Effect of cataract surgery on intraocular pressure control in glaucoma patients

Phacoemulsification in angle-closure glaucoma: A 360° evaluation

PURPOSE

To evaluate the effect of phacoemulsification on intraocular pressure (IOP) and anterior chamber angle (ACA) morphology in primary angle-closure glaucoma (PACG).

SETTING AND DESIGN

A hospital-based, prospective pre- and post-interventional study was carried out in 40 PAC and PACG eyes post patent PI with visually significant cataracts.

METHODS

All patients underwent phacoemulsification and were evaluated for IOP control, ACA widening, and disease progression for a minimum of 6 months. Failure was defined as an IOP of >21 mmHg necessitating another intervention, including trabeculectomy and/or an increase in the required number of antiglaucoma medications (AGMs) by >1.

RESULTS

A highly statistically significant reduction of IOP ( P < 0.0001) was seen with an overall reduction of 42.2% over 6 months and a mean reduction of 8.9 ± 3.59 mmHg, with the requirement of AGMs reducing from 39/40 patients preoperatively to 1/38 postoperatively. Success was seen in 95% of cases, with two patients not achieving target IOP and requiring trabeculectomy. Angle widening was documented in all cases by both gonioscopy and AS-OCT, and none of the patients showed any progression in disc damage and visual field changes.

CONCLUSION

Early cataract surgery in ACG not only helps to control IOP and disease progression by widening angles and improving aqueous outflow but also improves visual acuity and reduces the economic burden of AGMs. It also helps in better evaluation of disease progression by both structural and functional analysis, as was documented by the improved and more reliable visual field indices.

Three-Year Outcomes of the Paul Glaucoma Implant for Treatment of Glaucoma

PRCIS

In our case series, the 3-year failure for Paul Glaucoma Implant (PGI) implantation was 14.6%. At 3 years postoperatively, there was a significant reduction in mean intraocular pressure (IOP) and the number of glaucoma medications used.

OBJECTIVE

To determine the 3-year efficacy and safety of the PGI, a novel glaucoma tube shunt in patients with glaucoma.

METHODS

Retrospective review of all patients who had undergone PGI implantation in a single tertiary institution in Singapore between May 1, 2017 and January 1, 2022. Data were extracted from electronic health records (Computerized Patient Support System 2 and Epic). The primary outcome measure was failure, defined as IOP >18 mm Hg or <6 mm Hg on 2 consecutive visits after 3 months, reoperation for IOP-related indication, explantation of implant, or loss of light perception vision. Complete success was defined as the absence of failure without medications at 36 months, and qualified success similarly, but with medications. Postoperative mean IOP, mean number of IOP-lowering medications used, and visual acuity were also assessed.

RESULTS

Forty-eight eyes in 48 patients were identified. Thirty-one patients (64.6%) had primary open angle and angle closure glaucoma, and 18 (37.5%) had previous existing tube implants or trabeculectomy. At 3 years postoperatively, 7 cases (14.6%) fulfilled the criteria for failure and 36 (75%) met the criteria for complete success. The mean IOP at 36 months was 14.9 ± 4.11 mm Hg, from the mean preoperative IOP of 20.6 ± 6.13 mm Hg ( P < 0.001). The mean number of IOP-lowering medications used was reduced from 3.13 ± 0.959 preoperatively to 0.167 ± 0.476 at 36 months ( P < 0.001). The most common postoperative complication was hypotony (n = 17, 35.4%), of which the majority were self-limiting, followed by hyphema (n = 5, 10.4%) and tube exposure (n = 4, 8.3%).

CONCLUSION

The PGI demonstrated sustained IOP reduction and a reduction of medication burden at 3 years postoperatively.

Minimally invasive bleb surgery versus minimally invasive glaucoma surgery: a 12-month retrospective study

This study aimed to compare the IOP-lowering effectiveness and safety of standalone Preserflo MicroShunt and iStent 1st generation implantation combined with phacoemulsification in Caucasian patients with a 12-month follow-up period. This retrospective study analyzed the medical histories of patients undergoing antiglaucoma surgery at the Department of Ophthalmology, Medical University of Bialystok, between January 2019 and January 2022. The main outcome measures were success rates (complete: proportion of eyes with IOP < 18 mmHg (criterion A) and < 15 mmHg (criterion B) or 20% reduction in IOP without any glaucoma medication; qualified: proportion of eyes achieving IOPs < 18 mmHg and < 15 mmHg or 20% reduction in IOP from baseline with or without medications), mean reduction (%) in IOP, medication burden, number of complications and additional interventions. In both groups, a significant decrease in IOP and medication burden were observed at 6 and 12 months when compared with baseline. At 12 months, qualified surgical success in criterion A was recorded in 67.4% and 85.7% of patients in the Preserfo and iStent groups, respectively (p = 0.045). Complete surgical success in criterion B at 12 months accounted to 61.4% of patients from Prserflo group and 32.7% patients in iStent group (p = 0.04). Surgical failure at 12 months was documented in 30.2% and 6.3% of patients, respectively (p = 0.003). There was a significant difference between groups in %IOP reduction after 12 months. Greater reduction was observed in Preserflo group, MD = - 8.41 CI95 [- 15.88; - 0.95], p = 0.028, (- 33.49% ± 21.59 vs - 25.07% ± 14.15 in iStent group). Both procedures effectively reduced IOP and postoperative use of antiglaucoma medications in glaucoma patients.

The Effect of Trabecular Aspiration on Intraocular Pressure, Medication and the Need for Further Glaucoma Surgery in Eyes with Pseudoexfoliation Glaucoma

PURPOSE

To investigate whether trabecular aspiration (TA) has an effective medium-term intraocular pressure (IOP)-lowering and medication-saving effect in patients with pseudoexfoliation glaucoma (PEG). In addition, a subgroup analysis of patients with or without a previous trabeculectomy was performed.

METHODS

Records of 290 consecutive eyes with PEG that underwent TA between 2006 and 2012 at the Department of Ophthalmology, Mainz, Germany, were retrospectively analyzed with a follow-up period of 3 years. The main outcomes were IOP and the need for further medical treatment.

RESULTS

Of the 290 eyes with PEG that received TA, 167 eyes from 127 patients met the inclusion criteria. Among these eyes, 128 received TA and cataract surgery (Phaco-TA) without having had a trabeculectomy (group I) before, 29 had Phaco-TA after a previous trabeculectomy (group II) and 10 underwent stand-alone TA after a previous trabeculectomy (group III). In the whole cohort, the median IOP decreased immediately after TA and remained significantly lower compared to the baseline throughout the period of 36 months. Likewise, the median number of antiglaucoma drugs was reduced over the whole period. At the same time, in group I, the median IOP and the number of antiglaucoma drugs were reduced over 36 months. In contrast, in the post-trabeculectomy groups (group II and III), the median IOP and the number of antiglaucoma drugs could not be reduced. While most of the patients that received Phaco-TA with or without a previous trabeculectomy (group I and II) did not require further surgical intervention during the follow-up period, almost all patients receiving stand-alone TA after a previous trabeculectomy (group III) needed surgical therapy, most of them between the second and the third year following TA.

