Download Table 5. Comments and corresponding ratings for 42 clinical

Table 5. Comments and corresponding ratings for 42 clinical questions 1, 2
Clinical questions
Comments from survey respondents
1. Is laser iridotomy effective in preventing acute angle-closure
 Laser iridotomy is important in preventing acute ACG/ PACG as the rate
crisis and primary angle-closure glaucoma in patients with
of progression in angle closure eyes is not known. Also in the future, an
iridotrabecular contact, and normal intraocular pressure without
answer to such a question may not be available due to ethical
peripheral anterior synechiae?
considerations
 It’s important
 Laser iridotomy is effective in preventing pupil block and not effective in
preventing angle closure
 There is currently paucity of data regarding the natural history of angle
closure disease, except for data from India (Vellore Eye Study). Current
RCTs being conducted in Singapore and China will hopefully provide
dependable biomarkers that would help determine which of the PACS
eyes might go on to develop angle closure disease
 The data answers this already
 It is effective, at present we do not know how many with PACS will
progress or develop acute crisis. In such a situation not all eyes with
PACS will need PI
 Yes
 Yes
 Yes
2. Does routine monitoring of people with iridotrabecular contact
 Serial gonioscopy is very important for picking up early stages of PAC/
improve the identification of primary angle closure?
PACG. It should be opportunistically and routinely done in all patients
visiting the clinic, and also in patients on medical therapy who require
change of medical therapy apparently for the lack of control of
glaucoma
 Some people have pupil block at first and some have angle-closure at first
 This could be a potential waste of resources as only 22-28% of PACS
would convert to disease and hence might not be practical in either first
world nations or emerging economies. One should remember that the
prevalence of angle closure glaucoma is about 2-3% and there are other
eye diseases that warrant our attention
 I think the cost-effectiveness analysis of such an approach vis-a-vis the
prevalence of the disease is an important factor to consider in such a
research question
 Periodic indentation gonioscopy is needed in eyes with PACS
 Yes
 Yes
10/9/2012
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Page 1 of 13
Clinical questions
3. Is prophylactic laser iridotomy more effective than routine
monitoring in preventing acute angle-closure crisis and primary
angle-closure glaucoma in patients who are primary angle-closure
suspects when medication required may provoke pupillary block?
4. Is prophylactic laser iridotomy more effective than routine
monitoring in preventing acute angle-closure crisis and primary
angle-closure glaucoma in patients who are primary angle-closure
suspects when symptoms present suggest prior acute angleclosure?
5. Is prophylactic laser iridotomy more effective than routine
monitoring in preventing acute angle-closure crisis and primary
angle-closure glaucoma in patients who are primary angle-closure
suspects and have limited access to immediate ophthalmic care
(e.g., the patient resides in a nursing facility, travels frequently to
developing parts of the world, works on a merchant vessel)?
Comments from survey respondents
 Yes
 Medications like alpha-2 agonist tend to cause mydriasis and
consequently increase pupillary block. With the more frequent use of
such a medication amongst general ophthalmologist as well as glaucoma
fraternity and the lack of importance given to the procedure of
gonioscopy, a prophylactic iridotomy may be more effective in
preventing acute angle closure crisis and PACG
 Shown to a certain extend yet by leydecker (germany) decades ago
 At present the evidence is inconclusive
 It is very effective in preventing APAC, but not so effective in preventing
chronic PACG. I think the question may be separated for APAC and
chronic PACG
 Yes
 Yes
 Yes
 Any subject presenting with history of symptoms suggestive of an acute
event should be considered to have PAC and managed with LPI as first
line therapy, unless new evidence suggests otherwise
 With symptoms PI is needed
 It is very effective in preventing APAC, but not so effective in preventing
chronic PACG. I think the question may be separated for APAC and
chronic PACG
 Yes
 Yes
 Yes
 Relative indication for prophylactic iridotomy
 Such patients should be advised and undergo prophylactic LPI given the
difficulty in access to appropriate ophthalmic care
 I have rated these questions as "0" based on the fact that we have strong
consensus on these questions already and we may not need new research
on these questions
 PI is better option
 It is very effective in preventing APAC, but not so effective in preventing
chronic PACG. I think the question may be separated for APAC and
chronic PACG
 Yes
 Yes
10/9/2012
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8
9
7
8
7
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1
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8
10
1
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10
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Clinical questions
6. Is informing primary angle-closure suspects patients who have
not had a laser iridotomy about the danger of taking pupil dilation
medicines (e.g., over-the-counter decongestants, motion-sickness
medication, anticholinergic agents) effective in preventing acute
angle-closure crisis?
