Efficacy and safety of PEI combined with goniosynechialysis and goniotomy in the treatment of APACG

Efficacy and safety of PEI combined with goniosynechialysis and goniotomy in the treatment of APACG | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy and safety of PEI combined with goniosynechialysis and goniotomy in the treatment of APACG Zhang Liu, Yao Yihua, Jiang Hongqi, Sun Ting, Zou qian, Wang Xiaohui, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7127502/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 11 You are reading this latest preprint version Abstract Objective To evaluate the efficacy and safety profile of combined phacoemulsification with intraocular lens implantation (PEI), goniosynechialysis (GSL), and goniotomy (GT) in managing acute primary angle-closure glaucoma (APACG) with coexisting cataract. Methods This prospective case series enrolled 41 eyes from 39 APACG patients (mean age 66.95±8.51 years) at Fuzhou Eye Hospital (2022-2024). All subjects underwent triple surgery (PEI+GSL+GT). Primary endpoints included intraocular pressure (IOP) reduction, anti-glaucoma medication(AGM) burden, and complications over 36 months. Surgical success was defined as IOP 5-21 mmHg with ≥20% reduction from the baseline without vision-threatening complications. Statistical analyses employed paired t-tests and Wilcoxon signed-rank tests.Written informed consent was obtained from all 39 participants prior to enrollment, including specific authorization for surgical video recording and anonymized data publication. Results The study demonstrated significant efficacy of PEI+GSL+GT in controlling IOP and reducing AGM in APACG patients. At 36 months postoperatively, the complete success rate was 53.8% (95% CI: 42.5%–65.1%), while the qualified success rate(IOP control with ≤2 medications) reached 71.6% (95% CI: 61.3%–81.9%). Mean IOP decreased from 38.52±10.56 mmHg preoperatively to 17.12±4.54 mmHg at 36 months (Δ55.6%, P < 0.001), paralleled by a 71.8% reduction in AGM(from 3.02±0.6 to 0.85±0.8 agents, P < 0.001). Postoperative complications included transient IOP elevation (26.42%, 14/53), corneal edema (15.09%, 8/53), and anterior chamber hemorrhage (11.32%, 6/53), all managed conservatively without sight-threatening events or secondary surgical interventions Conclusions PEI+GSL+GT demonstrates significant reductions in intraocular pressure and medication burden in acute primary angle-closure glaucoma (APACG), whilst exhibiting a superior safety profile in comparison with conventional trabeculectomy. This minimally invasive approach integrates triple therapeutic mechanisms, namely cataract extraction, peripheral anterior synechiolysis (PAS) and trabecular meshwork excision, to reconstruct physiological outflow pathways. This represents a safer surgical alternative. It is recommended that further large-scale multicentre randomised trials are conducted in order to validate the efficacy of the treatment in the APACG and to standardise optimised surgical protocols. Acute primary angle-closure glaucoma (APACG) phacoemulsification with intraocular lens implantation (PEI) Goniosynechialysis (GSL) Goniotomy (GT) Efficacy Safety Figures Figure 1 Figure 2 Introduction Primary angle-closure glaucoma (PACG) constitutes 26.2% of global glaucoma cases and is responsible for 48.3% of glaucoma-related blindness, primarily due to its fivefold higher risk of irreversible vision loss compared to primary open-angle glaucoma (POAG)[ 1 , 2 ]. Over 76% of PACG cases occur in Asia, with China contributing approximately 50% of the global burden[ 1 , 3 ]. The annual incidence of acute PACG (APACG) in China ranges from 10.4 to 12.2 per 100,000 individuals[ 4 – 6 ]. Driven by rapid population aging, PACG prevalence in China is projected to reach 15 million patients by 2050, imposing substantial socioeconomic and quality-of-life burdens[ 7 , 8 ]. Lowering IOPremains the cornerstone for halting glaucomatous neurodegeneration progression. Although traditional interventions such as trabeculectomy and aqueous shunt implantation achieve deeper IOP reduction than medical therapy, they carry risks of sight-threatening complications (e.g., persistent hypotony, bleb-related infections) and significant efficacy attenuation beyond 5 years[ 9 , 10 ]. Minimally invasive glaucoma surgery (MIGS), particularly PEI combined with GSL and GT, has emerged as a promising alternative. This integrated approach demonstrates comparable IOP-lowering efficacy while offering advantages including minimal conjunctival trauma, accelerated visual recovery, and reduced severe complication rates[ 11 , 12 ]. However, the safety and applicability of PEI + GSL + GT in APACG patients with cataracts remain controversial. Conventional trabeculectomy or standalone PEI often fail to address the complex anatomical challenges in these cases. This study evaluates the clinical value and safety of PEI + GSL + GT in APACG patients with coexisting cataracts, focusing on IOP control, medication reduction, and postoperative complications. Methods Study patients This prospective case series enrolled 41 eyes from 39 consecutive APACG patients at Fuzhou Eye Hospital (January 2022-April 2024). The cohort comprised 9 males (23.1%) and 32 females (76.9%) with a mean age of 66.95 ± 8.51 years (range: 48–83 years). Participants underwent combined phacoemulsification with intraocular lens implantation (PEI), 360° goniosynechialysis (GSL), and 120° goniotomy (GT). Baseline ocular characteristics included axial length​ (22.45 ± 0.64 mm) and corneal endothelial cell density (2567.01 ± 475.25 cells/mm²). The mean follow-up duration was 28.90 ± 8.32 months (range: 9–38 months), with 22 right eyes (53.7%) and 19 left eyes (46.3%) completing the protocol. The study protocol was approved by the Institutional Review Board of Fuzhou Eye Hospital (Ethics No: FZYKYY-KY-2022-003), and written informed consent was obtained from all participants prior to intervention. Diagnostic Criteria for APACG APACG was defined by the following criteria[ 13 ]: (1) a history of acute episode(s) with at least two typical symptoms (e.g., ocular pain, blurred vision with halos, nausea/vomiting); (2) peak IOP > 30 mmHg during the acute phase; (3) gonioscopic evidence of peripheral anterior synechiae (PAS) and shallow anterior chamber; and (4) presence of ≥ 3 clinical signs, including marked conjunctival hyperemia, corneal epithelial edema, and mid-dilated pupil (≥ 4 mm in diameter). Inclusion Criteria for Surgical Intervention Patients were considered eligible if they met the following criteria[ 12 , 14 , 15 ].: (1) confirmed diagnosis of APACG by standardized gonioscopy; (2) presentation either during the acute phase (intraocular pressure > 30 mmHg within 72 hours of symptom onset) or post-resolution following medical therapy; (3) presence of visually significant cataract (best-corrected visual acuity ≤ 0.1 logMAR or surgeon-determined necessity for lens extraction); (4) absence of intraocular surgery/trauma history and systemic/ocular contraindications; (5) provision of written informed consent. Exclusion criteria for surgery Patients were excluded if they had a history of intraocular surgery (except laser peripheral iridotomy, laser iridoplasty, or anterior chamber paracentesis), ocular trauma, POAG or secondary glaucoma. Additional exclusion criteria encompassed concurrent ocular pathologies requiring surgical intervention, corneal edema/opacity precluding gonioscopic visualization of angle structures, active systemic diseases (e.g., severe cardiac/hepatic/renal dysfunction), hypersensitivity to study medications, pregnancy/lactation status, or inability to complete follow-up assessments[ 16 – 18 ]. Ophthalmologic examination and preoperative preparation All participants underwent comprehensive systemic history documentation and standardized ophthalmic assessment protocols prior to enrollment, including slit-lamp microscopy (Haag-Streit BQ-900, Switzerland) for anterior segment evaluation, pneumatic tonometry (Topcon CT-800, Japan) for IOP measurement, and gonioscopy (Ocular Instruments, USA) to quantify angle configuration. Best-corrected visual acuity (BCVA) was assessed using ETDRS charts (Precision Vision, USA) and converted to logMAR units. Biometric parameters (anterior chamber depth, axial length) were obtained via IOLMaster 700 (Carl Zeiss, Germany). All devices were calibrated according to manufacturer protocols to ensure reproducibility. Preoperative documentation included detailed records of AGM(types and dosing frequency). Prophylactic measures comprised topical administration of levofloxacin 0.5% and pranoprofen 0.1% eye drops four times daily (QID) to the operative eye for 3 days, along with bilateral conjunctival sac irrigation and lacrimal duct flushing to exclude conditions such as chronic dacryocystitis. Mydriasis was achieved 30 minutes preoperatively using compound tropicamide eye drops. Surgical technique All surgical procedures were performed by a glaucoma specialist (corresponding author ZJH with over 20 years of clinical experience) under topical anesthesia determined by preoperative evaluation. A standardized three-step approach was implemented: (1) The standardized PEI procedure was performed through two clear corneal incisions: a 2.4-mm main incision at the 11 o'clock position and an auxiliary incision at the 2 o'clock position; (2) GSL and GT: Following PEI, ophthalmic viscosurgical device (OVD) was injected to deepen the anterior chamber. Circumferential angle separation was achieved using an iris repositioner under direct gonioscopic visualization(shown in Fig. 1 A), with subsequent GT performed through two entry points to incise the lateral nasal portion of the Schlemm's canal to an extent of approximately 120 degrees(shown in Fig. 1 B). The extent of GT was adjusted based on intraoperative observations of trabecular meshwork pigmentation and blood reflux column; (3) Wound closure: Residual OVD and hyphema were meticulously irrigated, followed by stromal hydration of corneal incisions and anterior chamber stabilization with balanced salt solution. Postoperative tobramycin-dexamethasone ointment application and eye patching completed the procedure. Postoperative Management​ A standardized medication protocol was implemented: Topical 1% prednisolone acetate eye drops were administered four times daily (QID) combined with tobramycin-dexamethasone ointment at bedtime for the initial 7 postoperative days. From postoperative day 8, non-steroidal anti-inflammatory drugs (NSAIDs) replaced corticosteroids and were continued for an additional 21 days, while 1% pilocarpine eye drops were maintained for 28 days. Any IOP elevation ≥ 21 mmHg during corticosteroid use required immediate suspension of steroids and therapeutic escalation to NSAIDs, with subsequent IOP revaluation within 48 hours. Postoperative Follow-up Patients underwent standardized evaluations[ 12 , 16 ] at postoperative day (POD) 1, POD 7, and months 1, 3, 6, 12, 24, and 36, with data from the final follow-up visit analyzed as primary endpoints. Outcome measures included preoperative versus final follow-up comparisons of IOP, BCVA, and the number of AGM. Secondary outcomes encompassed documentation of postoperative complications (e.g., hyphema, corneal edema) and requirement for additional surgical interventions. Definition and Criteria for Surgical Success Complete surgical success was defined as postoperative