Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE)

a randomised controlled trial

Augusto Azuara-Blanco (Corresponding Author), Jennifer Burr, Craig Ramsay, David Cooper, Paul J. Foster, David S. Friedman, Graham Scotland, Mehdi Javanbakht, Claire Cochran, John Norrie, Eagle Study Group

Research output: Contribution to journalArticle

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Abstract

Background
Primary angle-closure glaucoma (PACG) is a leading cause of irreversible blindness worldwide. In its early stage, primary angle-closure (PAC), there is increased intraocular pressure (IOP) but no visual loss. Because the crystalline lens has a major mechanistic role, lens extraction as initial treatment may be more effective than standard treatment, laser peripheral iridotomy.
Methods
In this randomized controlled trial we compared lens extraction versus laser peripheral iridotomy (1:1). We enrolled 419 participants from 30 hospital eye services in five countries. A web-based randomization application was used. Participants were ≥ 50 years, without cataract, and newly diagnosed with (1) PAC with IOP above 30 mmHg (n=155) or (2) PACG (n=263). The primary outcome was multidimensional measuring, at three years, patient reported health status (EQ-5D), clinical efficacy (IOP) and efficiency (incremental cost effectiveness ratio [ICER] per Quality Adjusted life year [QALY] gained, from a UK health service perspective). IOP measurements were masked. An intent-to-treat analysis was conducted. (ISRCTN 44464607).
Findings
EQ-5D and IOP data at three years were complete in 351 (83.8%) and 366 (87.4%) participants, respectively. After lens extraction (n=208) EQ-5D (0·87, SD 0·12) was 0·052 higher (95% CI 0·015, 0·088, p=0·005) and IOP (16·6 mmHg, SD 3·5) was 1·18 lower (95% CI -1·99, -0·38, p = 0.004) than after laser iridotomy (n=211); ICER £14,284 for initial lens extraction versus standard care (n=285). Irreversible loss of vision was rare and occurred in one participant in the lens extraction and three in the laser iridotomy group. Ethnicity, status of fellow eye, and diagnosis did not influence the results.
Interpretation
Initial treatment with lens extraction for PACG and PAC (with IOP above 30 mmHg) is more effective and cost-effective than laser iridotomy after three years and should be considered as an alternative to current practice.
Original languageEnglish
Pages (from-to)1389-1397
Number of pages9
JournalThe Lancet
Volume388
Issue number10052
DOIs
Publication statusPublished - 1 Oct 2016

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Angle Closure Glaucoma
Intraocular Pressure
Lenses
Randomized Controlled Trials
Lasers
Therapeutics
Cost-Benefit Analysis
Crystalline Lens
Quality-Adjusted Life Years
Blindness
Random Allocation
Cataract
Health Status
Health Services
Costs and Cost Analysis

Cite this

Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE) : a randomised controlled trial. / Azuara-Blanco, Augusto (Corresponding Author); Burr, Jennifer; Ramsay, Craig; Cooper, David; Foster, Paul J.; Friedman, David S.; Scotland, Graham; Javanbakht, Mehdi; Cochran, Claire; Norrie, John; Eagle Study Group.

In: The Lancet, Vol. 388, No. 10052, 01.10.2016, p. 1389-1397.

Research output: Contribution to journalArticle

Azuara-Blanco, A, Burr, J, Ramsay, C, Cooper, D, Foster, PJ, Friedman, DS, Scotland, G, Javanbakht, M, Cochran, C, Norrie, J & Eagle Study Group 2016, 'Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial', The Lancet, vol. 388, no. 10052, pp. 1389-1397. https://doi.org/10.1016/S0140-6736(16)30956-4
Azuara-Blanco, Augusto ; Burr, Jennifer ; Ramsay, Craig ; Cooper, David ; Foster, Paul J. ; Friedman, David S. ; Scotland, Graham ; Javanbakht, Mehdi ; Cochran, Claire ; Norrie, John ; Eagle Study Group. / Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE) : a randomised controlled trial. In: The Lancet. 2016 ; Vol. 388, No. 10052. pp. 1389-1397.
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title = "Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial",
abstract = "BackgroundPrimary angle-closure glaucoma (PACG) is a leading cause of irreversible blindness worldwide. In its early stage, primary angle-closure (PAC), there is increased intraocular pressure (IOP) but no visual loss. Because the crystalline lens has a major mechanistic role, lens extraction as initial treatment may be more effective than standard treatment, laser peripheral iridotomy. MethodsIn this randomized controlled trial we compared lens extraction versus laser peripheral iridotomy (1:1). We enrolled 419 participants from 30 hospital eye services in five countries. A web-based randomization application was used. Participants were ≥ 50 years, without cataract, and newly diagnosed with (1) PAC with IOP above 30 mmHg (n=155) or (2) PACG (n=263). The primary outcome was multidimensional measuring, at three years, patient reported health status (EQ-5D), clinical efficacy (IOP) and efficiency (incremental cost effectiveness ratio [ICER] per Quality Adjusted life year [QALY] gained, from a UK health service perspective). IOP measurements were masked. An intent-to-treat analysis was conducted. (ISRCTN 44464607). Findings EQ-5D and IOP data at three years were complete in 351 (83.8{\%}) and 366 (87.4{\%}) participants, respectively. After lens extraction (n=208) EQ-5D (0·87, SD 0·12) was 0·052 higher (95{\%} CI 0·015, 0·088, p=0·005) and IOP (16·6 mmHg, SD 3·5) was 1·18 lower (95{\%} CI -1·99, -0·38, p = 0.004) than after laser iridotomy (n=211); ICER £14,284 for initial lens extraction versus standard care (n=285). Irreversible loss of vision was rare and occurred in one participant in the lens extraction and three in the laser iridotomy group. Ethnicity, status of fellow eye, and diagnosis did not influence the results. InterpretationInitial treatment with lens extraction for PACG and PAC (with IOP above 30 mmHg) is more effective and cost-effective than laser iridotomy after three years and should be considered as an alternative to current practice.",
author = "Augusto Azuara-Blanco and Jennifer Burr and Craig Ramsay and David Cooper and Foster, {Paul J.} and Friedman, {David S.} and Graham Scotland and Mehdi Javanbakht and Claire Cochran and John Norrie and {Eagle Study Group}",
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T1 - Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE)

