Effect of endocyclophotocoagulation on refractive outcomes in angle-closure eyes after phacoemulsification and posterior chamber intraocular lens implantation

Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study

Aims and background

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows.

Methods

All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures.

Results

A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively.

Conclusion

Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious.

Clinical significance

Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons.

How to cite this article

Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

The place of endoscopic laser cyclodestruction in the system of microinvasive glaucoma surgery

Glaucoma is one of the leading causes of irreversible blindness in the world. Reducing intraocular pressure is the only way to slow down the progression of glaucomatous optic neuropathy. Minimally invasive glaucoma surgery aims to provide a safer way of reduction of intraocular pressure than traditional methods, and at the same time it is capable to reduce dependence on antihypertensive therapy. Cyclodestructive high-precision method of reducing the production of aquоeus humor occupies a confident position among modern minimally invasive glaucoma surgery methods. The data obtained as a result of studying the literature confirm our idea on the endoscopic laser cyclodestruction method as a minimally invasive, safe, reliable antiglaucomatous component of the combined surgical treatment of cataract and glaucoma.

Safety and Efficacy of Isolated Endoscopic Cyclophotocoagulation in Pseudophakic Patients with Primary Open-Angle Glaucoma-12-Month Follow-Up

Background: We evaluated the safety and efficacy of endoscopic cyclophotocoagulation (ECP) for eyes with primary open-angle glaucoma (POAG). Methods: We included a total of 104 pseudophakic eyes treated with ECP. Visual acuity and intraocular pressure (IOP, mmHg) measurements were evaluated preoperatively and on days 1 and 7 and 2 and 12 months postoperatively. IOP ≤ 15 or ≥30% reduction from baseline were defined as therapeutic success. Results: The mean baseline IOP was 23.89 ± 8.63, and it decreased significantly at the day 1 (16.25 ± 7.32, p < 0.0001), day 7 (17.81 ± 6.37, p < 0.0001), 2nd month (17.77 ± 8.54, p < 0.0001) and 12th month (16.42 ± 7.05, p < 0.0001) follow-up visits. Therapeutic success was achieved in 55 (61.80%) eyes at the 12-month follow-up. Patients with POAG duration longer than 10 years or those using alpha agonist eye drops had a lower rate of therapeutic success (odds ratio: 0.52, 95% CI = 0.32–0.85, p < 0.05 and odds ratio: 0.92, 95% CI = 0.55–0.95, p = 0.024, respectively). A longer disease course was associated with higher IOP values (Rs =+0.281; p = 0.024) postoperatively. The number of antiglaucoma medications decreased significantly from 2.55 ± 1.16 to 2.11 ± 1.14 (p = 0.003). The ECP complications included a minor IOP increase (9.37%), pupil irregularity (15.73%), and the presence of fibrin (3.29%). Conclusions: The ECP is an effective and safe option, especially in eyes with a shorter glaucoma course.

Comparing the Effect of Lens Extraction With Endocycloplasty to Lens Extraction Alone in Eyes With Plateau Iris Configuration: Pilot Study

PRECIS

Lens extraction with endocycloplasty (LE/ECPL) results in greater angle deepening than LE alone in plateau iris eyes. This study directly compares an LE/ECPL treatment group with a control group.

PURPOSE

Quantitatively determine the effect of LE/ECPL versus LE alone for eyes with plateau iris configuration/plateau iris syndrome (PIC/PIS) on angle parameters.

METHODS

Patients with PIC/PIS who underwent LE/ECPL or LE alone were reviewed. Eyes with ultrasound biomicroscopy-documented PIC that underwent anterior segment optical coherence tomography examination before and after treatment were included. Angle parameters, angle opening distance (AOD), trabecular-iris space area (TISA), and trabecular-iris circumference volume (TICV) were calculated. Angle parameters were compared between treatments using a 2-sample t test. P-values were adjusted by the false discovery rate method (P*). A paired t test was used to compare treated (nasal) and untreated (temporal) angles in LE/ECPL-treated eyes.