IOP within 5–21 mmHg with ≥ 20% reduction from baseline, absence of light perception loss, and no requirement for adjunctive antiglaucoma medications or secondary surgery. Qualified success required meeting these criteria with the use of AGM. Surgical failure was defined as either IOP > 21 mmHg despite maximum tolerated medical therapy or the need for additional antiglaucoma surgery during follow-up[ 19 , 20 ] . Statistical Analysis Data analysis was performed using SPSS 26.0 (IBM Corp., USA). Continuous variables were assessed for normality via Shapiro-Wilk test. Normally distributed data were expressed as mean ± standard deviation (SD), with intergroup comparisons analyzed by independent samples t-test (parametric) or Mann-Whitney U test (non-parametric). Paired pre-/postoperative comparisons utilized paired samples t-test for parametric data or Wilcoxon signed-rank test for non-parametric data.Categorical variables were reported as frequencies and proportions (%), with intergroup differences evaluated using Pearson's χ² test or continuity-corrected χ² test as appropriate. For ordinal data, intergroup comparisons employed Mann-Whitney U test, while within-group analyses utilized Wilcoxon signed-rank test. All tests were two-tailed, with statistical significance defined as p < 0.05. Results Baseline data A total of 53 patients (eyes) with APACG were included in this study. The mean age of the patients was 66.5 ± 9.1 years (range: 52–82 years), with 13 (24.5%) males and 40 (75.5%) females, showing a clear female predominance (male to female ratio of approximately 1:3). The lateral distribution of the affected eyes was 28 cases (52.8%) in the right eye and 25 cases (47.2%) in the left eye. The median time from symptom onset to intervention was 2.0 hours (interquartile spacing IQR: 1.0-7.5 hours). Preoperative assessment showed that the mean IOP was 38.52 ± 10.56 mmHg and the patients were on a mean of 3.02 ± 0.6 IOP-lowering medications preoperatively. Biological parameters measured were: mean ocular axis length 22.3 ± 0.6 mm and corneal endothelial cell density 2540.1 ± 577.1 cells/mm². The baseline characteristics of all patients were fully documented and no missing data occurred, as shown in Table 1 . Table 1 Baseline characteristics of the patients Demographic characteristics Value (n = 53 eyes) Age (years) 66.5 ± 9.1 Gender Male 13 (24.5%) Female 40 (75.5%) Eye laterality Right (OD) 28 (52.8%) Left (OS) 25 (47.2%) Duration of attack (hours) 2.0 (1.0, 7.5) Preoperative IOP (mmHg) 38.52 ± 10.56 Preoperative medications 3.02 ± 0.6 Axial length (mm) 22.3 ± 0.6 Corneal ECD (cells/mm²) 2540.1 ± 577.1 IOP During the postoperative follow-up period, the patients' IOP exhibited a significant trend towards lowering, with statistically significant differences observed between pre- and post-operative comparisons. Specifically, IOP values decreased significantly at all postoperative time points (all P < 0.001) compared with preoperative baseline IOP (38.52 ± 10.56 mmHg), indicating a sustained effect of the surgical intervention in controlling IOP. At the final follow-up (36 months postoperatively), the mean IOP (17.12 ± 4.54 mmHg) was significantly reduced by 21.40 mmHg compared to the preoperative period. The trend of IOP changes demonstrated that the significant reduction was observed in the early postoperative period (e.g., week 1), which slightly rebounded over time but was always maintained at a safe level (< 21 mmHg), with the rate of reduction ranging from 72.3% in the early postoperative period to 55.6% at the final follow-up, indicating that the effect of surgical reduction of intraocular pressure was bpth long-lasting and stable (shown in Table 2 IOP). Table 2 Mean IOP(mmHg), BCVA,AGM at Each Study Visit Follow-up time point n IOP, mean mmHg ± SD P BCVA P AGM P Baseline 53 38.52 ± 10.56 / 0.43 ± 0.32 / 3.02 ± 0.6 / Day 1 53 11.07 ± 5.46 < 0.001 0.48 ± 0.29 0.41 0.06 ± 0.23 < 0.001 Week 1 52 10.68 ± 2.88 < 0.001 0.39 ± 0.28 0.61 0.19 ± 0.44 < 0.001 Month 1 51 13.46 ± 3.46 < 0.001 0.41 ± 0.28 0.78 0.69 ± 0.68 < 0.001 Month 3 49 13.51 ± 4.92 < 0.001 0.36 ± 0.24 0.04 0.78 ± 0.71 < 0.001 Month 6 45 15.79 ± 6.24 < 0.001 0.30 ± 0.23 < 0.001 0.87 ± 1.01 < 0.001 Month 12 43 16.79 ± 5.49 < 0.001 0.34 ± 0.27 0.02 0.77 ± 0.95 < 0.001 Month 24 31 18.05 ± 5.85 < 0.001 0.34 ± 0.25 0.01 0.84 ± 1.07 < 0.001 Month 36 13 17.12 ± 4.54 < 0.001 0.39 ± 0.24 0.62 0.85 ± 0.8 < 0.001 Note: IOP, intraocular pressure; BCVA, best corrected visual acuity; AGM, anti-glaucoma medications;n, number; SD, standard deviation. BCVA During the postoperative follow-up period, the patients' BCVA showed an overall trend of improvement, especially at the mid- and long-term postoperative time points. Specifically, BCVA changed less in the early postoperative period (e.g., day 1 and week 1) compared with the preoperative baseline level (0.43 ± 0.32, n = 53), and the difference was not statistically significant (day 1: 0.48 ± 0.29, P = 0.41; week 1: 0.39 ± 0.28, P = 0.61). However, BCVA began to improve significantly from 3 months postoperatively: at 3 months postoperatively BCVA decreased to 0.36 ± 0.24 (n = 49), a statistically significant difference from baseline ( P = 0.04); it further improved to 0.30 ± 0.23 (n = 45) at 6 months postoperatively, a decrease of 30.2% with a significant P value ( P < 0.001). This trend of improvement continued at long-term follow-up with BCVA of 0.34 ± 0.27 (n = 43, P = 0.02) at 12 months postoperatively and 0.34 ± 0.25 (n = 31, P = 0.01) at 24 months postoperatively, which were significantly better than preoperative levels. Although BCVA rebounded slightly to 0.39 ± 0.24 (n = 13) at 36 months postoperatively, the difference from baseline was not statistically significant ( P = 0.62), suggesting that visual acuity improvement may fluctuate mildly during long-term follow-up, but the overall effect is stable. Overall, the significant improvement in BCVA was mainly concentrated between 3 and 24 months postoperatively, reflecting the positive impact of the surgical intervention on visual function (shown in Table 2 BCVA). Anti-glaucoma Medications Changes in the use of AGMs were systematically assessed by preoperative and postoperative follow-up. The results showed that at preoperative baseline, patients' mean AGM use was 3.02 ± 0.6 (range: 1.0–5.0), suggesting preoperative reliance on multiple medications for IOP control. During the postoperative follow-up period, AGM use showed a significant trend toward reduction, and the differences were statistically significant at all time points when compared with the preoperative period (all P < 0.001). Specifically, AGM use decreased rapidly to 0.06 ± 0.23 species ( P < 0.001) on postoperative day 1, a decrease of 98.0%, and 0.19 ± 0.44 species ( P < 0.001) on postoperative week 1, a decrease of 93.7%. Over time, AGM use rebounded slightly but remained low: 0.69 ± 0.68 species at 1 month postoperatively ( P < 0.001), 0.78 ± 0.71 species at 3 months postoperatively ( P < 0.001), and 0.87 ± 1.01 species at 6 months postoperatively ( P < 0.001). At long-term follow-up, AGM dosage was 0.77 ± 0.95 species at 12 months postoperatively ( P < 0.001), 0.84 ± 1.07 species at 24 months postoperatively ( P < 0.001), and stabilised at 0.85 ± 0.8 species at the final follow-up at 36 months postoperatively ( P < 0.001), representing an overall decrease of 71.8%. This trend suggests that the surgical intervention significantly reduced antiglaucoma medication dependence, with the most significant reduction occurring in the early postoperative period (e.g., week 1), followed by a levelling off, with AGM dosage consistently lower than 1, confirming the sustained mitigating effect of the surgery on medication burden.(shown in Table 2 AGM). Success Rate Postoperative success rates showed a time-dependent downward trend, with conditional success (qualified success, allowing pharmacological assistance) decaying significantly less than complete success (no pharmacological intervention required). At 6 months postoperatively, the conditional success rate was 92.5% (95% CI: 87.3–97.7), and the complete success rate was 85.4% (95% CI: 78.6–92.2), reflecting the effectiveness of surgical intervention in controlling IOP in the short term. Conditional success rates declined by approximately 7% per year to 71.6% (95% CI: 61.3–81.9) at 36 months postoperatively, a decrease of 22.4% from 6 months. Complete success rates declined even more dramatically, to only 53.8% at 36 months (95% CI: 42.7%) The complete success rate declined even more significantly, to 53.8% (95% CI: 42.5–65.1) at 36 months, a decrease of 37.0% from 6 months, suggesting that long-term efficacy is dependent on partial pharmacological assistance(shown in Fig. 2 ). Complications The major postoperative complications in the operated eyes were transient elevation of intraocular pressure 26.42% (14/53), anterior chamber haematoma 11.32% (6/53), and corneal oedema 15.09% (8/53), and Shallow anterior chamber 3.77% (2/53).The above complications were cured by symptomatic management, and there were no sight-threatening complications occurring without the need of a Secondary surgery was not required. Discussion In patients with APACG, combined with cataract, PEI + GSL alone may not adequately improve their trabecular meshwork dysfunction and visual acuity[ 21 ]. Previous treatments have used laser peripheral iridectomy or trabeculectomy followed by PEI surgery, which may increase the patient's medical burden or expose them to the possibility of multiple surgeries. Traditional trabeculectomy remains an important option for glaucoma treatment due to its effectiveness in reducing IOP. However, there are three major limitations to this procedure: first, it is invasive and time-consuming, and second, the postoperative aqueous humor needs to rely on filtering bubbles to complete external drainage, which may lead to additional complications such as leakage, encapsulation, or scar formation. A variety of MIGS have emerged over the past two decades, successfully overcoming the shortcomings of traditional glaucoma surgeies. Aqueous humor drainage is mainly achieved through the trabecular meshwork, Schlemm's canal and distal outflow tissue. In MIGS, operations are mainly performed for the trabecular meshwork and Schlemm's canal. The results of several RCTs in China have also pointed out that the surgical methods of PEI + GSL + GT (also known as Phacogoniotomy), has a high degree of efficacy and safety for patients with middle to advanced PACG[ 22 , 23 ]. Nevertheless, whether PEI + GSL + GT is effective in controlling IOP and improving vision in patients with APACG remains controversial. This preliminary results of this prospective, small-sample study suggest that PEI + GSL + GT has satisfactory efficacy and safety in the treatment of APACG compared with conventional laser or trabeculectomy, achieving a sustained reduction in intraocular pressure (IOP), less dependence on medications, and some improvement in visual acuity without serious complications. Following a three-year postoperative follow-up period, the results showed a decrease in IOP from 38.52 mm Hg to 17.12 mm Hg in patients who received PEI + GSL + GT treatment. It is noteworthy that the patients were still on anti-glaucoma medications at the time of the final follow-up. However, a significant reduction in medication dosage was observed, from 3.02 preoperatively to 0.85 postoperatively. It