{"id":1460,"date":"2024-11-04T15:38:00","date_gmt":"2024-11-04T15:38:00","guid":{"rendered":"https:\/\/enfoca.com.mx\/?p=1460"},"modified":"2025-06-11T23:00:15","modified_gmt":"2025-06-11T23:00:15","slug":"samureye-dr-juan-sampaolesi","status":"publish","type":"post","link":"https:\/\/enfoca.com.mx\/eng\/samureye-dr-juan-sampaolesi\/","title":{"rendered":"SamurEye #3: Dr Juan Sampaolesi"},"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<h1 class=\"wp-block-heading\">Lensectomy in Young Hyperopic Patients with Angle Closure: A Paradigm Shift in Glaucoma<\/h1>\n\n\n\n<p>The <strong>Dr. Sampaolesi<\/strong> proposes a revolutionary vision in the management of <strong>angle closure glaucoma<\/strong> in young hyperopic patients. Is it the <strong>lens extraction (lensectomy)<\/strong> 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 <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>Traditionally, the <strong>lensectomy<\/strong> (lens removal) has been considered a very interventional procedure for young patients. However, Dr. Sampaolesi, based 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 are no obvious cataracts.<\/p>\n\n\n\n<p>A key example is the case of a 24-year-old patient with <strong>organic angle closure<\/strong> and <strong>hyperopia of +6 diopters<\/strong>, in whom previous treatments with <strong>iridotomy<\/strong> and <strong>iridoplasty<\/strong> were unsuccessful. For Dr. Sampaolesi, these procedures often merely \u201cbuy time\u201d until lensectomy becomes inevitable, with or without a 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>Dr. Sampaolesi introduces the concept of \u00ab<strong>lost decade<\/strong>\", 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 <strong>angle closure<\/strong>.<\/p>\n\n\n\n<p>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 <strong>chronic angle-closure glaucoma<\/strong>Here, the iris is no longer simply positioned against the trabeculum, but adheres 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>For cases of <strong>advanced organic chronic angle-closure glaucoma<\/strong>, two options are considered: the placement of a valve or the combination of <strong>phacoemulsification with thermolysis<\/strong>. Dr. Sampaolesi considers the valve a \"very bad idea\" in these scenarios.<\/p>\n\n\n\n<p>The preferred option is the <strong>phacoemulsification<\/strong> 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 <strong>thermolysis<\/strong> to reduce aqueous humor production. This combination is vital because angle distortion in chronic organic angle-closure glaucoma hampers the effectiveness of a <strong>trabeculectomy<\/strong> or a valve. This approach seeks to change the management paradigm, focusing on reducing aqueous humor production rather than 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>Dr. Sampaolesi highlights a crucial advantage of the <strong>phaco-thermolysis<\/strong>: la <strong>survival of the corneal endothelium<\/strong>. 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 <strong>corneal transplant<\/strong>. En contraste, la <strong>thermolysis<\/strong> shows significantly less loss, around 5% in 24 months, preserving the health of the cornea.<\/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>Dr. Sampaolesi recalls that, since its original description by Dr. Kass, the <strong>angle closure<\/strong> ha sido una de las principales contraindicaciones para la <strong>trabeculectomy<\/strong>In eyes with a protruding iridocrystalline diaphragm, attempting a trabeculectomy can lead to serious complications such as:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Intraoperative expulsive hemorrhages<\/strong><\/li>\n\n\n\n<li><strong>Uveal effusion<\/strong> or <strong>post-surgical choroidal hemorrhage<\/strong> due to sudden changes in pressure.<\/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>In situations of very high intraocular pressure and a marked advancement of the irido-crystalline diaphragm (similar to <strong>malignant glaucoma<\/strong>), decreasing anterior chamber pressure can be risky. In these cases, the <strong>cyclophotocoagulation of the ciliary body<\/strong> It is a less invasive alternative to reduce aqueous humor production and control ocular pressure without entering the anterior chamber, thus avoiding possible 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>Dr. Sampaolesi's experience has led to a significant change in the management of all <strong>farsighted eyes<\/strong>. Although the academy usually recommends lensectomy from the age of 50, he considers this option in hyperopic patients of <strong>38-40 years old<\/strong>, especially with the availability of the <strong>new intraocular lenses (IOLs)<\/strong>.