{"id":1460,"date":"2024-11-04T15:38:00","date_gmt":"2024-11-04T15:38:00","guid":{"rendered":"https:\/\/enfoca.com.mx\/?p=1460"},"modified":"2026-10-06T22:49:57","modified_gmt":"2026-10-06T22:49:57","slug":"samureye-dr-juan-sampaolesi","status":"publish","type":"post","link":"https:\/\/enfoca.com.mx\/eng\/samureye-dr-juan-sampaolesi\/","title":{"rendered":"Lensectomy in Hyperopes with Angle Closure | SamurEye #3"},"content":{"rendered":"<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe title=\"SamurEye #3: Dr Juan Sampaolesi\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/Qz23CA17p1s?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\">Angle Closure in Hyperopic Patients<\/h2>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Lensectomy in Young Hyperopic Patients with Angle Closure: A Paradigm Shift in Glaucoma<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\"><strong>Dr. Sampaolesi<\/strong> proposes a revolutionary view on the management of <strong>angle-closure glaucoma<\/strong> in young hyperopic patients. Is <strong>lens extraction (lensectomy)<\/strong> 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 <strong>eye health<\/strong>.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Redefining Lensectomy in Young People with Angle Closure<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Traditionally, <strong>lensectomy<\/strong> (removal of the crystalline lens) has been considered a highly interventional procedure for young patients. However, Dr. Sampaolesi, drawing on multicenter studies, argues that <strong>phacoemulsification (phaco)<\/strong> can be a highly effective solution in certain cases of <strong>angle closure<\/strong>, even when there is no evident cataract.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">A key example is the case of a 24-year-old patient with <strong>organic angle closure<\/strong> and <strong>+6 diopters of hyperopia<\/strong>, in whom previous treatment with <strong>iridotomy<\/strong> and <strong>iridoplasty<\/strong> was unsuccessful. For Dr. Sampaolesi, these procedures often only \"buy time\" until lensectomy becomes inevitable, with or without cataract.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">The \"Lost Decade\": A Late Diagnosis in Hyperopia<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Dr. Sampaolesi introduces the concept of the \"<strong>lost decade<\/strong>\", referring to the roughly 10-year period during which hyperopic patients visit ophthalmologists for their glasses without the underlying risk of <strong>angle closure<\/strong> being detected.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">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 <strong>chronic angle-closure glaucoma<\/strong>. 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.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Phacoemulsification and Thermolysis: An Alternative to the Valve in Advanced Glaucoma<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">For cases of <strong>advanced chronic organic angle-closure glaucoma<\/strong>, there are two options: implanting a valve or combining <strong>phacoemulsification with thermolysis<\/strong>. Dr. Sampaolesi considers the valve a \"very bad idea\" in these scenarios.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">The preferred option is <strong>phacoemulsification<\/strong> 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, <strong>thermolysis<\/strong> 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 <strong>trabeculectomy<\/strong> or a valve. This approach seeks to shift the management paradigm, focusing on decreasing aqueous humor production rather than on traditional filtration.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Advantages of Phaco-Thermolysis on the Valve: Endothelial Protection<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Dr. Sampaolesi highlights a crucial advantage of <strong>phaco-thermolysis<\/strong>: <strong>corneal endothelial survival<\/strong>. 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 <strong>corneal transplant<\/strong>. In contrast, <strong>thermolysis<\/strong> shows a significantly smaller loss, around 5% at 24 months, preserving corneal health.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Why is Trabeculectomy Contradicted in Angle Closure?<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Dr. Sampaolesi recalls that, since its original description by Dr. Kass, <strong>angle closure<\/strong> has been one of the main contraindications for <strong>trabeculectomy<\/strong>. In eyes with an anteriorly displaced iris-lens diaphragm, attempting a trabeculectomy can trigger serious complications such as:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Intraoperative expulsive hemorrhage<\/strong><\/li>\n\n\n\n<li class=\"translation-block\"><strong>Uveal effusion<\/strong> or <strong>postoperative choroidal hemorrhage<\/strong> due to sudden pressure changes.<\/li>\n<\/ul>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Cyclophotocoagulation: A Less Invasive Alternative for Severe Cases<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">In situations of very high intraocular pressure and marked anterior displacement of the iris-lens diaphragm (similar to <strong>malignant glaucoma<\/strong>), lowering the pressure in the anterior chamber can be risky. In these cases, <strong>cyclophotocoagulation of the ciliary body<\/strong> is a less invasive alternative to reduce aqueous humor production and control eye pressure without entering the anterior chamber, thus avoiding potential complications.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Change in the Approach to Hyperopic Eyes: A Proactive Vision<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Dr. Sampaolesi's experience has led to a significant change in the management of all <strong>hyperopic eyes<\/strong>. Although academic guidelines usually recommend lensectomy from age 50 onward, he considers this option in hyperopic patients aged <strong>38 to 40<\/strong>, especially given the availability of <strong>new intraocular lenses (IOLs)<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">In younger patients with good visual function and a healthy optic nerve, <strong>phacoemulsification with a multifocal or EDOF IOL implant<\/strong> can be performed. For the associated glaucoma, <strong>thermolysis<\/strong> is chosen in severe cases, or <strong>subcyclophotocoagulation<\/strong> (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.