing was observed in 6.7% of eyes. Patency was again noted up to three weeks later and remained unchanged. Immediate postoperative complications included a marked increase in ocular pressure (42% of eyes), minimal transitory bleeding, and transitory localised corneal oedema at the lasing site. Persistent iridocorneal adhesion at the lasing site was noted in three eyes, and localised lenticular opacities, of non-progressive type, were observed in one eye.     

New Management of Angle—closure Glaucoma by Phacoemulsification with Foldable Posterior Chamber Intraocular Lens Implantation

Objective: To investigate the management oi angle-closure glaucoma byphacoemulsification with foldable posterior chamber intraocular lens (PC-IOL)implantation.Design: Retrospective, noncontrolled interventional case series.Participants: In 36 eyes with angle-closure glaucoma (ACG) , there were 18 eyes withprimary acute angle-closure glaucoma (PACG) , 14 eyes with primary chronicangle-closure glaucoma (PCCG) , 3 eyes with secondary acute angle-closure glaucoma(SACG) and 1 eye with secondary chronic angle-closure glaucoma (SCCG).Intervention: Phacoemulsification with posterior chamber intraocular lens implantation.Main Outcome Measures: Postoperative visual acuity, IOP, axial anterior chamberdepth.Results: After a mean postoperative follow-up time of 8. 81±7. 45 months, intraocularpressure was reduced from a preoperative mean of 23. 81 ±17. 84 mmHg to apostoperative mean of 12. 54 4. 73 mmHg ( P =0. 001). Mean anterior chamber depthwas 1. 75 ± 0. 48 mm preoperatively and 2. 29 ?0. 38 mm postoperatively     

Preliminary clinical study on the management of angle-closure glaucoma by phacoemulsification with foldable posterior chamber intraocular lens implantation]

OBJECTIVE: To investigate the clinical results of phacoemulsification with foldable posterior chamber intraocular lens (PC-IOL) implantation in the management of angle-closure glaucoma with cataract. METHODS: Phacoemulsification with PC-IOL implantation performed on 47 eyes (42 cases) with angle-closure glaucoma and cataract was retrospectively studied, including 26 eyes with primary acute angle-closure glaucoma, 12 eyes with primary chronic angle-closure glaucoma, 5 eyes with secondary acute angle-closure glaucoma and 4 eyes with secondary chronic angle-closure glaucoma. RESULTS: After a mean postoperative follow-up of (18.40 +/- 9.51) months, the intraocular pressure was reduced from a preoperative mean of (25.47 +/- 18.43) mm Hg to a postoperative mean of (11.99 +/- 4.48) mm Hg (t = 4.918, P < 0.001). The mean anterior chamber depth was (1.69 +/- 0.46) mm preoperatively and (2.28 +/- 0.36) mm postoperatively (t = 7.738, P < 0.001). The best-corrected visual acuity was improved in 41 of 47 eyes (87.2%). CONCLUSION: Phacoemulsification with posterior chamber foldable intraocular lens implantation can be a good alternative in treating angle-closure glaucoma with cataract.     

氪离子与Q-开关Nd：YAG激光联合激光虹膜切除术的远期疗效

目的：观察氪离子激光与Q-开关Nd：YAG激光联合应用治疗原发性闭角型青光眼的远期疗效,并与近期疗效比较。方法：对我院39例（48眼）原发性闭角型青光眼患者,采用氪离子激光与Q-开关Nd：YAG激光联合应用的方法,行激光周边虹膜切除术。评价术后1a与7a的疗效,并进行统计学比较。结果：虹膜透切率达100．0％,一次透切成功率达97．9％。术后1a随访时发现眼压在正常水平内,且均值比术前低;术后7a随访眼压与1a无统计学差异。视力情况在术后1a不变或轻度改善,但在第2次随访时发现有5例（7眼）视力轻度下降。房角情况在术后1a也较术前略为改善,且这种改善维持到第2次随访时。至于周边前房深度,术后1a随访时明显强于术前,第2次随访时发现新出现5例患者周边前房深度变浅;视野情况术后1a与术后7a无明显变化,均发现早期青光眼视野缺损消失。结论：联合激光虹膜切除术是预防和治疗原发性闭角型青光眼临床前期的有效术式,近、远期疗效确切,是一种较为理想的术式,可在相当时期内有效预防青光眼急性发作。     

