Ophthalmology Times urges earlier lens extraction
What happened
- Ophthalmology Times reported on January 24, 2021 that Ruth D. Williams urged earlier clear-lens extraction for some primary angle-closure patients instead of defaulting to iridotomy. - The EAGLE trial enrolled 419 patients, and 60.6% of lens-extraction patients achieved intraocular-pressure control without medications versus 21.3% with iridotomy-based care. - The American Academy of Ophthalmology’s 2025 primary angle-closure guideline is available online, alongside the Lancet-published EAGLE trial and follow-up analyses.
Why it matters
Ophthalmology Times said in a January 24, 2021 article that clear-lens extraction should be considered earlier for some patients with primary angle closure and primary angle-closure glaucoma, rather than reserving surgery until a cataract becomes visually significant. The article, based on comments from Ruth D. Williams of Wheaton Eye Clinic in Illinois during the virtual Glaucoma 360 meeting, argued that the lens itself can be a driver of angle crowding in these eyes. Williams said the usual pathway — laser peripheral iridotomy followed by pressure-lowering drops — should not be treated as the automatic first answer in every case. ### Which patients were at the center of this argument? Ruth D. Williams said the discussion applies to patients with primary angle closure, known as PAC, and primary angle-closure glaucoma, or PACG, where the drainage angle is narrowed or blocked. The American Academy of Ophthalmology’s 2025 Preferred Practice Pattern defines PAC as at least 180 degrees of iridotrabecular contact with peripheral anterior synechiae and/or elevated intraocular pressure but no glaucomatous optic neuropathy, and PACG as the same angle findings with glaucomatous optic neuropathy present. (ophthalmologytimes.com) The AAO guideline also lists older age, female sex, hyperopia, shallow anterior chamber, shorter axial length and increased lens thickness among common risk factors for primary angle-closure disease. That framing supports the idea, advanced in the Ophthalmology Times report, that the natural crystalline lens is not just an incidental finding in some of these patients but part of the mechanism narrowing the angle. ### What evidence did Williams cite for operating earlier? (ophthalmologytimes.com) The Ophthalmology Times article pointed to the EAGLE trial, a randomized controlled study published in The Lancet, as the main basis for earlier lens extraction in selected patients. The trial found that initial clear-lens extraction was superior to laser peripheral iridotomy plus topical medical treatment for participants with primary angle closure and primary angle-closure glaucoma. (aao.org) The study enrolled 419 patients from 30 clinics in five countries, according to Ophthalmology Times. Of those, 208 were assigned to clear-lens extraction and 211 to standard care, and all were phakic, older than 50, and free of symptomatic cataract. At 36 months, Williams said, the lens-extraction group had better pressure and medication outcomes. Ophthalmology Times reported intraocular pressure was 1.3 mm Hg lower in that group, and 60.6% of patients achieved pressure control without medications versus 21.3% in the iridotomy group. (thelancet.com) ### Why does the lens matter before a cataract looks “ripe”? Williams said the rationale for surgery is anatomical. (ophthalmologytimes.com) In angle-closure disease, the natural lens can contribute to crowding in the front of the eye, and removing it can deepen the anterior chamber and open the angle. A later British Journal of Ophthalmology analysis of EAGLE data reinforced that point with longer-term figures. Among 369 patients who completed 36-month follow-up, 90% of patients in the clear-lens extraction arm met the study’s “good response” definition, compared with 67% in the laser iridotomy arm, and 66% met the medication-free “optimal response” definition versus 18% in the laser arm. (ophthalmologytimes.com) ### Does this mean iridotomy is no longer standard? The American Academy of Ophthalmology’s guideline still describes laser peripheral iridotomy as a core treatment in angle-closure disease, particularly where pupillary block is involved, and it remains standard in acute angle-closure crisis. (ophthalmologytimes.com) The newer argument is narrower: some patients with PAC or PACG may do better if surgeons weigh lens extraction earlier instead of moving directly from iridotomy to chronic drops. (bjo.bmj.com) Paul J. Harasymowycz, writing in a separate Ophthalmology Times report on EAGLE follow-up, put it this way: ophthalmologists should not “jump straight to iridotomy” in every patient with narrow angles, though he also said clear-lens extraction is not right for every case. That keeps the decision centered on patient selection rather than a blanket replacement of one procedure with another. ### What changes in day-to-day cataract and glaucoma practice? (aaojournal.org) Ophthalmology Times said the shift is partly about timing and partly about how surgeons classify the operation. For a patient with angle crowding, elevated pressure, or a growing medication burden, lens removal may be considered a glaucoma intervention as well as cataract or refractive surgery, according to Williams and other surgeons cited by the publication. (ophthalmologytimes.com) The AAO’s 2025 Preferred Practice Pattern and the published EAGLE trial now give clinicians a current reference point for that discussion. The guideline is posted on the academy’s website, and the EAGLE trial and its follow-up analyses remain available in The Lancet and the British Journal of Ophthalmology for surgeons weighing pressure control, angle anatomy and medication reduction in future treatment decisions. (aao.org) (ophthalmologytimes.com)
Key numbers
- Ophthalmology Times reported on January 24, 2021 that Ruth D.
- The EAGLE trial enrolled 419 patients, and 60.6% of lens-extraction patients achieved intraocular-pressure control without medications versus 21.3% with iridotomy-based care.
- The American Academy of Ophthalmology’s 2025 primary angle-closure guideline is available online, alongside the Lancet-published EAGLE trial and follow-up analyses.
- Williams of Wheaton Eye Clinic in Illinois during the virtual Glaucoma 360 meeting, argued that the lens itself can be a driver of angle crowding in these eyes.
