Advanced angle-closure glaucoma with cataract in a patient who cannot attend follow-up
A 66-year-old woman is referred with poor vision and headaches. She is hyperopic (+4.25 DS) and has bilateral nuclear sclerotic cataract. Intraocular pressure is 32 mmHg in the right eye on dorzolamide-timolol plus brimonidine and 24 mmHg in the left eye on the same drops. Gonioscopy shows 270° of peripheral anterior synechiae in the right eye and 180° in the left; anterior chamber depth is 1.95 mm. The right disc has a 0.85 cup-disc ratio with inferior rim notching and a field mean deviation of −9.2 dB; the left disc is 0.65 with a mean deviation of −1.8 dB. She lives in a village four hours from the hospital, is her husband's sole carer, and says she can realistically return only twice a year. She has had one previous episode of severe eye pain with haloes that resolved with drops in a local clinic.
1. What is the mechanism of her glaucoma, and how do these findings determine your target pressure and which eye is operated first?
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This is primary angle-closure glaucoma with synechial closure, not simple open-angle glaucoma. The hyperopic, short eye with a 1.95 mm anterior chamber and a thick crystalline lens produces pupillary block and a crowded angle; the previous painful episode with haloes was an acute or subacute attack. The critical point is that 270° of peripheral anterior synechiae are already permanent - removing the lens will deepen the anterior chamber and relieve the lens-related component, but the synechial segments will not reopen. That is why lens extraction alone is unlikely to be sufficient in the right eye.
The right eye has advanced damage (0.85 cup, inferior notching, mean deviation −9.2 dB), so the target pressure should be in the mid-teens, roughly a 40–50% reduction from the untreated level, and lower than what her current three medications are achieving. The left eye has early damage and a largely open angle; pressure control there is easier.
Operate the right eye first - it has the worse disc and field, the higher pressure, the greater synechial burden, and the denser cataract. The left eye should have definitive treatment (laser iridotomy or lens extraction) planned within weeks rather than months, because an untreated fellow eye after an attack carries a very high risk of a second attack. Acute attack prevention in the left eye is not optional.
2. Given her advanced damage but very limited access to follow-up, what operation would you recommend for the right eye and why? Address the alternatives explicitly.
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There is a genuine tension between efficacy and safety of the follow-up she can actually provide.
- Phacoemulsification alone will deepen the angle and typically lowers pressure by only a few mmHg in angle-closure eyes; with 270° of synechiae and advanced damage, it is not enough on its own.
- Phaco-trabeculectomy with mitomycin C gives the most predictable and largest pressure reduction and is the classic answer for synechial angle closure with advanced damage. The problem is the bleb: it needs early and repeated review, suture lysis decisions, and urgent attention if it leaks or becomes infected. A patient four hours away with two visits a year is a poor candidate for a bleb she cannot have monitored.
- Phaco plus a Schlemm's canal-based procedure (GATT or canaloplasty) or phaco plus a subconjunctival MIGS avoids bleb dependence and gives useful, though somewhat less certain, pressure reduction and medication sparing.
My recommendation would be phacoemulsification combined with a bleb-sparing angle procedure, with a clear plan for a local ophthalmologist to review her at one week and one month, and a low threshold to add topical therapy. If a local review arrangement cannot be secured at all, and if she understands the risks, a combined phaco-trabeculectomy performed with a planned early review by a colleague closer to home is still defensible for the right eye because her disease is advanced and the consequences of under-treatment are irreversible. The decision should be shared, documented, and revisited if her social circumstances change.
3. Two weeks before the planned surgery she presents to the local clinic with a painful red right eye, acuity counting fingers, pressure 54 mmHg, a fixed mid-dilated pupil and a hazy cornea. Outline your management and the definitive plan afterwards.
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This is an acute angle-closure attack in an eye with an already damaged optic nerve; every hour of high pressure costs field.
Immediate medical therapy: topical beta-blocker, topical alpha-agonist, topical and oral carbonic anhydrase inhibitor (acetazolamide 500 mg, intravenously or orally depending on vomiting), and a systemic hyperosmotic agent (oral glycerol or intravenous mannitol) if the pressure does not respond. Avoid pilocarpine until the pressure starts to fall - a pressure of 54 mmHg renders the iris sphincter ischaemic and unresponsive, so it is ineffective and delays definitive treatment. Corneal indentation can buy time while drugs take effect. Analgesia and antiemetics matter for a distressed patient.
Definitive treatment once the cornea clears: the right eye needs a laser peripheral iridotomy as a temporising measure if surgery cannot be brought forward, and then lens extraction with the glaucoma procedure already planned as soon as the cornea and inflammation allow, ideally within days rather than weeks. If the cornea is too hazy for laser, proceed to surgery once the pressure is medically controlled.
The fellow eye must not be forgotten. It should receive a prophylactic iridotomy (or be scheduled for clear lens extraction, which is the more effective option in a hyperopic eye with a rising pressure), and that should happen during this same admission if possible. She should leave hospital with written instructions about symptoms of a further attack, and with a telephone number - not just a routine appointment.