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When to add goniotomy in chronic angle-closure glaucoma with cataract: a prospective, imaging-based study

clinical-trials
ophthalmology

Abstract

Purpose: To quantify the incremental benefit of adjunctive goniotomy added to phacoemulsification with intraocular lens implantation and goniosynechialysis (Phaco+IOL+GSL) in chronic angle-closure glaucoma (CACG) with cataract, and to develop imaging-informed tools for patient selection.

Methods: Single-centre prospective cohort with target-trial emulation. Eighty-three CACG eyes underwent Phaco+IOL+GSL with (n=39) or without (n=44) adjunctive goniotomy and were followed for 12 months with standardized AS-OCT/UBM imaging. Treatment effects were estimated using propensity-score overlap weighting. Outcomes were 12-month qualified and complete success (IOP 5–18 mmHg with ≥20% reduction and no further glaucoma surgery, with or without medications). A 0–5 preoperative clinical–imaging risk score was developed for failure under Phaco+IOL+GSL alone, and a 1-month landmark analysis explored modification by early change in AOD500 (ΔAOD500).

Results: After weighting (effective n=67), adjunctive goniotomy provided additional IOP reduction at 12 months compared with Phaco+IOL+GSL alone (difference 2.40 mmHg; 95% CI, 1.11–3.69) and fewer medications (difference −0.96; 95% CI, −1.48 to −0.43). Qualified success was 0.59 vs 0.85 (risk difference [RD] 0.26; 95% CI, 0.06–0.47), and complete success was 0.43 vs 0.78 (RD 0.35; 95% CI, 0.14–0.56). The risk score predicted qualified failure under Phaco+IOL+GSL alone (AUC 0.68) and stratified absolute benefit. In the landmark analysis, benefit was greatest in the highest ΔAOD500 tertile (RD 0.48; 95% CI, 0.11–0.85).

Conclusions: In CACG eyes undergoing lens-based surgery with GSL, adjunctive goniotomy was associated with additional IOP lowering, fewer medications, and higher 12-month success. A simple imaging-informed risk score, together with early postoperative AS-OCT response, may help identify eyes most likely to benefit and merits longer-term validation.

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