7. Does informing primary angle-closure suspects patients who
have not had a laser iridotomy about the symptoms of acute
angle-closure crisis reduce the time to notify their
ophthalmologist about symptoms and receive eye care services?
8. Is prophylactic peripheral laser iridoplasty after laser iridotomy
effective in preventing primary angle-closure glaucoma and acute
angle-closure crisis in eyes with plateau iris?
9. Is further therapy (iridoplasty, chronic miotic therapy, or other
surgical procedures) effective in preventing primary angleclosure glaucoma and acute angle-closure crisis in eyes with
recurrent high intraocular pressure after laser iridotomy when the
pupil is dilated (plateau iris syndrome)?
Comments from survey respondents
 Yes
 Difficult to inform the patient about the complete list of such medication.
It would be rational to perform an iridotomy
 It has been demonstrated that routine dilatation has low risk of
precipitating acute angle closure
 It is important part of patient education
 Yes
 Yes
 Yes
 Yes, in urban centres with easy access to emergency health care and
availability of ophthalmologist it would be wise to inform the patients of
the symptoms of acute ACG. in patients who do not have such an access
it may be rational to perform an iridotomy
 Patient education and awareness are key to finding solutions to manage
angle closure disease more effectively, given that the prevalence of
sufferers is on the rise
 Yes
 Yes
 No
 Yes
 Given that there have been no RCTs to determine the efficacy of ALPI
and that the natural history of plateau iris is not fully understood, AND
that angle closure disease of mixed mechanisms, it would be important
to answer this research question
 Not so frequent at least in mid europe
 Yes if not at least miotics should be used
 Yes
 Yes
 Yes
 Not effective. May require incisional surgery filtering surgery
 Other surgical procedures are not determined yet whether they also
include trabeculectomy
 Chronic miotic therapy should be a last option for therapy in such
patients, given that we would effectively be inconveniencing the patient.
Extraction of visually significant cataract could be a possible solution
 Yes, otherwise there is always a risk of intermittent raise in IOP
10/9/2012
Rating
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Clinical questions
10. Is laser iridotomy effective in treating eyes with primary
angle closure?
11. Is laser iridotomy effective in treating eyes with primary
angle-closure glaucoma?
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12. Does pre- and post-operative care (e.g., performing at least
one IOP check within 30 minutes to 2 hours of surgery, and
prescribing topical corticosteroids in the postoperative period)
result in better outcomes in patients scheduled to undergo laser
iridotomy or incisional iridectomy?
Comments from survey respondents
Yes
Yes
Yes
It has been reported that LPI is not 100% effective in preventing increase
in IOP and/or PAS progression
Research data has answered this adequately already
Yes
Yes
Yes
No
Laser iridotoomy by itself may not treat PACG but the residual glaucoma
may be controlled with medication
Although LPI would be first line therapy, its efficacy has been shown to
be variable in eyes with extensive PAS and could lead to uncontrolled
inflammation and IOP increase post procedure
The answer to this is "in" already
Simple iridotomy is inadequate
PI is part of the treatment of PACG
Yes, sometimes
 Yes
 Yes
 This question should be made in 4 questions separating pre-operative
care, post-operative care, laser iridotomy and incisional iridectomy.
When it is made in one question it is generalized all the situations in one
condition which is very different
 Evidence exists for use of steroids or anti-inflammatory drugs usage and
episodes of IOP spikes after LPI
 Yes
 Yes
 Yes
 Yes
 Yes
10/9/2012
Rating
8
10
8
9
10
10
8
10
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8
8
10
7
10
5
8
8
5
0
10
10
8
10
8
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Clinical questions
13. Are preoperative miotics effective in facilitating laser
iridotomy or incisional iridectomy?
