ENG 
ESP 
Angle Closure in Hyperopic Patients
Lensectomy in Young Hyperopic Patients with Angle Closure: A Paradigm Shift in Glaucoma
Dr. Sampaolesi proposes a revolutionary view on the management of angle-closure glaucoma in young hyperopic patients. Is lens extraction (lensectomy) a viable and safe option, even without cataracts? We explore why this perspective challenges tradition and how it can deliver better long-term results for eye health.
Redefining Lensectomy in Young People with Angle Closure
Traditionally, lensectomy (removal of the crystalline lens) has been considered a highly interventional procedure for young patients. However, Dr. Sampaolesi, drawing on multicenter studies, argues that phacoemulsification (phaco) can be a highly effective solution in certain cases of angle closure, even when there is no evident cataract.
A key example is the case of a 24-year-old patient with organic angle closure and +6 diopters of hyperopia, in whom previous treatment with iridotomy and iridoplasty was unsuccessful. For Dr. Sampaolesi, these procedures often only "buy time" until lensectomy becomes inevitable, with or without cataract.
The "Lost Decade": A Late Diagnosis in Hyperopia
Dr. Sampaolesi introduces the concept of the "lost decade", referring to the roughly 10-year period during which hyperopic patients visit ophthalmologists for their glasses without the underlying risk of angle closure being detected.
In the case of the young patient, despite her history and failed procedures, the significant hyperopia and signs of organic angle closure were not definitively addressed, leading to progression to chronic angle-closure glaucoma. At this stage, the iris is no longer just positioned against the trabecular meshwork but adheres to it over 360 degrees, indicating irreversible organic closure.
Phacoemulsification and Thermolysis: An Alternative to the Valve in Advanced Glaucoma
For cases of advanced chronic organic angle-closure glaucoma, there are two options: implanting a valve or combining phacoemulsification with thermolysis. Dr. Sampaolesi considers the valve a "very bad idea" in these scenarios.
The preferred option is phacoemulsification to remove the crystalline lens (which tends to be large in hyperopic eyes) and correct the significant hyperopia, bringing the refraction to zero diopters with a high-power IOL. At the same time, thermolysis is performed to reduce aqueous humor production. This combination is vital because angle distortion in chronic organic angle-closure glaucoma undermines the effectiveness of a trabeculectomy or a valve. This approach seeks to shift the management paradigm, focusing on decreasing aqueous humor production rather than on traditional filtration.
Advantages of Phaco-Thermolysis on the Valve: Endothelial Protection
Dr. Sampaolesi highlights a crucial advantage of phaco-thermolysis: corneal endothelial survival. Valves, even with the best techniques, can cause a 22% loss of endothelial cells in 2 years, which in the long run could require a corneal transplant. In contrast, thermolysis shows a significantly smaller loss, around 5% at 24 months, preserving corneal health.
Why is Trabeculectomy Contradicted in Angle Closure?
Dr. Sampaolesi recalls that, since its original description by Dr. Kass, angle closure has been one of the main contraindications for trabeculectomy. In eyes with an anteriorly displaced iris-lens diaphragm, attempting a trabeculectomy can trigger serious complications such as:
- Intraoperative expulsive hemorrhage
- Uveal effusion or postoperative choroidal hemorrhage due to sudden pressure changes.
Cyclophotocoagulation: A Less Invasive Alternative for Severe Cases
In situations of very high intraocular pressure and marked anterior displacement of the iris-lens diaphragm (similar to malignant glaucoma), lowering the pressure in the anterior chamber can be risky. In these cases, cyclophotocoagulation of the ciliary body is a less invasive alternative to reduce aqueous humor production and control eye pressure without entering the anterior chamber, thus avoiding potential 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 hyperopic eyes. Although academic guidelines usually recommend lensectomy from age 50 onward, he considers this option in hyperopic patients aged 38 to 40, especially given the availability of new intraocular lenses (IOLs).
