Introduction: This study explored the current views of ophthalmologists in China on the preferred strategy and the primary influencing factors in managing primary angle-closure suspect (PACS). Methods: An online survey was distributed via WeChat to ophthalmologists working in hospitals at all levels throughout China to investigate the optimal management strategy and factors influencing the strategy for treating PACS from February to March 2023. Management strategies examined included regular observation (RO), laser peripheral iridectomy (LPI), and phacoemulsification with intraocular lens implantation (PEI). The study explored the factors that influenced clinical decision-making processes and collected demographic information from the respondents for analysis. Results: A total of 1009 ophthalmologists responded; 442 responders considered RO as a reasonable option for patients with PACS, while the majority opted for more positive treatments, with 460 choosing LPI and 107 selecting PEI. Further grouping analysis revealed significant differences between tertiary and lower-level hospitals (P < 0.01) and between public and private hospitals (P < 0.05). Significant differences were found among resident, attending, and senior doctors and between northern and southern hospitals. The top three considerations for ophthalmologists who selected RO were ultrasound biomicroscopy (UBM) without pupillary block, absence of a family history of glaucoma, and good compliance with regular follow-up. For LPI, the factors were UBM indicating pupillary block, glaucoma symptoms, and poor compliance with regular follow-up. For PEI the factors were age, family history of glaucoma, and poor compliance with regular follow-up. Conclusion: The majority of ophthalmologists prefer aggressive treatments such as LPI or PEI over RO when dealing with patients with PACS. Disparity existed among ophthalmologists based on their level of experience, hospital ownership and level, and geographical location. The survey underscores the complexity and multifactorial nature of PACS management and highlights the need for further research and standardization of treatment protocols to ensure optimal patient outcomes.
Keywords: Primary angle-closure suspect; Management; Regular observation; Laser peripheral iridectomy; Phacoemulsification with intraocular lens implantation
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s40123-023-00828-4.
The current management strategies for primary angle-closure suspect (PACS) are diverse and chaotic. Multiple large-scale clinical trials have provided different recommendations for PACS treatment. This study aimed to explore the current views of ophthalmologists in China on the preferred strategy and the primary influencing factors in managing PACS. The majority of ophthalmologists in China preferred aggressive treatments such as laser peripheral iridectomy or phacoemulsification with intraocular lens implantation over regular observation when dealing with patients with PACS. Significant differences in treatment options existed among ophthalmologists based on their level of experience, hospital ownership and level, and geographical location. The presence of glaucoma symptoms, a family history of glaucoma, and axial length of the eye were identified as the top three factors influencing treatment decisions. The complexity and multifactorial nature of PACS management highlights the need for further research and standardization of treatment protocols to ensure optimal patient outcomes.
Primary angle-closure glaucoma (PACG) is a leading cause of irreversible blindness worldwide. It is estimated that at least 10 million people were affected by PACG in China by 2020, which accounts for approximately three-quarters of the total worldwide, and it has become a serious challenge for public health in China [[
Since laser peripheral iridotomy (LPI) became available in the mid-1970s, it has been recommended as the initial treatment in subjects with PACD [[
Besides, a multicenter RCT to assess the efficacy of early lens extraction for the treatment of PACG (EAGLE) showed that clear-lens extraction was more effective in lowering intraocular pressure and cost-effective than LPI within 5 years and should be considered an option for first-line treatment [[
In the context of the emergence of new insights from various large-scale clinical trials and the variability in PACS management, achieving consensus on the treatment of PACS appears to be a challenge. The objective of this study is to examine the current opinions of ophthalmologists with respect to the preferred management strategy of PACS and the related considerations in China. The findings of this study should shed light on the real-world management of PACS in a country with the largest number of patients with PACS.
A nationwide questionnaire-based online survey was conducted among practicing ophthalmologists in China. The study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments and approved by the Ethics Committee of Peking University People's Hospital (2018PHC011). All participants were aware of the collection of their data for this study and informed consent was obtained from each participant. This survey was voluntary, ensuring that ophthalmologists with an interest in glaucoma were more prone to be engaged in completing the questionnaire.