has been established through the implementation of earlier research that this procedure has the capacity to significantly reduce IOP in patients diagnosed with PACG. The mean postoperative IOP reduction was (11.68 ± 1.43) mmHg (meta-analysis), with IOP decreasing from preoperative (33.0 ± 10.7) mmHg to (13.6 ± 2.9) mmHg in patients with advanced disease[ 11 , 12 , 22 , 23 ].Multiple regression analysis showed a significant positive correlation between baseline IOP level and postoperative IOP reduction[ 16 ]. Long-term follow-up data showed a complete success rate (defined as no IOP-lowering medication and IOP ≤ 21 mmHg) of 90% (95% CI: 86.2%-93.8%) at 36 months postoperatively, with IOP remaining stable (fluctuating ≤ 3 mmHg) for 24 months postoperatively [ 12 , 24 ]. Furthermore, following the incorporation of cataract surgical intervention, all patients exhibited varying degrees of enhancement in postoperative visual acuity in comparison with their preoperative levels.The combined PEI + GSL + GT procedure resulted in a consistent enhancement or the maintenance of BCVA, whilst concomitantly achieving a substantial reduction in IOP. A number of multicentre studies have previously demonstrated that the mean BCVA in patients with mid- to late-stage PACG improved from preoperative (0.92 ± 0.11) LogMAR to (0.88 ± 0.10) LogMAR at 6 months postoperatively[ 12 , 17 , 25 ]. Furthermore, the range of visual acuity fluctuation over the 36-month follow-up period was ≤ 0.04 LogMAR, suggesting that the BCVA improvement in the long term was more stable after the operation. The preliminary results of this study also demonstrated that early postoperative BCVA was not significantly different (P > 0.05) from the preoperative baseline (0.43 ± 0.32), suggesting that the surgery did not cause acute visual impairment. This phenomenon is consistent with the low perturbation characteristics of minimally invasive operations (e.g., GT limited to 120° range) on intraocular structures, which avoids early visual fluctuations due to filter bubble formation or corneal astigmatism in conventional filtration surgery. In this study, fluctuations in BCVA occurred in the mid-postoperative period, with BCVA decreasing to 0.36 ± 0.24 ( P = 0.04) at 3 months postoperatively and further improving to 0.30 ± 0.23 (30.2% decrease, P < 0.001) at 6 months. It is hypothesised that this is associated with a gradual enhancement in corneal transparency and the development of posterior cataracts during the mid-postoperative period. PEI + GSL + GT circumvented the complications associated with filtering bubbles by targeting and reconstructing the physiological atrial fluid drainage pathway of Schlemm's canal. The main postoperative complications in this study were transient IOP elevation (26.42%, 14/53), corneal oedema (15.09%, 8/53) and anterior chamber haematochezia (11.32%, 6/53).These complications were all reversible and mild, and did not include any sight-threatening complications, such as endophthalmitis or suprachoroidal haemorrhage. The transient elevation of IOP mainly originated from the fluctuation of atrial aqueous outflow resistance at the early stage of opening of Schlemm's canal severance after GT, as well as the temporary functional inhibition of the trabecular meshwork due to the release of inflammatory mediators. With postoperative dynamic IOP monitoring and timely application of topical β-blockers, all patients' IOPs returned to normal (≤ 21 mmHg) within 72 hours without surgical intervention. Another common postoperative complication was corneal oedema. Previous similar studies have shown that corneal oedema after this procedure may be correlated with the time of ultrasound emulsification energy accumulation, suggesting that endothelial damage mainly originates from ultrasound energy exposure rather than GT manipulation. However, due to limitations in data collection, the association between ultrasonic emulsification energy accumulation time and corneal oedema was not analysed in this study. Furthermore, intraoperative anterior chamber blood accumulation was observed, resulting from injury during GT dissection of the inner wall of Schlemm's canal. A total 11.32% (6/53) of the blood accumulation was attributed to microvascular tearing of the outer wall of Schlemm's canal during the GT operation, with blood flow recirculating into the anterior chamber through the severed end, constituting an inherent risk of the procedure. However, following a comprehensive clinical observation involving intraoperative viscoelastic compression and postoperative semirecumbent rest, it was observed that all six cases of blood accumulation were completely absorbed within a period of five days. No instances of secondary glaucoma or corneal blood staining were recorded. It is imperative to exercise caution in the event of damage to the outer wall of Schlemm's canal or the iridocyclic body, as this may result in severe haemorrhage or iris root detachment. In order to prevent and manage complications, three courses of action can be taken. The initial approach involves preoperative prevention, specifically targeting patients with corneal endothelial counts below 1500 cells/mm². In these cases, a combination of cryo-infusion techniques and the soft-shell technique, along with viscoelastic protection, is employed to mitigate the potential for damage to the cornea caused by PEI[ 26 ]. It is imperative that anticoagulation management is completed for patients with hypertension and systemic use of anticoagulants. This involves the discontinuation of antiplatelet drugs for a minimum of seven days prior to surgery, in addition to the intraoperative control of blood pressure. These measures are undertaken to mitigate the risk of anterior chamber effusion. Secondly, intraoperative quality control is imperative, and this is facilitated by GT to limit the incision range of 120°, thus avoiding damage to the outer wall of Schlemm's canal and the collecting ducts. For those who meet the necessary criteria, microcatheter-guided incision can be used to reduce the incidence of lost during the operation. It is imperative to exercise reasonable control over the ultrasonic emulsification energy and time in order to stabilise the depth of the anterior chamber and thereby reduce the large fluctuations of intraoperative endophthalmitis. The third is postoperative management, which includes the detection of anterior chamber inflammation and the timely application of hormonal eye drops. In cases where IOP > 25 mmHg and hormonal glaucoma is considered, switching to nonsteroidal anti-inflammatory drugs (NSAIDs) is a viable option. In patients diagnosed with haemorrhage, it is recommended that eye and head movement be restricted to a semi-recumbent position, in order to minimise any potential adverse effects. A decline in the postoperative success rate of PEI + GSL + GT was observed over time in this study, which may be related to the surgical incision of the atrial horn scar and the subsequent postoperative adhesive closure of the atrial horn itself. The high early success rate of the combined PEI + GSL + GT procedure validates its short-term value as a first-line treatment for APACG, but the long-term attenuation of the complete success rate reveals its dependence on pharmacological adjuvant. Future research directions may consider completing the ultrastructural exploration of the incision site in combination with animal models, or investigating the need to enhance the durability of efficacy through intraoperative antifibrotic enhancement and early postoperative targeted drug administration, especially in high-risk patients with preoperative PAS > 270° or non-pupil-blocking type. Although PEI + GSL + GT demonstrated short-term IOP control advantages in mid- to late-stage primary angle-closure glaucoma (PACG), its application in acute primary angle-closure glaucoma (APACG), which was explored in the present study, has the following limitations. (1) Technical challenges of emergency surgery APACG are frequently accompanied by corneal oedema, inflammation in the anterior chamber and pupil constriction. In such cases, PEI can increase the risk of posterior lens capsule rupture and corneal endothelial decompensation due to the poor stability of the anterior chamber. The risk of surgical complications is especially high in 'hot eyes' with IOP > 40 mmHg. (2) The irreversibility of anterior chamber angle adhesions has been demonstrated to limit the efficacy of PEI. In the presence of extensive peripheral anterior adhesions (PAS) > 270° preoperatively or non-pupil-blocking APACGs (e.g., anteriorly shifted ciliary body), it has been demonstrated that GSL is unable to completely detach the adherent atrial angle structures. Research has indicated that in cases where the PAS extent exceeds 270°, the incidence of postoperative atrial angle re-adhesion by GSL increases to 58.3%, resulting in a decline in the complete success rate to 42.1% at 36 months postoperatively[ 27 ]. (3) Patients with APACG in remission have a high prevalence of choroidal leakage, and the degree of leakage is positively correlated with the initial IOP. Although choroidal leakage was not observed in this study, direct PEI + GSL + GT in such patients may exacerbate ciliary choroidal detachment due to intraoperative low IOP, which in turn induces complications such as persistent postoperative low IOP and macular folds. It is imperative that these limitations are thoroughly explored in order to facilitate future surgical enhancements. Declarations Ethics approval and consent to participate This research protocol received ethical approval from the Ethics Committee of Fuzhou Eye Hospital (Approval ID: FZYKYY-KY-2022-003), and all procedures strictly adhered to the ethical principles outlined, and all participants provided written informed consent in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials Data supporting this study are available from the corresponding author upon reasonable request under institutional data sharing protocols. Competing interests The authors declare no competing interests. Funding This research was funded by grants from the Guiding Science and Technology Project Programme in Sanming City, Fujian Province (2023-S-32, Zhang Liu), the Joint Funding Project of Science and Technology Innovation from the Fujian Provincial Department of Science and Technology (No. 2023Y9027, Yao Yihua), the Fujian Provincial Clinical Medical Research Center for Eye Diseases and Optometry (YK-YJZX, Yao Yihua), the Science and Technology Innovation Joint Fund Project of the Fujian Provincial Department of Science and Technology (No. 2021Y9013, Wang Xiaohui), and the Natural Science Foundation of Fujian Province (No. 2023J01591, Wang Xiaohui). Authors' contributions ZL, YYH and WXH, ZJH conceived the study design, executed the research protocol, ZL, YYH, JHQ, ST, ZQ, WXH, ZJH were responsible for data acquisition, analysis, and interpretation. Both authors contributed equally to manuscript preparation through iterative drafting and critical revisions, with final approval of the version to be published. Acknowledgements The authors extend sincere gratitude to all clinical participants whose invaluable engagement in surgical protocols and postoperative assessments directly informed the refinement of ophthalmic operative techniques. Special recognition is accorded to nursing teams for their meticulous coordination of