CONCLUSIONS

Phaco-TA has an effective medium-term pressure-lowering and medication-saving effect, especially in patients without a previous trabeculectomy. In trabeculectomized eyes, the effect of TA is limited but still large enough to delay more invasive surgical interventions in some patients.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma

PURPOSE

To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma.

METHODS

This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity.

RESULTS

There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout.

CONCLUSION

Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Phacoemulsification combined with goniosynechialysis versus phacoemulsification alone for patients with primary angle‑closure disease: A meta-analysis

This meta-analysis aims to systematically compare the efficacy between phacoemulsification (PE) combined with goniosynechialysis (GSL) and PE alone for primary angle-closure disease (PACD) patients. All the data were searched from the PubMed, EMBASE and the Cochrane Library. The Cochrane Handbook was used to evaluate the quality of the included studies. Additionally, this meta-analysis was performed by using the Revman 5.4 software. Nine randomized controlled trials (RCTs) were included in this study. Compared with PE alone group, PE+GSL could result significant reduction in the IOP (MD, 1.81; p = 0.002). In the instrumental subgroup, also more reduction of IOP was shown in the PE+GSL group (MD, 2.11; p = 0.02). In the viscogonioplasty (VGP) subgroup, there was not no statistical difference between PE alone group and PE+GSL group (MD, 1.53; p = 0.11). Also, more reduction of peripheral anterior synechiae (PAS) was shown in the PE+GSL group (MD,59.15; p<0.00001). For the change in angle open distance (AOD)500, AOD 750, trabecular-iris space (TISA)500, number of glaucoma medications and best corrected visual acuity (BCVA), there was no difference between two groups (p = 0.25, 0.35, 0.17, 0.56, 0.08). For TISA 750, more improvement was shown in the PE+GSL group (p<0.00001). Instrumental separation had better effect on lowering IOP when it combined with PE. Both instrumental separation and VGP could reduce postoperative PAS. The operation of GSL has no obvious effect on postoperative vision.

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.

First-Generation iStent Bypass Implantation versus ab Externo Canaloplasty Combined with Phacoemulsification in Patients with Primary Open Angle Glaucoma-12-Month Follow-Up

This prospective, non-randomized, interventional clinical study evaluated the efficacy and safety profile of first-generation iStent bypass implantation versus ab externo canaloplasty, both combined with phacoemulsification, in patients with primary open-angle glaucoma (POAG) after 12-month follow-up. A total of 138 patients with POAG and their 138 eyes (69 phaco-iStent and 69 phacocanaloplasty) were included. Postoperatively at 12 months, the mean intraocular pressure (IOP) decreased from 18.44 ± 3.88 to 15.51 ± 2.50 mmHg and from 17.20 ± 4.04 to 14.97 ± 2.37 mmHg in the phaco-iStent (PiS) and phacocanaloplasty (PC) groups, respectively (p = 0.480). In both groups, 35.7% achieved >20% IOP reduction from baseline. A total of 86% and 71.4% of the eyes were medication-free at 12 months in the PiS and PC groups, respectively. In both groups, all eyes showed improvement in best-corrected visual acuity compared with baseline and demonstrated similar safety profiles throughout the 12-month follow-up period. This study showed equal hypotensive effects of PiS and PC. Both procedures significantly reduced the IOP and the requirement for IOP-lowering medications for at least 12 months postoperatively, with no significant differences between the groups.

Ocular Characteristics of Pseudophakic Eyes with Malignant Glaucoma

INTRODUCTION

The aim of the study was to investigate the clinical characteristics and treatment outcomes of the pseudophakic eyes with malignant glaucoma (MG).

METHODS

This retrospective case-control study enrolled 53 eyes of 47 patients with primary angle-closure glaucoma having cataract surgery history, including 19 patients (25 eyes) diagnosed with MG and 28 patients (28 eyes) without MG as the match. Among patients diagnosed with MG, 14 patients (18 eyes) underwent zonulo-hyaloido-vitrectomy (ZHV) and the other 5 patients (7 eyes) received conservative treatments. The visual acuity, refraction status, intraocular pressure (IOP), extent of peripheral anterior synechia, classes of anti-glaucoma medications, and ultrasound biomicroscopy (UBM) examination were recorded before cataract surgery, at the diagnosis of MG, and 3 months after ZHV or atropine application, respectively.

RESULTS

In the pseudophakic eyes with MG, the IOP cannot be well controlled compared to the matched eyes (27.24 ± 8.72 mm Hg vs. 14.30 ± 2.63 mm Hg, p < 0.001). In addition, there was a difference in the average spherical equivalent refractive error between 2 groups of patients (-2.23 ± 0.84 D in MG vs. -0.12 ± 0.64 D in the matched eyes, p < 0.001). By UBM analysis, the anterior chamber depth (ACD) was shallower in MG than that in the matched eyes (2.34 ± 0.20 mm vs. 3.47 ± 0.29 mm, p < 0.001). The difference between the anterior vault distance of the pseudophakic eyes with MG and that of the matched eyes was also significant (p < 0.001). After treated with ZHV, the IOP was greatly decreased from 27.84 ± 10.14 mm Hg to 15.85 ± 4.41 mm Hg (p < 0.001). The refractive error also changed from -2.11 ± 0.91 D to +0.42 ± 0.99 D (p < 0.001). At the same time, the central ACD was significantly deepened from 2.30 ± 0.39 mm to 3.30 ± 0.31 mm (p < 0.001).

CONCLUSION

Uncontrolled IOP and shallow anterior chamber both centrally and peripherally are the primary clinical characteristics for the pseudophakic eyes with MG. An unexpected refractive error or myopic shift for the eyes with PACG after cataract surgery can be an important hint for diagnosis of MG. The typical UBM image is an anterior displacement of the lens-iris diaphragm and a bow-shaped change of the intraocular lens. It is an effective way to treat pseudophakic MG with the ZHV through a peripheral iridectomy.

Prediction of postoperative effective lens position using iris root depth in primary angle-closure diseases

PURPOSE

To evaluate the role of a new parameter, iris root depth (IRD), in intraocular lens power calculation using ultrasound biomicroscopy (UBM) in primary angle-closure diseases (PACDs), and to compare the accuracy of 6 formulas in PACDs: Barrett Universal II (BUII), Haigis, Hill-Radial Basis Function (RBF) v. 3.0, Hoffer Q, Kane and Sanders Retzlaff Kraff/Theoretical (SRK)/T.

