Initial phaco for angle-closure glaucoma climbed to 48.4% in adults 50 and older, while surveys and IRIS data show shifting trabeculectomy and JOAG surgical patterns.
Initial phacoemulsification for
The PACG shift tracks the 2016 EAGLE trial, in which clear-lens extraction outperformed laser peripheral iridotomy (LPI) on quality of life, IOP control, and medication burden in patients aged 50 years and older.1,4 The 3 analyses draw on a national health records network, a specialist survey, and the IRIS Registry, giving complementary views of how glaucoma procedures are chosen.
Paras Shah, MD, of Manhattan Eye, Ear & Throat Hospital, Northwell Health, and colleagues used the TriNetX US Collaborative Network to identify 6535 adults with PACG who underwent LPI or phacoemulsification, with or without minimally invasive glaucoma surgery (MIGS), as a first intervention.1 Patients with prior glaucoma surgery, LPI, or phacoemulsification were excluded. The investigators split the cohort at age 50 years, matching the EAGLE enrollment cutoff, and analyzed four intervals with Cochran-Armitage trend tests.
Among 5,810 patients aged 50 years and older, LPI as the first procedure fell from 85.7% to 51.6% (P <.0001).1 The shift was smaller among 725 patients younger than 50 years, in whom initial phacoemulsification rose from 14.0% to 26.4%, and LPI fell from 86.0% to 73.6% (P = .0042).1 The authors cited EAGLE and the 2026 AAO Preferred Practice Pattern, which advises considering lens extraction, as likely drivers, and noted the database lacked gonioscopy, IOP, and visual field data.
Sarah Guo, MD, of the Gavin Herbert Eye Institute at the University of California, Irvine, and colleagues surveyed 154 fellowship-trained glaucoma specialists through the American Glaucoma Society, Eyeconnect, and an American Society of Cataract and Refractive Surgery glaucoma program.2 Annual trabeculectomy volume correlated strongly and inversely with the share of a surgeon's trabeculectomies replaced by other procedures (ρ = −0.779; P <.001). It correlated positively with surgeon age, years since fellowship, and, more weakly, fellowship trabeculectomy volume (ρ = 0.206; P = .010).2
High-volume surgeons, defined as performing more than 10 trabeculectomies per year, were about 7 years older than low-volume peers. Roughly 30% of low-volume surgeons no longer offered the procedure, and 47.6% of respondents had replaced trabeculectomy with the Xen gel stent (AbbVie) in some capacity.2 The authors pointed to fiscal pressure, since trabeculectomy typically requires 8 to 12 or more postoperative visits within the same 90-day global period as a Xen stent requiring 4 to 6.
In an IRIS Registry analysis from Massachusetts Eye and Ear, Uday Pratap Singh Parmar, MD, and colleagues compared 1881 patients with JOAG with 3,212,043 patients with adult POAG seen from 2013 to 2019.3 Glaucoma surgery was needed in 22.8% of patients with JOAG vs 8.4% with POAG (HR, 3.86; 95% CI, 3.52-4.25; P <.001), and tube shunts were placed in 10.5% vs 1.8%. Reoperation within 1 year occurred in 13.9% vs 6.0% of operated eyes, with an overall reoperation HR of 2.34 (95% CI, 1.98-2.77), while hypotony occurred in 1.6% vs 0.5%.3
"Patients with low target IOP may have limited access to surgeons willing and able to provide trabeculectomy," Guo and colleagues wrote.2
The JOAG investigators described the condition as a surgical disease regardless of race, with higher surgical risk across White, Black, and other racial groups.3 The PACG authors called for additional studies of lens extraction in patients younger than 50 years.1
