Combined Phacoemulsification and Goniosynechialysis for Uncontrolled Chronic Angle-closure Glaucoma after Acute Angle-closure Glaucoma Chaiwat Teekhasaenee, MD, 1 Robert Ritch, MD 2 Objective: To evaluate combined phacoemulsification, posterior chamber intraocular lens (PCIOL) implan- tation, and goniosynechialysis (phaco-GSL) prospectively in eyes with more than 180° of peripheral anterior synechiae (PAS) and uncontrolled intraocular pressure (IOP) when performed within 6 months of an attack of acute angle-closure glaucoma (ACG). Design: Prospective, noncontrolled clinical trial. Participants: Patients who had presented with acute ACG and had persistently uncontrolled IOP despite successful laser iridotomy for pupillary block and argon laser peripheral iridoplasty for continued appositional closure after iridotomy. Intervention: After the completion of phacoemulsification and posterior chamber lens implantation, gonio- synechialysis was performed in 52 eyes of 48 patients. Main Outcome Measures: Postoperative visual acuity, IOP, extent of PAS, and number of medications, if any, required for IOP control. Results: Intraocular pressure was less than 20 mmHg in 47 eyes (90.4%) without medications; 4 were controlled with medications and 1 required filtration. Mean extent of PAS was reduced from 310° to 60°. Peripheral anterior synechiae formation or IOP elevation did not recur after 3 months after surgery up to 6 years. Eight patients achieved 20/20 visual acuity, while 44 patients had less than 20/20 visual acuity. No patient had worse visual acuity after surgery compared to before surgery. Conclusion: Phaco-GSL and PCIOL implantation is effective in reducing PAS and IOP and improving visual acuity in eyes with persistent chronic ACG when performed within 6 months after treatment for acute ACG. Ophthalmology 1999;106:669 – 675 In chronic angle-closure glaucoma (ACG), portions of the anterior chamber angle are permanently closed by periph- eral anterior synechiae (PAS). 1 Control of intraocular pres- sure (IOP) after elimination of appositional closure depends on the amount of damage to the trabecular meshwork, which may or may not correlate with the extent of PAS. Intraocular pressure is usually elevated when more than 180° of the angle is closed by PAS. When more than 270° of the angle is closed, medical therapy is usually ineffective and filtering surgery becomes necessary. 2 Goniosynechialysis (GSL) is a surgical procedure de- signed to strip PAS from the angle wall and restore trabec- ular function in eyes with chronic ACG. 2 The procedure is successful in approximately 80% of eyes if the PAS have been present for less than 1 year. 2 Although GSL has not become widely popular in the United States, it has in Japan, where promising results have been reported in both phakic and pseudophakic eyes. 3–5 It can be effective in ACG when performed by itself, in conjunction with other surgical pro- cedures, 5,6 and after failed filtration surgery. 7 The shallow anterior chamber characteristic of eyes with ACG makes performing GSL more difficult than it would be in an eye with a widely open angle. An enlarged, catarac- tous lens or anterior movement of the lens, such as com- monly found in exfoliation syndrome, can force the iris against the trabecular meshwork, resulting in reformation of PAS. Chamber deepening 8 before GSL is an integral part of the procedure. 2 Cataract extraction before GSL makes chamber deepening unnecessary. Chronic ACG is a serious problem in the countries of East Asia. Eyes of Orientals are widely believed to be more prone to develop ACG, 9 particularly creeping ACG with PAS formation. 10 Goniosynechialysis is very effective in Originally received: October 27, 1997. Revision accepted: November 3, 1998. Manuscript no. 97616. 1 Department of Ophthalmology, Ramathibodi Hospital, Mahidol Univer- sity, Bangkok, Thailand. 2 The New York Eye and Ear Infirmary, New York, New York. Presented in part at the American Academy of Ophthalmology annual meeting, San Francisco, California, October 1997. Supported in part by the Ramathibodi Foundation, Bangkok, and the Glaucoma Center Development Fund of the New York Eye and Ear Infirmary. Reprint requests to Robert Ritch, MD, Glaucoma Service, New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003. 669