What happens next
- (ophthalmologytimes.com) The newer argument is narrower: some patients with PAC or PACG may do better if surgeons weigh lens extraction earlier instead of moving directly from iridotomy to chronic drops.
- For a patient with angle crowding, elevated pressure, or a growing medication burden, lens removal may be considered a glaucoma intervention as well as cataract or refractive surgery, according to Williams and other surgeons cited by the publication.
Quick answers
What happened in Ophthalmology Times urges earlier lens extraction?
Ophthalmology Times reported on January 24, 2021 that Ruth D. Williams urged earlier clear-lens extraction for some primary angle-closure patients instead of defaulting to iridotomy. The EAGLE trial enrolled 419 patients, and 60.6% of lens-extraction patients achieved intraocular-pressure control without medications versus 21.3% with iridotomy-based care. The American Academy of Ophthalmology’s 2025 primary angle-closure guideline is available online, alongside the Lancet-published EAGLE trial and follow-up analyses.
Why does Ophthalmology Times urges earlier lens extraction matter?
Ophthalmology Times said in a January 24, 2021 article that clear-lens extraction should be considered earlier for some patients with primary angle closure and primary angle-closure glaucoma, rather than reserving surgery until a cataract becomes visually significant. The article, based on comments from Ruth D. Williams of Wheaton Eye Clinic in Illinois during the virtual Glaucoma 360 meeting, argued that the lens itself can be a driver of angle crowding in these eyes. Williams said the usual pathway — laser peripheral iridotomy followed by pressure-lowering drops — should not be treated as the automatic first answer in every case. Which patients were at the center of this argument? Ruth D. Williams said the discussion applies to patients with primary angle closure, known as PAC, and primary angle-closure glaucoma, or PACG, where the drainage angle is narrowed or blocked. The American Academy of Ophthalmology’s 2025 Preferred Practice Pattern defines PAC as at least 180 degrees of iridotrabecular contact with peripheral anterior synechiae and/or elevated intraocular pressure but no glaucomatous optic neuropathy, and PACG as the same angle findings with glaucomatous optic neuropathy present. (ophthalmologytimes.com) The AAO guideline also lists older age, female sex, hyperopia, shallow anterior chamber, shorter axial length and increased lens thickness among common risk factors for primary angle-closure disease. That framing supports the idea, advanced in the Ophthalmology Times report, that the natural crystalline lens is not just an incidental finding in some of these patients but part of the mechanism narrowing the angle. What evidence did Williams cite for operating earlier? (ophthalmologytimes.com) The Ophthalmology Times article pointed to the EAGLE trial, a randomized controlled study published in The Lancet, as the main basis for earlier lens extraction in selected patients. The trial found that initial clear-lens extraction was superior to laser peripheral iridotomy plus topical medical treatment for participants with primary angle closure and primary angle-closure glaucoma. (aao.org) The study enrolled 419 patients from 30 clinics in five countries, according to Ophthalmology Times. Of those, 208 were assigned to clear-lens extraction and 211 to standard care, and all were phakic, older than 50, and free of symptomatic cataract. At 36 months, Williams said, the lens-extraction group had better pressure and medication outcomes. Ophthalmology Times reported intraocular pressure was 1.3 mm Hg lower in that group, and 60.6% of patients achieved pressure control without medications versus 21.3% in the iridotomy group. (thelancet.com) Why does the lens matter before a cataract looks “ripe”? Williams said the rationale for surgery is anatomical. (ophthalmologytimes.com) In angle-closure disease, the natural lens can contribute to crowding in the front of the eye, and removing it can deepen the anterior chamber and open the angle. A later British Journal of Ophthalmology analysis of EAGLE data reinforced that point with longer-term figures. Among 369 patients who completed 36-month follow-up, 90% of patients in the clear-lens extraction arm met the study’s “good response” definition, compared with 67% in the laser iridotomy arm, and 66% met the medication-free “optimal response” definition versus 18% in the laser arm. (ophthalmologytimes.com) Does this mean iridotomy is no longer standard? The American Academy of Ophthalmology’s guideline still describes laser peripheral iridotomy as a core treatment in angle-closure disease, particularly where pupillary block is involved, and it remains standard in acute angle-closure crisis. (ophthalmologytimes.com) The newer argument is narrower: some patients with PAC or PACG may do better if surgeons weigh lens extraction earlier instead of moving directly from iridotomy to chronic drops. (bjo.bmj.com) Paul J. Harasymowycz, writing in a separate Ophthalmology Times report on EAGLE follow-up, put it this way: ophthalmologists should not “jump straight to iridotomy” in every patient with narrow angles, though he also said clear-lens extraction is not right for every case. That keeps the decision centered on patient selection rather than a blanket replacement of one procedure with another. What changes in day-to-day cataract and glaucoma practice? (aaojournal.org) Ophthalmology Times said the shift is partly about timing and partly about how surgeons classify the operation. For a patient with angle crowding, elevated pressure, or a growing medication burden, lens removal may be considered a glaucoma intervention as well as cataract or refractive surgery, according to Williams and other surgeons cited by the publication. (ophthalmologytimes.com) The AAO’s 2025 Preferred Practice Pattern and the published EAGLE trial now give clinicians a current reference point for that discussion. The guideline is posted on the academy’s website, and the EAGLE trial and its follow-up analyses remain available in The Lancet and the British Journal of Ophthalmology for surgeons weighing pressure control, angle anatomy and medication reduction in future treatment decisions. (aao.org) (ophthalmologytimes.com)
