A 72-year-old woman with a history of acute angle-closure glaucoma (successfully treated with laser peripheral iridotomy 2 years ago) now presents with a mature cataract in the same eye and visual acuity of 6/60. She is keen for cataract surgery. Anterior chamber depth is shallow. Intraocular pressure is 14 mmHg on no medications. What is the most appropriate next step?

Explanation

## Clinical Context This patient has a history of acute angle-closure glaucoma (AACG) that was successfully treated with laser peripheral iridotomy (LPI). She now has a cataract and requires surgery. The key question is: does the prior AACG history change the surgical approach? ## The Role of Laser Peripheral Iridotomy **Key Point:** Laser peripheral iridotomy eliminates the mechanism of angle closure by allowing aqueous to bypass the iris. Once LPI is patent and effective, the risk of recurrent angle closure is virtually eliminated, even if the anterior chamber remains anatomically shallow. **High-Yield:** In a patient with prior AACG who has had successful LPI: - The anatomical predisposition (shallow chamber, thick lens) remains - But the MECHANISM of angle closure (pupillary block) is abolished - Cataract surgery is safe and does NOT require modification - Standard phacoemulsification with IOL is the standard of care ## Why Standard Surgery is Appropriate ```mermaid flowchart TD A[Prior AACG with patent LPI]:::outcome --> B{Risk of recurrent angle closure?}:::decision B -->|High| C[Avoid surgery or modify approach]:::urgent B -->|Low/Eliminated| D[Standard cataract surgery safe]:::action D --> E[Phacoemulsification + IOL]:::action E --> F[Anterior chamber deepens post-op]:::outcome ``` **Clinical Pearl:** Cataract removal actually DEEPENS the anterior chamber postoperatively by removing the thick lens that was pushing the iris forward. This further reduces any residual angle-closure risk. ## Why IOL is Beneficial - IOL placement is thinner than the natural cataractous lens - Anterior chamber depth increases after cataract removal - IOL provides refractive correction and better visual outcomes - There is no evidence that IOL increases angle-closure risk in post-LPI patients **Warning:** Do NOT withhold IOL or use artificially low-power IOL in post-LPI patients. These modifications are unnecessary and compromise visual outcomes without reducing any real risk. [cite:Ophthalmology textbook on angle-closure glaucoma management and cataract surgery in glaucoma patients]