14. Are perioperative medications effective in averting sudden
intraocular pressure elevation after laser iridotomy or incisional
iridectomy for patients who have severe disease?
15. Do follow-up evaluations (e.g., evaluation of the patency of
iridotomy, IOP measurement, Gonioscopy, pupil dilation, and
fundus examination) result in better outcomes in patients who
undergo laser iridotomy or incisional iridectomy?
16. Is topical antihypertensive therapy effective in lowering
intraocular pressure and preventing optic nerve damage after laser
iridotomy in patients with primary angle closure or primary
angle-closure glaucoma?
Comments from survey respondents
 For incisional iridectomy when pupil is not miosis we could use other
miotics substance to constrict the pupil during the surgery. So it is better
to have this question in 2 forms, one is for laser iridotomy and another
one for incisional iridectomy
 Anecdotal evidence might suggest that stretching the iris thin would be
the appropriate approach, but an RCT would confirm it
 The question has relevance to whether it is applicable to sequential or
isolated YAG iridotomy - evidence will be useful to apply in clinical
practice
 It enables to perform PI with minimum energy and in incisional surgery
prevents possible sector iridectomy
 Yes most of the time, No if the irides are thick
 Yes
 Yes
 Already answered
 Preoperative control of IOP is important, it helps in blunting the post laser
IOP
 Yes
 Yes
 Yes
 Periodic gonioscopy and IOP and ONH assessment post LPI have been
strongly recommended by AAO PPP and SEAGIG Guidelines, but not
all ophthalmologists practice this
 Already known
 Gonioscopy performed too rare!
 Yes
 Yes
 Yes
 Yes
 Most studies have shown this to be effective; no IOP lowering medication
currently available can prevent progression 100%
 Answered already
 Theoretically not sound…
 Yes, but a little
 Yes
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Clinical questions
17. Is laser iridoplasty effective in opening the drainage angle and
lowering the intraocular pressure when performed especially
within 6 to 12 months of an acute attack?
18. Is surgical lysis of synechiae (goniosynechialysis) effective in
opening the drainage angle and lowering the intraocular pressure
when performed especially within 6 to 12 months of an acute
attack?
19. How much of the trabecular meshwork needs to be open in
order that chronic topical ocular hypotensive agents can be
effective in managing elevated intraocular pressure and
preventing optic nerve damage after laser iridotomy to expect a
reasonable IOP reduction?
20. Is laser trabeculoplasty effective in managing elevated
intraocular pressure and preventing optic nerve damage if
sufficient open trabecular meshwork exists after laser iridotomy?
Comments from survey respondents
 Yes
 Laser iridotomy alone is not helpful in lowering IOP after 6-12 months of
an acute attack. Such patients generally require incisional glaucoma
surgery
 Evidence collected already.
 Not sure
 Yes
 No
 Mechanical trauma may induce further synechiae
 It depends on the degree of PAS
 Yes
 Yes
 Yes
 No
 The mechansm of action of various antiglaucoma meidcation is very
different. The quantification of IOP lowering effect of various
medication with respect to the functioning of the trabecular meshwork
after laser iridotomy cannot be done
 This approach is overly simplistic
 180 degrees
 Not sure, angle may look open but may not be functional because of the
previous attack. Probably at least 180 degrees
 At least 90 degrees of trabecular meshwork to needs to be open
 Over 90 degree
 Open doesn't mean functional. Optic nerve situation is another important
parameter
 At least 180 degrees open
 Individual variation is very great
 More than a half
 180
 Laser trabeculoplasty may be effective after iridotomy but comparison
between eyes may be difficult as some eyes even with obvious
peripheral synechiae seem to respond to medical therapy (function
well) and some eyes without PAS seem to have raised IOP. Till correct
quantification of the histological structure of the TM is done it will be
difficult to compare amongst the groups
10/9/2012
Rating
8
1
5
2
8
8
0
7
8
8
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4
*
5
9
4
8
8
1
9
*
10
9
2
Page 6 of 13
Clinical questions
21. Is incisional surgery (trabeculectomy,tube shunt, or other
procedures) effective in managing elevated intraocular pressure
and preventing optic nerve damage after laser iridotomy?