RESULTS

Twenty-three eyes of 14 participants were included. Ten eyes (43%) eyes of 7 participants were treated with LE/ECPL, and 13 eyes (57%) of 7 participants were treated with LE alone. Angles were deepened in both groups (P<0.001). Changes in AOD, TISA, and TICV showed that the magnitude of deepening in treated (nasal) quadrants was greater in LE/ECPL eyes than in LE alone eyes (P<0.05). ECPL-treated angles deepened more than the untreated angles by AOD, TISA, and TICV (P<0.002).

CONCLUSION

Our study suggests that LE/ECPL is more effective than LE alone in opening the anterior chamber angle and that ECPL deepens treated angles more than untreated angles. This study directly compares an LE/ECPL treatment group with a control group, LE alone, allowing for separation of the effect of ECPL from LE.

Refractive Outcomes of Cataract Surgery With or Without Endocyclophotocoagulation

PRECIS

Surgeons that perform cataract surgery combined with endocyclophotocoagulation (ECP) should rely on their preferred intraocular lens (IOL) calculation formula. There is no need to perform any correction to the IOL power, as this procedure does not modify the refractive outcome.

PURPOSE

The purpose of this study was to compare postoperative refractive outcomes in patients with glaucoma who underwent phacoemulsification and IOL implantation with or without ECP and the change in intraocular pressure (IOP) and number of antiglaucoma medications between groups.

METHODS

A cross-sectional study in which the medical records of the patients with any type of glaucoma, who underwent phacoemulsification with IOL implantation in the capsular bag in addition to ECP or as a standalone procedure from June 2016 to August 2019 were analyzed. Clinical data collected included axial length, steep, flat, and mean keratometry values, target spherical equivalent (SE) estimated by the SRK/T formula, manifest refraction SE at the 1-month follow-up, IOP, and number of antiglaucoma medications before and 12 months after surgery. Primary and secondary outcome measures were the mean predictive error (MPE), the postoperative SE, and the change in IOP after surgery in both groups, respectively. Significance was assessed using the Student t test for all variables between groups according to data distribution. P-values <0.05 were considered to be statistically significant.

RESULTS

A total of 196 eyes of 196 patients were included, 98 in the combined phacoemulsification-ECP group, and 98 in the non-ECP group. The observed MPE was -0.043±0.44, and 0.06±0.38 D MPE, respectively (P=0.079). Overall, 74.34% in the phacoemulsification-ECP group and 78.4% in the non-ECP group had a postoperative SE of ±0.50. The ECP group had lower IOP and a greater decrease in antiglaucoma medications at 12 months of follow-up.

CONCLUSIONS

SRK/T formula performed well in both groups, with no statistically significant difference in the MPE and the percentage of eyes achieving postoperative SE of ±0.50. We consider it is unnecessary to perform any kind of correction to the IOL power calculation when performing ECP.

The role of lens extraction in glaucoma management

Cataract extraction has become a much safer procedure with the development of phacoemulsification, extending its application in ocular conditions such as glaucoma for better disease control. This review aims at summarizing the effect of lens extraction with or without combined glaucoma surgeries in different types of glaucoma and describing the intraoperative techniques and changes of glaucoma care postoperatively. A comprehensive literature search was performed through Medline and PubMed, and 67 studies were selected for this review. In primary angle closure (PAC) diseases, studies have revealed significant intraocular pressure (IOP) and medication requirement reduction after lens extraction. Fewer studies described its application in primary open angle glaucoma (POAG) and ocular hypertension (OHT), but literature available suggests that it can also lead to better disease control. Likewise, lower postoperative IOP and pressure fluctuations have been shown in normal tension glaucoma (NTG). Advanced glaucoma, shallow anterior chamber and pseudoexfoliation glaucoma (PXG) are three difficult scenarios that are commonly encountered in cataract operations. Special techniques in preventing complications such as wipe out phenomenon are depicted. Goniosynechialysis, endoscopic cyclophotocoagulation and trabecular microbypass stents are a few of the popular choices of glaucoma procedures that can be performed concomitantly with phacoemulsification but evidence of their efficacy needs to be further verified. Cataract operation can improve visual field and retinal nerve fiber layer examination parameters and it is advised to set new baselines after the surgery for subsequent progression monitoring. Clearance of an optically significant cataract results in better quality of life, and with detailed and thorough explanation of the indications, expectations and risks of the surgery, cataract extraction could be considered even in cases of advanced glaucoma.