perioperative care, which ensured protocol adherence across all study phases. References Song P, Wang J, Bucan K, Theodoratou E, Rudan I, Chan KY: National and subnational prevalence and burden of glaucoma in China: A systematic analysis . Journal of global health 2017, 7 (2):020705. Parikh SR, Parikh RS: Clinical implication of recent randomized control trial in primary angle-closure disease management . Indian journal of ophthalmology 2022, 70 (8):2825-2834. Quigley HA, Broman AT: The number of people with glaucoma worldwide in 2010 and 2020 . The British journal of ophthalmology 2006, 90 (3):262-267. Ang LP, Aung T, Chew PT: Acute primary angle closure in an Asian population: long-term outcome of the fellow eye after prophylactic laser peripheral iridotomy . Ophthalmology 2000, 107 (11):2092-2096. Lai JS, Liu DT, Tham CC, Li RT, Lam DS: Epidemiology of acute primary angle-closure glaucoma in the Hong Kong Chinese population: prospective study . Hong Kong medical journal = Xianggang yi xue za zhi 2001, 7 (2):118-123. Chen JY, Huang WQ, Li HY, Lu YY, Yao YH, Zhu YP, Liang Y: [A meta-analysis on prevalence of primary angle-closure glaucoma in the middle-aged and elderly chinese population] . [Zhonghua yan ke za zhi] Chinese journal of ophthalmology 2022, 58 (11):896-906. Xiong K, Mao H, Chen J, Zhang Q, Yin X, Wang D, Sun H, Xing X, Duan G, Jia Z et al : High burden of blindness at initial hospitalisation with primary angle-closure glaucoma in a national multicentre study in China . BMJ open ophthalmology 2025, 10 (1). Zhang N, Wang J, Chen B, Li Y, Jiang B: Prevalence of Primary Angle Closure Glaucoma in the Last 20 Years: A Meta-Analysis and Systematic Review . Frontiers in medicine 2020, 7 :624179. Quaranta L, Riva I, Gerardi C, Oddone F, Floriani I, Konstas AG: Quality of Life in Glaucoma: A Review of the Literature . Adv Ther 2016, 33 (6):959-981. Yao Y, Gong J, Wu N, Liu S, Lin Y, Ye Q, Zhou B, Zhu Y, Wang X: Scleral tunneling combined with the Tenon's capsule coverage in Glaucoma Drainage Valve surgery . BMC ophthalmology 2025, 25 (1):224. Fang Z, Song Y, Jin L, Han Y, Zhang X: Phacoemulsification combined with trabecular meshwork-Schlemm canal-based minimally invasive glaucoma surgery in primary angle-closure glaucoma: a systematic review and meta-analysis . BMC ophthalmology 2025, 25 (1):168. Li M, Jin Y, Hu J: Comparative evaluation of phacoemulsification combined with goniosynechi-alysis with goniotomy versus trabeculectomy in patients with angle-closure glaucoma and cataract . BMC ophthalmology 2025, 25 (1):100. Huang H, Gao F, Sun X, Chen Y: Swept-source optical coherence tomography assessment of Schlemm's canal after phacoemulsification with goniosynechialysis in Chinese patients with primary angle-closure glaucoma . Quantitative imaging in medicine and surgery 2024, 14 (12):8119-8130. European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition . 2021, 105 (Suppl 1):1-169. Gedde SJ, Chen PP, Muir KW, Vinod K, Lind JT, Wright MM, Li T, Mansberger SL: Primary Angle-Closure Disease Preferred Practice Pattern® . Ophthalmology 2021, 128 (1):P30-p70. Yang F, Ma Y, Liang Z, Lv K, Yang K, Wu H: Combined Phacoemulsification, Goniosynechialysis and Ab Interno Trabeculectomy in Primary Angle-closure Glaucoma: Long-term Results . Int J Med Sci 2025, 22 (2):451-459. Senthil S, Rao HL, Choudhari N, Garudadri C: Phacoemulsification versus Phacotrabeculectomy in Medically Controlled Primary Angle Closure Glaucoma with Cataract in an Indian Cohort: A randomized controlled trial . International ophthalmology 2022, 42 (1):35-45. Zhou WS, Lin WX, Geng YY, Wang T: Combined phacoemulsification and goniosynechialysis with or without endoscopic cyclophotocoagulation in the treatment of PACG with cataract . International journal of ophthalmology 2020, 13 (9):1385-1390. Husain R, Do T, Lai J, Kitnarong N, Nongpiur ME, Perera SA, Ho CL, Lim SK, Aung T: Efficacy of Phacoemulsification Alone vs Phacoemulsification With Goniosynechialysis in Patients With Primary Angle-Closure Disease: A Randomized Clinical Trial . JAMA ophthalmology 2019, 137 (10):1107-1113. Gedde SJ, Feuer WJ, Lim KS, Barton K, Goyal S, Ahmed, II, Brandt JD: Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up . Ophthalmology 2022, 129 (12):1344-1356. Nguyen Xuan H, Nguyen Dinh N, Nguyen Thu H, Nguyen Van C, Aung T, Loo Y, Nguyen Do Thi Ngoc H, Do T: Comparing the Safety and Efficacy of Phacogoniosynechialysis With Phacotrabeculectomy in the Management of Refractory Acute Primary Closure Angle Glaucoma With Cataract: A Multicenter Randomized Trial . Journal of glaucoma 2021, 30 (7):552-558. Song Y, Fan S, Tang L, Lin F, Li F, Lv A, Li X, Wen T, Lu L, Xiao M et al : Two-Year Outcomes of Phacogoniotomy vs Phacotrabeculectomy for Advanced Primary Angle-Closure Glaucoma With Cataract: A Noninferiority Randomized Clinical Trial . JAMA ophthalmology 2025. Song Y, Xie L, Zhu X, Fan S, Lv A, Tang G, Zhang H, Tang L, Zhang Y, Lu L et al : Two-year outcome of phacogoniotomy for advanced primary angle-closure glaucoma with cataracts: a multicentre study . The British journal of ophthalmology 2025. Song Y, Zhu X, Zhang Y, Shu J, Dang G, Zhou W, Sun L, Li F, Lin F, Zhang Y et al : Outcomes of Partial Versus Complete Goniotomy With or Without Phacoemulsification for Primary Open Angle Glaucoma: A Multicenter Study . Journal of glaucoma 2023, 32 (7):563-568. Aboalazayem F, Elhusseiny AM, El Sayed YM: Gonioscopy-Assisted Transluminal Trabeculotomy: A Review . Current eye research 2023, 48 (4):329-338. Lin Y, Zhou B, Yao Y, Ye Q, Zhu Y, Wang X: Clinical observation of phacoemulsification under the low perfusion pattern and low negative pressure in patients with low corneal endothelial cell density . BMC ophthalmology 2023, 23 (1):340. Liu Y, Li W, Jiu X, Lei X, Liu L, Yan C, Li X: Systematic Review and Meta-Analysis of Comparing Phacoemulsification Combined with goniosynechialysis to other mainstream procedures in treating patients with angle-closure glaucoma . Medicine 2019, 98 (42):e17654. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 04 Aug, 2025 Reviews received at journal 03 Aug, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviews received at journal 21 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers agreed at journal 18 Jul, 2025 Reviewers invited by journal 18 Jul, 2025 Editor assigned by journal 18 Jul, 2025 Editor invited by journal 18 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7127502","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488680469,"identity":"5511ab10-3c58-446f-99f3-5339aa7cf1a7","order_by":0,"name":"Zhang Liu","email":"","orcid":"","institution":"Fuzhou Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Liu","suffix":""},{"id":488680470,"identity":"1af574ca-cbaa-4ee1-af3e-8e4e2a0c392f","order_by":1,"name":"Yao Yihua","email":"","orcid":"","institution":"The First Affiliated Hospital of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yao","middleName":"","lastName":"Yihua","suffix":""},{"id":488680471,"identity":"ebc00715-0736-4ac7-8403-b17dc913a3af","order_by":2,"name":"Jiang Hongqi","email":"","orcid":"","institution":"The Quangang General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiang","middleName":"","lastName":"Hongqi","suffix":""},{"id":488680472,"identity":"5e94e79f-763c-4d04-8cc5-2e6f837b05e6","order_by":3,"name":"Sun Ting","email":"","orcid":"","institution":"The Quangang General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sun","middleName":"","lastName":"Ting","suffix":""},{"id":488680473,"identity":"2872449e-756f-4200-9933-79e6ed38565f","order_by":4,"name":"Zou qian","email":"","orcid":"","institution":"The Quangang General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zou","middleName":"","lastName":"qian","suffix":""},{"id":488680474,"identity":"3b9ea41d-689d-4096-b886-fcaf20f0c4d6","order_by":5,"name":"Wang Xiaohui","email":"","orcid":"","institution":"The First Affiliated Hospital of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Xiaohui","suffix":""},{"id":488680475,"identity":"dea5c1fc-d4f1-40ed-a596-5e2fc615244c","order_by":6,"name":"Zhang Jianhui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIie3QMQrCMBiG4b8IdQnoGAfbEwgtBd0Ub2IQ6uLgJI4JQtyc6+YRnJxbHLpUZ4tLc4OOCg4mxT0ZBfMOmb4HkgDYbD9ZATXADKDNmKgNiZM0BF22ETYj6EvwgneRCfDZNWMvHpNTKThgGHsDqiEOvRHa40tyehBerWAeDVMNaUExqkK+UWQXYEjJWUdcKEJKFCkzjpEJQYpk6mJ3x5BgSRi9xdGhIPKTA4O3+Ikkz/W8v89zIerN2NMSwHLhuDA9NstAN1d1qDzeMPGpydpms9n+sg+uGk4NLuTnOAAAAABJRU5ErkJggg==","orcid":"","institution":"Fuzhou Eye Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Jianhui","suffix":""}],"badges":[],"createdAt":"2025-07-15 07:23:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7127502/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7127502/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-04501-1","type":"published","date":"2025-11-25T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87383177,"identity":"8f24d99a-7fff-4780-8579-e2149858f42a","added_by":"auto","created_at":"2025-07-23 08:41:29","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60781,"visible":true,"origin":"","legend":"\u003cp\u003eOperative illustration of combined goniosynechialysis (GSL) and goniotomy (GT). A: under direct gonioscopic visualization, circumferential synechiolysis was performed using an iris repositor to dissect peripheral anterior synechiae. B: goniotomy was initiated through two entry points at the lateral nasal quadrant of the trabecular meshwork, extending approximately 120 degrees along Schlemm's canal.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7127502/v1/c9a057455d39ee7eb091c392.jpeg"},{"id":87383179,"identity":"3c70ca26-c9f4-46b3-8b82-fe715768c2a1","added_by":"auto","created_at":"2025-07-23 08:41:29","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSuccess rate following PEI+GSL+GT. \u003c/strong\u003eThe images demonstrate the variation in success rates for this procedure. The data show that the success rate was highest at 1 month postoperatively (98.04 per cent), decreased slightly to 95.92 per cent at 2 months, decreased significantly to 84.44 per cent at 3 months (P\u0026lt;0.01 vs. 1 month), and continued to decay at 4 (81.40 per cent), 5 (74.19 per cent), and 6 months (69.23 per cent) (9.6 per cent average annual decrease).