Azuara-Blanco et al. (1) in their multicentric “EAGLE” study have done a remarkable work in comparing efficacy of clear lens extraction (CLE) vs. laser peripheral iridotomy (LPI) in 155 eyes having newly diagnosed primary angle closure (PAC) with ocular hypertension (IOP ≥30 mmHg) and 263 eyes with early to moderate primary angle closure glaucoma (PACG). The authors reported better quality of life scores and a mean intraocular pressure lower by 1 mmHg in eyes which underwent CLE as compared to LPI at 36 months follow-up. The conclusion of the study was that CLE has a greater efficacy and is more cost effective as compared to the current standard of care (LPI followed by topical therapy) and should therefore be considered as the first line therapy in management of PAC disease (PAC and PACG).

However, there are several issues which need to be addressed before this conclusion can be adopted as the standard of care:

At this point it would be prudent, to reserve CLE for PAC eyes with ocular hypertension post laser iridotomy especially if the IOP is not controlled on a single topical medication or the patient is not compliant with therapy/cannot afford therapy or suffers from a drug allergy.

We cannot change our preferred practice patterns with results of one RCT and we require more evidence in support for CLE before it can be adopted as the standard of care for PAC or PACG.

The risk vs. benefit ratio has to be carefully weighed before placing CLE on top of the chart in management options of PAC disease. Giving the green light for removal of clear lenses in all eyes with PAC(G) has the potential to cause more harm than benefit, especially in developing countries where manual small incision cataract surgery with a conjunctival incision is the most commonly performed mode of lens removal. In conclusion, one must not forget the primary rule for physicians laid down by Hippocrates—Primum non nocere (first do no harm).