氪离子与Q-开关Nd∶YAG激光联合激光虹膜切除术的远期疗效

目的:观察氪离子激光与Q-开关Nd∶YAG激光联合应用治疗原发性闭角型青光眼的远期疗效,并与近期疗效比较。方法:对我院39例(48眼)原发性闭角型青光眼患者,采用氪离子激光与Q-开关Nd∶YAG激光联合应用的方法,行激光周边虹膜切除术。评价术后1a与7a的疗效,并进行统计学比较。结果:虹膜透切率达100.0%,一次透切成功率达97.9%。术后1a随访时发现眼压在正常水平内,且均值比术前低;术后7a随访眼压与1a无统计学差异。视力情况在术后1a不变或轻度改善,但在第2次随访时发现有5例(7眼)视力轻度下降。房角情况在术后1a也较术前略为改善,且这种改善维持到第2次随访时。至于周边前房深度,术后1a随访时明显强于术前,第2次随访时发现新出现5例患者周边前房深度变浅;视野情况术后1a与术后7a无明显变化,均发现早期青光眼视野缺损消失。结论:联合激光虹膜切除术是预防和治疗原发性闭角型青光眼临床前期的有效术式,近、远期疗效确切,是一种较为理想的术式,可在相当时期内有效预防青光眼急性发作。     

Argon laser trabeculoplasty for chronic angle-closure glaucoma uncontrolled by iridotomy

Nineteen eyes of 19 Japanese patients with medically uncontrollable chronic angle-closure glaucoma following laser iridotomy or surgical iridectomy underwent argon laser trabeculoplasty (ALT), applying low-power and a small number of laser burns over a small extent of the trabecular meshwork. All the eyes had glaucomatous optic disc damage, visual field loss, and intraocular pressure elevation before ALT. In each case, the extent of peripheral anterior synechiae was equal or less than 50% of the angle. The mean follow-up was 35 months. Life-table analysis (Kaplan-Meier method) showed that the probability of success was 66% at the end of three years after ALT. It is concluded that in the cases of uncontrollable chronic angle-closure glaucoma following laser iridotomy or surgical iridectomy, ALT should be tried before filtration surgery.     

半导体激光联合YAG激光周边虹膜切除术治疗原发性闭角型青光眼

目的:探讨半导体激光联合YAG激光周边虹膜切除术治疗原发性闭角型青光眼疗效。方法:对89例110眼闭角型青光眼行半导体激光联合YAG激光周边虹膜切除术。结果:激光孔通畅100%,治愈98眼,好转8眼,无效4眼,总有效率96.4%。术前术后平均视力无明显变化。术后1wk眼压0.93～2.67(平均1.87)kPa。所有病例前房角均有不同程度的加宽。结论:半导体激光联合YAG激光周边虹膜切除术治疗原发性闭角型青光眼,操作简单,效果确切,并发症少,是治疗闭角型青光眼的理想术式,值得临床推广。     

OCT-Goniometrie vor und nach Iridotomie beim Engwinkelglaukom

PURPOSE: Visualization of the anterior chamber angle is an important diagnostic method in patients with angle-closure glaucoma. In this study, optical coherence tomography (OCT) was used to image the angle width, the iris configuration, and the iris thickness in patients with angle-closure glaucoma. METHODS: Thirteen eyes of 11 patients suffering from angle-closure glaucoma were studied with slitlamp-adapted OCT. All patients were treated with Nd:YAG laser iridotomy. The angle width ( degrees ), the angle opening distance (AOD) (microm), and the iris thickness (microm) were measured with OCT. The configuration of the iris was classified as steeply convex, convex, or flat. RESULTS: The mean angle width was preoperatively 5.1+/-5.0 degrees (0-15 degrees ) and enlarged significantly (p=0.007) to 10.4+/-5.5 degrees (0-19 degrees ) postoperatively. The AOD changed from 71+/-55 microm (0-157 microm) preoperatively to 143+/-74 microm (0-256 microm) postoperatively (p<0.001). The mean iris thickness was 338+/-33 microm. With the exception of two eyes the predominant iris configuration changed from convex to flat. CONCLUSIONS: OCT allowed visualization and noninvasive assessment of the anterior chamber angle region in patients with angle-closure glaucoma. Our results suggest that goniometry with OCT could improve the evaluation in patients with narrow or closed anterior chamber angles.     

