Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract

Phacoemulsification with gonioscopy-assisted transluminal trabeculotomy versus phacoemulsification alone in primary angle closure glaucoma: A randomized controlled study

PURPOSE

To assess the safety and efficacy of combining phacoemulsification with gonioscopy-assisted transluminal trabeculotomy (GATT) compared to phacoemulsification alone in the management of primary angle closure glaucoma (PACG).

METHODS

Prospective, institutional study in which eyes requiring surgery for PACG were randomized to undergo phacoemulsification followed by GATT (phaco-GATT group) or phacoemulsification alone. Success was defined as having a final IOP of 6-20 mmHg with no subsequent glaucoma surgery or vision-threatening complications.

RESULTS

Thirty-six eyes underwent phaco-GATT with 360° angle incision and 38 eyes underwent phacoemulsification alone. IOP and glaucoma medications were significantly lower in the phaco-GATT group at 1, 3, 6, 9 and 12 months. The success rate in the phaco-GATT group was 94.4% after 12.16 ± 2.03 months, with 75% of eyes being off medications compared to 86.8% after 12.47 ± 4.27 months in the phaco group, with 42.1% off medications. (p = 0.008). Hyphema and fibrinous anterior chamber reaction were the most common complications in the phaco-GATT group and resolved with conservative treatment or required YAG capsulotomy. Although this delayed visual rehabilitation in the phaco-GATT group, it did not affect the final visual outcome with no significant difference in the final best-corrected visual acuity between both groups (p = 0.25).

CONCLUSION

Combining phacoemulsification with GATT in PACG yielded more favourable outcomes in terms of IOP, glaucoma medications and surgical success. Although the postoperative hyphema and fibrinous reaction may delay visual rehabilitation, GATT further lowers the IOP by breaking residual peripheral anterior synechiae and removing the dysfunctional trabeculum circumferentially, while avoiding the risks inherent in more invasive filtering procedures.

Does Cataract Extraction Significantly Affect Intraocular Pressure of Glaucomatous/Hypertensive Eyes? Meta-Analysis of Literature

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the effect of cataract extraction on intraocular pressure at 6, 12, and 24 months and their difference compared to the baseline in diverse glaucoma subtypes.

MATERIALS AND METHODS

We carried out research in the MEDLINE, Cochrane Library and EMBASE databases, as of April 2022 for relevant papers, filtered according to established inclusion and exclusion criteria. The meta-analysis evaluated the Mean Reduction and relative Standard Error in these subpopulations at predetermined times. A total of 41 groups (2302 eyes) were included in the systematic review. Due to the significant heterogeneity, they were analysed through a Random Effects Model.

RESULTS

We obtained these differences from baseline: (1) Open Angle Glaucoma at 6, 12 and 24 months, respectively: -2.44 mmHg, -2.71 mmHg and -3.13 mmHg; (2) Angle Closure Glaucoma at 6, 12 and 24 months, respectively: -6.81 mmHg, -7.03 mmHg and -6.52 mmHg; (3) Pseudoexfoliation Glaucoma at 12 months: -5.30 mmHg; (4) Ocular Hypertension at 24 months: -2.27 mmHg.

CONCLUSIONS

Despite a certain variability, the reduction in ocular pressure was statistically significant at 6, 12 and 24 months in both Open Angle Glaucoma and Angle Closure Glaucoma, the latter being superior. Data for Pseudoexfoliation Glaucoma and for Ocular Hypertension are available, respectively, only at 12 months and at 24 months, both being significant.

Phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized non-inferiority trial

PURPOSE

To investigate the effectiveness and safety of phacogoniotomy versus phacotrabeculectomy (PVP) among patients with advanced primary angle-closure glaucoma (PACG) and cataracts.

DESIGN

Multicenter, randomized controlled, non-inferiority trial.

METHODS

A total of 124 patients (124 eyes) with advanced PACG and cataracts were enrolled, with 65 in the phacogoniotomy group and 59 in the phacotrabeculectomy group. Patients were followed up for 12 months with standardized evaluations. The primary outcome was the reduction in intraocular pressure (IOP) from baseline to 12 months postoperatively, of which a non-inferiority margin of 4 mmHg was evaluated. Secondary outcomes included the cumulative surgical success rate, postoperative complications, and changes in the number of glaucoma medications.

RESULTS

After 12 months, phacogoniotomy demonstrated non-inferiority to phacotrabeculectomy in terms of IOP reduction, with mean IOP reductions of - 26.1 mmHg and - 25.7 mmHg (P = 0.383), respectively, from baseline values of around 40 mmHg. Both groups experienced a significant reduction in the mean number of medications used postoperatively (P < 0.001). The cumulative success rate was comparable between the groups (P = 0.890). However, phacogoniotomy had a lower rate of postoperative complications and interventions (12.3% and 4.6%) compared to phacotrabeculectomy (23.7% and 20.3% respectively). The phacogoniotomy group reported shorter surgery time (22.1 ± 6.5 vs. 38.8 ± 11.1 min; P = 0.030) and higher quality of life (EQ-5D-5 L) improvement at 12 months (7.0 ± 11.5 vs. 3.0 ± 12.9, P = 0.010) than the phacotrabeculectomy group.

CONCLUSIONS

Phacogoniotomy was non-inferior to phacotrabeculectomy in terms of IOP reduction for advanced PACG and cataracts. Additionally, phacogoniotomy provided a shorter surgical time, lower postoperative complication rate, fewer postoperative interventions, and better postoperative quality of life.

Efficacy and Safety of Different Types of Intraocular Pressure-Lowering Surgeries in Patients with Primary Angle Closure (PAC) or PAC Glaucoma: Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

To compare the intraocular pressure (IOP)-lowering effect of different types of surgery available in the literature using a network meta-analysis (NMA) based on a systematic review.

METHODS

PubMed and the Cochrane database were searched. Randomized clinical trials involving surgical interventions for high IOP for PAC (primary angle closure) or PACG (primary angle closure glaucoma) were included. Descriptive statistics and outcomes were extracted. Bayesian NMA was performed to compare the IOP-lowering effect and the change in the number of antiglaucoma drugs required between baseline and endpoint, as well as success rates.

RESULTS

This NMA included 21 articles with 1237 eyes with PAC or PACG. Interventions were characterised as phacoemulsification (phaco), trabeculectomy, goniosynechialysis (GSL) with viscoelastic or blunt device, goniosurgery (GS) (trabeculotomy or goniotomy), micro-bypass stent (Istent®), endocyclophotocoagulation (ECPL) or various combinations of these procedures. Phaco+GSL [-1.73 (95%CrI: -3.53 to -0.13)] and phaco+GSL+GS [-3.92 (95%CrI: -6.91 to -1.31)] provided better IOP lowering effects than phaco alone. Phaco+trabeculectomy [-3.11 (95%CrI: -5.82 to -0.44)] was inferior to phaco+GSL+GS. Phaco+trabeculectomy [-0.45 (95%CrI: -0.81 to -0.13)] provided a better outcome in terms of reducing the need for antiglaucoma drug compared to phaco alone. There were no differences between the other surgeries in terms of reduction of antiglaucoma drug number and IOP lowering effect. Success rates were similar for all surgical procedures.

CONCLUSIONS

Phaco+GSL+GS showed the most promising results for lowering IOP. Phaco+trabeculectomy resulted in a significant reduction in the number of antiglaucoma drugs compared to phaco alone.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

Predictors of long-term intraocular pressure control after lens extraction in primary angle closure glaucoma: results from the EAGLE trial

BACKGROUND/AIMS

To assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria.

METHODS

This study is a secondary analysis of EAGLE data where we define the primary outcome of 'good responders' as those with IOP<21 mm Hg without requiring additional surgery and 'optimal responders' as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response.

RESULTS

A total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined 'good response' criterion compared with 67% in the LPI arm, and 66% met 'optimal response' criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months.

CONCLUSION

Patients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.

The Treatment of Primary Angle-Closure Glaucoma with Cataract: A Systematic Review and Meta-Analysis of Randomized Controlled Trails

BACKGROUND

Currently, there is no generally approved surgical treatment for patients with primary angle-closure glaucoma (PACG) and co-existing cataracts. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of phacoemulsification and phacotrabeculectomy in PACG patients with cataract.

METHODS

Diverse databases were searched, including PubMed, MEDLINE, EMBASE, Cochrane Library, Chinese Journal Full-text Database (CNKI), Wanfang database, and China Science and Technology Journal Database, for randomized controlled trials (RCTs) on phacoemulsification and phacotrabeculectomy for the treatment of PACG published up to 30 June 2021. ReviewManager (RevMan) version 5.4 software was used for the meta-analysis, and the effective quantity of measurement data was measured by the mean difference (MD) and 95% confidence interval (CI). The effect of counting data was measured by odds ratio (OR).

RESULTS

Our search of the databases identified 14 RCTs that satisfied the search criteria. Meta-analysis of these 14 RCTs showed that at the 1 month postoperative follow-up, intraocular pressure (IOP) of patients in the phacoemulsification group was higher than that of patients in the phacotrabeculectomy group (MD 2.04, 95% CI 1.42-2.65; P < 0.00001). However, the postoperative IOP was not significantly different between the two groups at the 3, 6, and 12 months postoperative follow-ups (P = 0.52, P = 0.51, and P = 0.05, respectively). More medications for IOP reduction were required by patients in the phacoemulsification group compared with those in the phacotrabeculectomy group at 3 months postoperation (MD 0.76, 95% CI 0.33-1.18; P = 0.0005), 6 months postoperation (MD 0.66, 95% CI 0.15-1.18; P = 0.01), and 12 months postoperation (MD 0.76, 95% CI 0.22-1.30; P = 0.006). Patients in the phacoemulsification group obtained better best corrected visual acuity (BCVA) than those in the phacotrabeculectomy group (MD - 0.17, 95% CI - 0.34 to - 0.01; P = 0.04) at 3 months postoperation, but there was no significant difference in BCVA between the two groups at 6 and 12 months postoperation (P = 0.33 and P = 0.56, respectively). The deepened anterior chamber was more obvious in patients in the phacoemulsification group versus those in the phacotrabeculectomy group (MD 0.61, 95% CI 0.03-1.18; P = 0.04). Patients in the phacoemulsification group experienced fewer postoperative complications than those in the phacotrabeculectomy group (OR 0.27, 95% CI 0.17-0.42; P < 0.00001).

