Combined small-incision cataract surgery and trabeculectomy--technique and results

In a prospective study 35 eyes of 25 patients with coexisting cataract and glaucoma underwent trabeculectomy, phacoemulsification and implantation of a folded polyHema intraocular lens through the trabeculectomy opening. Follow-up ranged from 6 to 27 months (mean 13.3). The mean age was 76.4 (68 to 88 years). 22 eyes suffered from primary open angle glaucoma, 10 eyes from a pseudoexfoliation glaucoma and 3 eyes had a chronic angle closure glaucoma. Preoperatively intraocular pressure was controlled in 10 eyes with a mean medication of 2.1 but uncontrolled in 25 eyes (mean medication: 2.5). The preoperative visual acuity ranged from 20/40 to hand motions. Postoperatively intraocular pressure was controlled (< 18 mmHg) in all (100%) eyes and without therapy in 32 (91%) eyes. Three (9%) eyes had to be treated with topical timolol twice a day after surgery. Mean intraocular pressure dropped from 21.2 +/- 6.0 mmHg preoperatively to 13.5 +/- 2.1 mmHg postoperatively. Vision improved in all but 4 eyes, 25 (74%) achieving a visual acuity of 20/40 or better. The causes for failed improvement or deterioration of vision were senile macular degeneration in 2 eyes and central retinal vein occlusion and vascular optic nerve atrophy in one eye respectively. Post-operative complications included hyphema in 9 (26%) eyes, fibrin effusion to a various extent into the anterior chamber in 19 (54%) eyes and delayed hypotony (< 5 mmHg) with chorioidal effusion in 1 (3%) eye. Fibrin effusion was frequently observed in eyes with intraocular pressure below 10 mmHg, iris surgery and hyphema. Finally the complications did not effect the results regarding visual acuity or glaucoma control.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of intraocular administration of acetylcholine and carbachol on postoperative intraocular pressure after cataract surgery]

In a consecutive series of 90 patients we examined the effect of intracameral acetylcholine and carbachol on intraocular pressure following extracapsular cataract surgery. In all cases phacoemulsification and implantation of a folded polyhema intraocular lens under healon was performed. After evacuation of the viscoelastic substance from the capsular bag behind the inserted lens and wound suturing we instilled 0.5 ml 1% acetylcholine, 0.5 ml 0.01% carbachol or 0.5 ml balanced salt solution respectively into the anterior chamber. Without the influence of antiglaucomatous drugs applanation tonometry was performed 6 and 18 hours postoperatively. When compared with preoperative values intraocular pressure decreased in the carbachol group (-2.8 mm Hg) but increased in the acetylcholine group (+0.6 mm Hg) and control group (+4.7 mm Hg). 18 hours postoperatively the mean change was -3.0 mm Hg in the carbachol group, +0.8 mm Hg in the acetylcholine group and +2.3 mm Hg in the control group. Intraocular pressure exceeding 22 mm Hg at 6 hours was observed in 33% of the control group and 13% of the acetylcholine group but none of the carbachol group. At 18 hours intraocular pressure was still elevated in 13% of the control group, 10% of the acetylcholine group and 3% of the carbachol group. Reviewing our results we conclude that the evacuation of viscoelastic substances from the capsular bag behind the implanted lens reduces the incidence of pressure rises in the early postoperative period. This effect can be enhanced by the use of acetylcholine and, the more potent, carbachol.

Effect of carbachol on intraocular pressure in small-incision cataract surgery

Sixty patients, who underwent phacoemulsification and implantation of a folded polyHema intraocular lens were assigned to two groups. Following wound closure 0.5 ml of 0.01% carbachol or balanced salt solution was instilled into the anterior chamber. Healon was used in all eyes but evacuated from the capsular bag behind the intraocular lens and the anterior chamber. Intraocular pressure was measured the day before as well as 6 and 18 hours postoperatively. At 6 hours the mean change of intraocular pressure from baseline was -2.8 +/- 5.3 mmHg in the carbachol group compared with +4.7 +/- 8.0 mmHg in the BSS group (p < 0.0001). At 18 hours the mean change from baseline was -3.0 +/- 4.6 mmHg in the treatment group and +2.3 +/- 8.5 in the control group (p < 0.0001). Intraocular pressure exceeding 25 mmHg at 6 hours was observed in 8 (27%) eyes of the control group but none of the treatment group. At 18 hours 4 (13%) eyes of the control group and 1 (3%) of the carbachol group still had an increase of intraocular pressure. Summarizing our results we conclude that the effect of Healon on the postoperative intraocular pressure is successfully counteracted by its aspiration from the capsular bag and the anterior chamber, especially when carbachol is used for intraoperative miosis.