Acute intraocular pressure response to argon laser iridotomy

Argon laser iridotomy (ALI) was performed in 50 eyes for prophylactic treatment of anatomically narrow iridocorneal angles and in 50 eyes for therapy of chronic angle-closure glaucoma. Intraocular pressure was increased 6 mmHg or more 1 to 2 hours after ALI in 19 of 50 eyes with anatomical narrow iridocorneal angles and in 23 of 50 eyes with chronic angle-closure glaucoma. Increases greater than 20 mmHg over baseline value occurred in 5 of 50 eyes with narrow iridocorneal angles and in 7 of 50 eyes with chronic angle-closure glaucoma. A clinically significant increase in intraocular pressure (defined as a pressure 30 mmHg or greater and 40% or more increased over the pre-laser value) occurred 1 to 2 hours after ALI in 11 of 50 eyes with narrow iridocorneal angles and in 17 of 50 eyes with chronic angle-closure glaucoma. There was no statistical difference (chi square P greater than 0.3) in the incidence of this complication in the two groups. Additional medical therapy was effective in lowering the acute laser-induced elevation in intraocular pressure. Patient diagnosis, patient demographics, preoperative glaucoma medication and laser treatment parameters did not predict which eyes would develop this complication. Eyes which did not have a clinically significant elevation in intraocular pressure 1 to 2 hours after ALI did not show a later increase at 24 hours.     

Acute primary angle-closure: long-term intraocular pressure outcome in Asian eyes

PURPOSE: To report the long-term outcome of intraocular pressure after laser peripheral iridotomy in Asian eyes with acute primary angle-closure. METHODS: Retrospective study of 111 eyes of 96 consecutive patients with acute primary angle-closure, presenting at the National University Hospital, Singapore, from 1990 to 1994. The presenting features of the affected eye and the treatment instituted were recorded. The subsequent long-term intraocular pressure outcome was analyzed. An increase in intraocular pressure on follow-up was defined as increase in intraocular pressure greater than 21 mm Hg and requiring treatment by medication or surgery. RESULTS: The mean follow-up period was 50.3 months (range, 9 to 107 months). The mean presenting intraocular pressure was 52.8 mm Hg (range, 28 to 80 mm Hg). One hundred ten eyes were treated with laser peripheral iridotomy, with resolution of the acute episode and intraocular pressure less than 21 mm Hg in all eyes after laser peripheral iridotomy. Of these, only 46 eyes (41.8%) were successfully treated with laser peripheral iridotomy alone in the long term. Sixty-four eyes (58.1%) developed an increase in intraocular pressure (requiring treatment) on follow-up, of which 49 eyes developed an increase in intraocular pressure within the first 6 months after acute primary angle-closure. Thirty-six eyes (32.7%) eventually underwent trabeculectomy because of uncontrolled intraocular pressure despite laser and medical therapy. CONCLUSIONS: In this study of Asian eyes, a high proportion (58.1%) of eyes with acute primary angle-closure developed an increase in intraocular pressure on long-term follow-up after resolution of the acute attack, despite the presence of a patent laser peripheral iridotomy. These results suggest a racial difference in the outcome of laser peripheral iridotomy after acute primary angle-closure in Asians, compared with Caucasians. Because a majority of eyes that develop an increase in intraocular pressure do so within the first 6 months of presentation, close monitoring of intraocular pressure is advised in the follow-up of patients with acute primary angle-closure.     

