International Ophthalmology 16: 405-408, 1992. 9 1992KluwerAcademic Publishers. Printedin the Netherlands.
Surgical management of closed angle glaucoma: our experience Alfredo Reibaldi & Maurizio G. Uva Catania University, institute of Ophthalmology, Via Bambino 32, 95124 Catania, Italy
Key words: closed angle glaucoma, cataract extraction procedure, gonioscopy Abstract
In this paper we present our experience of the last three years in the surgical treatment of eyes with closed angle glaucoma. We have performed an extracapsular lens extraction and posterior chamber intraocular lens implantation on 34 eyes of 34 patients. All of them were affected by closed angle glaucoma with variable control after a Yag laser iridotomy: 6 eyes had high I.O.P. notwithstanding maximal therapy, 11 eyes had I.O.P. under control (less than 21 mmHg) without therapy, 9 with I.O.P. controlled with topical therapy, 8 with I.O.P. controlled with maximal therapy (C.A.I. included). The cases with well controlled glaucoma were operated on because of the presence of a more or less significant lens opacities. After a follow-up of up to 40 months (mean = 20.3, range = 1-40), all eyes show satisfactory intraocular pressure and no eye needed a filtering procedure. The results of our studies are as follows (values are mean + SD). In the group of 6 eyes with high I.O.P., the mean pre-operative intraocular pressure was 29.7 + 5.6mmHg and the mean post-operative I.O.P. was 15.1 + 1.4mmHg. The mean reduction was 14.5 + 6.6 mmHg (p < 0.005). In the 28 eyes with pre-operative I.O.P. under control (17.5 _+ 1.6), the mean post-operative I.O.P. was 14.4 + 2.3 mmHg, with a mean reduction of 3.1 + 3.1 mmHg (p < 0.005). Before the E.C.C.E., 11 eyes had I.O.P. less than 21mmHg without anti-glaucoma medication, whereas after the E.C.C.E. 28 eyes did not need such a medication. No significant correlation was found between pre-operative and post-operative extension of peripheral anterior synechiae (when assessable) and post-operative intraocular pressure control. The difference between pre- and post-operative anterior chamber depth measured by ultrasonic biometry was remarkable, i.e. M = 1.93 + 0.36mm and 3.42 + 0.2mm (pre-operative and post-operative, respectively; p < 0.005).
Introduction
The anatomical peculiarities of eyes affected by closed angle glaucoma have been stressed in ophthalmological literature for many years [1-11]. The lens itself, although frequently mentioned as the main aetiological factor of a 'crowded anterior segment', has not been considered in relation to the surgical approach of closed angle glaucoma until a few years ago (except in those clear-cut cases of phacogenic glaucoma). After Greve's presentation of the good results
obtained in treatment of medically uncontrolled cases of closed angle glaucoma by extracapsular cataract extraction (E.C.C.E.) plus posterior chamber I.O.L. implantation only [12-20], we have followed the same path and in this paper. We present our experience of the last three years.
Materials and methods
34 eyes of 34 patients, 16 males and 18 females, mean age = 67 years (range 55-88), have been
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A. Reibaldi & M.G. Uva
operated on. All of them were affected by chronic closed angle glaucoma (24/34 eyes had suffered one or more acute attacks in their history). After Yag laser iridotomy, performed on all the eyes, the controls showed variability depending on the cases: 6 eyes having high I.O.P. notwithstanding maximal therapy, 11 eyes showing intraocular pressure under control (less than 2 mmHg) without therapy, 9 with I.O.P. controlled by topical therapy, 8 with I.O.P. controlled by maximal therapy (C.A.I. included). The cases with well controlled glaucoma were operated on because of the presence of more or less significant lens opacities. Any secondary cause of glaucoma (iridocyclites, subluxation of lens, phacolysis etc.) had been excluded. All patients had visual acuity determination; I.O.P. measurements carried out using Goldmann applanation-tonometry or non-contact tonometry in the first post-operative period and, eventually, provocative tests; gonioscopy with Sussman or Posner lenses (Ocular Instruments Inc. USA); ultrasound biometrical examinaton with standardized immersion technique; interferometry; perimetry and optic disc photography. In 10 eyes we performed E.C.C.E. with Sinskey J loop lens implantation in the ciliary sulcus. In 24 eyes we have implanted a compressible disk lens (Pharmacia AB, Uppsala, Sweden) in the capsular bag, with an E.C.C.E. procedure including synechiolysis, if necessary.