<\/p>\n\n\n\n<p>In younger patients with good visual function and optic nerve, a <strong>phacoemulsification with multifocal IOL implantation or EDOF<\/strong>. For associated glaucoma, the option is <strong>thermolysis<\/strong> in severe cases or <strong>subcyclophotocoagulation<\/strong> (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.<\/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>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><strong>Functional Primary Angle Closure (young, non-presbyopic, clear lens, good VA):<\/strong> <strong>Iridotomy<\/strong> to deepen the anterior chamber.<\/li>\n\n\n\n<li><strong>Functional Primary Angle Closure (over 50 years, presbyopia, significant hyperopia, reduced VA):<\/strong> <strong>Refractive phacoemulsification<\/strong> alone.<\/li>\n\n\n\n<li><strong>Iris Plateau (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><strong>Iris Plateau (over 50 years, presbyopic, significant hyperopia, reduced VA):<\/strong> <strong>Refractive phacoemulsification<\/strong> with multifocal IOL or EDOF implantation.<\/li>\n\n\n\n<li><strong>Recent Organic Angle Closure (acute block in the last 3 months):<\/strong> <strong>Facoemulsificaci\u00f3n con goniosinequiolisis<\/strong> (separation of peripheral synechiae) using heavy viscoelastic, miotic and manual iris traction.<\/li>\n\n\n\n<li><strong>Non-Recent Organic Angular Closure:<\/strong> Consider phaco-valve or ablative laser, but with preference for <strong>phaco-thermolysis<\/strong> for 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>In <strong>very small eyes (nanophthalmos)<\/strong>, 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 <strong>anterior vitrectomy<\/strong> or <strong>corvitrectomy<\/strong> If it isn't, Dr. Sampaolesi doesn't consider nanophthalmos a \"big problem\" as some describe it.<\/p>\n\n\n\n<p>In all hyperopic patients with angle closure, it is used <strong>mannitol prophylactically<\/strong> slowly intravenously before surgery to reduce intraocular pressure.<\/p>\n\n\n\n<p>The <strong>goniosynechiolysis<\/strong> 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.<\/p>\n\n\n\n<p>The <strong>postoperative management<\/strong> It includes ketorolac eye drops and a combination of prednisolone and 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>For the <strong>IOL selection<\/strong>, caution is exercised with high-order aberrometry. If the alpha angle is less than 500 microns, it can be considered <strong>Trifocal or pentafocal IOLs<\/strong>If 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.<\/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>Detailed Diagnostic Evaluation and Multidisciplinary Approach <strong>angle closure<\/strong> always includes an assessment in 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 seizures and the need for intervention.<\/p>\n\n\n\n<p>They are used <strong>anterior segment optical coherence tomography (OCT)<\/strong> and the <strong>ultrasound biomicroscopy (UBM)<\/strong> for diagnosis and planning. UBM is considered essential to assess the nature of angle closure (functional, organic, primary, plateau, pseudo-plateau). In cases of <strong>iris plateau<\/strong>, the importance of carrying out both the <strong>iridotomy<\/strong> like the <strong>peripheral iridoplasty<\/strong> in the same procedure.<\/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>Dr. Sampaolesi presents a modern and proactive perspective on the management of <strong>angle closure glaucoma<\/strong> in hyperopic patients. Its approach prioritizes the <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> emerging as a valuable alternative in advanced cases. Comprehensive evaluation with gonioscopy in different lighting conditions, along with the use of <strong>OCT and UBM<\/strong>, are essential for an accurate diagnosis and the selection of the most appropriate surgical approach. Dr. Sampaolesi advocates a <strong>paradigm shift<\/strong>, adopting techniques that offer better results and a higher quality of life for these patients.<\/p>\n\n\n\n<p><\/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><strong>YouTube:<\/strong> Subscribe to our channel for 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><strong>Instagram:<\/strong> Follow us on Instagram for 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><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><\/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":"open","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 v27.3 - 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