SETTING

Zhongshan Ophthalmic Center, Guangzhou, China.

DESIGN

Retrospective consecutive case series.

METHODS

Patients diagnosed with PACDs who had undergone cataract surgery were reviewed to first evaluate the performance of 6 formulas. Then preoperative UBM examinations of 58 eyes were used to measure IRD and predict effective lens position (ELP) to generate the Haigis IRD formula. The accuracy of Haigis IRD was compared with BUII, Haigis and Kane formulas. The SD of predicted error was the main indicator evaluating formula performance, according to heteroscedastic analysis.

RESULTS

103 eyes (103 patients) were included. The SDs of Kane (0.59, P = .01), RBF 3.0 (0.61, P = .02) and SRK/T formula (0.62, P = .04) were significantly lower than Hoffer Q. Modified with IRD, Haigis IRD generated the lowest SD (0.41), which was significantly lower than Haigis formula (0.54, P = .03) and was equal to Kane formula (0.45, P = .37).

CONCLUSIONS

Kane, RBF 3.0 and SRK/T were more accurate in PACD eyes. Optimized with IRD, Haigis IRD formula achieved the lowest SD and had comparable accuracy with Kane formula. IRD could be a promising parameter to improve accuracy of IOL power calculation for PACDs.

Comparison of Outcomes of Phacoemulsification Combined with Endoscopic Cyclophotocoagulation, iStent, or Both in the Management of Open-Angle Glaucoma

INTRODUCTION

To compare outcomes of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco/ECP), first generation iStent implantation (phaco/iStent), or both (phaco/iStent/ECP) in patients with open-angle glaucoma.

METHODS

A retrospective chart review was performed on patients at the University of Colorado Department of Ophthalmology. Outcomes included intraocular pressure (IOP), medication use, best corrected visual acuity (BCVA), and surgical complications were analyzed. Success was defined as IOP reduction of ≥ 20% and/or reduction by at least one glaucoma medication.

RESULTS

A total of 394 eyes were included in the study. There were 170 eyes (43.1%) in the phaco/ECP group, 175 eyes (44.4%) in the phaco/iStent group, and 49 eyes (12.4%) in the phaco/iStent/ECP group. The mean pre-operative IOP was 15.9 mmHg for phaco/ECP, 15.8 mmHg for phaco/iStent, and 15.2 mmHg for phaco/iStent/ECP. At 24 months, the mean IOP was 13.7 mmHg (p < 0.0001), 14.2 mmHg (p = 0.0001), and 13.0 mmHg (p = 0.0007), respectively. The mean pre-operative number of glaucoma medications was 2.0 for phaco/ECP, 1.4 for phaco/iStent, and 2.2 for phaco/iStent/ECP and at 24 months post-surgery decreased to, 1.8 (p = 0.011), 0.9 (p < 0.0001), and 1.7 (p = 0.01), respectively. The success rate at 24 months was 54.4% for phaco/ECP, 75.3% for phaco/iStent, and 55.6% for phaco/iStent/ECP.

CONCLUSION

Phacoemulsification when combined with ECP, iStent, or both, lowered IOP and glaucoma medication reliance at 24 months. The success rate for phaco/iStent was significantly higher than phaco/ECP. When iStent was added to phaco/ECP, the success rate was higher at earlier postoperative visits compared to the phaco/ECP alone.

Effectiveness of Microinvasive Glaucoma Surgery in the United States: Intelligent Research in Sight Registry Analysis 2013-2019

PURPOSE

To evaluate the effectiveness of microinvasive glaucoma surgery (MIGS) with and without concurrent phacoemulsification.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Patients in the Intelligent Research in Sight (IRIS®) Registry who underwent Xen gel stent (ab interno) implantation, endoscopic cyclophotocoagulation (ECP), or goniotomy or canaloplasty from 2013 through 2019.

METHODS

Kaplan-Meier survival analysis was used to assess reoperation rates. We defined reoperation as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine factors predictive of reoperation.

MAIN OUTCOME MEASURES

Reoperation rate, mean intraocular pressure (IOP) and visual acuity (VA), postoperative complications, predictors of reoperation, and reoperation procedure type.

RESULTS

A total of 79 363 eyes from 57 561 patients were included, with 15 118 eyes (19%) receiving stand-alone MIGS and 64 245 eyes (81%) receiving MIGS concurrent with phacoemulsification. Overall, patients who underwent MIGS concurrently with phacoemulsification showed lower reoperation rates compared with stand-alone MIGS, most pronounced in ECP and goniotomy or canaloplasty. At postoperative year 2, the cumulative reoperation rate for stand-alone procedures was 15% for ECP, 24% for Xen implantation, and 24% for goniotomy or canaloplasty compared with 3% for ECP, 19% for Xen implantation, and 6% for goniotomy or canaloplasty concurrent with phacoemulsification (P < 0.001 for each stand-alone MIGS vs. MIGS with phacoemulsification). Black race, older age, moderate and severe glaucoma, higher baseline IOP, and glaucoma subtype were associated with higher reoperation risk. Although IOP decreased in all groups, stand-alone MIGS showed a more substantial decrease in mean IOP. Complication rates from MIGS were low overall: 1% for ECP, 1% for Xen implantation, and 2% for goniotomy or canaloplasty.

CONCLUSIONS

In current United States clinical practice, MIGS has substantially lower reoperation rates when performed with phacoemulsification, especially for ECP and goniotomy or canaloplasty. Approximately one-sixth of patients undergoing stand-alone ECP and one-quarter of patients undergoing stand-alone Xen implantation or goniotomy or canaloplasty require reoperation by 2 years. Black race, diagnosis coding of moderate to severe glaucoma, and higher baseline IOP were associated with higher risk of reoperation after MIGS procedures.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Combined Microinvasive Glaucoma Surgery - A Review of the Literature and Future Directions

The use of microinvasive invasive glaucoma surgery (MIGS) in the treatment of glaucoma has increased exponentially over the last 10 years. However, practice patterns vary widely given the relative newness of these technologies. Some surgeons perform two or more MIGS simultaneously, such as those that target aqueous production and those that target aqueous outflow. These combined MIGS (cMIGS) may result in lower intraocular pressure (IOP) and reduced medication burden as compared to single MIGS (sMIGS). Current evidence suggests some cMIGS are more effective in reducing medication burden for at least 12 months versus sMIGS. This review focuses on the current evidence related to the efficacy of cMIGS as well as novel combinations of standalone MIGS, limitations of the current literature, and future directions for research.