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7127502/v1/681f5e4496042c54b0ae073f.jpeg"},{"id":97178224,"identity":"a530b927-7da6-4ccf-b4ef-c632c326262f","added_by":"auto","created_at":"2025-12-01 16:02:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2328572,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7127502/v1/f6b443d1-1393-4120-aee0-421e9eed6aa2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy and safety of PEI combined with goniosynechialysis and goniotomy in the treatment of APACG","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary angle-closure glaucoma (PACG) constitutes 26.2% of global glaucoma cases and is responsible for 48.3% of glaucoma-related blindness, primarily due to its fivefold higher risk of irreversible vision loss compared to primary open-angle glaucoma (POAG)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over 76% of PACG cases occur in Asia, with China contributing approximately 50% of the global burden[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The annual incidence of acute PACG (APACG) in China ranges from 10.4 to 12.2 per 100,000 individuals[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Driven by rapid population aging, PACG prevalence in China is projected to reach 15\u0026nbsp;million patients by 2050, imposing substantial socioeconomic and quality-of-life burdens[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLowering IOPremains the cornerstone for halting glaucomatous neurodegeneration progression. Although traditional interventions such as trabeculectomy and aqueous shunt implantation achieve deeper IOP reduction than medical therapy, they carry risks of sight-threatening complications (e.g., persistent hypotony, bleb-related infections) and significant efficacy attenuation beyond 5 years[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Minimally invasive glaucoma surgery (MIGS), particularly PEI combined with GSL and GT, has emerged as a promising alternative. This integrated approach demonstrates comparable IOP-lowering efficacy while offering advantages including minimal conjunctival trauma, accelerated visual recovery, and reduced severe complication rates[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the safety and applicability of PEI + GSL + GT in APACG patients with cataracts remain controversial. Conventional trabeculectomy or standalone PEI often fail to address the complex anatomical challenges in these cases. This study evaluates the clinical value and safety of PEI + GSL + GT in APACG patients with coexisting cataracts, focusing on IOP control, medication reduction, and postoperative complications.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy patients\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective case series enrolled 41 eyes from 39 consecutive APACG patients at Fuzhou Eye Hospital (January 2022-April 2024). The cohort comprised 9 males (23.1%) and 32 females (76.9%) with a mean age of 66.95 ± 8.51 years (range: 48–83 years). Participants underwent combined phacoemulsification with intraocular lens implantation (PEI), 360° goniosynechialysis (GSL), and 120° goniotomy (GT). Baseline ocular characteristics included axial length​ (22.45 ± 0.64 mm) and corneal endothelial cell density (2567.01 ± 475.25 cells/mm²). The mean follow-up duration was 28.90 ± 8.32 months (range: 9–38 months), with 22 right eyes (53.7%) and 19 left eyes (46.3%) completing the protocol. The study protocol was approved by the Institutional Review Board of Fuzhou Eye Hospital (Ethics No: FZYKYY-KY-2022-003), and written informed consent was obtained from all participants prior to intervention.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eDiagnostic Criteria for APACG\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eAPACG was defined by the following criteria[\u003cspan citationid=\"CR13\"\u003e13\u003c/span\u003e]: (1) a history of acute episode(s) with at least two typical symptoms (e.g., ocular pain, blurred vision with halos, nausea/vomiting); (2) peak IOP \u0026gt; 30 mmHg during the acute phase; (3) gonioscopic evidence of peripheral anterior synechiae (PAS) and shallow anterior chamber; and (4) presence of ≥ 3 clinical signs, including marked conjunctival hyperemia, corneal epithelial edema, and mid-dilated pupil (≥ 4 mm in diameter).\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eInclusion Criteria for Surgical Intervention\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003ePatients were considered eligible if they met the following criteria[\u003cspan citationid=\"CR12\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\"\u003e15\u003c/span\u003e].: (1) confirmed diagnosis of APACG by standardized gonioscopy; (2) presentation either during the acute phase (intraocular pressure \u0026gt; 30 mmHg within 72 hours of symptom onset) or post-resolution following medical therapy; (3) presence of visually significant cataract (best-corrected visual acuity ≤ 0.1 logMAR or surgeon-determined necessity for lens extraction); (4) absence of intraocular surgery/trauma history and systemic/ocular contraindications; (5) provision of written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003e Exclusion criteria for surgery\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003ePatients were excluded if they had a history of intraocular surgery (except laser peripheral iridotomy, laser iridoplasty, or anterior chamber paracentesis), ocular trauma, POAG or secondary glaucoma. Additional exclusion criteria encompassed concurrent ocular pathologies requiring surgical intervention, corneal edema/opacity precluding gonioscopic visualization of angle structures, active systemic diseases (e.g., severe cardiac/hepatic/renal dysfunction), hypersensitivity to study medications, pregnancy/lactation status, or inability to complete follow-up assessments[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\"\u003e16\u003c/span\u003e–\u003cspan citationid=\"CR18\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eOphthalmologic examination and preoperative preparation\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eAll participants underwent comprehensive systemic history documentation and standardized ophthalmic assessment protocols prior to enrollment, including slit-lamp microscopy (Haag-Streit BQ-900, Switzerland) for anterior segment evaluation, pneumatic tonometry (Topcon CT-800, Japan) for IOP measurement, and gonioscopy (Ocular Instruments, USA) to quantify angle configuration. Best-corrected visual acuity (BCVA) was assessed using ETDRS charts (Precision Vision, USA) and converted to logMAR units. Biometric parameters (anterior chamber depth, axial length) were obtained via IOLMaster 700 (Carl Zeiss, Germany). All devices were calibrated according to manufacturer protocols to ensure reproducibility.\u003c/p\u003e\n\u003cp\u003ePreoperative documentation included detailed records of AGM(types and dosing frequency). Prophylactic measures comprised topical administration of levofloxacin 0.5% and pranoprofen 0.1% eye drops four times daily (QID) to the operative eye for 3 days, along with bilateral conjunctival sac irrigation and lacrimal duct flushing to exclude conditions such as chronic dacryocystitis. Mydriasis was achieved 30 minutes preoperatively using compound tropicamide eye drops.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eSurgical technique\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed by a glaucoma specialist (corresponding author ZJH with over 20 years of clinical experience) under topical anesthesia determined by preoperative evaluation. A standardized three-step approach was implemented: (1) The standardized PEI procedure was performed through two clear corneal incisions: a 2.4-mm main incision at the 11 o'clock position and an auxiliary incision at the 2 o'clock position; (2) GSL and GT: Following PEI, ophthalmic viscosurgical device (OVD) was injected to deepen the anterior chamber. Circumferential angle separation was achieved using an iris repositioner under direct gonioscopic visualization(shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\"\u003e1\u003c/span\u003eA), with subsequent GT performed through two entry points to incise the lateral nasal portion of the Schlemm's canal to an extent of approximately 120 degrees(shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\"\u003e1\u003c/span\u003eB). The extent of GT was adjusted based on intraoperative observations of trabecular meshwork pigmentation and blood reflux column; (3) Wound closure: Residual OVD and hyphema were meticulously irrigated, followed by stromal hydration of corneal incisions and anterior chamber stabilization with balanced salt solution. Postoperative tobramycin-dexamethasone ointment application and eye patching completed the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003ePostoperative Management​\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eA standardized medication protocol was implemented: Topical 1% prednisolone acetate eye drops were administered four times daily (QID) combined with tobramycin-dexamethasone ointment at bedtime for the initial 7 postoperative days. From postoperative day 8, non-steroidal anti-inflammatory drugs (NSAIDs) replaced corticosteroids and were continued for an additional 21 days, while 1% pilocarpine eye drops were maintained for 28 days. Any IOP elevation ≥ 21 mmHg during corticosteroid use required immediate suspension of steroids and therapeutic escalation to NSAIDs, with subsequent IOP revaluation within 48 hours.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003ePostoperative Follow-up\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003ePatients underwent standardized evaluations[\u003cspan citationid=\"CR12\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\"\u003e16\u003c/span\u003e] at postoperative day (POD) 1, POD 7, and months 1, 3, 6, 12, 24, and 36, with data from the final follow-up visit analyzed as primary endpoints. Outcome measures included preoperative versus final follow-up comparisons of IOP, BCVA, and the number of AGM. Secondary outcomes encompassed documentation of postoperative complications (e.g., hyphema, corneal edema) and requirement for additional surgical interventions.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eDefinition and Criteria for Surgical Success\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eComplete surgical success was defined as postoperative IOP within 5–21 mmHg with ≥ 20% reduction from baseline, absence of light perception loss, and no requirement for adjunctive antiglaucoma medications or secondary surgery. Qualified success required meeting these criteria with the use of AGM. Surgical failure was defined as either IOP \u0026gt; 21 mmHg despite maximum tolerated medical therapy or the need for additional antiglaucoma surgery during follow-up[\u003cspan citationid=\"CR19\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\"\u003e20\u003c/span\u003e] .\u003c/p\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eData analysis was performed using SPSS 26.0 (IBM Corp., USA). Continuous variables were assessed for normality via Shapiro-Wilk test. Normally distributed data were expressed as mean ± standard deviation (SD), with intergroup comparisons analyzed by independent samples t-test (parametric) or Mann-Whitney U test (non-parametric). Paired pre-/postoperative comparisons utilized paired samples t-test for parametric data or Wilcoxon signed-rank test for non-parametric data.Categorical variables were reported as frequencies and proportions (%), with intergroup differences evaluated using Pearson's χ² test or continuity-corrected χ² test as appropriate. For ordinal data, intergroup comparisons employed Mann-Whitney U test, while within-group analyses utilized Wilcoxon signed-rank test. All tests were two-tailed, with statistical significance defined as p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 53 patients (eyes) with APACG were included in this study. The mean age of the patients was 66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1 years (range: 52\u0026ndash;82 years), with 13 (24.5%) males and 40 (75.5%) females, showing a clear female predominance (male to female ratio of approximately 1:3). The lateral distribution of the affected eyes was 28 cases (52.8%) in the right eye and 25 cases (47.2%) in the left eye. The median time from symptom onset to intervention was 2.0 hours (interquartile spacing IQR: 1.0-7.5 hours). Preoperative assessment showed that the mean IOP was 38.