Results
After a follow-up of up to 40 months (mean = 20.3, range 1-40), all eyes show a good intraocular pressure and no eye has needed a further filtering procedure. In the group of 6 eyes with high I.O.P. the mean pre-operative intraocular pressure was 29.7+ 5.6mmHg, the mean post-operative I.O.P. was 15.1 _+ 1.4 mmHg. The mean reduction was 14.5 _+ 6.6mmHg (p < 0.005). In the 28 eyes with pre-operative I.O.P. under control: mean = 17.5 _+ 1.6 mmHg, the mean post-
operative I.O.P. was 14.4_+ 2.3mmHg, with a mean reduction of 3.1 _+ 3.1 (p < 0.005). Before the E.C.C.E. 11.34 eyes (32.4%) had I.O.P. less than 21mmHg without antiglaucoma medication, whereas after the E.C.C.E. 28/34 eyes (82.4%) needed no such medication. Visual acuity varied from a pre-operative mean value of 0.39 _+ 0.18 to 0.68 _+ 0.16 at the end of follow up. The difference between pre- and post-operative anterior chamber depth, measured by ultrasonic biometry is remarkable: from M = 1.93 _+ 0.36 mm to M = 3.42 + 0.21mm (p < 0.005). By means of gonioscopy we have noticed in all eyes an enlargement of the width of the angle, due to iris convexity flattening. No statistically significant correlation was found between post-operative I.O.P. and gonioscopic changes. As regards the complications, these have been rare and clinically not relevant: 1 case (2.9%) of pupil capture, 1 case (2.9%) of fibrinous dispersion on I.O.L. surface.
Discussion
The description in ophthalmic literature of anatomical and biometrical features of eyes affected by closed angle glaucoma is not recent: cornea, anterior chamber, iris, ciliary bodies, axial length and moreover the lens are involved and play a role in the pathogenesis of closed angled glaucoma [5, 7, 9, 10, 21-25]. According to Greve [12], the extraction of a lens having a thickness of 4.5-5 mm and its replacement by a I.O.L. having a thickness of 1-1.2mm thickness causes all the described post-operative changes in the anterior chamber (increased depth), in the angle (increased width), in the iris profile (flattening) and removes the anatomical causes of ocular hypertension. Greve [12] and Wishart & Atkinson [26] report that the extent of peripheral anterior chamber synechiae, hard to estimate in most of the eyes, has no influence on the post-operative I.O.P. control. The issue of P.A.S. is the principal source of
Surgical managementof closed angle glaucoma objections from authors who disagree to this procedure. In our experience we have noticed no significative difference of glaucoma control among eyes with quite different post-operative gonioscopical findings, thus testifying the effectiveness of this new approach to the closed angle glaucoma. At the moment, it is not possible, according to us, to compare the E.C.C.E. plus I.O.L. implantation operation with the trabeculectomy or the combined procedure because of the limited number of case, the short follow-up and the overlap of surgical goals and indications. Our actual study applies to particular surgical indications: we treated with this method either eyes with closed angle glaucoma showing a fairly good I.O.P. control after Yag laser iridotomy and medical therapy but with a poor visual acuity due to the lens opacity, or eyes with an almost clear lens and good visual acuity but with a poor or uncontrolled glaucoma. Into the light of problems, we have recently proposed, in the last meeting of the 'Italian Association for the Study of glaucoma', a study protocol with the aim to verify the validity of this surgical choice with a larger number of cases, longer followup and with different surgeons [27]. Waiting for these results at present, we can recommend cataract extraction procedure in all the cases with concomitant cataract and angle closure glaucoma. In case of a clear lens, the choice becomes more difficult; however this approach remains correct, on condition that all the anatomo-functional conditions are present and the operation is executed by an experienced surgeon.
References 1. Rosengren B. Studien uber die Tiefe der vorderen Augenkammer mit besonderer Hinsicht auf ihr Verhalten beim primaren Glaukom. Acta Ophthalmol 1930; 8: 99136. 2. Sugar H.S. The mechanical factors in the etiology of acute glaucome. Am of J Ophthalmol 1941; 24: 851-873. 3. Tornquist R. Chamber depth in primary acute glaucoma. Br J Ophthalmol 1956; 40: 421-429.