T2 - a randomised controlled trial

AU - Azuara-Blanco, Augusto

AU - Burr, Jennifer

AU - Ramsay, Craig

AU - Cooper, David

AU - Foster, Paul J.

AU - Friedman, David S.

AU - Scotland, Graham

AU - Javanbakht, Mehdi

AU - Cochran, Claire

AU - Norrie, John

AU - Eagle Study Group

N1 - Medical Research Council (ref G0701604) and administered by the NIHR-EME (ref 09-800-26)

PY - 2016/10/1

Y1 - 2016/10/1

N2 - BackgroundPrimary angle-closure glaucoma (PACG) is a leading cause of irreversible blindness worldwide. In its early stage, primary angle-closure (PAC), there is increased intraocular pressure (IOP) but no visual loss. Because the crystalline lens has a major mechanistic role, lens extraction as initial treatment may be more effective than standard treatment, laser peripheral iridotomy. MethodsIn this randomized controlled trial we compared lens extraction versus laser peripheral iridotomy (1:1). We enrolled 419 participants from 30 hospital eye services in five countries. A web-based randomization application was used. Participants were ≥ 50 years, without cataract, and newly diagnosed with (1) PAC with IOP above 30 mmHg (n=155) or (2) PACG (n=263). The primary outcome was multidimensional measuring, at three years, patient reported health status (EQ-5D), clinical efficacy (IOP) and efficiency (incremental cost effectiveness ratio [ICER] per Quality Adjusted life year [QALY] gained, from a UK health service perspective). IOP measurements were masked. An intent-to-treat analysis was conducted. (ISRCTN 44464607). Findings EQ-5D and IOP data at three years were complete in 351 (83.8%) and 366 (87.4%) participants, respectively. After lens extraction (n=208) EQ-5D (0·87, SD 0·12) was 0·052 higher (95% CI 0·015, 0·088, p=0·005) and IOP (16·6 mmHg, SD 3·5) was 1·18 lower (95% CI -1·99, -0·38, p = 0.004) than after laser iridotomy (n=211); ICER £14,284 for initial lens extraction versus standard care (n=285). Irreversible loss of vision was rare and occurred in one participant in the lens extraction and three in the laser iridotomy group. Ethnicity, status of fellow eye, and diagnosis did not influence the results. InterpretationInitial treatment with lens extraction for PACG and PAC (with IOP above 30 mmHg) is more effective and cost-effective than laser iridotomy after three years and should be considered as an alternative to current practice.

AB - BackgroundPrimary angle-closure glaucoma (PACG) is a leading cause of irreversible blindness worldwide. In its early stage, primary angle-closure (PAC), there is increased intraocular pressure (IOP) but no visual loss. Because the crystalline lens has a major mechanistic role, lens extraction as initial treatment may be more effective than standard treatment, laser peripheral iridotomy. MethodsIn this randomized controlled trial we compared lens extraction versus laser peripheral iridotomy (1:1). We enrolled 419 participants from 30 hospital eye services in five countries. A web-based randomization application was used. Participants were ≥ 50 years, without cataract, and newly diagnosed with (1) PAC with IOP above 30 mmHg (n=155) or (2) PACG (n=263). The primary outcome was multidimensional measuring, at three years, patient reported health status (EQ-5D), clinical efficacy (IOP) and efficiency (incremental cost effectiveness ratio [ICER] per Quality Adjusted life year [QALY] gained, from a UK health service perspective). IOP measurements were masked. An intent-to-treat analysis was conducted. (ISRCTN 44464607). Findings EQ-5D and IOP data at three years were complete in 351 (83.8%) and 366 (87.4%) participants, respectively. After lens extraction (n=208) EQ-5D (0·87, SD 0·12) was 0·052 higher (95% CI 0·015, 0·088, p=0·005) and IOP (16·6 mmHg, SD 3·5) was 1·18 lower (95% CI -1·99, -0·38, p = 0.004) than after laser iridotomy (n=211); ICER £14,284 for initial lens extraction versus standard care (n=285). Irreversible loss of vision was rare and occurred in one participant in the lens extraction and three in the laser iridotomy group. Ethnicity, status of fellow eye, and diagnosis did not influence the results. InterpretationInitial treatment with lens extraction for PACG and PAC (with IOP above 30 mmHg) is more effective and cost-effective than laser iridotomy after three years and should be considered as an alternative to current practice.

U2 - 10.1016/S0140-6736(16)30956-4

DO - 10.1016/S0140-6736(16)30956-4

M3 - Article

VL - 388

SP - 1389

EP - 1397

JO - The Lancet

JF - The Lancet

SN - 0140-6736

IS - 10052

ER -