Visual outcomes of combined cataract surgery and minimally invasive glaucoma surgery

Minimally invasive glaucoma surgery (MIGS) has become a reliable standard of care for the treatment of glaucoma when combined with cataract surgery. This review describes the MIGS procedures currently combined with and without cataract surgery with a focus on visual outcomes based on the literature and the experience of the ASCRS Glaucoma Clinical Committee.

Refractive outcomes among glaucoma patients undergoing phacoemulsification cataract extraction with and without Kahook Dual Blade goniotomy

BACKGROUND

Glaucoma patients undergoing phacoemulsification alone have a higher rate of refractive surprise compared to patients without glaucoma. This risk is further increased with combined filtering procedures. Indeed, there are few and conflicting reports on the effect of combined phacoemulsification and micro-invasive glaucoma surgery (MIGS). Here, we look at refractive outcomes of glaucoma patients undergoing phacoemulsification with and without Kahook Dual Blade (KDB) goniotomy.

METHODS

Retrospective chart review of 385 glaucomatous eyes of 281 patients, which underwent either phacoemulsification alone (n = 309) or phacoemulsification with KDB goniotomy (n = 76, phaco-KDB) at the University of Colorado. The main outcome was refractive surprise defined as the difference in target and postoperative refraction spherical equivalent greater than ±0.5 Diopter (D).

RESULTS

Refractive surprise greater than ±0.5 D occurred in 26.3% of eyes in the phaco-KDB group and 36.2% in the phacoemulsification group (p = 0.11). Refractive surprise greater than ±1.0 D occurred in 6.6% for the phaco-KDB group and 9.7% for the phacoemulsification group (p = 0.08). There was no significant difference in risk of refractive surprise when pre-operative IOP, axial length, keratometry or performance of KDB goniotomy were assessed in univariate analyses.

CONCLUSION

There was no difference between refractive outcomes of glaucomatous patients undergoing phacoemulsification with or without KDB goniotomy.

Intermediate results of phaco-endocycloplasty in an exclusive cohort of angle closure glaucoma: potential for change

PURPOSE

The objective of this study was to investigate the efficacy and safety of phaco-endocycloplasty in an exclusive cohort of primary angle closure disease/glaucoma.

METHODS

The study was interventional and non-comparative, carried out at a tertiary level eye care Institute. All adult patients (> 18 years) with angle closure disease, who had controlled or uncontrolled intra-ocular pressure (IOP) and had visually significant cataract, requiring surgery, and had undergone phaco-endocycloplasty, performed for 180°-210° simultaneously with cataract surgery, were included.

MAIN OUTCOME MEASURES

Primary outcome measure includes IOP, and secondary outcome measures include best corrected logMAR visual acuity (BCVA), anti-glaucoma medication (AGM) and complications.

RESULTS

Thirty-two eyes of 28 patients were included. Median follow-up was 15 months (range 3-42 months, Q1 7.5, Q3 18, IQR 10.5). Median IOP pre-procedure (20.5 mmHg, range 11-46, Q1 16.75, Q3 31, IQR 14.25) decreased significantly post-procedure at last follow-up (IOP 16 mmHg, range 10-20, Q1 12, Q3 17.5, IQR 5.5) (p < 0.001). There was significant decrease in use of AGM (median 3 pre-procedure, range 1-5, Q1 2, Q3 3.25, IQR 1.25) at last follow-up (median 0) (p < 0.001) post-procedure. Median logMAR BCVA improved from 0.4 (Q1 0.3, Q3 0.625, IQR 0.325) to 0.05 (Q1 0, Q3 0.3, IQR 0.3) at last follow-up (p < 0.001). None of the patients had serious sight-threatening complications.