Efficacy and Safety of ab Externo Phaco-Canaloplasty versus First-Generation iStent Bypass Implantation Combined with Phacoemulsification in Patients with Primary Open Angle Glaucoma-Early Results

This study evaluated the early outcomes of the hypotensive efficacy and safety profile of ab externo phaco-canaloplasty versus first-generation iStent bypass implantation combined with phacoemulsification in patients with primary open-angle glaucoma (POAG). In total, 82 patients with POAG comprising 92 eyes were divided into phaco-canaloplasty (Group PC, (n = 47) or iStent combined with phacoemulsification (Group PiS, n = 45) groups. Primary outcome measures were intraocular pressure (IOP) reduction and number of glaucoma medications. Secondary outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (EECD), changes in anterior chamber depth (ACD), and complication rate. The follow-up period was approximately 6 months. Preoperative IOPs were 17.30 (15.00; 19.85) mmHg and 17.50 (15.10; 20.90) mmHg in the PC and PiS groups, respectively (p = 0.876). At the end of the follow-up, IOP decreased to 15.00 (13.00; 16.00) mmHg and 15.00 (14.00; 17.00) mmHg in the PC and PiS groups, respectively (p = 0.438). Medication usage decreased from 2.08 to 0.12 and 1.40 to 0.04 in PC and PiS eyes, respectively. Most patients in both groups were medication-free at 6 months follow-up. After 6 months of observation, EECD in PC and PiS groups decreased from 2309.50 (2032.00; 2533.00) to 1966.50 (1262.00; 2353.50) and 2160.00 (1958.50; 2372.50), to1231.00 (1089.00; 2050.00), respectively (p = 0.037). Pre-surgery BCVA was 0.80 (0.50; 1.00) and 0.60 (0.40; 1.00) in PC and PiS eyes, respectively (p = 0.456). Follow-up BCVA was 0.95 (0.60; 1.00) for PC and 1.00 (1.00; 1.00) for PiS. Hyphema and corneal oedema were noted on the first day post-surgery in both groups. Subsequent complications included a transient increase in IOP in the PC group. Phaco-canaloplasty and iStent bypass implantation combined with phacoemulsification significantly lowered IOP and decreased medication burden. All eyes in both groups maintained or exhibited improved BCVA relative to baseline. Both surgeries had low postoperative complication rates and exhibited comparable safety profiles over 6-month follow-up in patients with POAG.

Assessment of Iridotrabecular Contact and Its Association With Intraocular Pressure After Phacoemulsification in Primary Angle Closure

PURPOSE

To investigate the association between the quantitative assessment of iridotrabecular contact (ITC), measured by swept-source anterior segment optical coherence tomography (SS AS-OCT), and intraocular pressure (IOP) control after phacoemulsification in patients with primary angle closure disease (PACD).

DESIGN

Retrospective, clinical cohort study.

METHODS

Preoperative and postoperative anterior chamber angle parameters were measured using SS AS-OCT. IOP was measured preoperatively and until 6 months postoperatively. Percent IOP reduction and fluctuation after surgery were calculated, and their relationships with SS AS-OCT parameters were assessed by correlation analyses and locally weighted scatterplot smoothing (LOWESS) regression with change-point analysis.

RESULTS

A total of 51 eyes of 51 PACD patients were included. Preoperative ITC index and area (r = 0.626, r = 0.551), as well as changes in ITC index and area (r = 0.632, r = 0.543) after surgery, were significantly correlated with postoperative IOP reduction, after adjusting for age and gender (all P <.001). Higher postoperative ITC index (r = 0.405, P = .005) and ITC area (r = 0.460, P = 0.001) were associated with greater postoperative IOP fluctuations. Change points on LOWESS curves were observed for preoperative ITC index (33.0%) and change in ITC index (27.0%) and percent IOP reductions were significantly correlated with them above (β = 0.386, β = 0.664, all P < .001) but not below the change points.

CONCLUSIONS

Quantitative assessment of circumferential ITC can predict postoperative IOP control after phacoemulsification, and thus it may be used as a reference for determining lens extraction in PACD eyes.

Safety and Efficacy of Three Variants of Canaloplasty with Phacoemulsification to Treat Open-Angle Glaucoma and Cataract: 12-Month Follow-Up

Background: A single-center prospective randomized observational study to compare three types of canaloplasty, i.e., ab externo (ABeC), minicanaloplasty (miniABeC) and ab interno, (ABiC) combined with cataract surgery in primary open-angle glaucoma (POAG) patients over 12 months. Methods: 48 POAG patients underwent one of three canaloplasty procedures: ABeC (16 eyes), miniABeC (16 eyes) or ABiC (16 eyes) or combined with phacoemulsification. Patients were assessed at baseline, at day 0–1–7 and at month 1–3–6–12. Successful treatment was defined as unmedicated IOP reduction ≥20%. Complete surgical success was defined as an IOP ≤ 15 mmHg without medications, and a qualified surgical success as IOP ≤ 15 mmHg with or without medications. Results: Pre-washout IOP median values (mmHg) were 17 (ABeC), 18 (miniABeC) and 17 (AbiC) and decreased at 12-month follow up postoperatively to 13 (p = 0.005), 13 (p = 0.004) and 14 (p = 0.008), respectively—successful treatment was achieved in approximately 100% of patients for ABeC and in 93.8% for both miniABeC and AbiC groups. Preoperatively, the median number of medications was 2.0 (range 1–3) (ABeC), 2.0 (1–3) (miniABeC) and 2.0 (0–4) (ABiC); 12-month post-operatively, all medications were withdrawn except in two patients (followed miniABeC and AbiC). Conclusions: The three variants of canaloplasty significantly reduced IOP and the number of medications in patients with mild to moderate POAG and gave no significant complications.

Clear Lensectomy with Hydrus Stent in Black and Afro-Latino Patients: A 1-Year Retrospective Study

Purpose. To determine the efficacy and safety of phacoemulsification, clear lensectomy, and the Hydrus microstent (Ivantis, Inc.) in Black and Afro-Latino glaucoma patients. Method. This is a retrospective nonrandomized study of 134 Black and Afro-Latino patients who underwent clear lensectomy with Hydrus stent implant for the treatment of glaucoma. For comprehensive analysis, patients were divided into mild, moderate, and advanced glaucoma. The evaluated parameters were reductions in the number of medications, intraocular pressure (IOP), mean deviation on visual field test, and visual acuity. Results. A total of 134 patients with 1-year follow-up were evaluated. At 1 year, the average number of medications significantly decreased from 2.5 ± 1.4 preoperatively to 0.43 ± 1.04 ( $p<0.001$ ) and IOP decreased from 14.4 ± 3.9 to 13.8 ± 3.10 ( $p=0.16$ ). 110 (82.1%) patients were medication-free at 1 year (n = 57, 83.8% mild glaucoma; n = 37, 92.5% moderate glaucoma; n = 16, 61.5% advanced glaucoma). There was stabilization of mean deviation on the visual field test (baseline, −8.28; 1 year, −8.28; $p=1$ ). The most reported adverse effects were transient IOP spike and hyphema (n = 7, 5.2%; n = 3, 2.2%, respectively); both events were self-resolving. No decline in vision or sight-threatening complications were reported at 1 year, and no additional surgeries were required. Conclusion. This 1-year retrospective study demonstrated the efficacy and safety of clear lensectomy and Hydrus stent implantation in decreasing medication burden while maintaining lower IOP in Black and Afro-Latino glaucoma patients.