CONCLUSION

Our results provide evidence that phacotrabeculectomy has advantages over phacoemulsification for the treatment of PACG in terms of better IOP and reduced medication need during the early stage post surgery. However, in terms of the complication risk, phacoemulsification is the more secure treatment option.

Ten-year outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease

PURPOSE

To investigate the long-term outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease (PACD).

STUDY DESIGN

Retrospective case series.

METHODS

We reviewed the medical records of 87 eyes of 87 patients with PACD who underwent uncomplicated cataract surgery alone at the Kobe City Medical Center General Hospital. Only patients with a minimum follow-up of 10 years were included. The patients were divided into PACD spectrum categories: primary angle-closure glaucoma (PACG), primary-angle closure (PAC), and primary angle-closure suspect (PACS). The treatment outcomes were compared among the 3 groups. Intraocular pressure (IOP), number of glaucoma eye drops, requirement of additional glaucoma treatment, visual field progression, and progression to glaucoma during the follow-up period were evaluated.

RESULTS

Among the 87 patients, 39 had PACG; 26, PAC; and 22, PACS. Ten years after surgery, the IOP had significantly decreased from baseline in all 3 groups. The rate of requirement of additional glaucoma treatment during the follow-up period was significantly higher in the PACG group than in the other groups. Almost half of the patients with PACG required additional glaucoma treatment; of those patients, six (15.4%) underwent glaucoma surgery. Three patients (11.5%) with PAC required additional glaucoma medication. Visual field progression was observed in 28.1% of the patients with PACG. In 1 patient with PAC, the condition progressed to PACG, but there was no such progression in any of the patients with PACS.

CONCLUSIONS

We confirmed that cataract surgery had a long-term (> 10 years) effect on IOP reduction in eyes with PACD. Early intervention with cataract surgery may be preferable for glaucoma management in patients with PACD.

Meta-Analysis of Phacoemulsification and Laser Peripheral Iridotomy in the Treatment of Primary Angle-Closure Glaucoma

Background

In this meta-analysis, we aimed to systematically compare the efficacy and safety of phacoemulsification and laser peripheral iridotomy (LPI) in the treatment of primary angle-closure glaucoma (PACG).

Method

We searched PubMed, MEDLINE, EMBASE, the Cochrane Library, the Chinese Journal Full-text Database (CNKI), the Wanfang database, and the China Science and Technology Journal Database for randomized controlled trials (RCTs) of phacoemulsification and LPI in the treatment of PACG published up to September 30, 2022. Postoperative intraocular pressure (IOP), anterior chamber depth (ACD), complications, corneal endothelial cell count, and best-corrected visual acuity (BCVA) were compared. The effective quantity of measurement data was measured by the mean difference (MD) and 95% confidence interval (CI). The effect of counting data was measured by the odds ratio (OR).

Result

A total of 1731 potential studies were identified, and after screening, 8 RCT studies were included. The results of the meta-analysis showed that, compared to the LPI group, the patients in the phacoemulsification group showed lower IOP six and twelve months after operation (MD-3.39, 95% CI -4.15∼-2.63, P < 0.00001; -2.29, -3.52∼-1.06, 0.0003). The ACD in the phacoemulsification group was significantly deeper than that in the LPI group (1.59, 1.10∼2.09, 0.00001). Meanwhile, the incidence of complications in the phacoemulsification group was lower than that in the LPI group (OR = 0.46, 0.29∼0.72, 0.0006). There was no statistically significant difference between the phacoemulsification group and the LPI group in corneal endothelial cell count and BCVA at 6 and 12 months after operation (P=0.38; 0.11; 0.81).

Conclusion

Compared with LPI, phacoemulsification is safer and more effective in the treatment of PACG, especially in controlling IOP and minimizing postoperative complications.

One-Year Results of a Multicenter Study: Intraocular Pressure-Lowering Effect of Combined Phacoemulsification, Goniosynechialysis, and Goniotomy for Cases of Advanced Primary Angle-Closure Glaucoma With Cataract

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering effect of the combination of phacoemulsification with intraocular lens implantation (PEI), goniosynechialysis (GSL), and goniotomy (GT) in eyes of advanced primary angle-closure glaucoma (PACG) with cataract.

DESIGN

Multicenter observational study.

METHODS

We enrolled 83 eyes of 83 patients with advanced PACG who received combined PEI+GSL+GT at 8 ophthalmic institutes. Each patient was assessed before treatment and at 1, 7 days, 1, 3, 6, and 12 months postsurgery. The criteria for complete success were IOP within 6 to 18 mm Hg and at least 20% of reduction in IOP from baseline without ocular hypotensive medications or reoperation. The definition of qualified success was similar to that of complete success, except for the need for ocular hypotensive medications. The potential prognostic factors for surgical success were investigated using a multivariate logistic model.

RESULTS

All participants completed 1 year of follow-up. Complete and qualified success were achieved in 74 (89.1%) and 79 (95.2%) of 83 eyes, respectively. The mean preoperative and postsurgical IOPs were 27.4±7.3 and 14.2±2.6 mm Hg, respectively. Participants used an average of 2.0 and 0.3 types of ocular hypotensive medications before and after surgery, respectively. The chief complications included hyphema (n=9), IOP spike (n=9), and corneal edema (n=8). None of the eyes required reoperation or developed vision-threatening complications. Multivariate analysis showed that older age was associated with a higher probability of complete success (odds ratio=1.13; 95% CI: 1.02-1.25; P=0.020).

CONCLUSIONS

The 1-year results of combination of PEI+GSL+GT in treating advanced PACG cases with cataract appear to be safe and effective. Further large-scale multination and multicenter studies are warranted.

Factors Associated with Deterioration of Primary Angle Closure after Lens Extraction

The purpose of the study was to explore factors associated with glaucomatous deterioration in eyes with primary angle closure (PAC) after lens extraction, including PAC suspect (PACS), PAC, and PAC glaucoma (PACG). We retrospectively analyzed data of 77 eyes with PACS, PAC, and PACG that underwent lens extraction with more than 2 years postoperative follow-up. Postoperative glaucoma progression was analyzed by either structural (optic disc/retinal nerve fiber layer (RNFL) photographs or optical coherent tomography (OCT)) or functional (visual field (VF)) criterion. Cox proportional hazard analysis (hazard ratio (HR)) was used to determine risk factors for progression using uni-and multivariate analysis. The analysis was conducted in groups with or without glaucomatous optic neuropathy (PACS/PAC vs. PACG). Forty-one eyes with PACS/PAC and 36 eyes with PACG were included. The mean postoperative follow-up period was 3.5 ± 1.4 years. Intraocular pressure (IOP) was reduced postoperatively from 23.1 ± 14.4 to 13.4 ± 2.1 mmHg. In the PACS/PAC group, seven eyes (17.0%) showed structural progression, but none showed progression in VF. Preoperative RNFL thickness was the only risk factor for structural progression (HR = 0.928, p = 0.002) in the PACS/PAC group. In the PACG group, 24 eyes (66.7%) showed structural progression and 12 eyes (33.3%) showed VF progression. Thinner preoperative RNFL thickness (HR = 0.964, p = 0.043) and high postoperative IOP fluctuation (HR = 1.296, p = 0.011) were significantly associated with VF progression; none of the factors were associated with structural progression. Angle closure eyes with thinner baseline RNFL thickness and higher postoperative IOP fluctuation may require careful follow-up for glaucoma progression after lens extraction.

Glaucoma Progression After Lens Extraction in Primary Angle-closure Glaucoma According to Angle-closure Mechanism

PRCIS

Long-term prognosis of primary angle-closure was assessed after lens extraction (LE) according to different mechanisms of angle closure (AC). Patients with pupillary block (PB) had a higher probability of glaucomatous progression than patients with plateau iris configuration (PIC).

PURPOSE

The aim was to investigate and compare the clinical characteristics and long-term prognosis of primary angle-closure disease (PACD) after LE according to different mechanisms of AC.

METHODS

In this retrospective observational cohort study, 118 eyes with PACD that underwent LE (mean follow-up; 6.0±3.5 y after surgery) were included. PACD eyes were categorized into three subgroups according to their dominant AC mechanisms, determined by anterior segment optic coherent tomography obtained before LE; PB, PIC, and exaggerated lens vault (ELV). Postoperative glaucomatous progression was determined according to functional (visual field) or structural (optic disc photographs or optic coherent tomography measured retinal nerve fiber layer thickness) criteria. Univariate and multivariate logistic regression analysis was performed to determine the risk factors associated with glaucomatous progression.

RESULTS

Fifty-two, 51, and 15 eyes with PB, PIC, and ELV, respectively, were included. All eyes showed significant intraocular pressure reduction, with a greater reduction in the ELV group than in the PB group after LE (27.0% vs. 12.5%, P=0.018). Lower baseline retinal nerve fiber layer thickness [odds ratio (OR): 0.966, P=0.004] and thinner central corneal thickness (OR: 0.985, P=0.021), and the PB group (OR: 2.891, P=0.022, reference to PIC group) were significantly associated with glaucomatous progression after LE.

CONCLUSIONS

In eyes with PACD, glaucoma progression was observed following LE despite reduced intraocular pressure. The probability of progression was highest in eyes with pupil block as a mechanism of AC. Close monitoring of glaucoma in these patients is suggested.

Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial

PRCIS

We used anterior segment optical coherence tomography to investigate anterior chamber angle in primary angle-closure glaucoma (PACG) eyes following phacoemulsification and phacotrabeculectomy. Angle widening was significantly greater after phacoemulsification up to 6 months after the surgery.

PURPOSE

To compare anterior chamber angle following 2 common surgeries for PACG.

