Surgical management of chronic glaucoma in aphakia.

The surgical management of glaucoma in aphakia has been limited by poor success in the control of intraocular pressure and serious postoperative complications that threaten vision. A consecutive series of trabeculectomy filtering procedures in aphakic eyes with a mean preoperative intraocular pressure of 38 mmHg was followed for an average of 26 months and revealed a 62% control of intraocular pressure at 21 mmHg or less. Five additional patients (24%) had pressures lower than 21 mmHg following digital massage. The complication of decreased visual acuity following surgery was significant but not directly related to the surgical procedure. Another patient population with glaucoma and aphakia with a mean preoperative pressure of 25 mmHg was treated with laser trabeculoplasty. In 12 of 15 patients (80%) intraocular pressure was lower than 22 mmHg for an average of eight months and did not require glaucoma surgery. There were no significant complications following this therapy and all patients retained preoperative level of visual acuity. In aphakic patients who have uncontrolled glaucoma on maximal medical therapy, surgery is indicated. We recommend the following approach to surgical management: (1) Laser treatment to the trabecular meshwork if the angle is open; (2) if this fails, or the angle is extensively closed, a trabeculectomy filtering procedure is suggested; (3) cyclocryotherapy has been effective in controlling pressure but the unpredictable loss of vision has prompted caution in seeing eyes; (4) cyclodialysis; and (5) transpupillary or transscleral treatment of the ciliary processes are additional modes of therapy. Improved results of surgical treatment for glaucoma and aphakia have been encouraging and should be used when maximal medical therapy is ineffective.