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56 mmHg and the patients were on a mean of 3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 IOP-lowering medications preoperatively. Biological parameters measured were: mean ocular axis length 22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm and corneal endothelial cell density 2540.1\u0026thinsp;\u0026plusmn;\u0026thinsp;577.1 cells/mm\u0026sup2;. The baseline characteristics of all patients were fully documented and no missing data occurred, as shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics of the patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDemographic characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValue (n\u0026thinsp;=\u0026thinsp;53 eyes)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (75.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEye laterality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight (OD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (52.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft (OS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (47.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of attack (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0 (1.0, 7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative medications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAxial length (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorneal ECD (cells/mm\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2540.1\u0026thinsp;\u0026plusmn;\u0026thinsp;577.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eIOP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the postoperative follow-up period, the patients\u0026apos; IOP exhibited a significant trend towards lowering, with statistically significant differences observed between pre- and post-operative comparisons. Specifically, IOP values decreased significantly at all postoperative time points (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared with preoperative baseline IOP (38.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56 mmHg), indicating a sustained effect of the surgical intervention in controlling IOP. At the final follow-up (36 months postoperatively), the mean IOP (17.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54 mmHg) was significantly reduced by 21.40 mmHg compared to the preoperative period. The trend of IOP changes demonstrated that the significant reduction was observed in the early postoperative period (e.g., week 1), which slightly rebounded over time but was always maintained at a safe level (\u0026lt;\u0026thinsp;21 mmHg), with the rate of reduction ranging from 72.3% in the early postoperative period to 55.6% at the final follow-up, indicating that the effect of surgical reduction of intraocular pressure was bpth long-lasting and stable (shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e IOP).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMean IOP(mmHg), BCVA,AGM at Each Study Visit\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up time point\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIOP, mean mmHg\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBCVA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAGM\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.51\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.79\u0026thinsp;\u0026plusmn;\u0026thinsp;5.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth 36\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eNote: IOP, intraocular pressure; BCVA, best corrected visual acuity; AGM, anti-glaucoma medications;n, number; SD, standard deviation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eBCVA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the postoperative follow-up period, the patients\u0026apos; BCVA showed an overall trend of improvement, especially at the mid- and long-term postoperative time points. Specifically, BCVA changed less in the early postoperative period (e.g., day 1 and week 1) compared with the preoperative baseline level (0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32, n\u0026thinsp;=\u0026thinsp;53), and the difference was not statistically significant (day 1: 0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.41; week 1: 0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61). However, BCVA began to improve significantly from 3 months postoperatively: at 3 months postoperatively BCVA decreased to 0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24 (n\u0026thinsp;=\u0026thinsp;49), a statistically significant difference from baseline (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04); it further improved to 0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23 (n\u0026thinsp;=\u0026thinsp;45) at 6 months postoperatively, a decrease of 30.2% with a significant P value (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eThis trend of improvement continued at long-term follow-up with BCVA of 0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27 (n\u0026thinsp;=\u0026thinsp;43, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02) at 12 months postoperatively and 0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25 (n\u0026thinsp;=\u0026thinsp;31, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) at 24 months postoperatively, which were significantly better than preoperative levels. Although BCVA rebounded slightly to 0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24 (n\u0026thinsp;=\u0026thinsp;13) at 36 months postoperatively, the difference from baseline was not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.62), suggesting that visual acuity improvement may fluctuate mildly during long-term follow-up, but the overall effect is stable.\u003c/p\u003e\n\u003cp\u003eOverall, the significant improvement in BCVA was mainly concentrated between 3 and 24 months postoperatively, reflecting the positive impact of the surgical intervention on visual function (shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e BCVA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnti-glaucoma Medications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChanges in the use of AGMs were systematically assessed by preoperative and postoperative follow-up. The results showed that at preoperative baseline, patients\u0026apos; mean AGM use was 3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 (range: 1.0\u0026ndash;5.0), suggesting preoperative reliance on multiple medications for IOP control. During the postoperative follow-up period, AGM use showed a significant trend toward reduction, and the differences were statistically significant at all time points when compared with the preoperative period (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eSpecifically, AGM use decreased rapidly to 0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23 species (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) on postoperative day 1, a decrease of 98.0%, and 0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44 species (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) on postoperative week 1, a decrease of 93.7%. Over time, AGM use rebounded slightly but remained low: 0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 species at 1 month postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 0.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 species at 3 months postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and 0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01 species at 6 months postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At long-term follow-up, AGM dosage was 0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95 species at 12 months postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 0.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 species at 24 months postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and stabilised at 0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 species at the final follow-up at 36 months postoperatively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), representing an overall decrease of 71.8%.\u003c/p\u003e\n\u003cp\u003eThis trend suggests that the surgical intervention significantly reduced antiglaucoma medication dependence, with the most significant reduction occurring in the early postoperative period (e.g., week 1), followed by a levelling off, with AGM dosage consistently lower than 1, confirming the sustained mitigating effect of the surgery on medication burden.(shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e AGM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuccess Rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative success rates showed a time-dependent downward trend, with conditional success (qualified success, allowing pharmacological assistance) decaying significantly less than complete success (no pharmacological intervention required). At 6 months postoperatively, the conditional success rate was 92.5% (95% CI: 87.3\u0026ndash;97.7), and the complete success rate was 85.4% (95% CI: 78.6\u0026ndash;92.2), reflecting the effectiveness of surgical intervention in controlling IOP in the short term. Conditional success rates declined by approximately 7% per year to 71.6% (95% CI: 61.3\u0026ndash;81.9) at 36 months postoperatively, a decrease of 22.4% from 6 months. Complete success rates declined even more dramatically, to only 53.8% at 36 months (95% CI: 42.7%) The complete success rate declined even more significantly, to 53.8% (95% CI: 42.5\u0026ndash;65.1) at 36 months, a decrease of 37.0% from 6 months, suggesting that long-term efficacy is dependent on partial pharmacological assistance(shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe major postoperative complications in the operated eyes were transient elevation of intraocular pressure 26.42% (14/53), anterior chamber haematoma 11.32% (6/53), and corneal oedema 15.09% (8/53), and Shallow anterior chamber 3.77% (2/53).The above complications were cured by symptomatic management, and there were no sight-threatening complications occurring without the need of a Secondary surgery was not required.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn patients with APACG, combined with cataract, PEI\u0026thinsp;+\u0026thinsp;GSL alone may not adequately improve their trabecular meshwork dysfunction and visual acuity[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Previous treatments have used laser peripheral iridectomy or trabeculectomy followed by PEI surgery, which may increase the patient\u0026apos;s medical burden or expose them to the possibility of multiple surgeries. Traditional trabeculectomy remains an important option for glaucoma treatment due to its effectiveness in reducing IOP. However, there are three major limitations to this procedure: first, it is invasive and time-consuming, and second, the postoperative aqueous humor needs to rely on filtering bubbles to complete external drainage, which may lead to additional complications such as leakage, encapsulation, or scar formation.