Phaco-GSL outperforms in acute angle-closure glaucoma over chronic cases, 2-year study finds

Does the type of primary angle-closure glaucoma (PACG) a patient has influence how well they respond to combined cataract and synechialysis surgery? A 2-year prospective cohort study found that phacoemulsification combined with goniosynechialysis (Phaco-GSL) produced significantly better complete success rates in acute primary angle-closure glaucoma (APACG) than in chronic primary angle-closure glaucoma (CPACG), according to a study published in Ophthalmology and Therapy.¹

Gao and colleagues, of the Department of Ophthalmology and Visual Science at Eye and ENT Hospital, Fudan University, Shanghai, recruited 213 Han Chinese patients consecutively between January 2019 and December 2022, comprising 116 patients with APACG and 97 with CPACG.¹ All patients underwent phacoemulsification, foldable intraocular lens implantation, and goniosynechialysis, performed by 4 experienced glaucoma specialists. Patients were followed at 1 week, 1 month, 3 months, 6 months, and then every 6 months to 2 years postoperatively, with gonioscopy, visual field testing, and ocular biometry assessed at standardized intervals.¹ Complete success was defined as achieving target intraocular pressure (IOP) without medication, while qualified success permitted continued medication use.¹

Acute cases achieved higher complete success, but similar qualified success

At 2 years, complete success rates were 72.4% in the acute group versus 65.0% in the chronic group (P = .04), while qualified success rates were comparable between groups at 81.9% and 81.4%, respectively (P = .44).¹ Patients with APACG experienced a greater reduction in IOP, required fewer postoperative medications, and showed more pronounced improvement in visual acuity and anterior chamber depth (ACD) compared with those with CPACG.¹

On multivariable Cox regression analysis, 3 factors emerged as independent predictors of surgical failure across the overall cohort: worse baseline mean deviation on visual field testing, shallower ACD, and chronic disease type.¹ Within subgroup analyses, a longer duration of elevated IOP was strongly associated with poorer prognosis in APACG, whereas in CPACG, shallower ACD and, unexpectedly, younger age were linked to worse outcomes.¹

Postoperative synechiae recurrence offers a clue to the mechanism

Although complete 360° angle opening was confirmed intraoperatively under gonioscopy in all cases, postoperative peripheral anterior synechiae (PAS) developed in the majority of eyes in both groups, progressing most rapidly within the first postoperative month and stabilising after 6 months.¹ Despite a greater preoperative extent of PAS, the APACG group showed a significantly lower ratio of postoperative-to-preoperative PAS than the CPACG group, suggesting more durable angle opening. The authors proposed that this difference reflects the underlying angle-closure mechanism rather than the extent of synechiae alone, noting that APACG is predominantly driven by pupillary block, a mechanism more amenable to surgical correction than the mixed and non-pupillary block mechanisms common in CPACG.¹

Limitations and clinical implications

The authors acknowledged several limitations, including subjective variability in gonioscopic assessment across surgeons, a loss-to-follow-up rate that increased from 4.2% at 1 year to 14.6% at 2 years, and the observational design, which limits the identified prognostic factors to associations rather than confirmed causal determinants.¹ Building on this prognostic data, the authors constructed a nomogram incorporating baseline mean deviation, ACD, and glaucoma type to predict individual 1- and 2-year success probabilities, intended to support preoperative counselling and patient selection.¹

The authors concluded that the procedure benefits patients with either form of PACG, but that its advantage is clearest in acute disease, and they pointed to disease course and ACD as the most useful preoperative markers for setting realistic expectations around surgical outcomes.²

The authors declared no competing interests. The study was supported by the National Natural Science Foundation of China, the Shanghai Hospital Development Center, and the National Key Research and Development Program of China.

References

1. Gao F, Wang J, Kong X, et al. Long-term effects of phacoemulsification with goniosynechialysis in angle-closure glaucoma: a 2-year prospective cohort study. Ophthalmol Ther. doi:10.1007/s40123-026-01426-w

2. Husain R, Do T, Lai J, et al. Efficacy of phacoemulsification alone vs phacoemulsification with goniosynechialysis in patients with primary angle-closure disease: a randomized clinical trial. JAMA Ophthalmol. 2019;137(10):1107-1113. doi:10.1001/jamaophthalmol.2019.2493