The survey questionnaire was distributed through the WeChat platform to ophthalmologists in hospitals across provinces and cities in China from February 2023 to March 2023, as well as to ophthalmologists within various levels of ophthalmology associations. The questionnaire was disseminated either through ophthalmologists WeChat groups or sent directly to individual ophthalmologists. To ensure participation from interested physicians, the questionnaire was sent once with a reminder sent during the survey collection period. The inclusion criteria were practicing ophthalmologists in hospitals at all levels and all cities across China, including tertiary and lower-level hospitals, provincial, municipal, and county hospitals, public and private hospitals, specialized and general hospitals. All included ophthalmologists have obtained a professional ophthalmology license and completed specialized training for ophthalmic residents. Attending doctor refers to a doctor who has worked as a resident for 2 years and has passed the intermediate professional title examination. Senior doctor refers to a doctor who has worked as attending doctor for at least 5 years and has passed the senior professional title examination. The questionnaire (Supplementary Material) comprised a total of 14 items, with a primary focus on the following aspects: (
The determination of the sample size was based on preliminary findings drawn from a limited-scale questionnaire survey, utilizing binary logistic regression analysis. PASS (Power Analysis and Sample Size) 2019 software was employed for sample size calculation. Within the initial cohort comprising 355 participants, the proportion of northern hospitals opting for LPI and PEI in the management of PACS was 0.52, whereas their southern counterparts exhibited a ratio of 0.60 for this treatment preference. The coefficient of determination (R
Statistical analysis was performed by using SPSS software (version 24.0; SPSS Inc., Chicago, IL, USA). The questionnaire responses were analyzed as categorical variables and were compared using the chi-square test. Subsequently, logistic regression models were employed to investigate the influence of demographic variables on the selection of management strategy. P < 0.05 was considered statistically significant.
In total, the questionnaire was sent to 1538 ophthalmologists through WeChat groups and individuals and we received 1269 responses to the survey. After verification for logical consistency and completeness, 1009 questionnaires were eligible for analysis, a valid response rate of 79.51%.
Of the 1009 ophthalmologists who participated in the survey, 600 were female (59.46%) and 409 were male (40.54%). Among the participants, 646 worked in tertiary hospitals (64.02%), whereas the remaining worked in lower-level hospitals (35.98%). Of the total respondents, 775 worked in public hospitals (76.81%), while 234 worked in private hospitals (23.19%). Further stratification by hospital type revealed that 295 ophthalmologists worked in specialized hospitals (29.24%), and 714 worked in general hospitals (70.76%). Regarding the degree of economic development based on the administrative region, 344 participants (34.09%) worked in provincial hospitals, 414 (41.03%) in municipal hospitals, and 251 (24.88%) in county hospitals. The location of the hospital was analyzed on the basis of the traditional concept of the Qinling-Huaihe geographic demarcation line, which serves as a traditional dividing line between the northern and southern regions of China, and the socioeconomic divide that delineates the country into eastern and western regions. According to this analysis, 556 (55.10%) participants were from northern hospitals, whereas 453 (44.90%) were from southern hospitals. Moreover, 667 (66.11%) participants were from eastern hospitals, and 342 (33.89%) were from western hospitals. Of all the ophthalmologists who participated, 288 (28.54%) considered themselves glaucoma specialists, while the others were nonglaucoma specialists. Meanwhile, 577 (57.19%) responders were senior doctors, 319 (31.62%) responders were attending doctors, and 113 (11.19%) were resident doctors (Table 1).
Table 1 Distribution of professional features and titles of responders based on employing institution
Institution Grouping by specialty Grouping by professional titles Glaucoma specialty ( Non-glaucoma specialty ( Senior doctors ( Attending doctors ( Resident doctors ( Tertiary hospitals 646 (64.02%) 211 435 397 183 66 Lower-level hospitals 363 (35.98%) 77 286 180 136 47 Public hospitals 775 (76.81%) 208 567 457 238 80 Private hospitals 234 (23.19%) 80 154 120 81 33 Specialized hospitals 295 (29.24%) 115 180 155 97 43 General hospitals 714 (70.76%) 173 541 422 222 70 Provincial hospitals 344 (34.09%) 128 216 216 91 37 Municipal hospitals 414 (41.03%) 120 294 228 141 45 County hospitals 251 (24.88%) 40 211 133 87 31 Northern hospitals 556 (55.10%) 158 398 323 171 62 Southern hospitals 453 (44.90%) 130 323 254 148 51 Eastern hospitals 667 (66.11%) 183 484 382 214 71 Western hospitals 342 (33.89%) 105 238 195 105 42
Overall, the most frequently selected treatment for patients with PACS was LPI (45.59%), followed by RO (43.81%) and PEI (10.60%). The considerations cited by the majority of respondents when making this treatment selection were the presence of glaucoma symptoms (93.46%), family history of glaucoma (92.37%), and the patient's axial length (86.22%). Although not among the top three considerations, patients' age, treatment preference, and UBM findings suggestive of pupillary block were still selected by over 80% of respondents.
