status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the
European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean
intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0⋅004) after clear-lens
extraction than after standard care. The incremental cost-eff ectiveness ratio was £14 284 for initial lens extraction
versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and
three who received standard care. No patients had serious adverse events.
Interpretation
Clear-lens extraction showed greater effi
cacy and was more cost-eff ective than laser peripheral
iridotomy, and should be considered as an option for fi rst-line treatment.
Funding
Medical Research Council.
Copyright
© The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license.
Introduction
WHO ranks glaucoma as the leading cause of irreversible
blindness,
1
and prevalence is expected to increase
substantially: compared with 20 million people who have
primary angle-closure glaucoma now, by 2040, 34 million
people will be aff ected, of whom 5⋅3 million will be blind.
2
The prevalence of primary angle-closure glaucoma is
highest in people of east Asian origin.
2,3
Blindness is costly
to individuals and society.
4
Although most people with
glaucoma do not become blind, many have substantially
impaired quality of life due to restricted peripheral vision
and the need for long-term treatment.
5
Glaucoma has two
subtypes, open angle and angle closure, in which the
drainage pathway (trabecular meshwork at the anterior
chamber angle) is blocked or not, respectively.
6
Although
primary open-angle glaucoma is more common, primary
angle-closure glaucoma is more severe and more likely to
result in irreversible blindness if not properly treated.
Early and eff ective interventions are important.
In the early stage of the disease, primary angle closure
is accompanied by high intraocular pressure but no
visual loss. The standard of care for primary angle closure
and primary angle-closure glaucoma is laser peripheral
iridotomy to open the drainage pathways and medical
management with eye drops to reduce intraocular
pressure.
7
If the disease remains uncontrolled, surgery,
often trabeculectomy, is indicated, which is associated
with potentially serious complications.
7
Surgical lens extraction, as used in managing
age-related cataract, is an alternative approach for the
management of primary angle-closure glaucoma.
6,8
Age-related growth of the lens plays a major part in the
mechanisms leading to primary angle-closure glaucoma,
and lens extraction is used routinely in patients with
coexisting cataract. However, the effi
cacy and safety of
this treatment in people with primary angle-closure
glaucoma without cataract has not been fully assessed.
9
If
lens extraction could control the condition, the need for
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