407
4. Lowe RF. Aetiology of the anatomical basis for primary angle closure glaucoma. Biometrical comparisons between normal eye and eyes with primary angle-closure glaucoma. Br J Ophthalmol 1970; 54: 161-169. 5. Delmareelle Y, Collignon J, Luyckx-Bacus J, Weekers R. Etude biometrique du globe oculaire dans le glaucome a angle ferme. Bulletin des Societes D'Ophthalmologie de France 1971; 84: 449-460. 6. Storey JK, Phillips CI. Ocular dimensions in angle closure glaucoma. Br J Physiol and Optom 1971; 26: 228-232. 7. Lowe RF. Primary angle closure glaucoma. A review of ocular biometry. Austral J Ophthalmol 1977; 5: 9-13. 8. Lee DA, Brubaker RF, Ilstrup DM. Anterior chamber dimensions in patients with narrow angle and angle closure glaucoma. Arch Ophthalmol 1984; 102: 46-51. 9. Markowitz SN, Morin JD. Angle closure glaucoma. Relation between lens thickness, anterior chamber depth and age. Can J Ophthalmol 1984; 19: 300-305. 10. Cennamo G, Rosa N. Ecografia e glaucoma. Atti del XIX convegno Soc. Oft. Merid. 1985; Capri, 21-32. 11. Panek WC, Christensen RE, Lee DA, Fazio DT, Fox LE, Scott TV. Biometric variables in patients with occludable anterior chamber angles. Am J Ophthalmo11990; 110: 185188. 12. Greve EL, Wagemans MJ. Reduction of intraocular pressure after extracapsular cataract extraction with posterior chamber intraocular lens implantation in patients with narrow angle. In: Greve EL (ed) Surgical management of coexisting glaucoma and cataract. Amsterdam: Kugler Publisher 1987. 13. Greve EL. Primary angle closure glaucoma: extracapsular cataract extraction or filtering procedure? Int Ophtbalmol 1988; 12: 15%162. 14. Greve EL, Gunnings F. Long term results of E.C.C.E. in agle closure glaucoma. Glaucoma Symposium XXVI International Congress of Ophthalmology March 14-17, 1990 Singapore. 15. Reibaldi A, Uva MG, Fazio P. Our experience in the management of cataract and glaucome. New Trends in Ophthaltool 1989; vol. IV. 3: 21%226. 16. Reibaldi A, Uva MG, Fazio P. The best surgical approach to coesisting cataract and glaucomal: our view. Glaucoma Symposium XXVI International Congress of Ophthalmology, 16-17 March 1990. Singapore. 17. Reibaldi A, Uva MG, Panta G, Savarino F. A proposito di un nuovo approccio chirurgico al glaucoma ad angola chiuso. Bollettino d'Oculistical 1991; anno 70, suppl. 2: 451454. 18. Uva MG, Panta G, Reibaldi A. The effect on IOP of E.C.C.E. with posterior chamber IOL implantation. New Trends In Ophthalmol 1989; IV, 3: 241-250. 19. Uva MG, Fazio P, Panta G, Reibaldi A. IOL in cataract and glaucoma. Atti I International Congress 'Societas Ophthalmologica Mediterranea', Palermo 1989. 20. Uva MG, Scalia G, Reibaldi A. IOL e IOP. Bollettino d' Oculistica 1990; 69, suppl 2: 55-66.
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A. Reibaldi & M.G. Uva
21. Chandler PA. Narrow angle glaucoma. Arch Ophthalmol 1952; 47: 695-699. 22. Tomlinson A, Leighton PA. Ocular dimensions in the heredity of angle closure glaucoma. Br J Ophthalmol 1973; 57: 475-480. 23. Ritch R, Bruce Shields M, Krupin T. The glaucomas. The CN. Mosby Company, S. Louis 1989. 24. Lowe RF, Lim ASM. Primary angle closure glaucoma.P.G. Publishing PTE, UK, Ltd, 1990. 25. Uva MG, Scalia G, Panta G, Valvo F, Reibaldi A. Modificazioni di alcuni parametri oculari dopo chirurgia extra-
capsulare della cataratta in occhi normali e glaucomatosi. Bolletino d'Oculistica 1991; 70 suppl. 1: 289-294. 26. Wishart PK, Atkinson PL. Extracapsular cataract eraetion and posterior chamber lens implantation in patients with primary chronic angle-closure glaucoma: effect on intraocular pressure control. Eye 1989; 3: 706-712. 27. Reibaldi A, Uva MG. E.C.C.E. piu' IOL in camera posteriore nel glaucoma ad angolo chiuso: ipotesi di protocollo per studio multicentrico. Relazione all' VIII Congr. A.I.S.G. (in press) 14-15/3/1992 Rapallo.