In younger patients with good visual function and a healthy optic nerve, phacoemulsification with a multifocal or EDOF IOL implant can be performed. For the associated glaucoma, thermolysis is chosen in severe cases, or subcyclophotocoagulation (a gentler mode) in less aggressive glaucomas. With this approach, the patient perceives the surgery as a "cataract operation", with fast 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:
- Primary Functional Angle Closure (young, non-presbyopic, clear lens, good VA): Iridotomy to deepen the anterior chamber.
- Primary Functional Angle Closure (over 50, presbyopic, significant hyperopia, reduced VA): Refractive phacoemulsification alone.
- Plateau Iris (young, good VA, clear lens): Iridotomy and peripheral iridoplasty (with argon laser or SLT).
- Plateau Iris (over 50, presbyopic, significant hyperopia, reduced VA): Refractive phacoemulsification with a multifocal or EDOF IOL implant.
- Recent Organic Angle Closure (acute attack within the last 3 months): Phacoemulsification with goniosynechialysis (separation of peripheral synechiae) using heavy viscoelastic, a miotic, and manual traction of the iris.
- Non-Recent Organic Angle Closure: Consider phaco-valve or ablative laser, but with a preference for phaco-thermolysis because of better endothelial survival.
Special Considerations in Nanophthalmos and Additional Techniques
In very small eyes (nanophthalmos), the goal is to avoid vitrectomy whenever possible. In cases of very high-power lenses (over 30 diopters) where it is needed, lensectomy is combined with a vitreous tap if the vitreous is liquid, or with an anterior vitrectomy or core vitrectomy if it is not. Dr. Sampaolesi does not consider nanophthalmos the "big problem" that some describe it as.
In all hyperopic patients with angle closure, prophylactic mannitol is given as a slow intravenous infusion before surgery to lower intraocular pressure.
Goniosynechialysis is a key technique in recent organic angle closure. After the IOL is implanted, heavy viscoelastic is injected into the periphery along with a miotic to induce miosis, and then the pupillary margin is pulled to release the synechiae.
Postoperative management includes ketorolac eye drops and a combination of prednisolone and an antibiotic to reduce inflammation.
Selection of Advanced Intraocular Lenses
For IOL selection, caution is taken with high-order aberrometry. If angle alpha is less than 500 microns, trifocal or pentafocal IOLs can be considered. If it is greater, a monofocal IOL or a "monofocal plus" with a low central add is preferred. Heavy viscoelastics are used in goniosynechialysis to help separate the iris molecularly.
Detailed Diagnostic Evaluation and Multidisciplinary Approach
The evaluation of patients with angle closure always includes an assessment under 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 attacks and the need for intervention.
Anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy (UBM) are used for diagnosis and planning. UBM is considered essential for assessing the nature of the angle closure (functional, organic, primary, plateau, pseudo-plateau). In cases of plateau iris, the importance of performing both iridotomy and peripheral iridoplasty in the same procedure is emphasized.
Conclusion: Towards a Proactive Future in Angle Closure Glaucoma
Dr. Sampaolesi presents a modern, proactive perspective on the management of angle-closure glaucoma in hyperopic patients. His approach prioritizes early lensectomy, even in young patients without cataracts, as a definitive solution with lower long-term risk. The combination of phacoemulsification and thermolysis emerges as a valuable alternative in advanced cases. A thorough evaluation with gonioscopy under different lighting conditions, together with the use of OCT and UBM, is essential for an accurate diagnosis and for choosing the most appropriate surgical approach. Dr. Sampaolesi advocates a paradigm shift, adopting techniques that offer better outcomes and a higher quality of life for these patients.
Where can you find us?
- YouTube: Subscribe to our channel to watch full episodes and exclusive content: https://www.youtube.com/@SamurEyePodcast
- Instagram: Follow us on Instagram to hear about upcoming topics, guests and highlights: @samureyepodcast
- Spotify: Listen to our episodes wherever you go: https://open.spotify.com/show/2zMjQ14w1WdGDxBqrX4vEm?si=UIuMdz2YTueOnRqpiD6X6g