\u003c/p\u003e\n\u003cp\u003eA variety of MIGS have emerged over the past two decades, successfully overcoming the shortcomings of traditional glaucoma surgeies. Aqueous humor drainage is mainly achieved through the trabecular meshwork, Schlemm\u0026apos;s canal and distal outflow tissue. In MIGS, operations are mainly performed for the trabecular meshwork and Schlemm\u0026apos;s canal. The results of several RCTs in China have also pointed out that the surgical methods of PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT (also known as Phacogoniotomy), has a high degree of efficacy and safety for patients with middle to advanced PACG[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eNevertheless, whether PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT is effective in controlling IOP and improving vision in patients with APACG remains controversial. This preliminary results of this prospective, small-sample study suggest that PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT has satisfactory efficacy and safety in the treatment of APACG compared with conventional laser or trabeculectomy, achieving a sustained reduction in intraocular pressure (IOP), less dependence on medications, and some improvement in visual acuity without serious complications.\u003c/p\u003e\n\u003cp\u003eFollowing a three-year postoperative follow-up period, the results showed a decrease in IOP from 38.52 mm Hg to 17.12 mm Hg in patients who received PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT treatment. It is noteworthy that the patients were still on anti-glaucoma medications at the time of the final follow-up. However, a significant reduction in medication dosage was observed, from 3.02 preoperatively to 0.85 postoperatively.\u003c/p\u003e\n\u003cp\u003eIt has been established through the implementation of earlier research that this procedure has the capacity to significantly reduce IOP in patients diagnosed with PACG. The mean postoperative IOP reduction was (11.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43) mmHg (meta-analysis), with IOP decreasing from preoperative (33.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7) mmHg to (13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9) mmHg in patients with advanced disease[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].Multiple regression analysis showed a significant positive correlation between baseline IOP level and postoperative IOP reduction[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Long-term follow-up data showed a complete success rate (defined as no IOP-lowering medication and IOP\u0026thinsp;\u0026le;\u0026thinsp;21 mmHg) of 90% (95% CI: 86.2%-93.8%) at 36 months postoperatively, with IOP remaining stable (fluctuating\u0026thinsp;\u0026le;\u0026thinsp;3 mmHg) for 24 months postoperatively [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eFurthermore, following the incorporation of cataract surgical intervention, all patients exhibited varying degrees of enhancement in postoperative visual acuity in comparison with their preoperative levels.The combined PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT procedure resulted in a consistent enhancement or the maintenance of BCVA, whilst concomitantly achieving a substantial reduction in IOP. A number of multicentre studies have previously demonstrated that the mean BCVA in patients with mid- to late-stage PACG improved from preoperative (0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11) LogMAR to (0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10) LogMAR at 6 months postoperatively[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, the range of visual acuity fluctuation over the 36-month follow-up period was \u0026le;\u0026thinsp;0.04 LogMAR, suggesting that the BCVA improvement in the long term was more stable after the operation. The preliminary results of this study also demonstrated that early postoperative BCVA was not significantly different (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) from the preoperative baseline (0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32), suggesting that the surgery did not cause acute visual impairment.\u003c/p\u003e\n\u003cp\u003eThis phenomenon is consistent with the low perturbation characteristics of minimally invasive operations (e.g., GT limited to 120\u0026deg; range) on intraocular structures, which avoids early visual fluctuations due to filter bubble formation or corneal astigmatism in conventional filtration surgery. In this study, fluctuations in BCVA occurred in the mid-postoperative period, with BCVA decreasing to 0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) at 3 months postoperatively and further improving to 0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23 (30.2% decrease, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) at 6 months. It is hypothesised that this is associated with a gradual enhancement in corneal transparency and the development of posterior cataracts during the mid-postoperative period.\u003c/p\u003e\n\u003cp\u003ePEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT circumvented the complications associated with filtering bubbles by targeting and reconstructing the physiological atrial fluid drainage pathway of Schlemm\u0026apos;s canal. The main postoperative complications in this study were transient IOP elevation (26.42%, 14/53), corneal oedema (15.09%, 8/53) and anterior chamber haematochezia (11.32%, 6/53).These complications were all reversible and mild, and did not include any sight-threatening complications, such as endophthalmitis or suprachoroidal haemorrhage.\u003c/p\u003e\n\u003cp\u003eThe transient elevation of IOP mainly originated from the fluctuation of atrial aqueous outflow resistance at the early stage of opening of Schlemm\u0026apos;s canal severance after GT, as well as the temporary functional inhibition of the trabecular meshwork due to the release of inflammatory mediators. With postoperative dynamic IOP monitoring and timely application of topical \u0026beta;-blockers, all patients\u0026apos; IOPs returned to normal (\u0026le;\u0026thinsp;21 mmHg) within 72 hours without surgical intervention.\u003c/p\u003e\n\u003cp\u003eAnother common postoperative complication was corneal oedema. Previous similar studies have shown that corneal oedema after this procedure may be correlated with the time of ultrasound emulsification energy accumulation, suggesting that endothelial damage mainly originates from ultrasound energy exposure rather than GT manipulation. However, due to limitations in data collection, the association between ultrasonic emulsification energy accumulation time and corneal oedema was not analysed in this study.\u003c/p\u003e\n\u003cp\u003eFurthermore, intraoperative anterior chamber blood accumulation was observed, resulting from injury during GT dissection of the inner wall of Schlemm\u0026apos;s canal. A total 11.32% (6/53) of the blood accumulation was attributed to microvascular tearing of the outer wall of Schlemm\u0026apos;s canal during the GT operation, with blood flow recirculating into the anterior chamber through the severed end, constituting an inherent risk of the procedure. However, following a comprehensive clinical observation involving intraoperative viscoelastic compression and postoperative semirecumbent rest, it was observed that all six cases of blood accumulation were completely absorbed within a period of five days. No instances of secondary glaucoma or corneal blood staining were recorded. It is imperative to exercise caution in the event of damage to the outer wall of Schlemm\u0026apos;s canal or the iridocyclic body, as this may result in severe haemorrhage or iris root detachment.\u003c/p\u003e\n\u003cp\u003eIn order to prevent and manage complications, three courses of action can be taken. The initial approach involves preoperative prevention, specifically targeting patients with corneal endothelial counts below 1500 cells/mm\u0026sup2;. In these cases, a combination of cryo-infusion techniques and the soft-shell technique, along with viscoelastic protection, is employed to mitigate the potential for damage to the cornea caused by PEI[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. It is imperative that anticoagulation management is completed for patients with hypertension and systemic use of anticoagulants. This involves the discontinuation of antiplatelet drugs for a minimum of seven days prior to surgery, in addition to the intraoperative control of blood pressure. These measures are undertaken to mitigate the risk of anterior chamber effusion. Secondly, intraoperative quality control is imperative, and this is facilitated by GT to limit the incision range of 120\u0026deg;, thus avoiding damage to the outer wall of Schlemm\u0026apos;s canal and the collecting ducts. For those who meet the necessary criteria, microcatheter-guided incision can be used to reduce the incidence of lost during the operation. It is imperative to exercise reasonable control over the ultrasonic emulsification energy and time in order to stabilise the depth of the anterior chamber and thereby reduce the large fluctuations of intraoperative endophthalmitis. The third is postoperative management, which includes the detection of anterior chamber inflammation and the timely application of hormonal eye drops. In cases where IOP\u0026thinsp;\u0026gt;\u0026thinsp;25 mmHg and hormonal glaucoma is considered, switching to nonsteroidal anti-inflammatory drugs (NSAIDs) is a viable option. In patients diagnosed with haemorrhage, it is recommended that eye and head movement be restricted to a semi-recumbent position, in order to minimise any potential adverse effects.\u003c/p\u003e\n\u003cp\u003eA decline in the postoperative success rate of PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT was observed over time in this study, which may be related to the surgical incision of the atrial horn scar and the subsequent postoperative adhesive closure of the atrial horn itself. The high early success rate of the combined PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT procedure validates its short-term value as a first-line treatment for APACG, but the long-term attenuation of the complete success rate reveals its dependence on pharmacological adjuvant. Future research directions may consider completing the ultrastructural exploration of the incision site in combination with animal models, or investigating the need to enhance the durability of efficacy through intraoperative antifibrotic enhancement and early postoperative targeted drug administration, especially in high-risk patients with preoperative PAS\u0026thinsp;\u0026gt;\u0026thinsp;270\u0026deg; or non-pupil-blocking type.\u003c/p\u003e\n\u003cp\u003eAlthough PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT demonstrated short-term IOP control advantages in mid- to late-stage primary angle-closure glaucoma (PACG), its application in acute primary angle-closure glaucoma (APACG), which was explored in the present study, has the following limitations.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e(1) Technical challenges of emergency surgery APACG are frequently accompanied by corneal oedema, inflammation in the anterior chamber and pupil constriction. In such cases, PEI can increase the risk of posterior lens capsule rupture and corneal endothelial decompensation due to the poor stability of the anterior chamber. The risk of surgical complications is especially high in \u0026apos;hot eyes\u0026apos; with IOP\u0026thinsp;\u0026gt;\u0026thinsp;40 mmHg.