三种手术方式治疗闭角型青光眼临床前期及先兆期的疗效观察

目的:探讨超声乳化晶状体摘除并人工晶状体植入术治疗急性闭角型青光眼临床前期、先兆期的疗效。方法:选择原发性闭角型青光眼临床前期或先兆期患者66例66眼,随机分为3组,A组行激光周边虹膜造孔术,B组行单纯超声乳化,C组行超声乳化联合虹膜周边切除术(各22眼)。并比较观察3组术后眼压、中央前房深度、视力、房角Scheie分级等的变化。平均随访11.72±0.96mo。结果:术后最终随访时发现:A,B,C组患者的前房角(Scheie分级法)均显著增宽(P<0.05),3组间的房角Scheie分级无显著性差异;A组中央前房深度无明显变化,B、C组中央前房深度较术前均显著加深(P<0.05),A组的中央前房深度明显低于B、C组(P<0.05),B、C组间的中央前房深度无显著性差异;3组平均眼压无明显变化,三组间的平均眼压无明显差异(P<0.05);A组暗室激发试验的阳性率无显著变化,B,C组暗室激发试验的阳性率均显著小于术前。A,B,C3组暗室激发试验的阳性率无显著差异;A组患者最佳矫正视力无明显提高,B,C组患者最佳矫正视力较术前均显著提高(P<0.05)。结论:在加深中央前房深度、降低术后暗室激发试验的阳性(潜在的可能)及提高术后视力的效果方面,超声乳化晶状体摘除并人工晶状体植入术优于激光周边虹膜造孔术;超声乳化晶状体摘除并人工晶状体植入术中不需要进一步做周边虹膜切除术。     

超声乳化治疗白内障合并继发性闭角型青光眼

目的探讨单纯晶状体超声乳化吸出术联合后房型折叠人工晶状体植入术治疗合并有白内障的继发性闭角型青光眼的手术治疗效果。方法继发性闭角型青光眼45例（45眼），其中35例为继发性急性闭角型青光眼，10例为继发慢性闭角型青光眼，患者均有不同程度的晶状体浑浊。人院后均行透明角膜切口晶状体超声乳化吸出术联合后房型折叠人工晶状体植入术。术后随访3月～3年。对治疗效果进行临床分析。结果45例术中、术后没有出现严重的并发症。术后视力提两36例（80．00％），术后视力无明显提高者9例（20．00％）；术后眼压较手术前明显降低。结论单纯晶状体超声乳化吸出术联合人工晶状体植入术是治疗合并有白内障的继发性闭角型青光眼的一种有效的治疗方法。     

Clearing of corneal argyrosis by YAG laser.

A 75-year-old woman with corneal argyrosis was treated by a Q-switched Nd-YAG laser iridotomy after acute angle closure glaucoma. Each laser shot caused clearance of the argyrotic deposits anterior to the iridotomy site. The same effect was seen when a preventive iridotomy was performed in the other eye. The areas of clear cornea remained unchanged for a follow-up period of eight months.     

How large must an iridotomy be?

Four cases of acute angle closure glaucoma in eyes with a small but patent Nd-YAG laser iridotomy are presented, and similar cases in the literature are reviewed. Theoretically a 15 microns diameter iridotomy should be large enough to prevent angle closure glaucoma due to pupil block. Mechanisms by which larger iridotomies fail to prevent angle closure glaucoma, and the role of provocation tests following iridotomy, are discussed. An iridotomy should be at least 150-200 microns in diameter if acute angle closure glaucoma is to be reliably prevented.     

A comparison of neodymium: YAG and argon laser iridotomies

A prospective short-term clinical study evaluated argon and Q-switched neodymium:YAG laser iridotomies in 40 eyes of 20 patients with primary chronic angle-closure glaucoma. All patients had bilateral iridotomies with one eye randomly assigned to argon laser and the fellow eye to neodymium:YAG laser therapy. In all eyes a patent iridotomy was created in one treatment session. A mean of 12 +/- 11 and 0.033 +/- 0.025 J were needed for iridotomy formation in argon and neodymium:YAG treated eyes respectively. No neodymium:YAG and six (30%) argon iridotomies had marked closure requiring retreatment. Immediate postoperative intraocular pressure elevation greater than 10 mmHg was seen in seven (35%) argon and six (30%) neodymium:YAG-treated eyes. Nine (45%) eyes treated with the neodymium:YAG laser had bleeding from the iridotomy site. No acute lens damage was found in the neodymium:YAG eyes while seven (35%) lenses in the argon group had focal opacities. Seven (35%) neodymium:YAG and five (25%) argon treated eyes had focal nonprogressive corneal opacities above the iridotomy site. Specular microscopy showed a significant central corneal endothelial loss in argon laser treated eyes. No eyes had detectable retinal damage.