22. Is cataract extraction alone effective in lowering intraocular
pressure in primary angle-closure glaucoma patients?
23. Is medical therapy (e.g. topical beta-adrenergic antagonists,
topical alpha2-adrenergic agonists, topical or systemic carbonic
anhydrase inhibitors, topical miotics, or systemic hyperosmotic
agents) an effective initial treatment in lowering intraocular
pressure to reduce pain and clear corneal edema in acute angleclosure crisis?
Comments from survey respondents
 As long as the mechanism of increased intraocular pressure is caused by
the closed angle, it is not wise to do the laser trabeculoplasty
 Current evidence suggests that trabeculoplasty is a temporizing measure
only
 Some evidence already
 Not sure it may work
 Yes
 Yes
 No
 If the IOP is not getting controlled incisional surgery is required
 Yes
 Yes
 Yes
 Since the pathology lies at the trabecular meshwork level in PACG eyes,
extracting the lens may initially give usefull IOP control, but in the long
term, the IOP rises and patients may require glaucoma surgery
 It depends on the level of increased IOP or the number of antiglaucoma
drugs used before the surgery
 Depends up on the severity of glaucoma. Mild and moderate PACG can
be managed with cataract alone. In severe PACG combined approach is
better
 If IOP over 35 mmHg, or over 3 antiglaucomatic medication. Cataract op
alone is not adequate
 It depends, especially the optic nerve condition. A better optic nerve, the
more likely cataract operation alone can solve the problem
 No
 No
 Much evidence already accumulated
 Known yet and performed widely
 Already info available
 To minimize the chances of optic disc damage it is important to reduce
the IOP. Additionally it clears the cornea for further treatment
 Yes and No- depend on the case scenario. Yes if the IOP is < 30 mmHg
and initial presentation is diagnosed early as lowering of IOP by
medical means are safer than surgical method. No if the IOP is > 40
mmHg and the acute presentation are diagnosed much later whereby
signs like synechiae has already present with very shallow anterior
10/9/2012
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Clinical questions
24. Is laser iridotomy soon after medical therapy effective in
treating acute angle-closure crisis?
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25. What is the effectiveness of miotics alone in opening the
angle in acute angle-closure crisis?
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26. Are systemic hyperosmotic agents with miotic therapy
effective in decreasing IOP and opening the angle in acute angleclosure crisis?
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Comments from survey respondents
chamber
Yes, of course
Yes
Long answered
Already info available
Depending on the corneal condition. If corneal edema is severe, it's not
easy to perform LI
To eliminate the pupillary block PI is needed, having said so it may not
be effective in all cases and iridoplasty may be required as an additional
procedure to open up the angle
Yes & No Yes- if the case is diagnosed early No- if there other signs of
PAS or trabecular meshwork obstruction due to inflammation
Yes
Yes, it is
Yes
May not be very effective alone and until the raised IOP is reduced.
Using miotics alone wastes precious time which a patient with acute
ACG may not have
It depends on how long the crisis has been existed
For the early attack AACG
Only when the IOP is under control it should be used. On an ischemic iris
it may not be effective
Constrict pupil and lower IOP
It does not work well if the IOP is too high or within the iris posterior
synechia
Yes & No. Yes, if the presentation is early with IOP of < 30 mmHg. No,
if IOP >30 mmHg and present with synaechial
They are more effective to decrease the IOP but to open the angle it
depends on the pathology whether it is apposition or synechial closure
Not for everyone
Yes & No Yes- if there are no systemic contraindication, early diagnosis
and IOP< 38 mmHg No- if possible systemic contraindication with late
diagnosis and IOP>40 mmHg
Yes
Yes
10/9/2012
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Clinical questions
27. Is corneal indentation (performed with a four-mirror
gonioscopic lens, cotton-tipped applicator, or tip of a muscle
hook) effective in breaking pupil block in acute angle-closure
crisis?
28. Are topical hyperosmotic agents effective in clearing cornea
edema such that a laser iridotomy can be performed in patients
with acute angle-closure crisis?
29. Is anterior chamber paracentesis effective in clearing cornea
edema such that a laser iridotomy can be performed in patients
with acute angle-closure crisis?