METHODS

One hundred ten glaucoma patients were evaluated in this single center, prospective, randomized clinical trial. Those with concomitant PACG and senile cataract and without a history of ocular surgery, trauma, or chronic miotic use were recruited. Monocular patients were also excluded. Finally, 52 eligible subjects were randomly assigned to phacoemulsification ("Phaco" group, 25 eyes) or phacotrabeculectomy ("Combined" group, 27 eyes) surgeries. A swept-source, anterior segment optical coherence tomography device (CASIA SS-1000 OCT) was used to image the anterior segment. Mask graders used the images to measure the following parameters before and 1 week, 1 month, and 6 months after surgery: angle opening distance at 500 µm, trabecular iris surface area at 500 µm, and trabecular iris angle at 500 µm.

RESULTS

There was no significant difference between study groups regarding best-corrected visual acuity, intraocular pressure (IOP), and the number of glaucoma medications in preoperative or postoperative visits (P>0.076). Also, the measured angle parameters were not statistically significantly different between the 2 groups before surgery (P>0.123). After surgery, all measured parameters were significantly increased in both groups (P<0.0001). At the 6-month follow-up, nasal angle opening distance at 500 µm was 0.383±0.027 vs. 0.349±0.017, trabecular iris surface area at 500 µm was 0.141±0.007 vs. 0.125±0.005, and trabecular iris angle at 500 µm was 40.1±12.9 vs. 34.6±3.1 in Phaco and Combined groups, respectively (P<0.0001 for all).

CONCLUSIONS

Anterior chamber angle widening by anterior segment optical coherence tomography was observed in PACG patients following surgery and was significantly greater after phacoemulsification compared with combined phacotrabeculectomy at all time points. Similar IOP and medication burden were noted for up to 6 months as secondary outcomes. The contribution of angle changes to the IOP-lowering effect of phacoemulsification in PACG eyes needs further study.

Efficacy and safety of phacotrabeculectomy versus phacogoniotomy in advanced primary angle-closure glaucoma: study protocol for a multicentre non-inferiority randomised controlled trial (PVP Study)

INTRODUCTION

Primary angle-closure glaucoma (PACG) has a high prevalence and blinding rate across Asia. The first-line treatment of PACG is surgery, and phacotrabeculectomy remains the mainstream surgery for advanced PACG. However, it may cause vision-threatening complications with long learning curve. Minimally invasive glaucoma surgery has been gradually used in PACG combined with cataract surgery and achieved efficacy without excessive injury, of which goniotomy is the most commonly performed. Therefore, this study aimed to conduct a multicentre, non-inferiority randomised controlled clinical trial to compare the efficacy and safety of phacotrabeculectomy versus phacogoniotomy in advanced PACG.

METHODS AND ANALYSIS

This is a non-inferiority multicentre randomised controlled trial and will be conducted at eight ophthalmic departments and institutes in China. 124 patients with advanced PACG will be enrolled and randomised to undergo phacotrabeculectomy or phacogoniotomy. Comprehensive ophthalmic examinations will be performed before and after the surgery. The primary outcome is the change of intraocular pressure at 12 months after surgery compared with the baseline intraocular pressure. An extended follow-up period of 36 months will be required. Cumulative success rate of surgery, intraoperative and postoperative complications, and number of anti-glaucomatous medications will also be compared between the groups as secondary outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the ethical committee of Zhongshan Ophthalmic Center, Sun Yat-sen University, China (ID: 2021KYPJ090) and all subcentres. All the participants will be required to provide written informed consent. The results will be disseminated through scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04878458.

Combined Phacoemulsification-Endoscopic Cyclophotocoagulation versus Phacoemulsification Alone in Primary Angle-Closure Glaucoma: A Pilot Randomized Controlled Trial

PURPOSE

To compare combined phacoemulsification plus endoscopic cyclophotocoagulation (ECP) versus phacoemulsification alone in primary angle-closure glaucoma (PACG) with coexisting cataract.

DESIGN

Prospective randomized controlled clinical trial-a pilot study.

PARTICIPANTS

Forty-eight PACG eyes of 48 patients with coexisting cataract.

INTERVENTION

Recruited patients were randomized into undergoing phacoemulsification plus ECP or phacoemulsification alone. After surgery, patients were followed up every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Twenty-seven PACG eyes were randomized to receive combined phacoemulsification plus ECP, and 21 PACG eyes underwent phacoemulsification alone. There was no statistically significant difference in mean preoperative IOP between combined phacoemulsification plus ECP and phacoemulsification groups (20.0 mmHg vs. 20.7 mmHg; P = 0.71). Phacoemulsification plus ECP resulted in lower mean postoperative IOP than phacoemulsification alone at all follow-up visits, but the differences only reached statistical significance at 1 month (P = 0.01), 12 months (P = 0.01), and 24 months (P = 0.04) postoperatively. There was no statistically significant difference in mean preoperative number of topical glaucoma drugs between combined phacoemulsification plus ECP and phacoemulsification groups (3.3 vs 3.1, P = 0.71). Combined phacoemulsification plus ECP resulted in lower glaucoma drug requirement than phacoemulsification alone at all follow-up visits, but the differences did not reach statistical significance at any time points postoperatively (P ≥ 0.05). Both groups were comparable in visual improvement, complication rate, need for additional surgical intervention, and visual field changes.

CONCLUSIONS

Combined phacoemulsification plus ECP is noninferior to phacoemulsification alone in controlling IOP in PACG eyes with cataract. Combined phacoemulsification plus ECP resulted in lower mean IOP and glaucoma drug requirement than phacoemulsification alone at all follow-up visits in this pilot study, but the differences did not reach statistical significance at the majority of time points. A large-scale randomized controlled trial is in progress to evaluate these differences.

Long-Term Effect of Early Phacoemulsification in Primary Angle Closure Glaucoma Patients with Cataract: A 10-Year Follow-Up Study

Purpose

To assess the 10-year effects of early phacoemulsification with intraocular lens (IOL) implantation in primary angle closure glaucoma (PACG) patients with cataract.

Patients and Methods

This prospective cohort study included 102 eyes of 102 patients with PACG. All patients had coexisting cataracts compromising vision. Patients underwent phacoemulsification and foldable IOL implantation. The main outcome measures were anterior chamber depth (ACD), angle width, value of intraocular pressure (IOP), and number of medications needed postoperatively and during follow-up.

Results

Half (53%) of the patients were female, with ages ranging from 55 to 73 with a mean of 59.82±5.19 years. Mean IOP decreased significantly from 22.15±2.08 mmHg at baseline to 14.08±2.13 mmHg postoperatively (p˂ 0.05). The ACD increased from 2.2±0.21 preoperatively to 3.73±0.25 postoperatively (p˂0.001). Nasal angle width increased postoperatively to 40.05±2.09 compared to the preoperative value of 16.02±2.08 (p˂0.001). Temporal angle width increased from 13.05±2.07 to 41.9600±1.94 (p˂0.001). Anti-glaucoma treatment significantly decreased postoperatively (p˂0.001). A significant positive correlation was detected between ACD and angle width, while a negative correlation was detected between IOP and both ACD and angle width (p˂0.001). There was also a significant negative correlation between postoperative angle width and IOP (p˂0.001). Preoperative lens thickness was positively correlated with preoperative IOP and number of medications, while it was negatively correlated with preoperative AC depth and angle width. Preoperative lens thickness positively correlated with postoperative IOP and medications. Complete and qualified success was achieved in 69.65% and 30.4% of cases, respectively, while 2.9% failed to be controlled. Visual acuity significantly improved from 0.17±0.1 to 0.9±0.08 (p˂0.001). All parameters showed high stability throughout the follow-up period.

Conclusion

Phacoemulsification with IOL implantation is a safe and effective early modality for long-term control of IOP in PACG patients with coexisting cataract. The effects can persist for at least 10 years.

Phacoemulsification versus Phacotrabeculectomy in Medically Controlled Primary Angle Closure Glaucoma with Cataract in an Indian Cohort: A randomized controlled trial

PURPOSE

To compare the outcomes of phacoemulsification with phacotrabeculectomy in primary angle closure glaucoma (PACG) eyes with medically controlled intraocular pressure (IOP).

METHODS

Prospective, randomized control trial including 33 eyes of 33 patients who underwent phacoemulsification (Phaco) and 37 eyes (37 patients) who underwent phacotrabeculectomy (PT). The primary outcome measure was survival defined as IOP control (IOP ≥ 6 and ≤ 21 mmHg without antiglaucoma medications (AGM) at different time points. Secondary outcome measures were the rate of visual recovery and complications.

RESULTS

The mean age in years (PT: 58.5 ± 9.8, Phaco:61.6 ± 8.9; p = 0.16), preoperative mean deviation in decibel (PT: -18.7 ± 9.3; Phaco: -16.6 ± 7.9; p = 0.32) and the mean follow up in years (PT: 2.5 ± 1.8; Phaco: 2.8 ± 2.0; p = 0.63) were similar in the two groups. The mean preoperative AGMs were more in the PT group (PT: 2.13 ± 0.97, Phaco: 1.60 ± 0.78; p = 0.01). In both the groups the survival was similar at all-time points (PT: 78% at 1-year and 52% at 5-years, Phaco: 80% at 1 year and 59% at 5 years (P = 0.82). The postoperative visual acuity in LogMAR was significantly better in the Phaco group at 1 month (PT: 0.22 ± 0.38, Phaco:0.06 ± 0.07; p = 0.02). Postoperative AGM (p = 0.68) and rate of visual field progression PT: -0.46 ± 0.41 dB/year; Phaco: -0.38 ± 0.73 dB/year; p = 0.67) were similar in both groups. One eye in PT group developed malignant glaucoma which resolved with laser hyaloidotomy and cycloplegic therapy.

CONCLUSIONS

More rapid visual recovery with similar IOP control and similar visual field stability favor phacoemulsification to phacotrabeculectomy in medically controlled PACG eyes with cataract.

