Combined endocyclophotocoagulation and phacoemulsification in the management of moderate glaucoma

Efficacy of a novel low-cost torchlight transcorneal transillumination for diode laser transscleral cyclophotocoagulation in adult glaucoma

PURPOSE

To study the outcomes of diode laser transscleral cyclophotocoagulation (TSCPC) with trans-corneal transillumination using a novel low-cost torchlight method in refractory glaucoma.

METHODS AND ANALYSIS

This prospective interventional study included patients with refractory glaucoma who underwent TSCPC with trans-corneal transillumination (TSCPC-TI) using a novel low-cost torchlight method. Patients completing a minimum 6-month follow-up were analyzed. They were compared to a historical control group of patients who underwent TSCPC without transillumination (TSCPC-No TI) at 6-month follow-up period. We analyzed the mean laser energy delivered, post-laser intraocular pressure (IOP) reduction, number of antiglaucoma medications (AGM), the requirement of retreatment and complications of the procedure in both groups.

RESULTS

32 eyes of 29 patients comprised the TSCPC-TI group and were compared with 39 eyes of 37 patients in the TSCPC-No TI group. The TSCPC-TI group required lower energy than the TSCPC-No TI group (46.15 ± 22.8 Vs 80.65 ± 56.1 J p < 0.001). At 6-month follow-up, the TSCPC-TI group required lesser AGM for IOP control (2.33 ± 1.02 vs 3.02 ± 1.32 p = 0.01). There was a significantly reduced dependence of oral acetazolamide in the TSCPC-TI group at 6 months follow-up (15.6% vs 41% p = 0.03%). The success and response rates were 71.8% Vs 23.1%; p < 0.0001 and 87.5% Vs 51.2%; p = 0.001 significantly high in the TSCPC-TI group. The TSCPC-No TI group had a significantly high failure rate (12.5% Vs 48.2% p = 0.001). Hypotony (n = 1) and phthisis (n = 2) were noted TSCPC-No TI group.

CONCLUSIONS

TSCPC with transillumination with a low-cost torchlight resulted in a more efficient and effective cycloablation than TSCPC without transillumination.

Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification

Aim and background

Combined endocyclophotocoagulation and phacoemulsification (ECP/Phaco) are uncommonly associated with complications. We present the first case of a rare complication following ECP/Phaco.

Case description

A 72-year-old patient with dense nuclear sclerotic cataracts and primary open-angle glaucoma (POAG) underwent bilateral surgery uneventfully. He experienced a brief episode of postoperative elevated intraocular pressure (IOP), but only one eye with a lower baseline IOP developed a dilated pupil. No pupillary response was observed after applying 4% pilocarpine. The fixed mydriasis persisted without reaction to light or near stimulus, and the best-corrected vision (BCVA) was 20/30 in the affected eye.

Conclusion

This case reports a possible rare complication when undergoing ECP/Phaco therapy. The pathogenesis of Urrets-Zavalia syndrome is unknown, but we hypothesized that eyes with more pronounced increases in IOP from baseline may be more susceptible to ischemic injury to the pupillary sphincter, resulting in a chronically dilated pupil.

Clinical significance

Even a modest transient rise in postoperative IOP in a glaucomatous eye with normal baseline IOP could result in a chronically dilated pupil.

How to cite this article

Cheng AMS, Vedula GG, Kubal AA, et al. Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification. J Curr Glaucoma Pract 2024;18(1):28-30.

Six year outcomes of combined phacoemulsification surgery and endoscopic cyclophotocoagulation in refractory glaucoma

PURPOSE

This study is to describe the 6-year results of combined phacoemulsification surgery and endoscopic cyclophotocoagulation (Phaco-ECP) surgery in patients with uncontrolled glaucoma and no previous glaucoma surgery.

METHODS

This is a retrospective case series of 84 eyes. The primary outcome measure was intraocular pressure (IOP) reduction 6 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 6 years. Failure was defined as IOP higher than 21 mm Hg or lower than 6 mm Hg or IOP not reduced by 20% from baseline at the 1, 2, 3, 4, 5, or 6-year time points or further laser or other surgery to reduce IOP at any timepoint.

RESULTS

There was a statistically significant decrease in mean IOP from 18.9 mmHg pre-operatively to 13.7, 12.8, 13.0, 12.7, 12.5, and 12.3 mmHg at the 1, 2, 3, 4, 5, and 6 years post-operatively respectively (p < 0.001). Fifty-seven (68%) reached criteria for failure by 6 years. In 36% of cases, this was due to inadequate IOP control, whereas 32% required further laser or surgery. When we excluded patients who only had selective laser trabeculoplasty rather than further surgery, the failure rate reduced to 51%. Eleven percent had a post-operative complication, 2.4% requiring further surgical intervention.