30. Is laser peripheral iridoplasty (even with a cloudy cornea)
effective in treating acute angle-closure crisis if a laser iridotomy
cannot be successfully performed or the acute angle-closure crisis
Comments from survey respondents
 May be effective, have no experience with the technique, but with the
mechanism of pupillary block in place the moment the corneal
indentation is relieved the IOP will revert to the preindentation stage.
We see severe acute ACG in our centre and the patients come after 5
days to 1 month of acute attack
 Patient only tolerate the pain induced by above manipulation once
 May not work in all cases
 Not effective
 Yes, but only a little effective
 Yes- if no Posterior synaechia or PAS, No- If PS or PAS is already
present
 To weak
 Still IOP reduction is required. In eyes with corneal edema with normal
IOP definitely this trick will help
 Yes, when necessary
 Yes- if the corneal oedema is confine to epithelial oedema
No- if the oedema involve stroma and endothelium & is due to
endothelial insult because of the IOP
 Yes
 May be effective. But if one is planning to do a paracentesis one could
also perform an iridectomy at the same sitting. Paracentesis will only
shallow the anterior chamber further and thus increasing the
iridolenticular contact and exacerbating the pupillay block and also
aggravating the glaucoma
 The safety of this procedure needs to be evaluated
 Yes, and we often use it when the medicine does not work well
 There is a wound created
 Not a safe procedure
 Laser iridotomy should not be performed immediately follow
paracentesis. Infection is a major concern. If the pressure is coming
down, LI can be delayed one or two days later
 Yes
 Yes
 We have some evidence for this already
 Already info available
 If AC is very sharrow, it's not easy to perform safely
10/9/2012
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Page 9 of 13
Clinical questions
cannot be medically broken?
31. Is paracentesis effective in treating acute angle-closure crisis
if a laser iridotomy cannot be successfully performed or the acute
angle-closure crisis cannot be medically broken?
32. Is incisional iridectomy effective in treating acute angleclosure crisis if a laser iridotomy cannot be successfully
performed or the acute angle-closure crisis cannot be medically
broken?
33. Is simultaneous primary filtering surgery effective in treating
acute angle-closure crisis when incisional iridectomy is required
and extensive synechial closure is recognized or suspected?
Comments from survey respondents
 Yes it opens up the angle but PI will be needed to relieve the pupillary
block later
 The chance is similar to pupilloplasty
 Yes if PAS is not extensive
 Yes
 Yes
 Paracentesis alone is not effective but surgical iridectomy, the basic
surgery of a glaucoma surgeon will be more helpful
 Again even though it works it is not a safe procedure
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Rating
8
1
8
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0
4
Yes, when necessary
Yes
Yes
Safer than a paracentesis in an eye with very high IOP
A tarbeculectomy will be a better choice in this situation, if you are going
to sent the patient to operating room
Will likely worsen the acute attack as any surgical intervention will cause
more inflammation
Yes
Yes
Yes
Very rarely. It is always easier to perform surgery with an iridotomy/
iridectomy in place in eyes with acute PACG. The possibility of
devastating complications is less and the chamber is also relatively
deeper for intraocular manipulations
Cataract surgery is more preferable than filtering surgery
Risk of failure is high in eyes with an acute event
Feel this situation is so rare nowadays that a research study is not
warranted for this and the clinician can make his/her judgment
High risk
High failure rate if it is done during the acute phase in spite of using
MMC
A two step approach is ideal
Yes- trab do not work well in PACG if the eye is phakic
Yes
Yes
10/9/2012
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Clinical questions
34. Is cataract surgery more effective compared with surgical
iridectomy in lowering postoperative medication requirements
and decreasing complications in patients with angle-closure
glaucoma or acute angle-closure crisis?
37. Is evaluation of the fellow eye of a patient with acute angleclosure crisis effective in lowering the risk of poor outcomes in
future acute attacks in the fellow eye?