Treatment Success Across Different Levels of Preoperative Disease Burden: Stratified Two-Year Outcomes from the Pivotal Trial of iStent inject ® Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract

PURPOSE

To examine effectiveness outcomes stratified by preoperative disease burden in the pivotal trial of iStent inject ® with cataract surgery (INJ) vs cataract surgery alone (CS).

MATERIALS AND METHODS

Prospective, 3:1 randomized, single-masked, concurrently-controlled, multicenter trial enrolling 505 subjects with cataract and mild-to-moderate primary open-angle glaucoma who underwent iStent inject implantation with phacoemulsification or phacoemulsification alone, and were followed for 2 years including annual medication washouts. Post hoc stratification was completed for baseline mean diurnal intraocular pressure (BL DIOP; Low-DIOP <25mmHg, Mid-DIOP ≥25 to <30 mmHg, High-DIOP ≥30mmHg) and preoperative medication burden (Low-Med 1 medication, Mid-Med 2 medications, High-Med ≥3 medications).

RESULTS

The 24-month primary and secondary effectiveness endpoints were met, with significant treatment-over-control differences in percent of eyes achieving ≥20% unmedicated DIOP reduction and in unmedicated DIOP reduction, respectively. In subgroup analyses, the proportions of INJ eyes achieving the primary endpoint remained steady across all BL DIOP (75.4%, 77.1%, 74.4% in Low/Mid/High-DIOP strata, respectively) and preoperative medication levels (76.8%, 70.8%, 79.7% in Low/Mid/High-Med strata, respectively); meanwhile, the proportions of CS eyes diminished with higher BL DIOP (64.5%, 63.6%, 33.3%, respectively) and more medications (69.0%, 63.3%, 29.4%, respectively). Regarding secondary effectiveness, postoperative DIOP reduction increased with higher BL DIOP in INJ eyes (6.2mmHg, 7.8mmHg, 9.8mmHg, respectively) but plateaued in CS eyes (5.2mmHg, 5.8mmHg, 5.4mmHg, respectively). INJ eyes also had consistent DIOP reduction regardless of preoperative medication burden (6.8mmHg, 6.7mmHg, 7.8mmHg, respectively), while DIOP reduction diminished with more medications in CS eyes (6.1mmHg, 5.0mmHg, 3.3mmHg, respectively). Safety was favorable, comparable to phacoemulsification alone.

CONCLUSION

Significant IOP reductions occurred across all levels of BL DIOP and preoperative medication burden in iStent inject eyes. DIOP reductions increased with higher BL DIOP and remained stable across all levels of preoperative medication burden, suggesting the device's potential utility in more medically challenging cases.

Comparison of Treatment Outcomes of Selective Laser Trabeculoplasty for Primary Open-Angle Glaucoma and Pseudophakic Primary Angle-Closure Glaucoma Receiving Maximal Medical Therapy

Selective laser trabeculoplasty (SLT) is a useful treatment for intraocular pressure (IOP) control. However, there are only a few reports which compare the outcomes of SLT between primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG). We compared the efficacy of SLT for patients with PACG following phacoemulsification with POAG receiving maximal medical therapy (MMT). Consecutive glaucoma patients followed up for at least 1 year after SLT were retrospectively evaluated and IOP reductions at 6 months and 12 months were analyzed. Seventy-six patients were included in the analyses. The baseline IOPs in the POAG and PACG group were 18.5 ± 3.3 mmHg and 16.9 ± 2.5 mmHg, respectively, with 2.8 ± 0.9 and 2.7 ± 0.8 types of IOP lowering medication. The average IOP at the 6-month and 12-month follow-up after SLT was significantly decreased and comparable in both the POAG and PACG groups. For those with a low baseline IOP, the effect of SLT on IOP reduction at 12 months was significantly better in the PACG than in the POAG group (p = 0.003). IOP reduction at 6 and 12 months after SLT was significantly greater in those with a high baseline IOP than those with a low baseline IOP (p < 0.0065). In summary, the one-year efficacy of SLT was equivalent in POAG and pseudophakic PACG patients receiving MMT; however, SLT was more effective in eyes with PACG than eyes with POAG when focusing on those with a lower baseline IOP.

Comparing the Safety and Efficacy of Phacogoniosynechialysis With Phacotrabeculectomy in the Management of Refractory Acute Primary Closure Angle Glaucoma With Cataract: A Multicenter Randomized Trial

PRCIS

Combined phacoemulsification-goniosynechialysis (phaco-GSL) and unaugmented phacotrabeculectomy were both found to be effective in treating eyes with significant cataract and medically unresponsive acute primary angle closure glaucoma (PACG). Phaco-GSL seemed to be safer, with fewer surgical complications, and achieved better visual acuity than phacotrabeculectomy.

OBJECTIVES

To compare the results of combined phaco-GSL with unaugmented phacotrabeculectomy in the management of eyes with medically unresponsive acute PACG and cataract.

PARTICIPANTS AND RESEARCH METHODS

This was a prospective randomized controlled trial involving patients with significant cataract and acute PACG who were not responsive to maximal medical therapy. Three ophthalmic centers in Hanoi, Vietnam, participated in this trial. Study subjects were randomized into 2 groups: phaco-GSL or phacotrabeculectomy. Of note, mitomycin-C or 5-fluorouracil were not used during trabeculectomy, but postoperative bleb needling with 5-fluorouracil injection(s) was allowed. The primary outcome of the study was the rate of postoperative surgical complications in the first 3 months after surgery. The secondary outcome, determined at 1 year, assessed whether treatment was completely successful [defined as intraocular pressure (IOP)<21 mm Hg without IOP-lowering drops], or partially successful (IOP<21 mm Hg with IOP-lowering drops). Treatment failure was defined as IOP≥21 mm Hg with maximal IOP-lowering drops.

RESULTS

In total, 79 eyes from 79 patients (62 females, 17 males) were recruited (42 and 37 eyes in the phaco-GSL and phacotrabeculectomy groups, respectively). There were no statistically significant differences between the 2 groups at baseline in terms of age, visual acuity, IOP, anterior angle width, or preoperative ultrasound biomicroscopy index. Postoperative complications in the first 3 months were seen more frequently in the phacotrabeculectomy group (62.2%) than in the phaco-GSL group (14.3%, P<0.01). At 1 year postsurgery, treatment was 100% successful in both groups, with no difference in the mean IOP (15.38±3.42 vs. 15.72±4.47 mm Hg). The visual field index improved significantly following surgery in both groups, but there was also no significant difference between the 2 groups. However, there was a significant difference in the best corrected visual acuity at 1 year, with patients in the phaco-GSL group achieving better vision (0.45±0.21 logMAR in the phaco-GSL group vs. 0.64±0.27 logMAR in the phacotrabeculectomy group, P=0.04). The mean angle width was also significantly larger in the phaco-GSL group than the phacotrabeculectomy group (2.34±0.33 vs. 1.25±0.41 Shaffer degrees). Similarly, on ultrasound biomicroscopy, the anterior chamber was deeper after 12 months (2.87±0.28 to 2.48±0.33 mm), and the mean trabecular-iris angle area was wider at 12 months (21.88±7.07 vs. 14.95±4.39 degrees) in the phaco-GSL than the phacotrabeculectomy group.

CONCLUSIONS

Phaco-GSL and phacotrabeculectomy were both effective in treating medically unresponsive cases of acute PACG with cataracts. However, phaco-GSL showed better visual outcomes, wider drainage angles postsurgery, and fewer complications than phacotrabeculectomy.

Intraocular Pressure Reduction after Femtolaser Assisted Cataract Surgery and Its Association with the Use of Ultrasound

Background and Objectives: To quantify the change in intraocular pressure (IOP) after phacoemulsification in patients having undergone femtolaser assisted cataract surgery (FLACS), and study the influence of the use of ultrasound on this change. Setting: Jules-Gonin Eye Hospital, University Department of Ophthalmology, Lausanne, Switzerland. Materials and Methods: Interventional study. Methods: All consecutive cases operated with FLACS and with complete data for the studied parameters were selected for inclusion in the study. Data had been prospectively collected and was analysed retrospectively. Linear regression was performed to explore the association of change in IOP with time of measure, ultrasound use, sex, age, and duration of surgery. Results: There was a mean decrease in intraocular pressure of 2.5 mmHg (CI 95% −3.6; −1.4, p < 0.001) postoperatively. No association between the change in intraocular pressure and ultrasound time or effective phaco time was observed when the data were analyzed one at a time or in a multiple linear regression model. There was no association with sex, age, nuclear density, presence of pseudoexfoliation, duration of surgery, and time of ocular pressure measurement. Eyes with preoperative IOP ≥ 21 mmHg had a more significant IOP reduction after surgery (p < 0.0001) as did eyes with an anterior chamber depth <2.5 mm (p = 0.01). Conclusion: There was a decrease in intraocular pressure six months after FLACS in our study similar to that in the published literature for standard phacoemulsification. The use of ultrasound may not influence the size of the decrease, whereas the preoperative IOP and anterior chamber depth do. FLACS may be as valuable as standard phacoemulsification for cases where IOP reduction is needed postoperatively.

Matched Cohort Study of Cataract Surgery With and Without Trabecular Microbypass Stent Implantation in Primary Angle-Closure Glaucoma

PURPOSE

To compare 1-year outcomes of phacoemulsification alone (phaco-only) vs phacoemulsification with implantation of 2 trabecular microbypass stents (iStent or iStent inject; phaco-stent) in eyes with primary angle-closure glaucoma (PACG).

DESIGN

Retrospective matched clinical cohort study.

METHODS

PACG eyes that underwent phaco-only vs phaco-stent at a single ophthalmology center. Groups were matched for baseline intraocular pressure (IOP) and medication use with a tolerance of ±2 mm Hg and ±1 medication, respectively. Primary outcomes included postoperative change in the mean IOP and medications. One-year outcomes were assessed using generalized estimating equations corrected for baseline intergroup differences.

