The purpose of this study was to compare the effectiveness of goniosynechialysis combined with phacoemulsification in patients with acute primary angle closure (APAC) and chronic primary angle closure glaucoma (CPACG) and to investigate the possible differences in the outcome between the 2 groups. Materials and Methods Nine eyes of 9 patients with APAC and 18 eyes of 18 patients with CPACG were enrolled between January 2010 and September 2011. The surgical procedure and probable outcomes were explained in detail to the patients and informed consent was obtained from all patients. The present clinical study was approved by institutional review board. The criteria used to define APAC included (1) an eye with an occludable drainage angle (in which more than 270 degrees of the posterior trabecular meshwork cannot be seen on static gonioscopy) and features indicating that trabecular obstruction by the peripheral iris has occurred, such as PAS, (2) presence of at least 2 typical symptoms (ocular pain, nausea, vomiting, and antecedent history of intermittent blurring of vision with halo effect), (3) presence of at least 2 signs (conjunctival injection, corneal epithelial edema, mid-dilated pupil), (4) shallow anterior chamber depth; (5) elevated IOP (>21mmHg), and (6) no glaucomatous optic neuropathy. The criteria used to define CPACG included (1) an eye with an occludable drainage angle and features indicating that trabecular obstruction by the peripheral iris has occurred, such as PAS, (2) elevated IOP (>21mmHg), and (3) glaucomatous damage to optic disc and visual field. On the basis of definitions of APAC and CPACG, individuals with: (1) uncontrolled IOP (>21mmHg) despite medical therapy, laser iridotomy and argon laser peripheral iridoplasty; (2) synechial angle closure of 180 degrees or more confirmed by indentation gonioscopy by Sussman goniolens; (3) concurrent cataract with best corrected visual acuity (BCVA)≤0.5 (4) no history of acute attack or acute attack having occurred greater than 6 months previously for CPACG group were included in the study. Patients with secondary glaucoma, or those who had undergone any incisional surgery were excluded from the study. Surgical Technique A standard clear-cornea phacoemulsification was performed, with implantation of a foldable intraocular lens. After lens implantation, the patient’s head was tilted to the side opposite a chosen paracentesis track to orient the iris surface parallel to the optical axis of the microscope. Intraoperative direct gonioscopy was performed with a Swan-Jacob goinolens. Goniosynechialysis through clear cornea incision and three separate paracenteses evenly spaced 90 degrees apart was performed for 360 degrees with the anterior chamber formed with viscoelastic. A blunt iris spatula was pressed against the most peripheral edges of the iris next to the points of angle adhesion. After applying pressure toward the posterior of the iris, the trabecular meshwork was exposed. Statistical Analysis Snellen BCVAs were converted to the logarithm of the minimum angle of resolution (logMAR) for statistical analysis. Continuous and categorical variables were compared by using Mann- Whitney U test and Fisher’s exact test. Variables between preoperative and postoperative IOP in each group were compared using Wilcoxon signed-rank test. Analysis of covariance was performed to determine the difference in postoperative IOP between the APAC and CPACG groups because of an initially different preoperative IOP. Preoperative IOP had been adjusted. All statistical assessments were 2-sided, and the 0.05 level was considered statistically significant. Statistical analyses were performed using SPSS 18.0K statistics software (SPSS Inc, Chicago, IL). Table 1. Descriptive and clinical characteristics of the study groups Conclusion Goniosynechialysis combined with phacoemulsification in patients with uncontrolled acute primary angle closure and chronic primary angle-closure glaucoma Ji Woong Lee 1 , Eun Ah Kim 2 , Seong Jae Kim 3 1 Department of Ophthalmology, Pusan National University School of Medicine, Busan, Korea 2 Department of Ophthalmology, Daegu Fatima Hospital, Deagu, Korea 3 Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea Purpose Results Figure 1. (A) Intraoperative gonioscopy shows angle remains closed by PAS despite phacoemulsification and injection of viscoelastic near the angle. (B) The synechiae are stripped from the angle wall at the point of adhesion and trabecular meshwork are exposed. (A) (B) Total (n=27) APAC (n = 9) CPACG (n = 18) P between two groups Age (years) 68.33 ± 7.81 66.11 ± 8.81 69.44 ± 7.26 0.587 Follow-up (months) 10.3 ± 4.59 (range, 4-27) 9.33 ± 3.50 (range, 5-15) 10.78 ± 5.07 (range, 4-27) 0.587 OD/OS 17/10 5/4 12/6 0.683 Male/female 5/22 1/8 4/14 0.447 ACD (mm) 1.63 ± 0.21 1.52 ± 0.20 1.68 ± 0.19 0.080 Lens thickness (mm) 5.24 ± 0.34 5.33 ± 0.43 5.19 ± 0.28 0.519 Axial length (mm) 22.40 ± 0.77 22.62 ± 0.78 22.29 ± 0.77 0.280 Table 2. Preoperative and postoperative IOP (mmHg) in study groups Values are means±SD. *ANCOVA is performed because of an imbalance of baseline IOP. †Adjusted P value. Adjusted for preoperative IOP. ANCOVA, analysis of covariance; IOP, intraocular pressure; Preop., preoperative; Postop., postoperative. Table 3. Preoperative and postoperative BCVA (log MAR) in study groups Table 4. Preoperative and postoperative number of anti-glaucoma medications in study groups APAC (n = 9) CPACG (n = 18) P between two groups Preop. no. of medications 3.56 ± 0.53 2.61 ± 0.50 0.001 Postop. no. of medications* 0.67 ± 0.50 0.56 ± 0.62 0.722† P between preop. and postop. no. of medications 0.007 0.000 No. of medication reduction* -2.89 ± 0.78 -2.06 ± 0.64 0.722† *ANCOVA is performed because of an imbalance of baseline number of medications. †Adjusted P value. Adjusted for preoperative number of medications. Table 5. Preoperative and postoperative gonioscopic findings in study groups *ANCOVA is performed because of an imbalance of baseline PAS. †Adjusted P value. Adjusted for preoperative PAS. Goniosynechialysis combined with phacoemulsification is effective in reducing PAS and IOP and improving visual acuity in patients with uncontrolled APAC and CPACG. (A) (B) Figure 2. (A) Ultrasound biomicroscopy (UBM) shows synechial angle closure at the 9-o’clock position (nasal) in an eye with acute primary angle closure before surgery. (B) UBM at the same 9- o’clock position reveals that the angle is now open after phacoemulsification, intraocular lens implantation and goniosynechialysis.