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Angular Closure Handling Algorithm: A Customized Approach<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Dr. Sampaolesi proposes a management algorithm for angle closure based on its type:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Primary Functional Angle Closure (young, non-presbyopic, clear lens, good VA):<\/strong> <strong>Iridotomy<\/strong> to deepen the anterior chamber.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Primary Functional Angle Closure (over 50, presbyopic, significant hyperopia, reduced VA):<\/strong> <strong>Refractive phacoemulsification<\/strong> alone.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Plateau Iris (young, good VA, clear lens):<\/strong> <strong>Iridotomy<\/strong> and <strong>peripheral iridoplasty<\/strong> (with argon laser or SLT).<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Plateau Iris (over 50, presbyopic, significant hyperopia, reduced VA):<\/strong> <strong>Refractive phacoemulsification<\/strong> with a multifocal or EDOF IOL implant.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Recent Organic Angle Closure (acute attack within the last 3 months):<\/strong> <strong>Phacoemulsification with goniosynechialysis<\/strong> (separation of peripheral synechiae) using heavy viscoelastic, a miotic, and manual traction of the iris.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Non-Recent Organic Angle Closure:<\/strong> Consider phaco-valve or ablative laser, but with a preference for <strong>phaco-thermolysis<\/strong> because of better endothelial survival.<\/li>\n<\/ul>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Special Considerations in Nanophthalmos and Additional Techniques<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">In <strong>very small eyes (nanophthalmos)<\/strong>, 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 <strong>anterior vitrectomy<\/strong> or <strong>core vitrectomy<\/strong> if it is not. Dr. Sampaolesi does not consider nanophthalmos the \"big problem\" that some describe it as.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">In all hyperopic patients with angle closure, <strong>prophylactic mannitol<\/strong> is given as a slow intravenous infusion before surgery to lower intraocular pressure.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\"><strong>Goniosynechialysis<\/strong> 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\"><strong>Postoperative management<\/strong> includes ketorolac eye drops and a combination of prednisolone and an antibiotic to reduce inflammation.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Selection of Advanced Intraocular Lenses<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">For <strong>IOL selection<\/strong>, caution is taken with high-order aberrometry. If angle alpha is less than 500 microns, <strong>trifocal or pentafocal IOLs<\/strong> 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.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Detailed Diagnostic Evaluation and Multidisciplinary Approach<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">The evaluation of patients with <strong>angle closure<\/strong> always includes an assessment under light and dark (mesopic) conditions with the slit lamp and <strong>gonioscopy<\/strong>. An angle that appears open in the light but closes in the dark indicates a risk of subclinical attacks and the need for intervention.<\/p>\n\n\n\n<p class=\"wp-block-paragraph translation-block\"><strong>Anterior segment optical coherence tomography (OCT)<\/strong> and <strong>ultrasound biomicroscopy (UBM)<\/strong> 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 <strong>plateau iris<\/strong>, the importance of performing both <strong>iridotomy<\/strong> and <strong>peripheral iridoplasty<\/strong> in the same procedure is emphasized.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Conclusion: Towards a Proactive Future in Angle Closure Glaucoma<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Dr. Sampaolesi presents a modern, proactive perspective on the management of <strong>angle-closure glaucoma<\/strong> in hyperopic patients. His approach prioritizes <strong>early lensectomy<\/strong>, even in young patients without cataracts, as a definitive solution with lower long-term risk. The combination of <strong>phacoemulsification and thermolysis<\/strong> emerges as a valuable alternative in advanced cases. A thorough evaluation with gonioscopy under different lighting conditions, together with the use of <strong>OCT and UBM<\/strong>, is essential for an accurate diagnosis and for choosing the most appropriate surgical approach. Dr. Sampaolesi advocates a <strong>paradigm shift<\/strong>, adopting techniques that offer better outcomes and a higher quality of life for these patients.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\">Where can you find us?<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>YouTube:<\/strong> Subscribe to our channel to watch full episodes and exclusive content: <a href=\"https:\/\/www.youtube.com\/@SamurEyePodcast\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.youtube.com\/@SamurEyePodcast<\/a><\/li>\n\n\n\n<li class=\"translation-block\"><strong>Instagram:<\/strong> Follow us on Instagram to hear about upcoming topics, guests and highlights: <a href=\"https:\/\/www.instagram.com\/samureyepodcast\/\" target=\"_blank\" rel=\"noreferrer noopener\">@samureyepodcast<\/a><\/li>\n\n\n\n<li class=\"translation-block\"><strong>Spotify:<\/strong> Listen to our episodes wherever you go: <a href=\"https:\/\/open.spotify.com\/show\/2zMjQ14w1WdGDxBqrX4vEm?si=UIuMdz2YTueOnRqpiD6X6g\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/open.spotify.com\/show\/2zMjQ14w1WdGDxBqrX4vEm?si=UIuMdz2YTueOnRqpiD6X6g<\/a><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"<p>Cierre Angular en Pacientes Hiperm\u00e9tropes Lensectom\u00eda en J\u00f3venes Hiperm\u00e9tropes con Cierre Angular: Un Cambio de Paradigma en Glaucoma El Dr. [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":1461,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[9,11],"tags":[47,48,49,45,46,34,83,50,14,41,13],"class_list":["post-1460","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-podcast","category-samureye","tag-angulo-cerrado","tag-ciclofotocoagulacion","tag-cpcte","tag-dr-juan-sampaolesi","tag-entrevistas-oftalmologicas","tag-glaucoma","tag-medical-podcast","tag-migs","tag-oftalmologia","tag-podcast-medico","tag-samureye"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - 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