RESULTS

One hundred fifty-eight eyes (79 per group) were included. At 1 year, IOP decreased by 13% (from 16.8 ± 3.1 mm Hg preoperatively) in the phaco-only group (P < .001) and by 27% (from 17.6 ± 3.2 mm Hg) in the phaco-stent group (P < .001). Medication use decreased by 11% (from 1.8 ± 1.3 medications preoperatively) in the phaco-only group (P < .001) and by 46% (from 2.2 ± 1.2 medications) in the phaco-stent group (P < .001). The phaco-stent group experienced significantly larger reductions in IOP and medications compared with the phaco-only group (P < .001). The incidence of IOP spikes was significantly greater in the phaco-only group (18%) compared with the phaco-stent group (4%; P = .005). Safety was favorable with few transient postoperative adverse events.

CONCLUSION

The results of this study highlight that phacoemulsification with implantation of 2 trabecular microbypass stents is more effective and possibly more protective than phaco-only in PACG eyes, as evidenced by significantly larger IOP and medication reductions and smaller incidences of IOP spikes among the phaco-stent eyes.

Lens extraction for chronic angle-closure glaucoma

BACKGROUND

Primary angle-closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block being the most common underlying mechanism. There is increasing evidence that lens extraction may relieve pupillary block and thereby improve IOP control. As such, comparing the effectiveness of lens extraction against other commonly used treatment modalities can help inform the decision-making process.

OBJECTIVES

To assess the effectiveness of lens extraction compared with other interventions in the treatment of chronic PACG in people without previous acute angle-closure attacks.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, one other database, and two trials registers (December 2019). We also screened the reference lists of included studies and the Science Citation Index database. We had no date or language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing lens extraction with other treatment modalities for chronic PACG.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology.

MAIN RESULTS

We identified eight RCTs with 914 eyes. We obtained data for participants meeting our inclusion criteria for these studies (PACG only, no previous acute angle-closure attacks), resulting in 513 eyes included in this review. The participants were recruited from a diverse range of countries. We were unable to conduct meta-analyses due to different follow-up periods and insufficient data. One study compared phacoemulsification with laser peripheral iridotomy (LPI) as standard care. Participants in the phacoemulsification group were less likely to experience progression of visual field loss (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13 to 0.91; 216 eyes; moderate certainty evidence), and required fewer IOP-lowering medications (mean difference [MD] -0.70, 95% CI -0.89 to -0.51; 263 eyes; moderate certainty evidence) compared with standard care at 12 months. Moderate certainty evidence also suggested that phacoemulsification improved gonioscopic findings at 12 months or later (MD -84.93, 95% CI -131.25 to -38.61; 106 eyes). There was little to no difference in health-related quality of life measures (MD 0.04, 95% CI -0.16 to 0.24; 254 eyes; moderate certainty evidence), and visual acuity (VA) (MD 2.03 ETDRS letter, 95% CI -0.77 to 4.84; 242 eyes) at 12 months, and no observable difference in mean IOP (MD -0.03mmHg, 95% CI -2.34 to 2.32; 257 eyes; moderate certainty evidence) compared to standard care. Irreversible loss of vision was observed in one participant in the phacoemulsification group, and three participants in standard care at 36 months (moderate-certainty evidence). One study (91 eyes) compared phacoemulsification with phaco-viscogonioplasty (phaco-VGP). Low-certainty evidence suggested that fewer IOP-lowering medications were needed at 12 months with phacoemulsification (MD -0.30, 95% CI -0.55 to -0.05). Low-certainty evidence also suggested that phacoemulsification may have improved gonioscopic findings at 12 months or later compared to phaco-VGP (angle grading MD -0.60, 95% CI -0.91 to -0.29; TISA500 MD -0.03, 95% CI -0.06 to -0.01; TISA750 MD -0.03, 95% CI -0.06 to -0.01; 91 eyes). Phacoemulsification may result in little to no difference in best corrected VA at 12 months (MD -0.01 log MAR units, 95% CI -0.10 to 0.08; low certainty evidence), and the evidence is very uncertain about its effect on IOP at 12 months (MD 0.50 mmHg, 95% CI -2.64 to 3.64; very low certainty evidence). Postoperative fibrin reaction was observed in two participants in the phacoemulsification group and four in the phaco-VGP group. Three participants in the phaco-VGP group experienced hyphema. No data were available for progression of visual field loss and quality of life measurements at 12 months. Two studies compared phacoemulsification with phaco-goniosynechialysis (phaco-GSL). Low-certainty evidence suggested that there may be little to no difference in mean IOP at 12 months (MD -0.12 mmHg, 95% CI -4.72 to 4.48; 1 study, 32 eyes) between the interventions. Phacoemulsification did not reduce the number of IOP-lowering medications compared to phaco-GSL at 12 months (MD -0.38, 95% CI -1.23 to 0.47; 1 study, 32 eyes; moderate certainty evidence). Three eyes in the phaco-GSL group developed hyphemas. No data were available at 12 months for progression of visual field loss, gonioscopic findings, visual acuity, and quality of life measures. Three studies compared phacoemulsification with combined phaco-trabeculectomy, but the data were only available for one study (63 eyes). In this study, low-certainty evidence suggested that there was little to no difference between groups in mean change in IOP from baseline (MD -0.60 mmHg, 95% CI -1.99 to 0.79), number of IOP-lowering medications at 12 months (MD 0.00, 95% CI -0.42 to 0.42), and VA measured by the Snellen chart (MD -0.03, 95% CI -0.18 to 0.12). Participants in the phacoemulsification group had fewer complications (risk ratio [RR] 0.59, 95% CI 0.34 to 1.04), and the phaco-trabeculectomy group required more IOP-lowering procedures (RR 5.81, 95% CI 1.41 to 23.88), but the evidence was very uncertain. No data were available for other outcomes.

AUTHORS' CONCLUSIONS

Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow-up; ultimately, the decision for intervention should be part of a shared decision-making process between the clinician and the patient. For people with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. There was insufficient evidence to draw any meaningful conclusions regarding phacoemulsification versus trabeculectomy. Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. These conclusions only apply to short- to medium-term outcomes; studies with longer follow-up periods can help assess whether these effects persist in the long term.

Long-term outcomes of prediction error after combined phacoemulsification and trabeculectomy in glaucoma patients

Background

To investigate long-term outcomes of prediction error after phacotrabeculectomy and to determine risk factors that may cause unstable prediction error after phacotrabeculectomy in glaucoma patients.

Methods

A total 120 eyes of 120 patients who had underwent uncomplicated phacotrabeculectomy (combined group) or phacoemulsification (phaco-only group) were included. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) were measured before and after surgery, and anterior segment parameters including anterior chamber depth (ACD), lens vault (LV), and anterior vault (AV) measured using anterior-segment optical coherence tomography were compared between the two groups. The mean absolute error (MAE) at 3, 6, 12, and 24 months postoperatively were compared. Risk factors associated with unstable prediction error (MAE ≥ 0.5) were investigated in the combined group.

Results

In both groups, BCVA was improved and IOP was decreased significantly. MAE at 3, 6, 12, 24 months postoperatively were not significantly different between two groups. The risk factors for unstable prediction error after 12 months of phacotrabeculectomy were old age and LV. Whereas, the only factor predicting unstable prediction error after 24 months of phacotrabeculectomy was LV. The cut-off value of LV for predicting unstable refractive error analyzed by the ROC curve was 0.855 mm.

Conclusions

Phacotrabeculectomy may be an effective treatment with stable long-term outcomes of prediction error similar to phacoemulsification in patients with glaucoma. However, elderly patients or patients with large LV may be predisposed to unstable prediction error after phacotrabeculectomy.

Comparison of Gonioscopy-assisted Transluminal Trabeculotomy Versus Trabeculectomy With Mitomycin C in Patients With Open-angle Glaucoma

PRCIS

Trabeculectomy (TRAB) lowers the intraocular pressure (IOP) more than gonioscopy-assisted transluminal trabeculotomy (GATT) at 18 months, with a reduction in IOP of 30% or more and a significant reduction in the number of glaucoma medications compared with baseline.

PURPOSE

To compare the IOP-lowering efficacy of GATT with mitomycin-C augmented TRAB in patients with uncontrolled open-angle glaucoma.

METHODS

Single-center, retrospective, comparative cohort study. One hundred ten consecutive patients (110 eyes) underwent GATT (n=61) or TRAB (n=49). The primary outcome measure was IOP reduction, defined as a percentage decrease ≥30% and absolute IOP≤18 mm Hg at 18 months with (qualified) or without (complete) medications. Secondary outcomes were visual field change, number of glaucoma medications, complications, and reintervention.

RESULTS

The mean±SD baseline IOP was 30.04±7.5 and 27.59±4.70 (P=0.072) with the mean number of medications of 3.08±0.73 and 2.92±0.91 (P=0.310) in TRAB and GATT, respectively. At 18 months, the mean±SD IOP was 15.26±3.47 mm Hg and 12.48±4.58 mm Hg after GATT and TRAB, respectively (P=0.002). The percentage of IOP lowering from baseline was 56.05±17.72 after TRAB and 42.04±15.56 after GATT (P<0.001). Percentages of complete and qualified success were 59% and 27% after TRAB and 46% and 31% after GATT (P=0.353). No change in visual field loss was observed in both groups. The mean reduction in medications was 2.3±1.4 and 2.1±1.5 in TRAB and GATT, respectively (P=0.493). The most frequent complication after TRAB was hypotony and after GATT hyphema. Reintervention occurred in 8.2% of cases after TRAB and in 14.8% after GATT (P=0.341).

CONCLUSIONS

IOP lowering was greater after TRAB than after GATT at 18 months with a significant reduction in the number of medications after both procedures. Complications and reintervention occurred equally in both groups but differed in type.

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.

Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract: Long-Term Clinical Outcomes

PRECIS

Phacotrabeculectomy was more effective in reducing intraocular pressure (IOP) and glaucoma drugs than phacoemulsification alone in primary angle-closure glaucoma (PACG) eyes with cataract but was associated with more postoperative complications, up to 5 years after surgery.