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e(2) The irreversibility of anterior chamber angle adhesions has been demonstrated to limit the efficacy of PEI. In the presence of extensive peripheral anterior adhesions (PAS)\u0026thinsp;\u0026gt;\u0026thinsp;270\u0026deg; preoperatively or non-pupil-blocking APACGs (e.g., anteriorly shifted ciliary body), it has been demonstrated that GSL is unable to completely detach the adherent atrial angle structures. Research has indicated that in cases where the PAS extent exceeds 270\u0026deg;, the incidence of postoperative atrial angle re-adhesion by GSL increases to 58.3%, resulting in a decline in the complete success rate to 42.1% at 36 months postoperatively[\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e(3) Patients with APACG in remission have a high prevalence of choroidal leakage, and the degree of leakage is positively correlated with the initial IOP. Although choroidal leakage was not observed in this study, direct PEI\u0026thinsp;+\u0026thinsp;GSL\u0026thinsp;+\u0026thinsp;GT in such patients may exacerbate ciliary choroidal detachment due to intraoperative low IOP, which in turn induces complications such as persistent postoperative low IOP and macular folds. It is imperative that these limitations are thoroughly explored in order to facilitate future surgical enhancements.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research protocol received ethical approval from the Ethics Committee of Fuzhou Eye Hospital (Approval ID: FZYKYY-KY-2022-003), and all procedures strictly adhered to the ethical principles outlined, and all participants provided written informed consent in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting this study are available from the corresponding author upon reasonable request under institutional data sharing protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by grants from the Guiding Science and Technology Project Programme in Sanming City, Fujian Province (2023-S-32, Zhang Liu), the Joint Funding Project of Science and Technology Innovation from the Fujian Provincial Department of Science and Technology (No. 2023Y9027, Yao Yihua), the Fujian Provincial Clinical Medical Research Center for Eye Diseases and Optometry (YK-YJZX, Yao Yihua), the Science and Technology Innovation Joint Fund Project of the Fujian Provincial Department of Science and Technology (No. 2021Y9013, Wang Xiaohui), and the Natural Science Foundation of Fujian Province (No. 2023J01591, Wang Xiaohui).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZL, YYH and WXH, ZJH conceived the study design, executed the research protocol, ZL, YYH, JHQ, ST, ZQ, WXH, ZJH were responsible for data acquisition, analysis, and interpretation. Both authors contributed equally to manuscript preparation through iterative drafting and critical revisions, with final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend sincere gratitude to all clinical participants whose invaluable engagement in surgical protocols and postoperative assessments directly informed the refinement of ophthalmic operative techniques. Special recognition is accorded to nursing teams for their meticulous coordination of perioperative care, which ensured protocol adherence across all study phases.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSong P, Wang J, Bucan K, Theodoratou E, Rudan I, Chan KY: \u003cstrong\u003eNational and subnational prevalence and burden of glaucoma in China: A systematic analysis\u003c/strong\u003e. \u003cem\u003eJournal of global health \u003c/em\u003e2017, \u003cstrong\u003e7\u003c/strong\u003e(2):020705.\u003c/li\u003e\n\u003cli\u003eParikh SR, Parikh RS: \u003cstrong\u003eClinical implication of recent randomized control trial in primary angle-closure disease management\u003c/strong\u003e. \u003cem\u003eIndian journal of ophthalmology \u003c/em\u003e2022, \u003cstrong\u003e70\u003c/strong\u003e(8):2825-2834.\u003c/li\u003e\n\u003cli\u003eQuigley HA, Broman AT: \u003cstrong\u003eThe number of people with glaucoma worldwide in 2010 and 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JD: \u003cstrong\u003eTreatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up\u003c/strong\u003e. \u003cem\u003eOphthalmology \u003c/em\u003e2022, \u003cstrong\u003e129\u003c/strong\u003e(12):1344-1356.\u003c/li\u003e\n\u003cli\u003eNguyen Xuan H, Nguyen Dinh N, Nguyen Thu H, Nguyen Van C, Aung T, Loo Y, Nguyen Do Thi Ngoc H, Do T: \u003cstrong\u003eComparing the Safety and Efficacy of Phacogoniosynechialysis With Phacotrabeculectomy in the Management of Refractory Acute Primary Closure Angle Glaucoma With Cataract: A Multicenter Randomized Trial\u003c/strong\u003e. \u003cem\u003eJournal of glaucoma \u003c/em\u003e2021, \u003cstrong\u003e30\u003c/strong\u003e(7):552-558.\u003c/li\u003e\n\u003cli\u003eSong Y, Fan S, Tang L, Lin F, Li F, Lv A, Li X, Wen T, Lu L, Xiao M\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eTwo-Year Outcomes of Phacogoniotomy vs Phacotrabeculectomy for Advanced Primary Angle-Closure Glaucoma With Cataract: A Noninferiority Randomized Clinical Trial\u003c/strong\u003e. \u003cem\u003eJAMA ophthalmology \u003c/em\u003e2025.\u003c/li\u003e\n\u003cli\u003eSong Y, Xie L, Zhu X, Fan S, Lv A, Tang G, Zhang H, Tang L, Zhang Y, Lu L\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eTwo-year outcome of phacogoniotomy for advanced primary angle-closure glaucoma with cataracts: a multicentre study\u003c/strong\u003e. \u003cem\u003eThe British journal of ophthalmology \u003c/em\u003e2025.\u003c/li\u003e\n\u003cli\u003eSong Y, Zhu X, Zhang Y, Shu J, Dang G, Zhou W, Sun L, Li F, Lin F, Zhang Y\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eOutcomes of Partial Versus Complete Goniotomy With or Without Phacoemulsification for Primary Open Angle Glaucoma: A Multicenter Study\u003c/strong\u003e. \u003cem\u003eJournal of glaucoma \u003c/em\u003e2023, \u003cstrong\u003e32\u003c/strong\u003e(7):563-568.\u003c/li\u003e\n\u003cli\u003eAboalazayem F, Elhusseiny AM, El Sayed YM: \u003cstrong\u003eGonioscopy-Assisted Transluminal Trabeculotomy: A Review\u003c/strong\u003e. \u003cem\u003eCurrent eye research \u003c/em\u003e2023, \u003cstrong\u003e48\u003c/strong\u003e(4):329-338.\u003c/li\u003e\n\u003cli\u003eLin Y, Zhou B, Yao Y, Ye Q, Zhu Y, Wang X: \u003cstrong\u003eClinical observation of phacoemulsification under the low perfusion pattern and low negative pressure in patients with low corneal endothelial cell density\u003c/strong\u003e. \u003cem\u003eBMC ophthalmology \u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):340.\u003c/li\u003e\n\u003cli\u003eLiu Y, Li W, Jiu X, Lei X, Liu L, Yan C, Li X: \u003cstrong\u003eSystematic Review and Meta-Analysis of Comparing Phacoemulsification Combined with goniosynechialysis to other mainstream procedures in treating patients with angle-closure glaucoma\u003c/strong\u003e. \u003cem\u003eMedicine \u003c/em\u003e2019, \u003cstrong\u003e98\u003c/strong\u003e(42):e17654.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute primary angle-closure glaucoma (APACG), phacoemulsification with intraocular lens implantation (PEI), Goniosynechialysis (GSL), Goniotomy (GT), Efficacy, Safety","lastPublishedDoi":"10.21203/rs.3.rs-7127502/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7127502/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate the efficacy and safety profile of combined phacoemulsification with intraocular lens implantation (PEI), goniosynechialysis (GSL), and goniotomy (GT) in managing acute primary angle-closure glaucoma (APACG) with coexisting cataract.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective case series enrolled 41 eyes from 39 APACG patients (mean age 66.95±8.51 years) at Fuzhou Eye Hospital (2022-2024). All subjects underwent triple surgery (PEI+GSL+GT). Primary endpoints included intraocular pressure (IOP) reduction, anti-glaucoma medication(AGM) burden, and complications over 36 months. Surgical success was defined as IOP 5-21 mmHg with ≥20% reduction from the baseline without vision-threatening complications. Statistical analyses employed paired t-tests and Wilcoxon signed-rank tests.Written informed consent was obtained from all 39 participants prior to enrollment, including specific authorization for surgical video recording and anonymized data publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study demonstrated significant efficacy of PEI+GSL+GT in controlling IOP and reducing AGM in APACG patients. At 36 months postoperatively, the complete success rate was 53.8% (95% CI: 42.5%–65.1%), while the qualified success rate(IOP control with ≤2 medications) reached 71.6% (95% CI: 61.3%–81.9%). Mean IOP decreased from 38.52±10.56 mmHg preoperatively to 17.12±4.54 mmHg at 36 months (Δ55.6%, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), paralleled by a 71.8% reduction in AGM(from 3.02±0.6 to 0.85±0.8 agents, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Postoperative complications included transient IOP elevation (26.42%, 14/53), corneal edema (15.09%, 8/53), and anterior chamber hemorrhage (11.32%, 6/53), all managed conservatively without sight-threatening events or secondary surgical interventions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePEI+GSL+GT demonstrates significant reductions in intraocular pressure and medication burden in acute primary angle-closure glaucoma (APACG), whilst exhibiting a superior safety profile in comparison with conventional trabeculectomy. This minimally invasive approach integrates triple therapeutic mechanisms, namely cataract extraction, peripheral anterior synechiolysis (PAS) and trabecular meshwork excision, to reconstruct physiological outflow pathways. This represents a safer surgical alternative. It is recommended that further large-scale multicentre randomised trials are conducted in order to validate the efficacy of the treatment in the APACG and to standardise optimised surgical protocols.\u003c/p\u003e","manuscriptTitle":"Efficacy and safety of PEI combined with goniosynechialysis and goniotomy in the treatment of APACG","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 08:41:25","doi":"10.21203/rs.3.rs-7127502/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T05:48:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T08:51:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192697885459508582597247118786149130904","date":"2025-07-22T02:36:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T07:14:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64104681955747217855457457287567752160","date":"2025-07-21T06:11:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247136649027205702557689276001879579175","date":"2025-07-18T18:48:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-18T18:31:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-18T18:24:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T10:05:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T17:05:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-07-17T10:06:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"360393ed-65eb-4867-a486-a2cc5130f03b","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T15:59:16+00:00","versionOfRecord":{"articleIdentity":"rs-7127502","link":"https://doi.org/10.1186/s12886-025-04501-1","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-11-25 15:56:51","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-07-23 08:41:25","video":"","vorDoi":"10.1186/s12886-025-04501-1","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04501-1","workflowStages":[]},"version":"v1","identity":"rs-7127502","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7127502","identity":"rs-7127502","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}