ENG 
ESP 
Angle Closure in Hyperopic Patients
Lensectomy in Young Hyperopic Patients with Angle Closure: A Paradigm Shift in Glaucoma
The Dr. Sampaolesi proposes a revolutionary vision in the management of angle closure glaucoma in young hyperopic patients. Is it the lens extraction (lensectomy) a viable and safe option, even without cataracts? We explore why this perspective challenges tradition and how it can offer better long-term outcomes for the eye health.
Redefining Lensectomy in Young People with Angle Closure
Traditionally, the lensectomy (lens removal) has been considered a very interventional procedure for young patients. However, Dr. Sampaolesi, based on multicenter studies, argues that phacoemulsification (phaco) can be a highly effective solution in certain cases of angle closure, even when there are no obvious cataracts.
A key example is the case of a 24-year-old patient with organic angle closure and hyperopia of +6 diopters, in whom previous treatments with iridotomy and iridoplasty were unsuccessful. For Dr. Sampaolesi, these procedures often merely “buy time” until lensectomy becomes inevitable, with or without a cataract.
The "Lost Decade": A Late Diagnosis in Hyperopia
Dr. Sampaolesi introduces the concept of «lost decade", referring to the period of approximately 10 years in which farsighted patients go to ophthalmological consultations for their glasses without the underlying risk of being detected angle closure.
In the case of the young patient, despite the history and failed procedures, significant hyperopia and signs of organic angle closure were not definitively addressed, leading to a progression towards chronic angle-closure glaucomaHere, the iris is no longer simply positioned against the trabeculum, but adheres 360 degrees, indicating irreversible organic closure.
Phacoemulsification and Thermolysis: An Alternative to the Valve in Advanced Glaucoma
For cases of advanced organic chronic angle-closure glaucoma, two options are considered: the placement of a valve or the combination of phacoemulsification with thermolysis. Dr. Sampaolesi considers the valve a "very bad idea" in these scenarios.
The preferred option is the phacoemulsification to remove the lens (which is usually large in hyperopes) and correct significant hyperopia, bringing the refraction to zero diopters with a high-power IOL. Simultaneously, a thermolysis to reduce aqueous humor production. This combination is vital because angle distortion in chronic organic angle-closure glaucoma hampers the effectiveness of a trabeculectomy or a valve. This approach seeks to change the management paradigm, focusing on reducing aqueous humor production rather than traditional filtration.
Advantages of Phaco-Thermolysis on the Valve: Endothelial Protection
Dr. Sampaolesi highlights a crucial advantage of the phaco-thermolysis: la survival of the corneal endothelium. Valves, even with the best techniques, can cause a loss of 22% of endothelial cells in 2 years, which in the long term could require a corneal transplant. En contraste, la thermolysis shows significantly less loss, around 5% in 24 months, preserving the health of the cornea.
Why is Trabeculectomy Contradicted in Angle Closure?
Dr. Sampaolesi recalls that, since its original description by Dr. Kass, the angle closure ha sido una de las principales contraindicaciones para la trabeculectomyIn eyes with a protruding iridocrystalline diaphragm, attempting a trabeculectomy can lead to serious complications such as:
- Intraoperative expulsive hemorrhages
- Uveal effusion or post-surgical choroidal hemorrhage due to sudden changes in pressure.
Cyclophotocoagulation: A Less Invasive Alternative for Severe Cases
In situations of very high intraocular pressure and a marked advancement of the irido-crystalline diaphragm (similar to malignant glaucoma), decreasing anterior chamber pressure can be risky. In these cases, the cyclophotocoagulation of the ciliary body It is a less invasive alternative to reduce aqueous humor production and control ocular pressure without entering the anterior chamber, thus avoiding possible complications.
Change in the Approach to Hyperopic Eyes: A Proactive Vision
Dr. Sampaolesi's experience has led to a significant change in the management of all farsighted eyes. Although the academy usually recommends lensectomy from the age of 50, he considers this option in hyperopic patients of 38-40 years old, especially with the availability of the new intraocular lenses (IOLs).
In younger patients with good visual function and optic nerve, a phacoemulsification with multifocal IOL implantation or EDOF. For associated glaucoma, the option is thermolysis in severe cases or subcyclophotocoagulation (a gentler approach) in less aggressive glaucomas. This approach makes the patient perceive the surgery as a "cataract operation" with rapid visual recovery and a lower risk of serious complications.