PURPOSE

The purpose of this study was to compare long-term clinical outcomes of phacoemulsification versus phacotrabeculectomy in PACG eyes with cataract.

PATIENTS AND METHODS

The 2 initial prospective randomized controlled trials recruited PACG eyes with cataract using the same criteria and randomized these eyes to receiving either phacoemulsification or phacotrabeculectomy. Clinical data up to 5 years of follow-up were pooled for retrospective analysis.

RESULTS

Clinical data of 35 patients in the phacoemulsification group and 44 patients in the phacotrabeculectomy group were analyzed. At 5 years after surgery, the mean IOP was decreased by 20.7% and 29.5% from before surgery to 5 years after phacoemulsification and phacotrabeculectomy, respectively (P<0.001 for both groups). Phacotrabeculectomy was significantly more effective than phacoemulsification in reducing IOP up to 5 years after surgery (P<0.001). At 5 years, the mean number of glaucoma drugs required±1 SD was 1.6±1.2 in the phacoemulsification group, and 0.7±1.0 in the phacotrabeculectomy group (P=0.004). Phacotrabeculectomy was associated with more postoperative complications than phacoemulsification up to 5 years (25 complications in the phacotrabeculectomy group versus 6 in the phacoemulsification group, P<0.001).

CONCLUSIONS

Phacoemulsification alone reduces IOP and the need for glaucoma drugs in PACG eyes with cataracts for up to 5 years. Phacotrabeculectomy was more effective in reducing IOP and glaucoma drugs than phacoemulsification alone but was associated with more postoperative complications, up to 5 years after surgery.

Differential Efficacy of Combined Phacoemulsification and Endocyclophotocoagulation in Open-angle Glaucoma Versus Angle-closure Glaucoma

PRéCIS:: This retrospective study found that combined phacoemulsification and endocyclophotocoagulation reduced intraocular pressure (IOP) to a greater degree in angle-closure glaucoma versus open-angle glaucoma and was effective for all stages of glaucoma.

PURPOSE

Endocyclophotocoagulation (ECP) laser treatment of the ciliary processes is believed to decrease IOP by reducing aqueous production. Anecdotal experience in angle-closure glaucoma suggests that it may also lower IOP by opening the drainage angle to promote aqueous outflow. This study sought to evaluate combined phacoemulsification and ECP (phaco/ECP) in eyes with different types and stages of glaucoma.

PATIENTS AND METHODS

A Retrospective chart review of eyes that underwent phaco/ECP between October 2010 and December 2016 at one institution was conducted.

RESULTS

In 63 eyes of 63 patients with an average of 3.0±1.7 years of follow-up, the 22 eyes with chronic angle-closure glaucoma (CACG) had greater IOP reduction and medication reduction than the 41 eyes with primary open-angle glaucoma at both 1 year (6.4 vs. 2.1 mm Hg, P=0.01; 0.9 vs. 0.2 medications, P=0.04) and final follow-up (6.2 vs. 2.4 mm Hg, P=0.02; 0.9 vs. 0.3 medications, P=0.05). There was no difference in IOP reduction or medication reduction for eyes with mild, moderate, or advanced glaucoma at both 1 year (3.5, 3.9, 0.5 mm Hg, respectively, P=0.18; 0.3, 0.6, 0.4 medications, P=0.58) and final follow-up (3.3, 4.8, 0.7 mm Hg, P=0.11; 0.1, 0.8, 0.4 medications, P=0.14).

CONCLUSIONS

Eyes with CACG were more responsive to phaco/ECP in terms of IOP and medication reduction compared with eyes with primary open-angle glaucoma. This finding could be partially or entirely due to concurrent cataract extraction and greater CACG preoperative IOP. Phaco/ECP was effective in all stages of glaucoma.

Mitomycin C-augmented Phacotrabeculectomy Versus Phacoemulsification in Primary Angle-closure Glaucoma: A Randomized Controlled Study

PRECIS

Phacotrabeculectomy yielded similar results to phacoemulsification in primary angle-closure glaucoma (PACG) in terms of intraocular pressure (IOP) lowering, glaucoma medications and success rates. Although releasable sutures may have reduced the risk of hypotony; complications and interventions were more common with phacotrabeculectomy.

PURPOSE

To compare the efficacy and safety of phacotrabeculectomy using releasable sutures and adjunctive mitomycin C versus phacoemulsification alone in the management of PACG.

PATIENTS AND METHODS

In total, 63 eyes of 63 PACG patients were randomized to undergo either mitomycin C-augmented phacotrabeculectomy with tight scleral flap closure using releasable sutures aiming at no flow or phacoemulsification alone. The primary outcomes were success rates and complications. Secondary outcomes were IOP and glaucoma medications.

RESULTS

The IOP and glaucoma medications were significantly reduced at 1, 3, 6, and 12 months postoperatively in both groups (P<0.001). There was no statistically significant difference in IOP, IOP reduction, success rates, or survival times between both groups. Glaucoma medications were only significantly lower in the phacotrabeculectomy group at 1 and 3 months. The rates of postoperative interventions and complications were higher in the phacotrabeculectomy group. Complete success, defined as an IOP of 6 to 21 mm Hg on no medications and with no signs of glaucoma progression, was achieved in 58% in the phacotrabeculectomy group, compared with 62% in the phacoemulsification group (P=0.9). Only 2 eyes (6%) in the phacoemulsification group required a subsequent trabeculectomy.

CONCLUSIONS

Trabeculectomy did not seem to add an advantage when combined with phacoemulsification in PACG patients and was associated with more postoperative interventions. Despite the use of releasable sutures to allow titration of the IOP postoperatively, the rate of hypotony and other complications was higher in the phacotrabeculectomy group.

Long term outcomes of cataract surgery in severe and end stage primary angle closure glaucoma with controlled IOP: a retrospective study

Background

To investigate the long term surgical outcomes of cataract surgery in severe and end stage glaucoma patients with preoperative intraocular pressure less than 21 mmHg, and to detect the associated factors.

Methods

A retrospective study of primary angle closure glaucoma patients was conducted on who underwent cataract surgery or combined with goniosynechialysis from March 2015 to April 2018. Main outcome measures were visual acuity, intraocular pressure, number of glaucoma medications and complications.

Results

Sixteen patients (19 eyes) were included. The mean age was 64.89 ± 11.68 years and the mean followed up duration was 21.89 ± 7.85 months. The final visual acuity was significantly improved from 0.69 ± 0.55 to 0.46 ± 0.52 logMAR, within 12 (63.2%) eyes improved, 4 (21.1%) eyes kept unchanged, and 3 (15.8%) eyes reduced. Linear regression analysis indicated that higher mean deviation, higher visual field index and lower glaucoma stage associated with better final visual acuity (r = − 0.511, r = − 0.493, r = 0.537 respectively). Moreover, the final number of medications were reduced from 1.26 ± 0.99 to 0.26 ± 0.56 (p < 0.01). The mean intraocular pressure was not significantly reduced with the final IOP of 14.48 ± 3.74 mmHg (p = 0.97). While the eyes with intraocular pressure above 15 mmHg was decreased to 6 (31.6%) eyes compared to 10 (52.6%) eyes at baseline. Moreover, the number of eyes free of medications was increased from 4 (21.1%) preoperatively to 15 (78.9%) eyes postoperatively.

Conclusions

Final visual acuity was significantly improved in the severe and end stage primary angle closure glaucoma patients and the number of eyes came off medications increased by 57.8% after cataract surgery. Preoperatively, the glaucoma stage, mean deviation and visual field index are important parameters to predict the final visual acuity after cataract surgery.

Pentacam changes in primary angle-closure glaucoma after different lines of treatment

AIM

To assess the changes in the anterior chamber parameters using Pentacam following four different lines of treatment of primary angle-closure glaucoma (PACG).

METHODS

A retrospective comparative study included 126 patients (126 eye) presented within 24-48h after acute angle-closure glaucoma (AACG). Patients were divided into 2 groups: group A (68 eyes) with controlled intraocular pressure (IOP) ≤21 mm Hg, which included subgroup A1 (34 eyes) with clear lens underwent Nd:YAG laser peripheral iridotomy (LPI) and subgroup A2 (34 eyes) with cataract underwent standard phacoemulsification; and group B (58 eyes) with uncontrolled IOP, which included subgroup B1 (30 eyes) with clear lens underwent trabeculectomy and subgroup B2 (28 eyes) with cataract underwent combined phacoemulsification and trabeculectomy. Patients were followed up for at least 3mo. Primary outcomes were Pentacam anterior segment measurements [anterior chamber angle (ACA) and depth (ACD)]. Secondary outcomes were changes in IOP, visual acuity (VA) and recorded complications.

RESULTS

At the 3rd month, there was significant increase in the ACA values in all studied groups compared to preoperative values (P<0.001). The highest percent of increase in ACA was recorded in phacotrabeculectomy group B2 (128.40%). There was significant increase in ACD values at 3rd month compared with baseline values (P<0.001) for groups A1, A2, and B2; without change in B1 trabeculectomy group. The maximum deepening of ACD was noticed in group B2 with 94.27% increase. Significant decrease in postoperative IOP in groups A2, B1 and B2 (P<0.001, P=0.014, and P<0.001 respectively). In group A1 there was significant increase in 3rd month postoperative IOP from baseline values (P<0.001). The maximum decrease in IOP was noticed in group B2 with 59.54% decrease. VA improvement in 3rd month postoperative was recorded in all studied groups, maximum VA improvement was observed in group B2 up to 0.2 logMAR.

CONCLUSION

Pentacam can be a helpful tool in studying and comparing the effect of the different lines of management of PACG on the anterior chamber measures. Phacotrabeculectomy was proved to be an effective line for managing PACG with resultant significant increase in the anterior chamber parameters, IOP reduction as well as maximum VA improvement. LPI has only temporary effect on IOP with significant changes in ACA and ACD. Phacoemuslification alone can be an option in treating PACG. Trabeculectomy resulted in temporary increase in the anterior chamber parameter which subsequently returned to baseline values.