Comments from survey respondents
 If the attack is early and was reverse early enough then if indentation
gonioscopy shows opening of at least 180 degrees then cataract surgery
is more likely to achieve our goal
 Chance of explosive choroidal hemorrhage
 Small percentage of patient may not respond to cataract surgery whereby
PAS is extensive
 Yes
 Yes
 This would depend on the extent of synechial closure at presentation
 We have partial answers already
 I think trabeculectomy is not warranted in AAC or PACG unless there are
real indications for that
 No, cataract surgery not effective for lowering IOP
 It really depends, especially the severity of cataract
 If extensive PAS is present then cataract surgery may not be effective. If
the require targeted IOP is much lower then 2-3mmHg then cataract
surgery is not effective
 Wouldn’t be doing trab in AAC
 Yes
 RCTs have shown that cataract surgery to be more effective in the
immediate management of an acute event
 Seems to be a similar question with minor variation to a previous one
 It depends on the remaining open angles but if it is synechial closure. I
think combined trabeculectomy and cataract is still the best
 No pi should tried in an eye that responded to treatment
 Yes
 Yes
 Assessing biomarkers that would help determine high risk cases would be
a strong research question
 We know the answer to this
38. Is immediate laser peripheral iridotomy in the fellow eye
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35. Is cataract surgery more effective compared with
trabeculectomy in lowering postoperative medication
requirements and decreasing complications in patients with
angle-closure glaucoma or acute angle-closure crisis?
36. Is cataract surgery soon after acute angle-closure crisis is
broken more effective in lowering intraocular pressure compared
with routine follow-up after laser iridotomy in patients with high
risk of developing uncontrollable IOP after acute angle-closure
crisis?
Well known since the 70s
Other eye should be tackled during the treatment of the affected eye
Yes
Yes, of course
As we know there is another option that is using miotics
10/9/2012
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Page 11 of 13
Clinical questions
effective in preventing acute attacks in patients with acute angleclosure crisis?
39. Is laser iridotomy in the fellow eye at the initial visit effective
in preventing acute attacks if the eye in acute angle-closure crisis
cannot have successful laser iridotomy because of poor
visualization of the iris due to corneal edema?
40. Is chronic miotic therapy in the fellow eye effective in
preventing acute angle-closure crisis in the fellow eye?
Comments from survey respondents
 There would be ethical issues in delaying LPI for the fellow eye since it is
known that there is increased risk to the fellow eye once the other eye
has had an acute event
 We have long-standing evidence for this
 See Q37
 If not tackled chances of patient not turning up to the follow up is very
high
 Yes
 Yes
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41. What is the relative effectiveness of laser iridotomy vs.
chronic miotic therapy in preventing acute angle-closure crisis in
the fellow eye?
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42. What is the optimal interval of examinations to assess the
response to laser iridotomy?
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We know the answer!
Yes
Yes
Yes
Chronic miotic therapy may paradoxically shallow the chamber and
increase the pupillary block and exacerbate the glaucoma. Miotic
therapy should not be instituted without iridotomy in PACS/ PAC/
PACG
Laser iridotomy is a simple and effective method and chronic miotic
therapy has proven disadvantages
Too many side effects for chronic use in many patients
Not recommended ,this can cause chronic angle closure
Yes, but preventive laser PI is the first choice
Yes, but it has more side effects
Laser iridotomy is very effective
I highly agree. Pilocarpine might even predispose the fellow eye to more
shallowing
Miotics can prevent acute attack (most of the times) but will lead in to
PAS
Laser PI is more effective
LI is better
LI is still needed
One visit 1 week after the laser and 2nd visit after 4 weeks and 3rd visit
after 3 months
1~2 weeks
4 to 6 weeks
24 hours later, one week, one month and 3 months
10/9/2012
Rating
5
5
5
10
8
10
5
10
8
10
1
0
2
0
8
2
10
9
0
8
10
9
10
8
8
10
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Clinical questions
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




Comments from survey respondents
2 weeks
2 weeks
For a really pupillary block, one or two hours later.
Slit lamp examination, mesurement of IOP, gonioscopy, UBM, AS-OCT
1 week
One day
Rating
8
8
10
10
7
*
*No judgment
1
Question number corresponds to Questionnaire I numbering
2
Possible ratings were 0 - 10 where 0 = “not important at all” and 10 = “highly important”
10/9/2012
Page 13 of 13