CONCLUSIONS

At 6 years postoperatively, combined phaco-ECP achieved a significant reduction in IOP in patients with uncontrolled glaucoma and no previous drainage surgery. Significant complications were uncommon, but 68% was classified as surgical failures by the six year point.

Surgical Outcome of Combined MicroPulse Transscleral Laser Therapy with Phaco Emulsification in Patients with Cataract and Glaucoma

Purpose:

To determine the effectiveness and safety of combined MicroPulse transscleral laser therapy (TLT) and phacoemulsification in patients with co-existing cataracts and glaucoma.

Methods:

A retrospective consecutive case series of 22 eyes of 19 patients with co-existing cataract and glaucoma. The patients underwent MicroPulse TLT, phacoemulsification, and intraocular lens implantation during the same setting. A comparison of baseline data with the data at 18 months follow-up was made to determine the variation in best-corrected visual acuity (BCVA), intraocular pressure (IOP), and changes in the number of anti-glaucoma drugs.

Results:

Twenty-two eyes of 19 patients (57.9% were female) underwent combined MicroPulse TLT and phacoemulsification. The mean age was 60.5±9.3 years (range: 39.0 to 76.0). Nine eyes (40.9%) had primary open-angle glaucoma, nine eyes (40.9%) had chronic angle-closure glaucoma, and four eyes (18.2%) had pseudoexfoliation glaucoma. The mean baseline IOP was 26.3±4.7, which was significantly reduced to 15.3±2.4 mmHg (43.9%±10.2%) at 18 months (p<0.001). The median number of glaucoma medications was 4 (2 to 5) at baseline and 2 (0 to 4) at 18 months (p=0.002). The mean BCVA was 0.84±0.31 LogMAR (Snellen: 20/138) at baseline and 0.28±0.23 LogMAR (Snellen:20/38) at 18 months (p<0.001). The mean follow-up period was 15.8±3.0 months (range 12 to 18).

Conclusions:

Combined MicroPulse TLT and phacoemulsification was a safe and effective procedure that achieved reduction in both IOP and glaucoma medications for up to 18 months, with no associated vision-threatening complications.

Cyclophotocoagulation under Microscopy Combined with Phacoemulsification for Primary Angle-Closure Glaucoma

The purpose of this study was to evaluate the safety and efficacy of cyclophotocoagulation under microscopy combined with phacoemulsification in patients with primary chronic angle-closure glaucoma. We retrospectively reviewed the results of cyclophotocoagulation under microscopic direct vision combined with phacoemulsification in 35 eyes (35 patients) with primary chronic angle-closure glaucoma and coexisting visually significant cataracts, treated between January 2017 and April 2020 at the glaucoma unit of the affiliated Changshu Hospital of Xuzhou Medical University. All patients were followed up for at least 12 months postoperatively. The preoperative to postoperative changes in best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of antiglaucoma medications, and surgery-associated complications were recorded. The BCVA improved from 1.15 ± 0.91 logMAR preoperatively to 0.86 ± 0.82 logMAR at the final postoperative examination (Z = −3.62, P < 0.0001). The mean IOP was 36.63 ± 13.50 mmHg preoperatively and 15.14 ± 3.19 mmHg at the final examination (Z = −5.16, P < 0.0001). The number of antiglaucoma drugs was significantly reduced from 2.23 ± 0.55 preoperatively to 0.54 ± 0.86 at the final postoperative examination (Z = −5.26, P < 0.0001). The absolute value of the mean defect and retinal nerve fiber layer thickness at the last follow-up postoperatively were significantly reduced compared to preoperative values (Z = −3.35, P=0.001; Z = −4.56, P < 0.001, respectively). One patient experienced an explosive suprachoroidal hemorrhage during the operation. The sclera was incised at the corresponding site of the intraoperative hemorrhage. The operation was continued once there was no active bleeding, and the outcome was satisfactory. None of the patients required additional surgery to treat complications. Thus, cyclophotocoagulation under microscopic direct vision combined with phacoemulsification can be performed safely for the management of primary angle-closure glaucoma.

Does prior endoscopic cyclophotocoagulation (ECP) affect subsequent trabeculectomy outcomes?

Purpose

To report long-term outcomes of trabeculectomy following prior endoscopic cyclophotocoagulation (ECP).

Methods

Retrospective case-controlled comparative study reporting 2-year outcomes of eyes undergoing trabeculectomy following failed prior ECP (group 1), using eyes undergoing trabeculectomy as a primary glaucoma procedure as controls (group 2).