Prospective 12-month outcomes of combined iStent inject implantation and phacoemulsification in Asian eyes with normal tension glaucoma

BACKGROUND

Glaucoma is the leading cause of irreversible blindness. Normal tension glaucoma (NTG) is a subset of open-angle glaucoma, demonstrating glaucomatous optic nerve damage in the absence of raised intraocular pressure (IOP). NTG is more prevalent in Asian populations. While generally slow-progressing, NTG may be associated with significant central visual field loss. In recent years, minimally invasive glaucoma surgery has been added to the armamentarium of glaucoma surgery. This prospective study aims to evaluate 12-month surgical outcomes of combined iStent inject (Glaukos Corporation, Laguna Hills, CA) implantation and phacoemulsification in Asian eyes with NTG.

METHODS

This is a prospective, single-centre case series of 30 eyes followed up until 12 months after surgery. Outcome measures included IOP, number of glaucoma medications, best-corrected visual acuity (BCVA) and intra and postoperative complications.

RESULTS

Mean age of subjects was 73.1 ± 6.3 years. Majority were ethnic Chinese (n = 27, 90%). Baseline medicated mean IOP was 13.8 ± 2.4 mmHg and mean number of glaucoma medications was 1.3 ± 0.7. Mean Humphrey visual field mean deviation was - 13.7 ± 7.6. The mean IOP reduction at all timepoints from postoperative month (POM) 3 onwards was statistically significant (all P < 0.05), with mean reduction of 1.2 mmHg (95% CI: 0.1-2.2, P = 0.037) by POM12. There was statistically significant reduction in mean number of medications from postoperative day (POD) 1 onwards (all P < 0.05), with mean decrease of 1.0 medication (95% CI: 0.9-1.1, P < 0.001) by POM12. By POM12, 25 (83.3%) eyes were medication-free. Three (10%) eyes had stent occlusion by iris requiring laser iridoplasty. One eye had gross hyphema which resolved on conservative management before POM1. Mean BCVA improved from the baseline 0.3 ± 0.3 logMAR to 0.1 ± 0.1 logMAR postoperatively (P < 0.001). There were no major adverse or sight-threatening events. No eyes required further glaucoma surgery during the 12-month follow-up period.

CONCLUSION

Asian eyes with NTG which underwent combined iStent inject implantation and phacoemulsification demonstrated a significant and sustained reduction in IOP and glaucoma medications, up to 12 months postoperatively.

EFFICACY OF PHACOEMULSIFICATION AND PHACOEMULSIFICATION COMBINED WITH GONIOSYNECHIALYSIS IN SURGICAL TREATMENT OF CHRONIC ANGLE-CLOSURE GLAUCOMA: 2-YEARS STUDY

Aim. To study the degree of angle opening and the decrease of intraocular pressure in primary angle-closure glaucoma (PACG) after cataract phacoemulsification and cataract phacoemulsification with goniosynechialysis (phaco + GLS). Materials and Methods. The study involved 28 patients (28 eyes) with primary chronic angle-closure glaucoma. The patients were divided into two groups, group 1 of 15 patients undergoing phaco with posterior chamber IOL implantation, and group 2 of 13 patients undergoing phaco with IOL implantation and GLS. The patients were followed for 24 months. Phaco was indicated in cases with IOP above 22 mmHg, appositional anterior chamber angle closure, and optic neuropathy; Phaco with GSL was indicated in cases of synechial angle closure and IOP above 22 mmHg Results. In group 1 after Phaco, postoperative anterior chamber angle opening was >20° in all quadrants. Postoperative IOP after 24 month follow-up it decreased by 32,6 % from the preoperative levels. In group 2 after Phaco+GSL, anterior chamber angle opened at least to 20° in three or more quadrants in all cases. Postoperative IOP after 24 month follow-up it decreased by 33.0% from the preoperative levels. Conclusions. Thus, phacoemulsification is an efficient procedure for PACG and appositional angle closure, leading to reopening of the anterior chamber angle with significant IOP reduction. Phacoemulsification alone does not lead to reopening of anterior chamber angle in cases with synechial angle closure, necessitating a combined surgery of phacoemulsification with GSL.

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.

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.

Cataract extraction and intraocular pressure-lowering agents delivery: A nationwide French study between 2005 and 2017

PURPOSE

Cataract and glaucoma are among the leading causes of blindness worldwide in older people, and they are often concomitant. To assess topical intraocular (IOP)-lowering agents delivery changes after cataract extraction.

MATERIAL AND METHODS

Longitudinal matched exposed-unexposed study from the French national healthcare database from January 1, 2005 to January 1, 2017. We compared individuals using topical IOP-lowering agents who underwent bilateral cataract extraction with individuals matched on IOP-lowering agents load, age, and sex who did not undergo cataract extraction. IOP-lowering agents number of drops was assessed 12 months before the first cataract extraction and compared with number of drops 12 months after the second cataract extraction.

RESULTS

About 1194 individuals treated with IOP-lowering agents were included, 597 exposed to bilateral cataract extraction and 597 unexposed to any surgery (total mean age 74.8 ± 8.3 years; 69.0% women). Mean IOP-lowering agents delivery at baseline was 1.4 daily drops in both groups. The mean number of drops decreased greater in the exposed than unexposed group (-25.5% vs -3.5%; p < 0.0001). Overall, 159 (26.6%) and 48 (8.0%) individuals in the exposed and unexposed groups interrupted medication (p < 0.0001).

CONCLUSIONS

A decrease of around one quarter of IOP-lowering agents delivery was observed after cataract extraction in the present real-life study with a longstanding interruption observed in one quarter of patients. Phacoemulsification as a standalone procedure reduces IOP-lowering agents delivery in ocular hypertension and glaucoma.

Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification

PURPOSE

To investigate the costs and effects of implanting trabecular meshwork bypass stents during cataract surgery from a societal perspective in the United States.

DESIGN

Cost-utility analysis using Markov models and efficacy/safety data from published pivotal or randomized control trials (RCTs) of devices investigated.

