Outcomes of chronic angle-closure glaucoma treated by phacoemulsification and endocyclophotocoagulation with or without endoscopically goniosynechialysis

INTRODUCTION

Glaucoma is the second leading cause of blindness worldwide. It is predicted that about one-fourth of all glaucoma cases will be angle closure in the following years.Ethnic Asians, females, and the aged are risk factors. Additional factors include shallow anterior chamber, shorter axial length, abnormal lens position, and thicker lenses. Choroidal thickness and iris volume may play vital roles in angle-closure mechanisms

. Chronic angle-closure glaucoma (CACG),caused by the closure of the angle secondary to extensive peripheral anterior synechiae (PAS), is the leading cause of irreversible blindness worldwide. Further, the Asian population is prone to developing CACG with a high prevalence and increased intraocular pressure (IOP). The treatment for CACG includes lens extraction, goniosynechialysis (GSL),laser peripheral iridotomy (LPI), argon laser peripheral iridoplasty (ALPI), filtering surgery, drainage implants, and cyclodestruction. There is no consensus on the subsequent treatment steps in patients with CACG. CACG frequently coexists with cataracts in older patients. Trabeculectomy alone or combined with phacoemulsification (phaco) is often used to treat patients with CACG. Still, it is associated with more complications, such as the shallow anterior chamber,choroidal detachment, thin-walled bleb, hypotony, aqueous misdirection, and endophthalmitis. Other treatments with fewer complications and visual impairment could be used before filtering surgery have been investigated. The advent of phaco brought about an IOP reduction of 30% in CACG, increased anterior chamber width with fewer complications, and visual improvement in patient outcomes

. A study has also reported that primary lens extraction controlled IOP and reduced the need for future glaucoma drainage surgery in primary angleclosure glaucoma (PACG)

. The PAS of CACG persists, with limited aqueous outflow, after phaco or filtering procedures.Synechialysis is conventionally performed using direct goniolens, but can also be carried out endoscopically. The procedure can separate the PAS from the angle under direct visualization, exposing the functional trabecular meshwork and restoring its filtering function. This procedure, combined with phaco under an endoscope for CACG, effectively lowers IOP and minimizes the postoperative complications of the filtering procedures

.

Endocyclophotocoagulation (ECP; Endo Optiks, Little Silver,NJ, USA) was first reported by Uram in 1992 and delivers laser energy

an ab interno approach under direct visualization of ciliary processes

. Because the procedure allows the laser to be precise and efficient during the procedure, its indications have been expanded to patients with better visual potential

.The procedure was used to lower IOP effectively and safely alone or combined with phaco; the maximal effect was observed about one month after the procedure

.

The IOP for both groups is shown in Table 3 and Figure 1. The preoperative baseline IOP was 22.18±6.48 and 22.95±6.71 mm Hg in the ECP group and E-GSL group, respectively (

=0.644). The IOP declined significantly in both groups (14.16±2.45 and 18.25±5.20 mm Hg)on day seven after surgery (

<0.001 and

=0.007 compared with the baseline). The IOP of the ECP group was 14.16±2.45,14.62±1.18, 15.33±2.04, and 16.36±2.45 mm Hg at 1, 3, 6, and 12mo, respectively. The IOP of the E-GSL group dropped from 14.13±2.47 mm Hg at one month to 12.41±1.26, 13.48±1.68,13.41±1.46 mm Hg at 3, 6, and 12mo, respectively. An earlier IOP reduction during the first month after surgery was observed in the ECP group compared with the E-GSL group.From 3 to 12mo, the IOPs of the E-GSL group were lower than those of the ECP group (

<0.001). Moreover, the mean IOP reduction was 26.2% in the ECP group and 41.6% in the E-GSL group at 12mo.

“中國古代風俗畫的描繪對象常常是以人為中心的社會風俗，應該非常清楚，中國古代的風俗人物畫是依托在各種功利性需求上而產生的?！盵2]如果必須要找到一些早期原始的風俗畫作為其源頭進行討論的話，則應上溯到石器時代。那些刻在巖石上的線條和彩繪在陶器上的圖案，雖然遠古先民受原始的生活環境與創作條件的限制，但是他們仍是可以用如此簡單的筆觸勾勒出那時的場景，即使他們創作的目的并非是欣賞藝術之美。遠古先民僅僅是為了生存而進行創作，他們的創作意識是單一而獨特的，這種生存包括巫術形式、紀念、祝禱等。很明顯，即使這一時期的繪畫只是當時社會生活的單純表現，但其寫實性卻非常值得人們關注。

SUBJECTS AND METHODS

林德認為，國際貿易是國內貿易的延伸，產品的出口結構、流向及貿易量的大小決定于本國的需求偏好，而一國的需求偏好又決定于該國的平均收入水平。這是因為三個方面的原因：

Fifty-three patients with CACG who accepted phaco with ECP alone (ECP group) or with ECP and GSL (E-GSL group) from 2018 to 2019 were reviewed(Table 1). The ECP group (32 eyes of 27 patients, mean±SD age 67.5±7.1y) and the E-GSL group (32 eyes of 26 patients,mean±SD age 69.9±7.4y) were followed for at least one year.

讀萬卷書，行千里路，是每個文人的夢想。但在那個時代，沒有祖蔭庇護，或是天上掉餡餅，只能是夢想。李白二十五歲時離家遠游，一游就是十七年。游蹤遍及長江、黃河下游地區，風景宜人處都留下深深的足跡。那足跡上留下的是詩名，還有散發著酒味、豪氣，給人留下夢幻般的回憶。多么暢快的旅行啊！結交當地名士，或飲酒作詩，或邀伴同游，而且往往出手大方得驚人。

All of the patients were followed up for at least one year after the surgery. We focused on changes in best-corrected visual acuity (VA), IOP, and the number of antiglaucoma drugs. All of the patients underwent gonioscopy six to twelve months after surgery. Final gonioscopy conducted at one year was used uniformly for analysis of all subjects. Any postoperative complications were recorded. In this study, there was no washout period for an antiglaucoma medication.

The VA (logMAR units) for both groups are shown in Table 4 and Figure 2. Compared to the mean baseline of VA(0.33), the mean VA was 0.40 (

=0.015), 0.50 (

<0.001), 0.50(

<0.001), 0.50 (

<0.001), 0.49 (

<0.001), 0.47 (

<0.001)in the ECP group, respectively, and 0.28 (

=0.093), 0.33(

=0.931), 0.38 (

=0.036), 0.38 (

=0.032), 0.38 (

=0.036),0.36 (

=0.241) in E-GSL group, respectively. The two groups showed a significantly difference in VA at seven days (

=0.038).

RESULTS

We diagnosed the patients with CACG based on the International Society of Geographic and Epidemiologic Ophthalmology criteria. Patients with cataracts and PAS of more than 180 degrees were included. Those who had accepted anti-glaucoma surgeries other than LPI were excluded

.Glaucoma severity was determined by the 2010 American Academy of Ophthalmology Preferred Practice Pattern guidelines. The patients with mild to moderate glaucoma underwent the phaco/ECP procedure, whereas patients with severe glaucoma underwent the phaco/GSL with ECP. Mildto-moderate glaucoma was defined as a normal visual field or only a visual field defect in one hemifield. Severe glaucoma was defined as a visual field defect in both hemifields

.

引人注目的是，整部小說差不多有四章(第三、十五、二十二和三十八章前半部分)完全沒有人的參與，純粹是對四大元素(the elements)的描述?！?br>