Results

Filtration surgery was required in only 19.4% (12/62) of eyes undergoing ECP. Of these, nine eyes that underwent trabeculectomies were included in group 1. Nine matched eyes were used as controls and included in group 2. Mean baseline IOPs were 23.7 ± 7.7 and 26.0 ± 6.7 mmHg (p = 0.452) in groups 1 and 2, respectively, on a mean of 3.4 ± 0.9 and 2.8 ± 1.4 medications, respectively (p = 0.274). The mean 2-year IOP was 10.6 ± 5.2 and 12.9 ± 4.0 mmHg (p = 0.285) in groups 1 and 2, respectively, on a mean of 0.1 ± 0.3 and 0.1 ± 0.4 medications (p = 0.931) respectively. Complete success rates were 77.8% and 88.9% in groups 1 and 2, respectively (p = 0.527). Qualified success rates were 11.1% in both groups. Combined success rates were 88.9% and 100.0% in groups 1 and 2, respectively (p = 0.318). There were no failures in group 2, compared to 11.1% in group 1 (p = 0.318). There were no significant between-group differences in hypotony, bleb needling, cystoid macular oedema, persistent uveitis, or repeat filtration surgery rates.

Conclusions

ECP is a safe initial procedure in eyes with progressive glaucomas, and may substantially reduce the need for trabeculectomy without compromising outcomes in the minority that go on to require it.

Long-term Surgical Outcomes of Phacoemulsification with Endoscopic Cyclophotocoagulation vs Phacoemulsification with Trabeculectomy and Mitomycin in Cataract and Glaucoma Patients

Purpose

To evaluate the long-term surgical outcomes of endoscopic cyclophotocoagulation (ECP) after four years follow-up in cataract and glaucoma patients that needed combined phacoemulsification and ECP (phaco-ECP) in comparison to combined phacoemulsification with trabeculectomy (phaco-trabeculectomy) with mitomycin C (MMC).

Patients and Methods

Retrospective case–control study of 34 patients (34 eyes) with glaucoma who underwent phaco-ECP compared with phaco-trabeculectomy in tertiary eye specialist hospital in Saudi Arabia from 2010 to 2012. Participants were enrolled in two groups; ECP and trabeculectomy with MMC when combined with phacoemulsification. Success is defined as complete success when the IOP ≤21 mmHg without medication, qualified success when the IOP ≤21 mmHg with aid of topical medication.

Results

Mean IOP decreased from 25.76 SD ±8.227 to 15.24 SD ±7.049 at last visit in phaco-trabeculectomy group and from 21.47 SD ±4.215 to 12.88 SD ±3.480 in phaco-ECP group. Mean medication use reduced from 2.89 SD ±0.3 preoperatively to 1.50 SD ±1.1 postoperatively (P<0.001) in phaco-trabeculectomy group. It reduced in phaco-ECP group from 2.24 SD ±0.8 preoperatively to 2.00 SD ±0.9 postoperatively, 35.3% of phaco-trabeculectomy group developed vision-threatening complications while 0% in phaco-ECP group (P<0.001), 29.4% in phaco-trabeculectomy group required second surgical intervention compared to 17.6% in phaco-ECP group. In phaco-trabeculectomy group, 29.4% reached complete success, meanwhile in phaco-ECP group, 64.7% reached qualified success (P=0.026).

Conclusion

ECP illustrates significant reduction of IOP and less postoperative complications if associated with phacoemulsification. Furthermore, it is safe and effective as a primary procedure alternative to combined cataract and trabeculectomy surgery for glaucoma patients having cataract and requiring surgical intervention.

Glaucoma in Adults-Screening, Diagnosis, and Management: A Review

IMPORTANCE

Glaucoma is the most common cause of irreversible blindness worldwide. Many patients with glaucoma are asymptomatic early in the disease course. Primary care clinicians should know which patients to refer to an eye care professional for a complete eye examination to check for signs of glaucoma and to determine what systemic conditions or medications can increase a patient's risk of glaucoma. Open-angle and narrow-angle forms of glaucoma are reviewed, including a description of the pathophysiology, risk factors, screening, disease monitoring, and treatment options.

OBSERVATIONS

Glaucoma is a chronic progressive optic neuropathy, characterized by damage to the optic nerve and retinal nerve fiber layer, that can lead to permanent loss of peripheral or central vision. Intraocular pressure is the only known modifiable risk factor. Other important risk factors include older age, nonwhite race, and a family history of glaucoma. Several systemic medical conditions and medications including corticosteroids, anticholinergics, certain antidepressants, and topiramate may predispose patients to glaucoma. There are 2 broad categories of glaucoma, open-angle and angle-closure glaucoma. Diagnostic testing to assess for glaucoma and to monitor for disease progression includes measurement of intraocular pressure, perimetry, and optical coherence tomography. Treatment of glaucoma involves lowering intraocular pressure. This can be achieved with various classes of glaucoma medications as well as laser and incisional surgical procedures.

