Clear-lens extraction as a treatment for primary angle closure

Glaucoma is a multifactorial spectrum of diseases in which progressive optic nerve damage leading to blindness occurs with raised intraocular pressure as the main risk factor. The outfl ow of fl uids through the trabecular meshwork decreases when the iris moves forward and comes into contact with it. This condition is called “angle closure” and can lead to glaucoma damage if intraocular pressure remains suffi ciently raised. When no other cause besides anatomical predisposition is present for the iridotrabecular contact, the condition is classifi ed as primary angle closure, and if glaucomatous optic neuropathy is present it is classifi ed as primary angle-closure glaucoma. The reported prevalence varies because of heterogeneity in defi nitions of primary angle-closure glaucoma and methods of angle assessment used in diff erent surveys. Even more common than primary angle closure and primary angle-closure glaucoma is primary open-angle glaucoma. These three disorders have similarities, such as increasing prevalence after improvement, readily equalled by patients not so mobilised in the weeks after hospital discharge. Far less is known about these later eff ects of early mobilisation, whether provided by an additional physical therapist or by more eff ective coordination and communication of existing resources. Regrettably, the International Early SOMS-guided Mobilisation Research Initiative achieved only 42% (84 of 200 patients) follow-up at 3 months. Such low fi gures at followup are not uncommon in ICU RCTs, although not universal. A full endorsement of early mobilisation must wait for more data, even as many pragmatically attempt early mobilisation based on the hope that its eff ects on trajectory are durable. Large trials of mobilisation in other patient groups provide caution to making assumptions about its long-term benefi t. The future of early mobilisation research must move beyond the ICU and must include randomised tests of the hypothesis that early mobilisation provides enduring improvements for patients. Additionally, future research must go beyond the question of no mobilisation or some mobilisation. At some point— which will need more than 200 patients to be achieved— the diff erent strategies for mobilisation need to be compared. These diff erent strategies should include not only diff erent specifi c regimes of active exercise, but also diff erent approaches to integrate active exercise in the core interdisciplinary teamwork of the ICU. Use of these strategies will need use of all the tools of quality improvement, both RCTs and registries. Patients who are at particularly high risk for adverse outcomes of mobilisation need to be identifi ed, cognizant of the non-signifi cant diff erence in mortality seen in Schaller and colleagues’ and other RCTs. Furthermore, an understanding is needed of how early mobilisation can be integrated into coherent programmes of before ICU, in the ICU, and after ICU care to mitigate the postintensive care syndrome, maximising recovery for all critically ill patients.