Surgical management of closed angle glaucoma: our experience Alfredo Reibaldi & Maurizio G. Uva Catania University, institute of Ophthalmology, Via Bambino 32, 95124 Catania, Italy
Key words: closed angle glaucoma, cataract extraction procedure, gonioscopy Abstract
In this paper we present our experience of the last three years in the surgical treatment of eyes with closed angle glaucoma. We have performed an extracapsular lens extraction and posterior chamber intraocular lens implantation on 34 eyes of 34 patients. All of them were affected by closed angle glaucoma with variable control after a Yag laser iridotomy: 6 eyes had high I.O.P. notwithstanding maximal therapy, 11 eyes had I.O.P. under control (less than 21 mmHg) without therapy, 9 with I.O.P. controlled with topical therapy, 8 with I.O.P. controlled with maximal therapy (C.A.I. included). The cases with well controlled glaucoma were operated on because of the presence of a more or less significant lens opacities. After a follow-up of up to 40 months (mean = 20.3, range = 1-40), all eyes show satisfactory intraocular pressure and no eye needed a filtering procedure. The results of our studies are as follows (values are mean + SD). In the group of 6 eyes with high I.O.P., the mean pre-operative intraocular pressure was 29.7 + 5.6mmHg and the mean post-operative I.O.P. was 15.1 + 1.4mmHg. The mean reduction was 14.5 + 6.6 mmHg (p < 0.005). In the 28 eyes with pre-operative I.O.P. under control (17.5 _+ 1.6), the mean post-operative I.O.P. was 14.4 + 2.3 mmHg, with a mean reduction of 3.1 + 3.1 mmHg (p < 0.005). Before the E.C.C.E., 11 eyes had I.O.P. less than 21mmHg without anti-glaucoma medication, whereas after the E.C.C.E. 28 eyes did not need such a medication. No significant correlation was found between pre-operative and post-operative extension of peripheral anterior synechiae (when assessable) and post-operative intraocular pressure control. The difference between pre- and post-operative anterior chamber depth measured by ultrasonic biometry was remarkable, i.e. M = 1.93 + 0.36mm and 3.42 + 0.2mm (pre-operative and post-operative, respectively; p < 0.005).
Introduction
The anatomical peculiarities of eyes affected by closed angle glaucoma have been stressed in ophthalmological literature for many years [1-11]. The lens itself, although frequently mentioned as the main aetiological factor of a 'crowded anterior segment', has not been considered in relation to the surgical approach of closed angle glaucoma until a few years ago (except in those clear-cut cases of phacogenic glaucoma). After Greve's presentation of the good results
obtained in treatment of medically uncontrolled cases of closed angle glaucoma by extracapsular cataract extraction (E.C.C.E.) plus posterior chamber I.O.L. implantation only [12-20], we have followed the same path and in this paper. We present our experience of the last three years.
Materials and methods
34 eyes of 34 patients, 16 males and 18 females, mean age = 67 years (range 55-88), have been
406
A. Reibaldi & M.G. Uva
operated on. All of them were affected by chronic closed angle glaucoma (24/34 eyes had suffered one or more acute attacks in their history). After Yag laser iridotomy, performed on all the eyes, the controls showed variability depending on the cases: 6 eyes having high I.O.P. notwithstanding maximal therapy, 11 eyes showing intraocular pressure under control (less than 2 mmHg) without therapy, 9 with I.O.P. controlled by topical therapy, 8 with I.O.P. controlled by maximal therapy (C.A.I. included). The cases with well controlled glaucoma were operated on because of the presence of more or less significant lens opacities. Any secondary cause of glaucoma (iridocyclites, subluxation of lens, phacolysis etc.) had been excluded. All patients had visual acuity determination; I.O.P. measurements carried out using Goldmann applanation-tonometry or non-contact tonometry in the first post-operative period and, eventually, provocative tests; gonioscopy with Sussman or Posner lenses (Ocular Instruments Inc. USA); ultrasound biometrical examinaton with standardized immersion technique; interferometry; perimetry and optic disc photography. In 10 eyes we performed E.C.C.E. with Sinskey J loop lens implantation in the ciliary sulcus. In 24 eyes we have implanted a compressible disk lens (Pharmacia AB, Uppsala, Sweden) in the capsular bag, with an E.C.C.E. procedure including synechiolysis, if necessary.
