Field Notes from APACRS 2023

Day 1 kicks off with a rapid-fire session on angle closure surgery

by Matt Herman

From phacoemulsification to MIGS and LPI… Day 1 at the 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2023) annual meeting in Singapore kicked off with a jam-packed, informationloaded session entitled “Angle Closure Surgery – New Insights.”

The infamous Day 1, Session 1 is the ophthalmic conference’s version of the graveyard shift, with jet-lagged, traveled-out delegates either in bed or shuffling listlessly around the conference venue.

But at the “Angle Closure Surgery –New Insights” session, the tenor was different. Seats were full of inquiring eyes — and we were there to get the lowdown on the latest in open-angle glaucoma surgery.

At the top of the order was Dr. Baskaran Mani (India), who got it cooking in Hall A of Singapore’s Suntec Convention Centre with his talk, “Phaco is the Best Angle Closure Treatment We Have.” Though the main argument of his talk was that phaco is the best weapon against angle closure, he cautioned against blanket statements. Most important for deploying this powerful tool for Dr. Mani were the magnitude of angle closure, the cause of the closure (i.e., caused primarily by the lens), and making sure the cataract grade and resulting visual improvement are high enough to justify such an invasive procedure.

Up next, Prof. Jimmy Lai (Hong Kong) wanted people to know that goniosynechialysis (GSL) is back from the dead in his lecture, “Goniosynechialysis – A Resurgent

Technique.”

After an overview of the technique, Prof. Lai argued that goniosynechialysis has a place in primary angle closure glaucoma treatment — if medication and laser peripheral iridotomy (LPI) have failed, peripheral anterior synechiae are extensive, and the glaucoma is not advanced.

The venerable Prof. Prin Rojanapongpun (Thailand) picked it up from there by revisiting a thorny topic in angle closure treatment with his talk, “Phaco – MIGS in Angle Closure. Is it as Controversial as it Seems?” Though Prof. Rojanapongpun suggested the contentiousness of this topic is subsiding, especially with MIGS’ advantages to postrefractive stability, he cited a lack of published literature, study standardization, and patient selection as hurdles to overcome to settle the debate for good.

Prof. Graham Lee (Australia) continued on with surgical technique in his demonstration, “Incisional Surgery in Angle Closure. Tips and Tricks.” And though there were pearls aplenty, one in particular got both the panel and audience arguing in the Q+A session due to its exotic nature — using a oneport vitrectomy (he used a 25-gauge port) to remove vitreous for a slight softening of the eye in patients with very narrow (in his example case, <2 mm) anterior chamber depths.

Unlike Prof. Lee, Prof. Hon Tym Wong (Singapore) was in the business of quashing controversy in his talk, “ALPI and SLT in Angle Closure.” In the end, Prof. Wong concluded that iridoplasty while argon laser peripheral iridoplasty (ALPI) might be great for acute cases, for chronic cases its use is best limited to patients with plateaued irises. Selective laser trabeculoplasty (SLT)’s uses are also similarly limited to iridotomy patients who don’t respond to or are unable to use eye drops.

Optical coherence tomography (OCT) is coming to the masses, and Dr. Joseph Anthony Tumbocon (Philippines) explained in his talk, “Risk Factors for Progression in PACD – How Can Imaging Help Determine Risk”, that anterior segment OCT (AS-OCT) has a significant role to play in primary angle closure disease (PACD). His talk laid out the case for AS-OCT as a tool to stratify risk and identify patients likely to progress from PACS, as well as provide quantitative data critical in monitoring.

Dr. David Lubeck rounded things out with his illuminating discussion, “Current MIGS Treatment Strategies for Cataract and Refractive Surgeons.” The talk functioned as an overview of MIGS available to cataract surgeons, including a well-received recommendation that patients with uncontrolled IOP or ocular surface disease and narrow angle glaucoma make excellent candidates for GSL and canaloplasty.