CONCLUSIONS

This study indicates that phaco-endocycloplasty can effectively control IOP, significantly reducing need for AGM, without compromising safety, in angle closure glaucoma. When combined surgery is indicated, this conjunctiva-sparing procedure may be employed in the management of coexisting cataract and glaucoma prior to bleb-forming surgery.

A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety

As cataract occurs frequently in patients with glaucoma, combining phacoemulsification and endoscopic cyclophotocoagulation has been gaining attention recently due to its minimally invasive nature. A variety of studies had evaluated the efficacy and safety of this procedure and had shown extremely promising results. This review article has shown here that combined phacoemulsification and endoscopic cyclophotocoagulation procedure could effectively reduce intraocular pressure in medically uncontrolled glaucoma patients while avoiding serious complications associated with traditional cyclophotocoagulation procedure and adverse effects related to filtering surgery such as trabeculectomy.

Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma

Primary angle closure glaucoma (PACG) is more blinding (1 in 4 cases) than primary open angle glaucoma (1 in 10 cases). Cataract surgery is an effective initial treatment for majority of cases of PACG. However, cataract surgery alone may not be enough to control intraocular pressure (IOP) in cases with extensive synechial angle closure glaucoma. It is reported that glaucoma drainage surgery is needed in 12% of PACG cases after cataract surgery. Some experts combine cataract surgery with either goniosynechialysis (GSL) or endocyclophotocoagulation (ECP) to enhance IOP control. However, neither combination ensures complete success. We report three subjects with extensive synechia! angle closure in whom we facilitated a technique that combines lens extraction with ECP and endoscopic-GSL (PIECES). We demonstrated that this combined technique was a more effective and efficient method of achieving lower IOP in the presence of extensive synechial PACG. We believe that it addresses both the inflow and outflow of the aqueous humor simultaneously. Two out of three patients had good IOP control without medication and one patient needed one drop after a minimum 12 months of follow up. Furthermore, it may reduce the need for medical therapy and future more invasive glaucoma drainage surgery. How to cite this article: Alaghband P, Rodrigues IAS, Goyal S. Phacoemulsification with Intraocular Implantation of Lens, Endocyclophotocoagulation, and Endoscopic-Goniosynechialysis (PIECES): A Combined Technique for the Management of Extensive Synechial Primary Angle Closure Glaucoma. J Curr Glaucoma Pract 2018;12(1):45-49.

Refractive outcomes of phacoemulsification cataract surgery in glaucoma patients

PURPOSE

To evaluate refractive outcomes after phacoemulsification cataract surgery in patients with glaucoma.

SETTING

University of Colorado Health Eye Center, Aurora, Colorado, USA.

DESIGN

Retrospective case series.

METHODS

The incidence of refractive surprise was evaluated in patients with and without glaucoma after phacoemulsification cataract surgery. Refractive surprise was defined as the difference in spherical equivalent of the refractive target and postoperative refraction in diopters (D).

RESULTS

The study comprised 206 eyes in the glaucoma group and 1162 control eyes. The refractive surprise greater than ±0.5 D and ±1.0 D was 29.9% and 4.9% in the control group and 40.3% (P = .0061) and 11.2% (P = .0011) in the glaucoma group. Primary open-angle glaucoma (POAG) (n = 154 eyes), chronic angle-closure glaucoma (n = 18 eyes), and pseudoexfoliation glaucoma (n = 23 eyes) had odds ratios of 1.90 (P = .1760), 14.54 (P = .0006), and 7.27 (P = .0138), respectively, of refractive surprise greater than ±1.0 D compared with patients without glaucoma. Refractive surprise was noted more often in POAG eyes with axial lengths longer than 25.0 mm (P = .0298). Glaucoma eyes had worse mean postoperative corrected distance visual acuity than control eyes (glaucoma: 0.1088 logarithm of the minimum angle of resolution [logMAR]; controls: 0.0358 logMAR; P = .01).

CONCLUSION

Patients with a diagnosis of glaucoma were more likely to have a refractive surprise and/or worse visual outcome after phacoemulsification cataract surgery.