PARTICIPANTS

Patients aged 65 years and older with mild to moderate primary open-angle glaucoma with or without visually significant cataract.

METHODS

With the use of Markov models, glaucoma progression through 4 glaucoma states (mild, moderate, advanced, severe/blind) and death were simulated over 35 years. The cohort with cataract entered the model and received cataract surgery with or without device implantation. We included a medication management only reference group to calculate total costs and outcomes for those without cataract. Intraocular pressure (IOP) reductions from RCTs were converted to glaucoma state transition probabilities using visual field (VF) mean deviation (MD) decline rates from the Early Manifest Glaucoma Trial. Progressive thinning of the retinal nerve fiber layer (RNFL) on OCT imaging related to IOP control warranted further intervention, including adding medication, selective laser trabeculoplasty (SLT), or incisional glaucoma surgery. We estimated whole costs at Medicare rates and obtained utility values for glaucoma states from previous studies. Incremental costs per quality-adjusted life-year (QALY) gained were evaluated at a QALY threshold of $50 000. One-way deterministic sensitivity analysis, scenario analyses, and probabilistic sensitivity analyses addressed parameter uncertainty and demonstrated model robustness.

MAIN OUTCOME MEASURES

Total costs, QALY, and incremental cost-effectiveness ratio (ICER).

RESULTS

Over 35 years in the base case, the Hydrus (Ivantis, Inc.) implanted with cataract surgery arm cost $48 026.13 and gained 12.26 QALYs. The iStent inject (Glaukos Corp.) implanted with cataract surgery arm cost $49 599.86 and gained 12.21 QALYs. Cataract surgery alone cost $54 409.25 and gained 12.04 QALYs. Initial nonsurgical management cost $57 931.22 and gained 11.74 QALY. The device arms dominated or were cost-effective compared with cataract surgery alone within 5 years and throughout sensitivity analyses. The iStent inject arm was cost-effective in 94.19% of iterations in probabilistic sensitivity analyses, whereas the Hydrus arm was cost-effective in 94.69% of iterations.

CONCLUSIONS

Implanting the Hydrus Microstent or iStent inject during cataract surgery is cost-effective at a conservative QALY threshold.

Surgical Outcomes of Combined 2nd-Generation Trabecular Microbypass (iStent Inject) and Cataract Surgery for the Treatment of Primary Open-Angle Glaucoma in the Saudi Population

INTRODUCTION

To investigate the 24-month efficacy and safety of iStent inject trabecular microbypass system implantation combined with phacoemulsification in subjects with primary open-angle glaucoma (POAG) and concomitant cataract.

METHODS

This prospective, uncontrolled, interventional case series included 36 eyes (29 subjects) with POAG of mild to moderate severity and coexisting cataract that underwent combined phacoemulsification and implantation of a second-generation trabecular microbypass stent (iStent inject®). Main outcome measures involved mean intraocular pressure (IOP), number of antiglaucoma medications, and proportional analysis of eyes with IOP ≤ 18 mmHg or ≤ 15 mmHg, or with 0 or ≥ 2 glaucoma medications. Secondary outcome measures involved the cup-to-disc ratio, corrected distance visual acuity (CDVA), and adverse issues.

RESULTS

In 36 eyes, the mean IOP at baseline was 18.28 ± 2.87 mmHg, which decreased to 14.24 ± 1.36 (22.1%) and 14.46 ± 1.56 mmHg (20.9%) at 18 and 24 months, respectively (p < 0.001). At the last follow-up, 100% of eyes had an IOP ≤ 18 mmHg (vs. 50% preoperatively), and 75.7% of eyes had an IOP ≤ 15 mmHg (vs. 16.7% preoperatively); 58.3% of eyes achieved ≥ 20% IOP reduction from preoperative status. At baseline, eyes were treated with a mean of 2.35 ± 1.18 medications, which was reduced to 0.80 ± 1.04 (66% reduction) and 0.69 ± 0.95 medications (70.6% reduction) at 18 and 24 months, respectively (p < 0.001). At the last follow-up, 54.1% of eyes were medication-free (vs. 0% preoperatively) and 24.3% of eyes were treated with ≥ 2 medications (vs. 64.9% preoperatively). This combined procedure demonstrated an excellent safety profile with no reported intraoperative complications or adverse events; CDVA was maintained throughout the entire follow-up period.

CONCLUSIONS

This real-world series demonstrated that iStent inject device implantation at the time of phacoemulsification is a safe and effective method to decrease IOP and the necessity for antiglaucoma medications in patients with mild-to-moderate POAG and cataract; no associated vision-threatening complications were noted.

Accuracy of intraocular lens power calculation in primary angle-closure disease: comparison of 7 formulas

PURPOSE

To assess the accuracy of intraocular lens power calculation formulas Barrett Universal II (BUII), Hill-Radial Basis Function (RBF) 3.0, Kane, Ladas Super Formula (LSF), Haigis, Hoffer Q, and SRK/T in primary angle-closure disease (PACD).

METHODS

A total of 129 PACD eyes were enrolled. Prediction refraction was calculated for each formula and compared with actual refraction. Accuracy was determined by formula performance index (FPI), median absolute error (MedAE) and percentage of eyes with a prediction error (PE) within ± 0.50D. Subgroup analysis was performed according to axial length (AL).

RESULTS

Overall, FPI was ranked as follows: Kane (0.067), RBF 3.0 (0.064), Haigis (0.062), SRK/T (0.060), BUII (0.058), Hoffer Q (0.055), and LSF (0.049). Kane got the highest (71.3%) percentage of eyes with PE within ± 0.50 D. In medium AL eyes (22 mm < AL ≤ 25 mm), FPI ranked the same as in total group. MedAEs were equal across all formulas (P = 0.121). In short eyes (AL ≤ 22 mm), FPI was Kane (0.055), RBF 3.0 (0.050), SRK/T (0.050), Haigis (0.049), BUII (0.047), Hoffer Q (0.045), and LSF (0.033). MedAEs were significantly different across all formulas (P = 0.033). Haigis showed the lowest MedAE (0.35 D), Haigis and Kane got the highest percentage (63.6%) of eyes with PE within ± 0.50 D.

CONCLUSION

Kane outperformed in total PACD eyes; RBF 3.0, Haigis, and SRK/T achieved satisfying performance. When dealing with PACD eyes shorter than 22 mm, Kane achieved the best accuracy. RBF 3.0, SRK/T, Haigis, and BUII achieved comparable outcomes. No formula showed superiority over others for medium AL PACD eyes.

Real-world Surgical Outcomes of Primary Angle-closure Glaucoma

Purpose

To evaluate surgical outcomes of the four common procedures utilized for primary angle-closure glaucoma (PACG).