For ophthalmologists who chose LPI as the preferred treatment for PACS, the top three factors that were considered in the diagnostic and therapeutic process were the patient's family history of glaucoma, willingness of the patient to receive treatment, and presence of glaucoma symptoms (Fig. 1a). When all the factors were weighted and ranked, among the doctors who chose LPI, the factor most often selected as a key factor was UBM indicating the presence of pupil blockage (48.64%). The second most frequently selected factor was the presence of glaucoma symptoms (40.7%), and patient compliance with follow-up visits (61.18%) was third (Fig. 2a).
Graph: Fig. 1The top 10 most considered factors for each selected treatment. Percentages of the considered factors for a LPI, b PEI, and c RO. LPI laser peripheral iridectomy, PEI phacoemulsification with intraocular lens implantation, RO regular observation, UBM ultrasound biomicroscopy
Graph: Fig. 2Results of importance ranking analysis of the considered factors the respondents chose for each selected treatment. Importance ranking analysis of the considered factors for a LPI, b PEI, and c RO. LPI laser peripheral iridectomy, PEI phacoemulsification with intraocular lens implantation, RO regular observation, UBM ultrasound biomicroscopy
For ophthalmologists who preferred PEI as the initial treatment for PACS, the therapeutic process prioritized the following three key factors: patient age above 50 years, willingness of the patient to receive treatment, and a family history of glaucoma (Fig. 1b). Upon weighting and ranking all relevant factors, ophthalmologists who opted for PEI consider patient age to be the most crucial factor (47.79%), followed by a family history of glaucoma (40.57%) and patient compliance with follow-up visits (57.53%), which were the second and third most commonly selected factors (Fig. 2b).
However, ophthalmologists who considered RO as the first choice of treatment were more influenced by the following factors: good compliance with regular follow-up, the absence of glaucoma symptoms, and UBM showing no pupillary block (Fig. 1c). Further ranking all relevant factors according to their importance, the most frequently selected was UBM indicating the absence of pupil blockage (45.76%), followed by axial length (38.14%) and good compliance with regular follow-up (59.62%). These results indicated that good compliance is a fundamental requirement for doctors who choose RO, but they placed a greater emphasis on the absence of pupillary blockage on UBM (Fig. 2c).
We further categorized respondents on the basis of different demographic characteristics and analyzed the variations in clinical practice attitudes toward PACS management among different subgroups (Table 2). Significant differences were observed in treatment choices between ophthalmologists working in tertiary hospitals and those in lower-level hospitals (42.11%, 49.07%, and 8.82% versus 46.84%, 39.39%, and 13.77% for RO, LPI, and PEI, respectively; χ
Table 2 Differences in preferred management strategies under different categories
Male Female Tertiary hospitals Lower-level hospitals Public hospitals Private hospitals Specialized hospitals General hospitals Glaucoma specialists Non-glaucoma specialists LPI 190 (40.59%) 270 (45.00%) 317 (49.07%) 143 (39.39%) 360 (46.45%) 100 (42.74%) 327 (45.61%) 133 (45.55%) 128 (44.44%) 332 (46.05%) PEI 53 (12.96%) 54 (9.00%) 57 (8.82%) 50 (13.77%) 72 (9.29%) 35 (14.96%) 76 (10.60%) 31 (10.62%) 38 (13.19%) 69 (9.57%) RO 166 (46.45%) 276 (46.00%) 272 (42.11%) 170 (46.84%) 343 (44.26%) 99 (42.30%) 314 (43.79%) 128 (43.83%) 122 (42.37%) 320 (44.38%) 5.333 11.331 6.144 0.000 2.857 0.069 0.003* 0.046* 1.000 0.240
Table 2 Differences in preferred management strategies under different categories
Senior doctors Attending doctors Resident doctors Provincial hospitals Municipal hospitals County hospitals Northern hospitals Southern hospitals Eastern hospitals Western hospitals LPI 257 (44.54%) 143 (44.83%) 60 (53.10%) 159 (46.22%) 196 (47.34%) 105 (41.83%) 236 (42.55%) 223 (49.23) 298 (44.76%) 161 (47.08%) PEI 70 (12.13%) 22 (6.90%) 15 (13.27%) 27 (7.85%) 45 (10.87%) 35 (13.94%) 54 (9.69%) 53 (11.70) 71 (10.63%) 36 (10.53%) RO 250 (43.33%) 154 (48.27%) 38 (33.63%) 178 (45.93%) 173 (41.79%) 111 (44.23%) 266 (47.76%) 177 (39.07) 298 (44.61%) 145 (42.39%) 11.899 6.966 7.688 0.521 0.018* 0.138 0.021* 0.771
Data are presented as n (%) LPI laser peripheral iridectomy, PEI phacoemulsification with intraocular lens implantation, RO regular observation *P < 0.05
Besides, 49.23% of ophthalmologists in southern hospitals recommended LPI, and 11.70% recommended PEI, compared with 42.55% and 9.69% in northern hospitals, respectively, while only 39.07% would advise RO for the management of PACS. Surprisingly, there was no significant difference in the preferred treatment choices for PACS between hospitals in the East and West regions, despite the traditionally perceived greater economic disparity between them.
