Financial Interest Disclosure LPI: There’s No Harm in Waiting and Observing • Research Affiliation • Advisory Boards • Allergan, Inc. • Allergan Shan Lin, MD • Memantine Study • Iridex • National Eye Institute Professor Director, Glaucoma Service • OHTS study • Carl Zeiss Meditec Dept. of Ophthalmology • Visante OCT study UCSF School of Medicine • Genentech • Lucentis/Ahmed valve Koret Vision Center study UCSF Medical School LPI for PACS Angle Closure Disease • Why you shouldn’t do LPI • Primary Angle Closure Suspect (PACS) • Occludable angle • NO evidence LPI reduces risk for glaucoma • No PAS • Natural history of PACS mostly benign • Primary Angle Closure (PAC) • May cause significant side effects • Occludable angle • Later Phaco obviates the need for LPI • PAS +/- OHTN • Primary Angle Closure Glaucoma (PACG) • Angle closure • Optic nerve +/- VF damage 1
PACS Foster Definition • What defines PACS and when should you do LPI? • Foster definition: ≥ 270 degrees of ant TM or less • AAO definition: ≥ 180 degrees of ant TM or less Foster PJ et al. Br J Ophthalmol. 2002;86:238-242 What is the Risk for Glaucoma What is the Risk for Glaucoma in PACS? in PACS? • PACS Progression in a Population Study • 50 PACS cases • 11 (22%) � Primary Angle Closure (PAC) • Vellore Eye Study (India) • NONE � PACG • N=972 patients • PACS=118 patients • 10.5% of eyes • 5 year follow up � 50 PACS cases Thomas R et al. Br J Ophthalmol 2003;87:450-454 Thomas R et al. Br J Ophthalmol 2003;87:450-454 2
Should You Do LPI? Should You Do LPI? Thomas R et al. Br J Ophthalmol 2003;87:450-454 Thomas R et al. Br J Ophthalmol 2003;87:450-454 20% do not respond to prophylactic LPI What You Should Do Who likely NOT respond to LPI? • Larger angle (AOD) • More anterior iris insertion (SS-IR: 0.085 vs 0.125mm) • Thicker peripheral iris (0.447 vs 0.415 mm) • More CB anterior rotation (TCPD: 0.514 vs 0.562mm) Lee R…Lin S. IOVS 2013 Huang G…Lin S. Curr Eye Res 2012 Jul;37(7):575-82 Thomas R et al. Br J Ophthalmol 2003;87:450-454 Lee R…Lin S. Ophthalmology 2014 Jun;121(6):1194-202 He M Ophthalmology 2007 3
Side effects of LPI • Variety of visual symptoms •775 bilateral PACS were • haloes, shadows, glare, crescents randomized • linear dysphotopsia (the most specific and •LPI one eye • Untreated fellow eye as problematic symptom) control •Angle width of treated eyes • 2.7% to 6.8% of patients after LPI Angle width (degree) AOD250 ( µ m) •increased markedly after LPI • Monocular diplopia •remained stable for 6 • IOP rise, transient uveitis, hyphema months •decreased significantly by • Corneal trauma, cataract, closure of the iridotomy, 18 months •Untreated eyes retinal detachment •consistent and rapid decrease in angle width over the 18 months. ARA ( µ m) TISA500 ( µ m) Am J Ophthalmol 2014;157:929–935 Jiang, He, Ophthalmology 2014 Additional IOP-lowering interventions Phaco Effect in Narrow Angles after LPI • Peng et al. 356 Vietnamese patients, 12 years • PACS 7% needed additional therapy • PAC 42% needed additional therapy • PACG 100% needed additional therapy • Rosman et al. CACG in New York and Asia, 56 months • 41% topical glaucoma medication • 31% underwent filtering surgery • 28% underwent a glaucoma laser procedure Peng P H…Lin S. Br J Ophthalmol, 2011 Bansal S, et al. Am J Ophthalmol, 2015 Rosman M, et al. Ophthalmology, 2002 Blondeau P, et al. Can J Ophthalmol, 2011 Huang G…Lin S. Arch Ophthalmol 2011;129(10):1283-90 4
AOD Change Summary Narrow angle group Open angle group P Value 0.179 ± 0.014 0.297 ± 0.019 AOD500(mm),Nasal 0.399 ± 0.017 0.427 ± 0.019 Preoperative <0.001* • NO evidence that LPI is effective in 0.405 ± 0.024 0.452 ± 0.014 10 days 0.021* preventing progression compared to No LPI 0.403 ± 0.024 0.452 ± 0.017 1 month 0.005* 0.389 ± 0.025 0.451 ± 0.015 3 months 0.008* • Side effects of LPI not insignificant 6 months 0.002* • Future Phaco for cataract obviates LPI 0.215 ± 0.018 0.129 ± 0.024 Changes in AOD500(mm),Nasal 0.215 ± 0.019 0.154 ± 0.020 10 days 0.217 ± 0.023 0.156 ± 0.020 1 month 0.003* 0.196 ± 0.023 0.155 ± 0.021 3 months 6 months AOD500= angle opening distance at 500 µ m anterior to the scleral spur *Statistically significant from linear mixed model Huang G…Lin S. Arch Ophthalmol 2011;129(10):1283-90 5
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