Results
After a follow-up of up to 40 months (mean = 20.3, range 1-40), all eyes show a good intraocular pressure and no eye has needed a further filtering procedure. In the group of 6 eyes with high I.O.P. the mean pre-operative intraocular pressure was 29.7+ 5.6mmHg, the mean post-operative I.O.P. was 15.1 _+ 1.4 mmHg. The mean reduction was 14.5 _+ 6.6mmHg (p < 0.005). In the 28 eyes with pre-operative I.O.P. under control: mean = 17.5 _+ 1.6 mmHg, the mean post-
operative I.O.P. was 14.4_+ 2.3mmHg, with a mean reduction of 3.1 _+ 3.1 (p < 0.005). Before the E.C.C.E. 11.34 eyes (32.4%) had I.O.P. less than 21mmHg without antiglaucoma medication, whereas after the E.C.C.E. 28/34 eyes (82.4%) needed no such medication. Visual acuity varied from a pre-operative mean value of 0.39 _+ 0.18 to 0.68 _+ 0.16 at the end of follow up. The difference between pre- and post-operative anterior chamber depth, measured by ultrasonic biometry is remarkable: from M = 1.93 _+ 0.36 mm to M = 3.42 + 0.21mm (p < 0.005). By means of gonioscopy we have noticed in all eyes an enlargement of the width of the angle, due to iris convexity flattening. No statistically significant correlation was found between post-operative I.O.P. and gonioscopic changes. As regards the complications, these have been rare and clinically not relevant: 1 case (2.9%) of pupil capture, 1 case (2.9%) of fibrinous dispersion on I.O.L. surface.
Discussion
The description in ophthalmic literature of anatomical and biometrical features of eyes affected by closed angle glaucoma is not recent: cornea, anterior chamber, iris, ciliary bodies, axial length and moreover the lens are involved and play a role in the pathogenesis of closed angled glaucoma [5, 7, 9, 10, 21-25]. According to Greve [12], the extraction of a lens having a thickness of 4.5-5 mm and its replacement by a I.O.L. having a thickness of 1-1.2mm thickness causes all the described post-operative changes in the anterior chamber (increased depth), in the angle (increased width), in the iris profile (flattening) and removes the anatomical causes of ocular hypertension. Greve [12] and Wishart & Atkinson [26] report that the extent of peripheral anterior chamber synechiae, hard to estimate in most of the eyes, has no influence on the post-operative I.O.P. control. The issue of P.A.S. is the principal source of
Surgical managementof closed angle glaucoma objections from authors who disagree to this procedure. In our experience we have noticed no significative difference of glaucoma control among eyes with quite different post-operative gonioscopical findings, thus testifying the effectiveness of this new approach to the closed angle glaucoma. At the moment, it is not possible, according to us, to compare the E.C.C.E. plus I.O.L. implantation operation with the trabeculectomy or the combined procedure because of the limited number of case, the short follow-up and the overlap of surgical goals and indications. Our actual study applies to particular surgical indications: we treated with this method either eyes with closed angle glaucoma showing a fairly good I.O.P. control after Yag laser iridotomy and medical therapy but with a poor visual acuity due to the lens opacity, or eyes with an almost clear lens and good visual acuity but with a poor or uncontrolled glaucoma. Into the light of problems, we have recently proposed, in the last meeting of the 'Italian Association for the Study of glaucoma', a study protocol with the aim to verify the validity of this surgical choice with a larger number of cases, longer followup and with different surgeons [27]. Waiting for these results at present, we can recommend cataract extraction procedure in all the cases with concomitant cataract and angle closure glaucoma. In case of a clear lens, the choice becomes more difficult; however this approach remains correct, on condition that all the anatomo-functional conditions are present and the operation is executed by an experienced surgeon.
References 1. Rosengren B. Studien uber die Tiefe der vorderen Augenkammer mit besonderer Hinsicht auf ihr Verhalten beim primaren Glaukom. Acta Ophthalmol 1930; 8: 99136. 2. Sugar H.S. The mechanical factors in the etiology of acute glaucome. Am of J Ophthalmol 1941; 24: 851-873. 3. Tornquist R. Chamber depth in primary acute glaucoma. Br J Ophthalmol 1956; 40: 421-429.