We also conducted a multiple logistic regression analysis to clarify the specific impact of different factors on the selection of the three treatment strategies (Tables 3 and 4). In the unadjusted regression models, hospital level, ownership of the hospital, professional title, and city level all exerted a statistically significant influence on the treatment preference between PEI and LPI. However, when a regression model that adjusted for all relevant factors was applied, only professional title and city level retained their significant impact on the choice between PEI and LPI. Regarding the selection between RO and LPI, the table demonstrated that both hospital level and geographical location (southern or northern) had a statistically significant effect on treatment choice, whether in fully adjusted models or not.
Table 3 Association between different demographic characteristics and preferred treatment options (PEI/LPI)
PEI/LPI Unadjusted Adjusted for all relevant factors OR (95% CI) OR (95%CI) Gender 0.122 1.395 (0.915–2.127) 0.862 1.039 (0.676–1.597) Professional titles 0.039* 1.300 (1.014–1.666) 0.042* 1.311 (1.010–1.703) Glaucoma specialists or not 0.117 1.428 (0.915–2.230) 0.180 1.387 (0.860–2.237) Hospital levels 0.011* 1.564 (1.106–2.211) 0.437 1.202 (0.756–1.913) Ownership of hospitals 0.017* 1.750 (1.104–2.774) 0.084 1.651 (0.935–2.912) Hospital types 0.974 1.008 (0.634–1.602) 0.393 1.273 (0.732–2.212) City levels of the hospital location 0.019* 0.719 (0.545–0.948) 0.031* 0.697 (0.502–0.968) Northern or southern hospitals 0.844 1.043 (0.685–1.589) 0.862 1.039 (0.676–1.597) Eastern or western hospitals 0.791 0.942 (0.604–1.469) 0.714 0.919 (0.585–1.444)
PEI phacoemulsification with intraocular lens implantation, LPI laser peripheral iridectomy, OR odds ratio, CI confidence interval *P < 0.05
Table 4 Association between different demographic characteristics and preferred treatment options (RO/LPI)
RO/LPI Unadjusted Adjusted for all relevant factors OR (95% CI) OR (95% CI) Gender 0.239 0.852 (0.652–1.113) 0.226 0.841 (0.636–1.113) Professional titles 0.583 0.961 (0.833–1.108) 0.733 0.974 (0.838–1.133) Glaucoma specialists or not 0.984 0.997 (0.745–1.334) 0.619 1.082 (0.793–1.476) Hospital levels 0.014* 1.334 (1.061–1.677) 0.006* 1.511 (1.123–2.033) Ownership of hospitals 0.825 1.036 (0.756–1.419) 0.214 0.785 (0.537–1.150) Hospital types 0.943 0.990 (0.743–1.318) 0.180 1.259 (0.899–1.764) City levels of the hospital location 0.823 0.981 (0.826–1.164) 0.524 1.067 (0.874–1.302) Northern or southern hospitals 0.010* 0.707 (0.543–0.921) 0.026* 0.737 (0.564–0.963) Eastern or western hospitals 0.472 0.904 (0.686–1.191) 0.702 0.947 (0.716–1.252)
RO regular observation, LPI laser peripheral iridectomy, OR odds ratio, CI confidence interval *P < 0.05
This study revealed that the majority of ophthalmologists preferred more aggressive treatments, such as LPI or PEI, over RO for patients with PACS. The presence of glaucoma symptoms, family history of glaucoma, and axial length of the eye were identified as the top three factors influencing treatment decisions. Subsequent analysis revealed a noteworthy degree of heterogeneity in the treatment decisions by different groups of ophthalmologists. This disparity was particularly pronounced among doctors who differed in their level of experience, hospital ownership and level, and geographical location.