Methods

A retrospective study of survival rate in surgical management of PACG was conducted in a referral eye center. One hundred and ninety-nine eyes from 173 PACG patients were collected for chart review. The procedures used were phacoemulsification (PE), combined PE with goniosynechialysis (PE-GSL), combined PE with trabeculectomy (PE-Trab), and trabeculectomy alone. Failure was defined as postoperative IOP >21 mmHg in patients who needed second surgical intervention or those who had IOP <5 mmHg with loss of light perception. Cumulative survival rates, risk of surgical failure, and complications were analyzed.

Results

PE, PE-GSL, PE-Trab, and trabeculectomy were performed in 84 eyes (42.2%), 76 eyes (38.2%), 21 eyes (10.6%), and 18 eyes (9%), respectively. Cumulative survival rates at 60 months were 13%, 55%, 42% and 43%, respectively. Cox regression analysis indicated that each mmHg IOP increased, the risk of surgical failure decreased by 13% (adjusted hazard ratio (HR) 0.87; 95%CI: 0.84-0.93, p<0.001).

Conclusion

Real-world surgical outcomes of PACG showed that PE alone had a low survival rate of 13% in 60-month follow-up whereas PE-GSL achieved the highest rate of 55%. PE-GSL should be initially considered for management of PACG, since it can restore and sustain the physiologic aqueous pathway and preserve the conjunctiva for future filtering surgery if needed.

A cost-effectiveness analysis of iStent inject combined with phacoemulsification cataract surgery in patients with mild-to-moderate open-angle glaucoma in France

OBJECTIVE

To investigate the cost-effectiveness of implementing iStent inject trabecular bypass stent (TBS) in conjunction with cataract surgery (Cat Sx) in patients with mild-to-moderate glaucoma from a societal perspective in France. The secondary objective was to explore the economic impact of iStent inject TBS in patients who comply to different degrees with their anti-glaucoma medications.

METHODS

A previously published Markov model was adapted to estimate the cost-effectiveness of treatment with iStent inject TBS + Cat Sx versus Cat Sx alone over a lifetime time horizon in patients with mild-to-moderate open-angle glaucoma in France. Progression was modeled by health states reflecting increasing stages of vision loss. Disease progression was obtained from the two-year randomized clinical trial assessing safety and effectiveness of both interventions. French specific health-state utilities and costs were obtained through a targeted literature review. Model structure and inputs were validated by French ophthalmologists. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY) gained. The robustness of results was tested through sensitivity analyses.

RESULTS

iStent inject TBS + Cat Sx reduced the number of medications needed and risk of blindness. Incremental cost and QALYs were €75 and 0.065 leading to an incremental cost-effectiveness ratio (ICER) of €1,154/QALY gained. ICER ranged from dominating for non-persistent patients to €31,127 patients fully persistent with their medication regime. Results from one-way sensitivity analysis had a maximum ICER of €29,000 when varying input parameters. iStent inject TBS + Cat Sx had an 86% chance of being cost-effective at a willingness-to-pay threshold of €30,000 per QALY gained.

CONCLUSION

Results demonstrate that iStent inject TBS + Cat Sx is a cost-effective intervention for intraocular pressure reduction when compared to Cat Sx alone in France.

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.

Phacoemulsification with Goniosynechialysis versus Phacoemulsification Alone in Angle-Closure Glaucoma: A Meta-Analysis of Randomized Controlled Trials

Purpose

This meta-analysis aimed to compare the efficacy and safety of phacoemulsification with goniosynechialysis (Phaco-GSL) with those of phacoemulsification alone (Phaco-alone) in patients with angle-closure glaucoma and cataract.

Methods

Randomized controlled trials (RCTs) were selected through a search of electronic databases. Trial eligibility and risk of bias were assessed using Cochrane review methods. Primary measures included the intraocular pressure (IOP), number of antiglaucoma medications, peripheral anterior adhesion (PAS) extent, and their pre- and postoperative changes. For continuous parameters, we calculated weighted mean differences and 95% confidence intervals. Statistical analysis was performed using RevMan 5.3 software.

Results

Eight RCTs were included, where 224 and 236 eyes were in the Phaco-GSL and Phaco-alone groups, respectively. Both postoperative IOP and number of medications were not significantly different between the study groups at the six- and twelve-month follow-up. However, the 12-month postoperative PAS extent was significantly smaller in the Phaco-GSL group than in the Phaco-alone group. Similarly, changes from the preoperative to 12-month postoperative PAS extent were significantly greater in the Phaco-GSL group than in the Phaco-alone group, but IOP and the number of medication changes were not different.

Conclusions

Our results provide evidence that Phaco-GSL provides advantages over Phaco-alone treatment regarding PAS reduction. In terms of IOP and medication reduction, both groups were comparable. Thus, Phaco-GSL can be considered for the treatment of patients with angle-closure glaucoma and cataract due to its ease, safety, and potential benefit for the anterior chamber angle.

Twelve-month surgical outcome and prognostic factors of stand-alone ab interno trabeculotomy in Japanese patients with open-angle glaucoma

The purpose of the study was to evaluate the 12-month surgical outcome and prognostic factors of stand-alone ab interno trabeculotomy. The changes in the intraocular pressure (IOP) and medication score and the success rate of the surgery were analyzed. Thirty-four eyes of 29 patients with primary open-angle glaucoma (POAG; n = 16) or pseudoexfoliation glaucoma (PEG; n = 18) with a 12-month follow-up period were included in the study. The decreases in IOP and medication score from the baseline to the all-time-point were statistically significant (P < 0.001). The surgical success rates were 97.1%, 76.5%, and 44.0% at 3 months (90 days), 6 months (180 days), and 12 months (365 days), respectively. A mixed effect Cox model revealed that the type of glaucoma (POAG) was significantly associated with surgical failure (P = 0.044). Furthermore, the surgical success rate was significantly higher in eyes with PEG than it was in those with POAG (P = 0.019). Stand-alone ab interno trabeculotomy significantly lowered both the IOP and the medication score in patients with glaucoma, although almost one quarter of the cases needed additional glaucoma surgeries. The surgical success rate was significantly higher in eyes with PEG than it was in those with POAG.

Predictors of Intraocular Pressure Lowering after Phacoemulsification and iStent Implantation

PURPOSE

To explore the demographic and clinical variables associated with intraocular pressure (IOP) lowering after cataract extraction (CE) alone or CE in combination with the iStent (Glaukos Corporation) placement (CE+IS).

DESIGN

Retrospective data extraction and survival analysis of consecutive patients identified over a 2-year period.

PARTICIPANTS

Patients with mild to moderate glaucoma who underwent CE (48 eyes of 32 patients) or CE+IS (61 eyes of 37 patients) were analyzed.

