Conventional treatment of PACG adopts a stepwise approach, beginning with laser and medication, and if the intraocular pressure (IOP) remains uncontrollable, trabeculectomy is indicated. Concerns about trabeculectomy specific to PACG include further shallowing of the already crowded anterior chamber and increasing the extent of angle closure and degree of lens opacity. Subsequent cataract extraction may in turn compromise the filtering bleb function. More importantly, it doesn’t deal with a large and anterior-positioned lens, which is believed to play an important role in PACG.

Accumulating evidence have shown cataract extraction alone widens the drainage angle, even for eyes with plateau iris, and results in substantial decrease in the postoperative mean IOP. With recent advances in the technology and technique of cataract surgery, rapid visual rehabilitation, minimal post-op inflammation, undistorted angle architecture, and less surgical risk have been achieved. However, performing phacoemulsification in eyes with shallow anterior chamber and reduced corneal endothelium cells is not without risk. For patients who are already on multiple glaucoma medications preoperatively, they may find the postoperative regimen complex and hard to follow. For patients who are corticosteroid-responder, oral acetazolamide may be required to control the IOP. Finally, subsequent IOP-reducing procedure may be needed in a minority of cases.