Induced astigmatism following small incision cataract surgery combined with trabeculectomy

The combination of phacoemulsification and implantation of foldable intraocular lenses through a small incision with a trabeculectomy is increasingly preferred in glaucoma patients with coexisting cataract. Small incisions induce less astigmatism and thereby enhance visual recovery. This study should clarify if this benefit of small incision cataract surgery is preserved when combined with a trabeculectomy. Thirty-five eyes were included in this study. Preoperative astigmatism measurements were compared with those obtained one month and one year postoperatively. Vector analysis was performed. A series of 30 cases which underwent small incision cataract surgery alone were used as a control group. One month postoperatively the eyes undergoing the combined procedure showed about the same with-the-rule astigmatic peak (mean: +0.32 dpt.) as the control group eyes (mean: +0.26 dpt.; p > 0.05). One year postoperatively both groups showed the same against-the-rule astigmatic shift (mean: -0.28 dpt.; p > 0.05). In conclusion, patients undergoing small incision cataract surgery combined with trabeculectomy showed a small amount of surgically induced astigmatism. When compared with patients which underwent small incision cataract surgery alone, the difference in astigmatic changes was found to be statistically not significant.

Effect of acetylcholine on intraocular pressure following small-incision cataract surgery

40 patients, who underwent phacoemulsification and implantation of a polyHema intraocular lens (IOGEL-1103) were assigned to two groups. After evacuation of Healon from the capsular bag behind the lens and the anterior chamber, either 0.5 ml of 1% acetylcholine chloride or 0.5 ml of balanced salt solution was injected into the anterior chamber. When compared with preoperative values, the mean intraocular pressure (IOP) 6 h postoperatively was unchanged in the acetylcholine group (0 +/- 8.5 mm Hg) but increased in the control group (+4.1 +/- 7.4 mm Hg). 18 h postoperatively, the mean intraocular pressure slightly decreased in the acetylcholine group (-0.5 +/- 6.1 mm Hg) compared with an increase of +1.4 +/- 4.4 mm Hg in the control group. Intraocular pressure exceeding 25 mm Hg was observed at 6 h in 2 (10%) patients of the acetylcholine group and in 4 (20%) of the control group. At 18 h, intraocular pressure was elevated in only 1 (5%) patient of the acetylcholine group and in 3 (15%) of the control group. From these results, we conclude that the evacuation of Healon from the capsular bag behind the implanted lens and acetylcholine reduce the incidence of postoperative elevations of intraocular pressure.

Evaluation of 150 consecutive cases of poly HEMA posterior chamber lenses implanted in the bag using a small-incision technique

We report the results of 150 capsular bag implantations of the IOGEL PC-12 hydrogel lens. Mean follow-up was seven months. Following capsulorhexis and phacoemulsification, a Faulkner folder was used to insert the lens through a 3.5 mm to 4.0 mm scleral tunnel incision. Initially, a number of surgical complications were encountered. Because of increasing experience and modified instrumentation and technique, these did not occur in the later cases. Visual results were good, all eyes gaining a best case visual acuity of 20/40 or better and 97% achieving 20/25 or better. Morphological results were satisfactory. Generally the lenses remained centered and at a distance from the iris. Retention of viscoelastic substance or debris between the lens and the posterior capsule, occasionally observed at the start of the series, has been avoided by retrolental aspiration. Persistent pigment dispersion, which was observed when the lens had been implanted in the sulcus, was not seen. Tolerance of the lens material was generally satisfactory. There were six cases (4%) of fibrinoid uveitis, which is a relatively high incidence. From our experience and results we conclude that this implantation procedure allowed controlled insertion and placement of the IOGEL lens, provided that adequate instrumentation and technique was used; visual performance was comparable to that of poly(methyl methacrylate) lenses; capsular bag fixation furnished satisfactory morphological results, provided an adequately shaped capsulorhexis was performed.

Long-term follow-up of argon laser trabeculoplasty in uncontrolled primary open-angle glaucoma. A study with standardized extensive preoperative treatment

The long-term results of 180 degrees argon laser trabeculoplasty (ALT) were studied in 61 eyes of 43 patients with uncontrolled primary open-angle glaucoma [intraocular pressure (IOP) less than 22 mm Hg]. In order to enhance the relevance of this prospective study, only eyes that had not responded to medication despite standardized extensive therapy were followed up over an average period of 4.4 years [52.8 +/- 7.3 (mean +/- SD) months]. The success rate of treatment (decrease in IOP less than 5 mm Hg, IOP below 20 mm Hg, stable visual field, stable optic nerve head and no further laser or surgical intervention) after 4.4 years was 73.7%. The mean decrease in IOP was 8.5 +/- 2.9 mm Hg (mean +/- SD). Eyes receiving ALT before cataract surgery retained control of IOP after surgery. A comparable pressure control was also attained with those eyes that had undergone previous trabeculectomy. Failures (26.3%) all occurred in the 1st year after treatment. The results and conclusions from our study are compared with those reported in the literature. The different theories regarding the mechanisms of action of ALT are discussed.