CONCLUSIONS AND RELEVANCE

Vision loss from glaucoma can be minimized by recognizing systemic conditions and medications that increase a patient's risk of glaucoma and referring high-risk patients for a complete ophthalmologic examination. Clinicians should ensure that patients remain adherent with taking glaucoma medications and should monitor for adverse events from medical or surgical interventions used to treat glaucoma.

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.

Primary outcomes of combined cataract extraction technique with Ab-Interno trabeculectomy and endoscopic Cyclophotocoagulation in patients with primary open angle Glaucoma

BACKGROUND

Glaucoma surgery have been developed to lower intraocular pressure in a less invasive manner than traditional glaucoma surgery. The purpose of this article is to determine the outcome of using combined phacoemulsification technique, ab-interno trabeculectomy dual blade and endoscopic cyclophotocoagulation (ECP) surgeries in patients with primary open angle glaucoma.

METHODS

A retrospective case series was performed on 27 consecutive eyes with both primary open-angle glaucoma (POAG) and cataract; each eye was treated with combined phacoemulsification, ab-interno trabeculectomy-Kahook Dual Blade and Endocyclophotocoagulation at Instituto de ojos Oftalmosalud, Lima, Peru, between April 2017 and May 2017.

INCLUSION CRITERIA

1) Patients with uncontrolled mild to advanced POAG (according to Glaucoma Grading Scale HODAPP) 2) cataract condition 3) treatment with two or more glaucoma medications due to rapid progression in the visual fields (at least two in a short period of time). Intraocular pressure (IOP), best corrected visual acuity (BCVA) logMAR and number of glaucoma medications were recorded prior to the study, at day 1, week 1, and 1,3,6 and 9 months after surgery. Primary outcome measure was surgical success defined in terms of IOP < 14 mmHg either with no medications (complete success) or with medications (qualified success).

RESULTS

A total of 27 eyes from 27 patients were included. The mean basal IOP was 17.0 ± 3.7 mmHg and postoperatively was 11.6 ± 1.9 mmHg and 11.4 ± 1.8 mmHg (P < 0.001) at 6 and 9 months respectively. Glaucoma medications decreased from 1.9 ± 1.4 to 0.56 ± 1.05 at 9 month follow-ups (P < 0.001). Preoperative best corrected visual acuity (BCVA) showed and improvement from 0.4 ± 0.4 LogMAR to 0.2 ± 0.4 logMAR at 9 months. The main complication was blood reflux intra-operatively (66.7%), which resolved without re-operation. The mean IOP was reduced by 32.9% from baseline and the surgical success was 92,6%, (complete success 70,3% and qualified success 29,6%) at 9 months.

CONCLUSIONS

In patients with POAG, combined treatment with phacoemulsification, ab-interno trabeculectomy and endoscopic cyclophotocoagulation effectively reduced IOP and glaucoma medication dependence.

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.

Phacoemulsification and endocyclophotocoagulation in uncontrolled glaucoma: Three-year results

PURPOSE

To describe the 3-year outcomes of combined cataract surgery and 360-degree endocyclophotocoagulation (ECP) in eyes with uncontrolled glaucoma and no previous glaucoma drainage surgery.

SETTING

University Hospital Eye Department, Exeter, United Kingdom.

DESIGN

Retrospective case series.

METHODS

The study included patients who had combined cataract surgery and 360-degree ECP. The primary outcome measure was intraocular pressure (IOP) reduction at 3 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 3 years and the complications of surgery. Failure was defined by 1 of 2 criteria: (1) IOP higher than 21 mm Hg or lower than 6 mm Hg or not reduced by 20% from baseline at the 1-, 2-, or 3-year timepoint and (2) further laser or other surgery to reduce IOP at any timepoint.

RESULTS

The study comprised 84 patients (84 eyes). The mean IOP dropped from 18.7 mm Hg preoperatively to 13.3 mm Hg, 13.8 mm Hg, and 14.0 mm Hg at 1, 2, and 3 years postoperatively, respectively. By the 3-year timepoint, 58.3% had met the criteria for failure. The mean number of glaucoma medications was similar at 2.5 at 3 years postoperatively compared with 2.6 preoperatively. Nine patients (10.7%) had a significant complication, but all resolved without long-term sequelae.

CONCLUSIONS

At 3 years postoperatively, combined cataract surgery and 360-degree ECP achieved a modest but significant drop in IOP in phakic patients with uncontrolled glaucoma and no previous drainage surgery. There was a low incidence of serious side effects but nearly 60% were classified as failures by 3 years.