Case Series of Combined XEN Implantation and Phacoemulsification in Chinese Eyes: One-Year Outcomes

PURPOSE

The outcome of XEN implantation in Chinese eyes has not been previously reported. The purpose of our study is to evaluate the efficacy and safety of combined cataract surgery and XEN implantation in Chinese eyes with glaucoma.

METHODS

We conducted a prospective study of 31 consecutive Chinese patients who underwent combined phacoemulsification and XEN implantation at the National University Hospital (Singapore) in this study. Patients were assessed preoperatively and postoperatively on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, Snellen visual acuity (VA), and complications were assessed at each visit. The Wilcoxon signed rank test for non-parametric data was used for the analysis of IOP and glaucoma medications at baseline versus 12 months after the procedure.

RESULTS

The mean age of the patients was 70 ± 7.9 years and 48.4% were male. Twelve patients (38.7%) were diagnosed with primary open angle glaucoma and 19 patients (61.3%) were diagnosed with primary angle closure glaucoma. There was a significant decrease in IOP at 12 months (12.1 ± 2.6 mmHg) compared with preoperative medicated (15.6 ± 2.7 mmHg, p < 0.0001) and unmedicated IOP (22.1 ± 3.6 mmHg, p < 0.001). as well as a significant reduction in the number of glaucoma medications (1.4 ± 0.6 vs 0.1 ± 0.4, p < 0.0001). The most common complications were transient hypotony (12.9%) and ptosis (12.9%) and there were no sight-threatening intraoperative or postoperative complications. One patient required additional glaucoma surgery for uncontrolled IOP at 8 months after combined phacoemulsification and XEN implantation.

CONCLUSION

Combined XEN implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications in Chinese eyes for at least 12 months, with a favorable safety profile.

Factors Associated With Long-term Intraocular Pressure Fluctuation in Primary Angle Closure Disease: The CUHK PACG Longitudinal (CUPAL) Study

PURPOSE

To determine the demographic, ocular, and systemic factors associated with long-term intraocular pressure (IOP) fluctuation in primary angle closure disease (PACD).

METHODS

This prospective cohort study included 422 PACD eyes from 269 Chinese patients, including 274 primary angle closure glaucoma (PACG) eyes and 152 primary angle closure/primary angle closure suspect (PAC/PACS) eyes. Long-term IOP fluctuation defined as the SD of all IOP measurements over 2 years (at least 5 measurements in total). Chinese patients with PACD were recruited and followed up 3 monthly. Eyes with IOP-lowering surgery or lens extraction performed within the 2-year study period were excluded. Patient demographics, received treatments, ocular biometry, retinal nerve fiber layer thickness, and systemic factors (eg, hypertension, smoking) were evaluated. Generalized estimating equations adjusting for inter-eye correlation were used to determine the associations.

RESULTS

Eyes with PACG had significantly higher IOP fluctuation than PAC/PACS (2.4±1.2 versus 2.1±0.9 mm Hg; P=0.04). In the multivariate analysis with PACG eyes, higher baseline IOP (P<0.001), greater number of IOP-lowering medications (P<0.001), previous trabeculectomy (P=0.002), and current smoking (P=0.03) were significantly associated with larger IOP fluctuation, whereas diabetes mellitus was associated with lower IOP fluctuation (P=0.03). Among PAC/PACS eyes, younger age group (P<0.001), male sex (P=0.002), and higher baseline IOP (P<0.001) were significantly associated with larger IOP fluctuation.

CONCLUSIONS

PACG eyes have greater IOP fluctuation than PAC/PACS eyes. Certain demographic, ocular, and systemic factors are associated with IOP fluctuation in PACD eyes.

Phacoemulsification, visco-goniosynechialysis, and goniotomy in patients with primary angle-closure glaucoma: A comparative study

OBJECTIVE

The aim of this study was to evaluate the effects of goniotomy on patients with primary angle-closure glaucoma who underwent "phacoemulsification and visco-goniosynechialysis."

MATERIALS AND METHODS

This prospective randomized clinical trial was carried out on 63 eyes of 61 patients (48-85 years) with primary angle-closure glaucoma who were enrolled. The subjects were randomly assigned into two groups. In the first group (32 eyes) and the second group (31 eyes), the patients underwent "phacoemulsification + visco-goniosynechialysis + goniotomy" and "phacoemulsification + visco-goniosynechialysis," respectively. Intraocular pressure and antiglaucoma medication were evaluated (1 week, as well as 1, 3, and 6 months after the surgery). Anterior segment optical coherence tomography parameters (Casia, Tomey, USA) and goniotomy were evaluated preoperatively and 6 months after the surgery.

RESULTS

The mean intraocular pressure lowering the effects in the "phacoemulsification + visco-goniosynechialysis + goniotomy" group was higher than that in the "phacoemulsification + visco-goniosynechialysis" group (6.93 and 4.6, respectively). Furthermore, the difference in intraocular pressure between the two groups was significant at 3 months (P = 0.014) and 6 months (P = 0.021) after the surgery. There was no difference in anterior segment optical coherence tomography findings before the intervention; however, after the intervention, the anterior segment optical coherence tomography indices were significantly different between the two groups. Moreover, the difference in "phacoemulsification + visco-goniosynechialysis + goniotomy" indices was more than the changes in the "phacoemulsification + visco-goniosynechialysis" group.

CONCLUSION

The results of this study showed that phacoemulsification + visco-goniosynechialysis + goniotomy is a more effective surgery than phacoemulsification + visco-goniosynechialysis alone in undercounted primary angle-closure glaucoma.

Cataract surgery reduces intraocular pressure but not posture-induced intraocular pressure changes in patients with angle-closure glaucoma

Cataract surgery leads to a sustained decrease in sitting intraocular pressure (IOP) in patients with angle-closure glaucoma (ACG). The purpose of this study is to evaluate whether cataract surgery can also reduce postural IOP changes. We prospectively examined 106 eyes from 53 patients with narrow angles scheduled for phacoemulsification. IOP was measured in the sitting, supine, and lateral decubitus positions using an ICare rebound tonometer before and 1 week, 1 month, and 3 months postoperatively. The mean baseline IOP in the sitting and lateral decubitus positions was 17.9 ± 4.8 mmHg and 21.43 ± 6.44 mmHg, which significantly reduced to 13.52 ± 3.8 and 17.46 ± 3.62, respectively, 3 month postoperatively (p < 0.001). However, postural IOP change (lateral decubitus minus sitting) at 3 months postoperatively was not significantly different from that at the baseline (3.17 ± 2.63 vs. 3.53 ± 3.38 mmHg, p = 0.85). Postural IOP change was not associated with preoperative sitting IOP, anterior chamber depth, axial length, fixed pupil, or presence of glaucomatous optic neuropathy. Patients with higher preoperative IOP exhibited greater IOP reduction after cataract surgery in every posture (p < 0.0001). In conclusion, cataract surgery reduces IOP in all postures among patients with ACG; however, it does not reduce the magnitude of postural IOP change.

Comparative Evaluation of Phacoemulsification Alone versus Phacoemulsification with Goniosynechialysis in Primary Angle-Closure Glaucoma: A Randomized Controlled Trial

PURPOSE

Comparative evaluation of phacoemulsification (phaco) alone versus phacoemulsification combined with goniosynechialysis (phacoGSL) in primary angle-closure glaucoma (PACG).

DESIGN

Prospective, randomized, parallel group, active controlled trial.

PARTICIPANTS

Patients with PACG.

METHODS

A total of 120 consecutive patients with PACG were screened, of whom 80 met inclusion criteria, with PACG uncontrolled on maximal hypotensive therapy and were recruited. Patients were randomized into 2 groups and underwent phaco alone in group 1 or phacoGSL in group 2. The patients were examined at baseline and at 1 week and 1, 3, and 6 months. The anterior chamber angle parameters on swept-source anterior segment OCT (SS-ASOCT) were noted at 1 and 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was intraocular pressure (IOP) reduction. A reduction in IOP of ≥ 20% from baseline IOP with or without medications was considered a success. Secondary outcome measures included change in the anterior chamber angle temporal parameters, angle-opening distance, trabecular-iris space area and scleral spur angle, surgical safety, visual acuity, and reduction in the number of glaucoma medications postoperatively.

RESULTS

The average age of patients was 58.77±8.14 years and 56.50±9.17 years in groups 1 and 2, respectively (P = 0.31). The mean baseline IOP was 29.48±6.76 mmHg and 30.72±3.88 mmHg in groups 1 and 2, respectively (P = 0.13). Success was obtained in 93.33% of patients in group 1 and 91.18% of patients in group 2 at 6 months (P = 0.39). Mean IOP was 13.17±1.66 mmHg and 13.21±1.97 mmHg at 6 months in groups 1 and 2, respectively (P = 0.001). The reduction in IOP was 55.32% and 56.99% at 6 months in groups 1 and 2 (P = 0.48). Significant widening of the angle parameters was noted at 6 months with an increase compared with baseline values in both groups. In multivariate analysis, the significant predictor of decrease in IOP was the higher baseline IOP.

CONCLUSIONS

Both phaco and phacoGSL are associated with a significant reduction in IOP along with a noteworthy widening of the anterior chamber angle parameters. Both procedures succeeded in reducing the necessity of glaucoma medications postoperatively in PACG eyes. There is no additional benefit of phacoGSL over phaco in PACG.

Intraocular pressure reduction in a spectrum of angle closure disease following cataract extraction

Purpose

The purpose is to study the effect of cataract extraction on intraocular pressure (IOP) in patients with angle closure disease (ACD).

Methods

In this retrospective study, patients with ACD including medically uncontrolled and advanced primary angle closure glaucoma (PACG) who underwent only cataract surgery were included. The IOP trend was analyzed at postoperative day 1, day 7, 1 month, 3 months, 6 months, 1 year, and final follow-up along with requirement of antiglaucoma medication (AGM)/surgery.

