Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated?

Angle-closure glaucoma is an aggressive condition that causes millions to become blind worldwide. This review explores the use of prophylactic laser peripheral iridotomy (PI) in patients classified as primary angle-closure suspects (PACS), and additionally, the use of clear lens exchange as a primary treatment option in established angle-closure disease with or without glaucoma. As PI has a strong prophylactic effect in fellow eyes of patients who have had an acute attack, its use has been widely adopted in those patients classified as PACS, but with limited evidence to support this. A large randomised trial conducted in China has demonstrated that although PI reduces the risk of incident angle-closure disease, the incidence of disease that would threaten vision was much lower than anticipated. This suggests that the benefit of prophylactic PI is very limited. Health services data shows an association between rising cataract surgical rates and of decreasing rates of acute angle-closure. Age-related growth of the lens is a major component of angle-closure disease. Several studies have shown that clear lens extraction (CLE) effectively lowers IOP in angle-closure. The use of CLE as a primary treatment option has been tested against LPI in the EAGLE study, a large RCT that enroled people with angle-closure and an IOP 30 mmHg, and those with angle-closure glaucoma. The trial showed CLE to be superior to PI both for IOP control and patient reported quality of life. On these grounds, CLE should be considered for first-line treatment of more advanced angle-closure disease.摘要 : 原发性闭角型青光眼已成为严峻的社会公共卫生问题, 已引起全球百万人致盲 。本文旨在探讨预防性激光周边虹膜切除术(PI)在可疑原发性房角关闭(PACS)患者中的作用, 此外, 对于已确诊的伴或不伴有青光眼的原发性房角关闭的患者, 是否首选清亮晶状体摘除术。研究已证实预防性激光周边虹膜切除术(PI)可有效预防既往有急性发作史的患者对侧眼发作, 因此PI现已广泛应用于PACS的治疗, 但是尚缺乏更多有效证据。一项中国大型随机试验证实, 尽管PI降低了房角关闭发生的风险, 但是并未降低威胁视力的眼病的发病率, 这说明预防性PI的作用还是有限的。卫生服务数据提示白内障手术率的增加与急性房角关闭发生率下降具有相关性。随年龄增加晶体的改变与房角关闭具有相关性。多项研究表明, 尚未混浊的晶体摘除术 (CLE)可以有效降低房角关闭的眼压。在EAGLE研究中, 将CLE作为主要治疗方案与LPI进行了比较。这项大型的RCT研究纳入了闭角型青光眼患者与IOP30mmHg的房角关闭患者。研究认为在控制眼压以及提高生活质量方面, CLE较PI具有明显优势。因此, CLE可考虑作为严重房角关闭的一线治疗。.