Although LPI is recommended as the initial treatment for patients with PAC and PACG in preferred practice guidelines [[
It is reassuring to note that although there is a greater proportion of ophthalmologists electing to administer aggressive interventions, the differences in ratio between these strategies are no longer as great as those reported in previous studies. In the current study, 45.59% of the responders chose LPI, 10.60% chose PEI, and 43.81% chose RO. A national survey conducted in Singapore found that 85% of ophthalmologists advocated routine LPI treatment for patients with PACS [[
The current study also found significant differences in the treatment choices for PACS between doctors from tertiary hospitals and those from secondary or lower-level hospitals, as well as between doctors from public and private hospitals, doctors with different professional titles, and doctors from the northern and southern regions. Notably, lower-level hospitals and private hospitals had more ophthalmologists who preferred PEI as the first-line treatment for PACS, while LPI was more frequently chosen in tertiary hospitals and public hospitals. One possible explanation for this finding is that PEI can offer greater potential for generating economic benefits, while variations in the laser equipment configurations across different hospitals may also contribute to the difference. Furthermore, senior doctors and residents exhibited a greater propensity for PEI, and residents also tended to opt for LPI. In contrast, attending doctors preferred RO as the primary strategy for managing PACS. This may be related to the fact that doctors with intermediate years of experience are most receptive to new research findings. Geographical location-based statistical analysis revealed that doctors from southern hospitals were inclined to favor LPI and PEI, while doctors from northern hospitals were more prone to adopt an observation approach. After adjustment for other potential confounding factors, a significant difference persisted between the northern and southern regions with respect to the selection of RO versus LPI. In the southern regions of China, which are relatively more economically developed, the higher utilization of aggressive treatments may also be attributed to their potential economic benefits. Intriguingly, despite the well-known ZAP trial conducted in a southern city of China, doctors from the southern region do not seem to have fully adhered to the research's recommendations in their clinical practice.
The present study showed that the top three considerations varied among ophthalmologists who selected different management strategy. These findings indicate that although doctors may have inherent preferences toward certain treatments for PACS, their choices are predominantly based on patients' anatomical characteristics and potential benefits. Previous studies have focused on the anatomical factors that contribute to the progression of PACS. Specifically, Zhang's study [[
This study has some limitations. Although the questionnaire survey reflects the clinical diagnosis and treatment status of PACS in China to some extent, as a result of uneven sample distribution across different groups, random stratified sampling could not be achieved. This may introduce some bias into the study results compared to the actual situation. Additionally, this study is initiated by a single center with a relatively small sample size. Further large-sample, multicenter investigations are needed to reinforce our conclusion or detect new perspectives.
This study investigated the current treatment preferences of PACS in China and concluded that the majority of ophthalmologists prefer aggressive treatments such as LPI or PEI over RO when dealing with patients with PACS. Many clinical factors influenced their treatment choices, and significant differences were identified among ophthalmologists based on their level of experience, hospital type, and geographical location. Given the complexity and multifactorial nature of PACS management, there is no one-size-fits-all approach that is most suitable for all situations. The 2020 European Glaucoma Society guidelines [[
We thank the participants of the study. We sincerely thank Shang Xu for his technical support in questionnaire design.
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work, and have given their approval for the version to be published.
Fei Yang and Huijuan Wu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Huijuan Wu. Acquisition, analysis, or interpretation of data: Fei Yang and Huijuan Wu. Drafting of the manuscript: Fei Yang. Critical revision of the manuscript for important intellectual content: Fei Yang and Huijuan Wu. Statistical analysis: Fei Yang. Obtained funding: Huijuan Wu.
This study was supported by the program of development and cultivation of medical innovative varieties and industrial support, Beijing Municipal Science and Technology Commission [Z191100007619045]; and National Natural Science Foundation of China [61634006]. The sponsor or funding organization had no role in the design or conduct of this research. The Rapid Service Fee was funded by the authors.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Fei Yang and Huijuan Wu declare that they have no competing interests.
The study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments and approved by the Ethics Committee of Peking University People's Hospital (2018PHC011). All participants were aware of the collection of their data for this study and informed consent was obtained from each participant.
Below is the link to the electronic supplementary material.
Graph: Supplementary file1 (PDF 146 KB)
By Fei Yang and Huijuan Wu
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