AAO 2024: Early cataract extraction for angle closure glaucoma

Nathan Radcliffe, MD, shared insights from his presentation at the annual meeting of the American Academy of Ophthalmology entitled, "Early cataract extraction for angle closure glaucoma."

This transcript has been lightly edited for clarity.

Nathan Radcliffe, MD: Hello, this is Nathan Radcliffe, cataract and glaucoma specialist from New York City. I practice at New York Ophthalmology, the New York Eye Surgery Center, and I'm affiliated with Mount Sinai School of Medicine. Why you should consider early cataract extraction for patients with angle closure, elevated pressures, or angle closure glaucoma. And there are actually a few good studies on this topic. But I'd like to start with the alternative to taking the cataract out, which is to use a laser iridotomy and place a patient on medications. The data for laser iridotomy isn't that strong. This was looked at in a study called the ZAP study, which was a prospective study where patients had iridotomy in 1 eye or cataract in the other. There weren't a lot of people that benefited from the laser. And in fact, you needed to treat almost 50 patients in order to benefit 1 patient, in terms of the study's outcomes.

There are no approved IOP lowering medications for angle closure glaucoma. We're you using them all off label. Cataract surgery was studied in a trial called the EAGLE, prospective, multicenter randomized trial comparing laser iridotomy and meds to cataract surgery, and a cataract group did very well. Their angles were more open. They had a higher quality of life, and they either used fewer medications or had lower intraocular pressures, and in a long-term, different design, but similar study, these patients went on to have better outcomes with long-term lower medication use, up to 10 years, and even fewer cases of lost vision. So why does cataract surgery work so well? Well because it relieves relative pupillary block. It opens up the angle. It even relaxes the ciliary body.

So if you have plateau with angle closure, it should help there, and it opens up the trabecular meshwork face by relaxing the scleral spur. So in summary, I think the data is very clear. This is a good way to treat patients, I would say, who either have nerve damage or on pressure lowering medications with angle closure and so cataract surgery should be considered. One of the unique indications for patients with angle closure to undergo cataract surgery is if they have optic nerve damage with angle closure, or are on a number of medications. Interestingly, what isn't really necessary for the cataract extraction to be beneficial is for that cataract to be visually significant. Now, some insurances, some insurance companies, may quibble over this, but the data from the EAGLE study and the patient benefit is there, even if the cataract is not visually significant with angle closure, it's still medically significant and beneficial to remove it. When patients with angle closure undergo early cataract extraction, the benefits are essentially a disease modification, opening of their angle and either lowering the pressure or reducing the number of medications.

There are risks to cataract surgery. Most experienced surgeons find those risks to be less than 1 percent, but they include things like need for second surgery, inflammation, and in rare cases, glaucoma can result from cataract surgery, although the bulk of patients experience a glaucoma benefit. In a 10-year study comparing patients who received iridotomy to patients who received cataract surgery, the patients who received the cataract surgery did better, they needed fewer medications, and they had fewer cases of severe vision loss. But what's most interesting is the patients who underwent the iridotomy, in other words, who tried to avoid the early cataract surgery, over 10 years, 76 percent or so of them had their cataract out anyway. So the reality is, the cataract is coming out. It's just that removing it earlier is going to give that patient a longer period of benefit to their vision and to their glaucoma status.