I was intrigued by the recent article by Elwehidy et al., in which the authors cited my contribution in Romanian and affirmed that I would have classified glaucoma in primary and secondary forms, and each of them in open and narrow (closed) angle entities.1,2
It is the gonioscopic classification of the European Glaucoma Society (EGS) that sustains this; in fact my paper specifically fought the EGS classification for 9 counts.2 The main count is that it does not allow direct therapeutic references. Being based on etiologic and clinical criteria, it does not clarify the pathogeny and may push the user into error: the same cause may trigger several pathogenic mechanisms, several causes may act through the same mechanism, and the same clinical manifestation may be produced by several mechanisms and respond to different, even opposed, treatments. In all my papers since 1986 to 1992 (some presented at international congresses), I sustained that only a pathogenic classification allows direct therapeutic references because only a treatment addressed to all pathogenic links could cure the disease.3 On the contrary, if we conduct our treatment following the EGS classification, after framing a case in a scheme built on gonioscopic observation, a second stage of pathogenic analysis is required, and the ophthalmologist is able to decide the correct treatment only in the third stage. This is a longer thinking pathway during which errors might happen.
This is the short version of my paper. I do not understand why the authors cited a paper printed in a language they do not understand and disregarded the open access English version (listed as a reference in my paper printed in Romanian).2,4
As for the discussed paper, it proves that the EGS classification may push the users into error: the authors adopted an illogical treatment by practicing procedures addressed to trabecular alteration (trabecular stretching [viscocanalostomy] or even bypass [trabeculotomy and trabeculectomy]), although nothing proved that the trabeculum was nonfunctional beneath goniosynechiae.1 According to the EGS classification, they did nothing wrong: those cases were uncontrolled forms of angle-closure glaucomas, and EGS consensus recommends trabecular procedures in uncontrolled pupillary (block) glaucoma. An additional observation: the first group cannot be named “phako-viscosynechialysis-trabeculotomy group” because the term hides the nonperforant external drainage procedures (deep sclerectomy with viscocanalostomy) mentioned in the surgical protocol.
To avoid errors, I suggested a glaucoma classification with 6 consecutive pathogenic crossings, where all forms have a nonspecific pathogenic treatment, and each pathogenic form has a specific pathogenic treatment (Supplemental Digital Content, available at http://links.lww.com/JRS/A53).5 Only rare cases did not fit in the suggested scheme. Guided by this classification, I practice a much simpler surgery in much more severe cases (full attacks of pupillary glaucoma neglected for 10–30 days): Charleux's peripheral iridectomy plus angle repermeation (tractional goniosynechialysis by centripetal pulls on the pupillary margin until it arrives at 1.0 mm from pupil center on 360 degrees).6 The trabecular procedures should be reserved to cases with a confirmed trabecular alteration.
Cases such as those described in the paper could show almost similar late pressure results after a much simpler surgery: phako-intraocular lens plus angle repermeation on areas with goniosynechiae. Instead of spending 1 hour or more in the operating room, everything is solved in 1 minute after implantation. Unfortunately, the ophthalmic audience continues to refuse the pathogenic classification, appreciating more the comfort brought by habit.
1. Elwehidy AS, NHL Bayoumi, Badawi AE, Hagras SM, Kamel R. Combined phacoemulsification–viscosynechialysis–trabeculotomy vs phacotrabeculectomy in uncontrolled primary angle-closure glaucoma with cataract. J Cataract Refract Surg 2019;45:1738–1745
2. Bordeianu CD. [Criticism of the gonioscopic classifications of the glaucoma: with particular reference to the classification issued by the European Glaucoma Society in 2008]. [Romanian]. Oftalmologia (Bucuresti) 2014;58:7–22
3. Bordeianu CD. The pathogenic classification of glaucomas. [English]. Oftalmologia (Bucuresti) 1992;36(4):331–342
4. Bordeianu CD. Critical analysis of the classification of glaucomas issued by the European Glaucoma Society in 2008. Clin Ophthalmol 2014;8:271–282
5. Bordeianu CD. A new classification of glaucomas. Clin Ophthalmol 2014;8:1801–1817
6. Bordeianu CD. Angle repermeation—surgery of choice in neglected pupillary glaucomas. In “14th Congress of the European Society of Ophthalmology, Madrid (Spain), June 7-12, 2003”, Monduzzi Editore, International Proceedings Division, Bologna 2003