Financial Interest Disclosure LPI: Theres No Harm in Waiting and - - PowerPoint PPT Presentation

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Financial Interest Disclosure LPI: Theres No Harm in Waiting and - - PowerPoint PPT Presentation

Mar 13, 2023 151 likes •211 views

Financial Interest Disclosure LPI: Theres No Harm in Waiting and Observing Research Affiliation Advisory Boards Allergan, Inc. Allergan Shan Lin, MD Memantine Study Iridex National Eye Institute Professor

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LPI: There’s No Harm in Waiting and Observing

Shan Lin, MD Professor Director, Glaucoma Service

  • Dept. of Ophthalmology

UCSF School of Medicine

Koret Vision Center UCSF Medical School

Financial Interest Disclosure

  • Research Affiliation
  • Allergan, Inc.
  • Memantine Study
  • National Eye Institute
  • OHTS study
  • Carl Zeiss Meditec
  • Visante OCT study
  • Genentech
  • Lucentis/Ahmed valve

study

  • Advisory Boards
  • Allergan
  • Iridex

LPI for PACS

  • Why you shouldn’t do LPI
  • NO evidence LPI reduces risk for glaucoma
  • Natural history of PACS mostly benign
  • May cause significant side effects
  • Later Phaco obviates the need for LPI

Angle Closure Disease

  • Primary Angle Closure Suspect (PACS)
  • Occludable angle
  • No PAS
  • Primary Angle Closure (PAC)
  • Occludable angle
  • PAS +/- OHTN
  • Primary Angle Closure Glaucoma (PACG)
  • Angle closure
  • Optic nerve +/- VF damage
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PACS

  • What defines PACS and when should you do

LPI?

  • Foster definition: ≥ 270 degrees of ant TM or less
  • AAO definition: ≥ 180 degrees of ant TM or less

Foster Definition

Foster PJ et al. Br J Ophthalmol. 2002;86:238-242

What is the Risk for Glaucoma in PACS?

  • PACS Progression in a Population Study
  • Vellore Eye Study (India)
  • N=972 patients
  • PACS=118 patients
  • 10.5% of eyes
  • 5 year follow up 50 PACS cases

Thomas R et al. Br J Ophthalmol 2003;87:450-454

What is the Risk for Glaucoma in PACS?

  • 50 PACS cases
  • 11 (22%) Primary Angle Closure (PAC)
  • NONE PACG

Thomas R et al. Br J Ophthalmol 2003;87:450-454

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Should You Do LPI?

Thomas R et al. Br J Ophthalmol 2003;87:450-454

Should You Do LPI?

Thomas R et al. Br J Ophthalmol 2003;87:450-454

What You Should Do

Thomas R et al. Br J Ophthalmol 2003;87:450-454

20% do not respond to prophylactic LPI Who likely NOT respond to LPI?

  • Larger angle (AOD)
  • More anterior iris insertion (SS-IR: 0.085 vs 0.125mm)
  • Thicker peripheral iris (0.447 vs 0.415 mm)
  • More CB anterior rotation (TCPD: 0.514 vs 0.562mm)

Lee R…Lin S. IOVS 2013 Huang G…Lin S. Curr Eye Res 2012 Jul;37(7):575-82 Lee R…Lin S. Ophthalmology 2014 Jun;121(6):1194-202 He M Ophthalmology 2007

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Angle width (degree) AOD250 (µm) ARA (µm) TISA500 (µm)

  • 775 bilateral PACS were

randomized

  • LPI one eye
  • Untreated fellow eye as

control

  • Angle width of treated eyes
  • increased markedly after

LPI

  • remained stable for 6

months

  • decreased significantly by

18 months

  • Untreated eyes
  • consistent and rapid

decrease in angle width

  • ver the 18 months.

Jiang, He, Ophthalmology 2014

Side effects of LPI

  • Variety of visual symptoms
  • haloes, shadows, glare, crescents
  • linear dysphotopsia (the most specific and

problematic symptom)

  • 2.7% to 6.8% of patients after LPI
  • Monocular diplopia
  • IOP rise, transient uveitis, hyphema
  • Corneal trauma, cataract, closure of the iridotomy,

retinal detachment

Am J Ophthalmol 2014;157:929–935

Additional IOP-lowering interventions after LPI

  • Peng et al. 356 Vietnamese patients, 12 years
  • PACS 7% needed additional therapy
  • PAC 42% needed additional therapy
  • PACG 100% needed additional therapy
  • Rosman et al. CACG in New York and Asia, 56 months
  • 41% topical glaucoma medication
  • 31% underwent filtering surgery
  • 28% underwent a glaucoma laser procedure

Peng P H…Lin S. Br J Ophthalmol, 2011 Bansal S, et al. Am J Ophthalmol, 2015 Rosman M, et al. Ophthalmology, 2002 Blondeau P, et al. Can J Ophthalmol, 2011

Phaco Effect in Narrow Angles

Huang G…Lin S. Arch Ophthalmol 2011;129(10):1283-90

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Narrow angle group Open angle group P Value AOD500(mm),Nasal Preoperative 0.179±0.014 0.297±0.019 <0.001* 10 days 0.399±0.017 0.427±0.019 0.021* 1 month 0.405±0.024 0.452±0.014 0.005* 3 months 0.403±0.024 0.452±0.017 0.008* 6 months 0.389±0.025 0.451±0.015 0.002* Changes in AOD500(mm),Nasal 10 days 0.215±0.018 0.129±0.024 0.003* 1 month 0.215±0.019 0.154±0.020 3 months 0.217±0.023 0.156±0.020 6 months 0.196±0.023 0.155±0.021 AOD500= angle opening distance at 500µm anterior to the scleral spur *Statistically significant from linear mixed model

AOD Change

Huang G…Lin S. Arch Ophthalmol 2011;129(10):1283-90

Summary

  • NO evidence that LPI is effective in

preventing progression compared to No LPI

  • Side effects of LPI not insignificant
  • Future Phaco for cataract obviates LPI