Results

A total of 110 eyes of 79 patients [primary angle closure suspect (PACS): 21, PAC: 34, PACG: 55 eyes] were analyzed. Of these patients, 31 eyes had advanced PACG and 20 eyes had medically uncontrolled glaucoma. Best-corrected visual acuity >6/12 was seen in 51 eyes at baseline and 87 eyes at final follow-up. After cataract surgery alone, there was significant reduction (median) in IOP [19.1 ± 18.00% (18.8) in PACS (P < 0.01), 8.55 ± 17.9% (10) in PAC (P = 0.04), 22.82 ± 15.45%(14.3) in PACG (P < 0.01), 18.27 ± 15.99% (14.5) in advanced PACG (P = 0.01) and 36.56 ± 14.58% (28.57) in medically uncontrolled glaucoma (P < 0.01)] and AGM [51.85% (1) in PAC, 32.35% (2) in PACG, 17.71% (2) in advanced PACG, and 40.74% (1.5) in medically uncontrolled PACD] at median follow-up of 1, 2.5, 1, 1.3, and 1 year. Eleven PACG patients, who were on systemic medication preoperatively, were off systemic therapy at final follow-up, while six other PACG eyes (10.9%) required glaucoma surgery.

Conclusion

Cataract surgery leads to significant drop in IOP across the spectrum of ACD with visually significant cataract. Cataract surgery may be considered initially for IOP control even in advanced or medically uncontrolled PACG followed by glaucoma surgery later if required.

Effect of Preoperative Factor on Intraocular Pressure after Phacoemulsification in Primary Open-angle Glaucoma and Primary Angle-closure Glaucoma

Purpose

To compare the effects of cataract surgery on intraocular pressure (IOP) according to preoperative factor in primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

Methods

The medical records of 75 POAG and 95 PACG patients who underwent cataract surgery were reviewed. We classified POAG patients with a preoperative peak IOP of less than 31 mmHg and less than three medications used before surgery and PACG patients with a peak IOP of less than 42 mmHg, less than three medications used, and peripheral anterior synechiae of less than four clock hours into group 1. Patients with levels exceeding these thresholds were classified into group 2. The IOP, numbers of medications, and success rates were compared between two groups.

Results

At 36 months after surgery, IOP reduction in group 1 was significantly greater than that in group 2 among POAG patients (−1.7 ± 2.1 vs. −0.6 ± 2.0 mmHg, p = 0.021); however, there was no significant difference between the two groups for PACG patients (−2.5 ± 2.0 vs. −2.2 ± 3.3 mmHg, p = 0.755). The medication changes were similar between the two groups for both POAG and PACG patients. The success rate at 36 months was significantly higher in group 1 than in group 2 for POAG patients (66.7% vs. 35.7%, p = 0.009), but there was no significant difference between the two groups for PACG patients (79.1% vs. 69.2%, p = 0.264).

Conclusions

For patients with relatively low peak IOP who used fewer medications before surgery, cataract surgery alone was effective for IOP control in both POAG and PACG patients. Conversely, For POAG patients with a history of higher peak IOP and who used more medications, cataract surgery was not effective in lowering IOP, whereas it resulted in relatively good IOP values in PACG patients.

Long term effect of phacoemulsification on intraocular pressure in patients with medically controlled primary open-angle glaucoma

Background

The effect of cataract surgery on IOP in patients with primary open-angle glaucoma (POAG) is a subject of debate. We investigated the effect of cataract surgery by phacoemulsification on intraocular pressure (IOP) in patients with medically POAG .

Methods

Seventy eyes of 40 POAG patients undergoing cataract surgery by phacoemulsification were retrospectively evaluated. All patients had their POAG medically controlled without prior glaucoma surgery. Baseline demographics and clinical characteristics were recorded. IOP and the number of glaucoma medications were evaluated before and for 1 year after cataract surgery. We analyzed IOP variations from baseline with a Student t-test for a paired sample. We used a Pearson correlation coefficient and linear regression to study the relation between IOP change from baseline and preoperative characteristics.

Results

One year after phacoemulsification, IOP decreased by a mean 1.15 ± 3 mmHg (6.8 ± 18.1%) (P = 0.01) and the number of glaucoma medications remained unchanged with a difference of − 0.1 ± 0.43 (P = 0.09). Higher preoperative IOP was associated with a greater IOP decrease after 1 year of follow-up (P < 0.001). One and 7 days after cataract surgery, 12.9 and 4.2% of the eyes had IOP spikes > 30 mmHg, respectively. One year after cataract surgery, 75.7% of the POAG eyes maintained the same number of glaucoma medications while 17.1% had a decrease and 7.2% of the eyes required adding glaucoma medications.

Conclusion

Cataract surgery by phacoemulsification in eyes with medically controlled POAG resulted at 1 year in a very small IOP decrease without a change in the number of glaucoma medications. A drop in IOP should not be expected after performing phacoemulsification alone in POAG patients.

Surgical outcomes of phacoemulsification/goniosynechialysis with and without endocyclophotocoagulation in patients with chronic angle closure glaucoma

Purpose:

To compare surgical outcomes of patients after phacoemulsification with goniosynechialysis (phaco/GSL) versus phaco with GSL and endocyclophotocoagulation (phaco/GSL/ECP) in patients with chronic angle closure glaucoma (CACG) through 12-month follow-up.

Methods:

A retrospective, nonrandomized, comparative case series was performed. Patients with CACG who underwent phaco in combination with either GSL alone (group 1) or GSL with ECP with intracameral injection of kenalog (group 2) from 2011 to 2018 were included. Group 1 included 6 eyes of 6 patients and group 2 included 11 eyes of 10 patients. All surgeries were performed by a single surgeon (RSA). Primary outcome measures included changes in intraocular pressure (IOP), visual acuity (VA), failure based on IOP (>18 or <6 mmHg at 1 year), and secondary operative procedures and complication rates. Data were analyzed using a paired two-tailed T-test.

Results:

The mean preoperative IOP decreased from 23.5 ± 11.2 to 14.2 ± 2.4 mmHg (P < 0.0073) in group 1 and 24.4 ± 8.2 to 14.5 ± 2.7 mmHg (P < 0.0001) in group 2. The mean % IOP reduction was 33.7% in group 1 and 34.2% in group 2. The mean improvement in VA (logMAR units) was 0.24 (P = 0.085) in group 1 and 0.13 (P = 0.657) in group 2. The mean number of topical meds decreased from 2.50 ± 1.76 to 1.80 ± 1.64 in group 1 (P = 0.513) and from 2.82 ± 1.25 to 1.17 ± 0.98 in group 2 (P = 0.014).

Conclusion:

Phaco/GSL and phaco/GSL/ECP both achieve a significant reduction in IOP without the complications associated with traditional glaucoma filtration surgeries.

Case Series of Combined iStent Implantation and Phacoemulsification in Eyes with Primary Angle Closure Disease: One-Year Outcomes

PURPOSE

To evaluate the safety and efficacy of combined iStent® trabecular micro-bypass device (Glaukos, Laguna Hills, CA) and phacoemulsification in eyes with primary angle closure disease.

METHODS

A two-center prospective interventional case series of consecutive patients with primary angle closure (PAC) or primary angle closure glaucoma (PACG) on at least one glaucoma medication, who underwent iStent implantation with cataract surgery. Postoperatively, patients were assessed on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, visual acuity, and the presence of complications were assessed at each visit. Complete success was defined as IOP reduction of at least 20% without the use of glaucoma medications.

RESULTS

Thirty-seven eyes with angle closure disease were included in this study. At 1-year, postoperative mean IOP (14.8 ± 3.94 mmHg) was significantly decreased compared with preoperative medicated (17.5 ± 3.82 mmHg, p = 0.008) and unmedicated (24.6 ± 3.41 mmHg, p < 0.001) IOP. Complete success was achieved in 89.2% of the eyes. The number of glaucoma medications decreased from 1.49 ± 0.77 to 0.14 ± 0.48 (p < 0.001). Preoperative medicated IOP was a risk factor for failure (hazard ratio 3.45, 95% confidence interval 1.52-7.85, p = 0.003), after adjustment for age, gender, and race. The most common postoperative complications were iStent occlusion with iris (27.0%) and hyphema (18.9%). There were no sight-threatening intraoperative or postoperative complications.

CONCLUSION

Combined iStent implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications for at least 12 months, with a favorable safety profile.

FUNDING

Glaukos Corporation; NMRC Science Translational and Applied Research (STAR) award.

Effect of Phacoemulsification on Intraocular Pressure in Healthy Subjects and Glaucoma Patients

BACKGROUND

We investigated how cataract surgery might influence long-term intraocular pressure (IOP) change in both healthy subjects and glaucoma patients.

METHODS

A retrospective analysis of patients who had had clear corneal phacoemulsification with a minimum of 12 months of follow up was performed. Glaucoma patients with medically controlled open-angle glaucoma and healthy subjects with no glaucoma were included in the analysis. The change of IOP after phacoemulsification and factors associated with postoperative IOP change were investigated.

RESULTS

In total, 754 eyes of 754 patients, specifically 106 patients with glaucoma and 648 patients with no glaucoma (i.e., healthy subjects) were enrolled. The phacoemulsification effected a reduction of IOP: 1.03 ± 3.72 mmHg in healthy subjects and 1.08 ± 3.79 mmHg in glaucoma patients at postoperative 1 year (P = 0.656). There were negative coefficients of IOP until 1 year of follow up (all P < 0.001), but the IOP change gradually showed a less steeply decreasing slope (correlation coefficient: -0.993), compared with those for 1 week and 1 month of follow up (correlation coefficients: -1.893 and -1.540, respectively). In the multivariate analysis, age and preoperative IOP showed significant associations with postoperative IOP change (regression coefficients: -0.034 and 0.419 respectively, all P < 0.001).

CONCLUSION

Phacoemulsification resulted in IOP reduction, which effect regressed in healthy subjects and glaucoma patients over the course of long-term follow up. Therefore, long-term monitoring of IOP change is needed. In cases of higher preoperative IOP and young patients, phacoemulsification alone is a reliable option for IOP control.