Juvenile angle closure management: The role of lens extraction and goniosynechialysis

PURPOSE: Angle closure (AC) is a rare condition in young people. In adults with AC, lens extraction and goniosynechialysis (LE-GSL) are effective in restoring angle anatomy and function. However, the efficacy of LE-GSL is poorly understood in the juvenile population. In this study, we report the efficacy and safety of LE-GSL in a series of young patients with AC. METHODS: We reviewed the medical records of consecutive patients with AC. Eyes were included if aged <40 years at the time of diagnosis, had angle closure, at least one month of postoperative follow-up, and had undergone LE-GSL between January 1, 2015 and June 30, 2019. Eyes were excluded if they had undergone prior incisional glaucoma surgery. AC was defined as elevated untreated intraocular pressure (IOP) > 24 mmHg and (1) less than 180° of visible trabecular meshwork, or (2) any peripheral anterior synechiae noted on gonioscopy, or (3) iridocorneal apposition prior to dilation > 180° identified on anterior segment imaging. RESULTS: A total of 11 eyes (7 patients) were included. The mean ages of diagnosis and LE-GSL were 19.0 and 21.2 years, respectively. Of the 11 eyes, 8 had a history of laser retinal ablation for the treatment of retinopathy of prematurity (ROP, 72.7%). Intraoperatively, 7 eyes received intraocular lens (63.3%), 6 had concurrent vitrectomy (54.5%), and 4 had concurrent endocyclophotocoagulation (36.4%). Following LE-GSL, visual acuity (VA) improved from a mean preoperative LogMAR of 0.88 (20/150 Snellen equivalence) to a mean LogMAR of 0.68 (20/100 Snellen equivalence, P = 0.029). IOP significantly decreased from 18.2 mmHg (Tmax 38.4±12.2 mmHg) preoperatively to a mean of 11.3 mmHg postoperatively (P = 0.009). The number of glaucoma medications was significantly reduced from a mean of 2.4 preoperatively to no medications at final follow-up (mean duration of 13.7 months, P < 0.001). There were no significant intra- or postoperative complications in any eyes. CONCLUSIONS AND IMPORTANCE: In our cohort, LE-GSL significantly lowered IOP, improved visual outcomes, and decreased medication burden in young patients with AC, many of which had infantile retinal ablation for ROP. LE-GSL may be considered an effective intervention in young patients with AC.