407
4. Lowe RF. Aetiology of the anatomical basis for primary angle closure glaucoma. Biometrical comparisons between normal eye and eyes with primary angle-closure glaucoma. Br J Ophthalmol 1970; 54: 161-169. 5. Delmareelle Y, Collignon J, Luyckx-Bacus J, Weekers R. Etude biometrique du globe oculaire dans le glaucome a angle ferme. Bulletin des Societes D'Ophthalmologie de France 1971; 84: 449-460. 6. Storey JK, Phillips CI. Ocular dimensions in angle closure glaucoma. Br J Physiol and Optom 1971; 26: 228-232. 7. Lowe RF. Primary angle closure glaucoma. A review of ocular biometry. Austral J Ophthalmol 1977; 5: 9-13. 8. Lee DA, Brubaker RF, Ilstrup DM. Anterior chamber dimensions in patients with narrow angle and angle closure glaucoma. Arch Ophthalmol 1984; 102: 46-51. 9. Markowitz SN, Morin JD. Angle closure glaucoma. Relation between lens thickness, anterior chamber depth and age. Can J Ophthalmol 1984; 19: 300-305. 10. Cennamo G, Rosa N. Ecografia e glaucoma. Atti del XIX convegno Soc. Oft. Merid. 1985; Capri, 21-32. 11. Panek WC, Christensen RE, Lee DA, Fazio DT, Fox LE, Scott TV. Biometric variables in patients with occludable anterior chamber angles. Am J Ophthalmo11990; 110: 185188. 12. Greve EL, Wagemans MJ. Reduction of intraocular pressure after extracapsular cataract extraction with posterior chamber intraocular lens implantation in patients with narrow angle. In: Greve EL (ed) Surgical management of coexisting glaucoma and cataract. Amsterdam: Kugler Publisher 1987. 13. Greve EL. Primary angle closure glaucoma: extracapsular cataract extraction or filtering procedure? Int Ophtbalmol 1988; 12: 15%162. 14. Greve EL, Gunnings F. Long term results of E.C.C.E. in agle closure glaucoma. Glaucoma Symposium XXVI International Congress of Ophthalmology March 14-17, 1990 Singapore. 15. Reibaldi A, Uva MG, Fazio P. Our experience in the management of cataract and glaucome. New Trends in Ophthaltool 1989; vol. IV. 3: 21%226. 16. Reibaldi A, Uva MG, Fazio P. The best surgical approach to coesisting cataract and glaucomal: our view. Glaucoma Symposium XXVI International Congress of Ophthalmology, 16-17 March 1990. Singapore. 17. Reibaldi A, Uva MG, Panta G, Savarino F. A proposito di un nuovo approccio chirurgico al glaucoma ad angola chiuso. Bollettino d'Oculistical 1991; anno 70, suppl. 2: 451454. 18. Uva MG, Panta G, Reibaldi A. The effect on IOP of E.C.C.E. with posterior chamber IOL implantation. New Trends In Ophthalmol 1989; IV, 3: 241-250. 19. Uva MG, Fazio P, Panta G, Reibaldi A. IOL in cataract and glaucoma. Atti I International Congress 'Societas Ophthalmologica Mediterranea', Palermo 1989. 20. Uva MG, Scalia G, Reibaldi A. IOL e IOP. Bollettino d' Oculistica 1990; 69, suppl 2: 55-66.
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A. Reibaldi & M.G. Uva
21. Chandler PA. Narrow angle glaucoma. Arch Ophthalmol 1952; 47: 695-699. 22. Tomlinson A, Leighton PA. Ocular dimensions in the heredity of angle closure glaucoma. Br J Ophthalmol 1973; 57: 475-480. 23. Ritch R, Bruce Shields M, Krupin T. The glaucomas. The CN. Mosby Company, S. Louis 1989. 24. Lowe RF, Lim ASM. Primary angle closure glaucoma.P.G. Publishing PTE, UK, Ltd, 1990. 25. Uva MG, Scalia G, Panta G, Valvo F, Reibaldi A. Modificazioni di alcuni parametri oculari dopo chirurgia extra-
capsulare della cataratta in occhi normali e glaucomatosi. Bolletino d'Oculistica 1991; 70 suppl. 1: 289-294. 26. Wishart PK, Atkinson PL. Extracapsular cataract eraetion and posterior chamber lens implantation in patients with primary chronic angle-closure glaucoma: effect on intraocular pressure control. Eye 1989; 3: 706-712. 27. Reibaldi A, Uva MG. E.C.C.E. piu' IOL in camera posteriore nel glaucoma ad angolo chiuso: ipotesi di protocollo per studio multicentrico. Relazione all' VIII Congr. A.I.S.G. (in press) 14-15/3/1992 Rapallo.