Angular Closure Handling Algorithm: A Customized Approach
Dr. Sampaolesi proposes a management algorithm for angle closure based on its type:
- Functional Primary Angle Closure (young, non-presbyopic, clear lens, good VA): Iridotomy to deepen the anterior chamber.
- Functional Primary Angle Closure (over 50 years, presbyopia, significant hyperopia, reduced VA): Refractive phacoemulsification alone.
- Iris Plateau (young, good VA, clear lens): Iridotomy and peripheral iridoplasty (with argon laser or SLT).
- Iris Plateau (over 50 years, presbyopic, significant hyperopia, reduced VA): Refractive phacoemulsification with multifocal IOL or EDOF implantation.
- Recent Organic Angle Closure (acute block in the last 3 months): Facoemulsificación con goniosinequiolisis (separation of peripheral synechiae) using heavy viscoelastic, miotic and manual iris traction.
- Non-Recent Organic Angular Closure: Consider phaco-valve or ablative laser, but with preference for phaco-thermolysis for better endothelial survival.
Special Considerations in Nanophthalmos and Additional Techniques
In very small eyes (nanophthalmos), vitrectomy is avoided if possible. In cases of very high lenses (more than 30 diopters) where it is necessary, lensectomy is accompanied by a vitreous puncture if the vitreous is liquid, or a anterior vitrectomy or corvitrectomy If it isn't, Dr. Sampaolesi doesn't consider nanophthalmos a "big problem" as some describe it.
In all hyperopic patients with angle closure, it is used mannitol prophylactically slowly intravenously before surgery to reduce intraocular pressure.
The goniosynechiolysis It is a key technique in recent organic angle closure. After implanting the IOL, heavy viscoelastic is injected peripherally and a miotic is injected to induce miosis, then the pupillary margin is tractioned to release the synechiae.
The postoperative management It includes ketorolac eye drops and a combination of prednisolone and antibiotic to reduce inflammation.
Selection of Advanced Intraocular Lenses
For the IOL selection, caution is exercised with high-order aberrometry. If the alpha angle is less than 500 microns, it can be considered Trifocal or pentafocal IOLsIf it is larger, a monofocal or "monofocal plus" IOL with a low central addition is preferred. Heavy viscoelastics are used in goniosynechiolysis to help separate the iris molecularly.
Detailed Diagnostic Evaluation and Multidisciplinary Approach
Detailed Diagnostic Evaluation and Multidisciplinary Approach angle closure always includes an assessment in light and dark (mesopic) conditions with the slit lamp and gonioscopy. An angle that appears open in the light but closes in the dark indicates a risk of subclinical seizures and the need for intervention.
They are used anterior segment optical coherence tomography (OCT) and the ultrasound biomicroscopy (UBM) for diagnosis and planning. UBM is considered essential to assess the nature of angle closure (functional, organic, primary, plateau, pseudo-plateau). In cases of iris plateau, the importance of carrying out both the iridotomy like the peripheral iridoplasty in the same procedure.
Conclusion: Towards a Proactive Future in Angle Closure Glaucoma
Dr. Sampaolesi presents a modern and proactive perspective on the management of angle closure glaucoma in hyperopic patients. Its approach prioritizes the early lensectomy, even in young patients without cataracts, as a definitive solution with lower long-term risk. The combination of phacoemulsification and thermolysis emerging as a valuable alternative in advanced cases. Comprehensive evaluation with gonioscopy in different lighting conditions, along with the use of OCT and UBM, are essential for an accurate diagnosis and the selection of the most appropriate surgical approach. Dr. Sampaolesi advocates a paradigm shift, adopting techniques that offer better results and a higher quality of life for these patients.
Where can you find us?
- YouTube: Subscribe to our channel for full episodes and exclusive content: https://www.youtube.com/@SamurEyePodcast
- Instagram: Follow us on Instagram for upcoming topics, guests, and highlights: @samureyepodcast
- Spotify: Listen to our episodes wherever you go: https://open.spotify.com/show/2zMjQ14w1WdGDxBqrX4vEm?si=UIuMdz2YTueOnRqpiD6X6g