METHODS

Inability to reduce the number of medications or the IOP by at least 20% compared with baseline on 2 consecutive visits was considered surgical failure. Using Cox proportional hazards models, survival analysis was performed, and demographic and clinical variables were evaluated as risk factors.

MAIN OUTCOME MEASURES

Time to failure after surgical procedure.

RESULTS

CE+IS had lower odds of failure than CE alone (hazard ratio [HR], 2.01; P = 0.047). In White patients, CE+IS showed greater odds of success compared with CE alone (HR, 2.86; P = 0.007). For non-White patients, no difference was found in the outcomes for the 2 procedures (HR, 0.59; P = 0.48). In the multivariate analysis, non-White race (HR, 8.75; P = 0.0002) and longer axial length (HR, 1.61; P = 0.03) were associated with greater hazard of failure after CE+IS. In the CE group, greater odds of failure were associated with steeper corneal curvature (HR, 1.74; P = 0.008), shallower anterior chamber (HR, 0.22; P = 0.008), and longer axial length (HR, 1.58; P = 0.01).

CONCLUSIONS

Addition of the iStent to CE improved the duration of IOP lowering in White patients, but not in non-White patients. Associations between IOP lowering after CE and biometric parameters may allow for leveraging these clinical parameters for better case selection for these procedures.

Effectiveness of iStent Trabecular Microbypass System Combined with Phacoemulsification versus Phacoemulsification Alone in Patients with Glaucoma and Cataract Depending on the Initial Intraocular Pressure

INTRODUCTION

To assess the effect of iStent trabecular microbypass implantation combined with phacoemulsification on intraocular pressure (IOP) and glaucoma medications and to compare this to outcomes of phacoemulsification alone in patients with mild to moderate primary open-angle glaucoma (POAG) depending on initial IOP.

MATERIALS AND METHODS

Eighty subjects with cataract and POAG were randomized 1:1 into either iStent implantation and cataract surgery (iStent group) (n = 44) or cataract surgery alone (control group) (n = 36). Groups were divided according to initial IOP (after washout period) into IOP <26 mm Hg and IOP ≥26 mm Hg. Patients were assessed preoperatively and at postoperative day 1, week 1, and months 1, 3, 6, 12, and 24. Outcome measures included best-corrected visual acuity, IOP, and glaucoma medications.

RESULTS

Postoperatively at 24 months, mean IOP decreased from 20.93 ± 1.28 to 17.79 ± 2.50 mm Hg in the IOP subgroup <26 mm Hg and from 26.00 ± 0.00 to 19.86 ± 2.19 in the subgroup ≥26 mm Hg in the control group. In the iStent group <26 mm Hg, IOP decreased from 22.04 ± 1.64 to 15.57 ± 2.13 mm Hg and from 26.6 ± 1.09 to 17.06 ± 2.43 mm Hg in the iStent group ≥26 mm Hg.

CONCLUSION

In patients with open-angle glaucoma and cataract, iStent implantation combined with cataract surgery reduced IOP significantly through 2 years, with greater reductions achieved versus phacoemulsification alone. In patients with baseline IOP <26 mm Hg, surgery reduced IOP and medication use significantly declined through 2 years, with greater reductions achieved versus patients with baseline IOP ≥26 mm Hg. The study was registered at ClinicalTrials.gov under the number NCT03807869.

Intraocular pressure variation after conventional extracapsular cataract extraction, manual small incision cataract surgery and phacoemulsification in an indigenous black population

Introduction

intraocular pressure changes have been reported following the various cataract surgical technique. This study aims to compare the intra-ocular pressure (IOP) variation following conventional extra-capsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS) and phacoemulsification in an indigenous black population.

Methods

a comparative cross-sectional study of adult patients aged 40 years and above who had pressure was measured with Goldman’s applanation tonometer pre-operatively and 1^st day, 1^st week, 1^st month as well as 3^rd month post-operative periods and recorded. Data was analyzed using SPSS version 21. Mean IOP changes between study groups were compared using ANOVA. P-value of < 0.05 was taken as statistically significant.

Results

total of 82 patients consisting of 20(24.4%) ECCE, 32(39%) MSICS and 30(36.6%) phacoemulsification with mean preoperative 13.4mmHg, 13.5mmHg and 14.1 mmHg (p = 0.657) respectively was studied. Mean IOP increased from baseline at 1st day post-operative period in the ECCE and MSICS groups (13.4 ± 3.0mmHg to 13.7 ± 4.5mmHg (p = 0.84) and 13.5 ± 3.1mmHg to 15.3 ± 5.1mmHg (P = 0.48) respectively), and decrease in the phacoemulsification group (14.1 ± 2.6mmHg to 13.9 ± 3.5mmHg (p = 0.378). There was a decline in IOP in all the 3 study groups by one week post-operative period; the difference was significant only in the ECCE group (p = 0.032). By 3^rd month postoperatively, there was a reduction in mean IOP when compared with pre-operative IOP the difference being greatest in the ECCE group.

Conclusion

ECCE, MSICS, and Phacoemulsification cause a decline in IOP below preoperative levels at 3^rd month postoperatively in the MSICS group.

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.

Outcomes of effective goniosynechialysis under an endoscopic view combined with phacoemulsification in residual angle-closure glaucoma with lens opacity: 6-month results

PURPOSE

We aimed to evaluate the efficacy and safety of effective goniosynechialysis (GSL) under an endoscopic view combined with phacoemulsification in residual angle-closure glaucoma with lens opacity.

METHODS

This was a retrospective study. Patients with residual angle-closure glaucoma, lens opacity, and uncontrolled intraocular pressure (IOP) who were receiving anti-glaucoma medications were selected to undergo effective GSL under an endoscopic view combined with phacoemulsification. Follow-up examinations were conducted until 6 months postoperatively.

RESULTS

Twenty-five eyes of 24 patients diagnosed with residual angle-closure glaucoma and lens opacity and peripheral anterior synechiae (PAS) at least ≥ 270° were included. Their mean age was 61.32 ± 6.11 years. Preoperatively, the mean (standard error) IOP was 29.69 (11.22) mmHg, and the median number of IOP-lowering medications used was 3.0. The decreases in the rates of IOP of the patients were 44.29%, 52.17%, 46.95%, 48.37%, and 47.29% at 1 day, 1 week, 1 month, 2.5 months, and 6 months after the surgery, respectively. At 6 months, the median number of IOP-lowering medications used decreased from 3 to 0 and the range of PAS compared to the baseline decreased from 312° to 107° (P < 0.001). We also found that 21/25 eyes achieved improved or stable visual acuity after surgery. Postoperative complications included transiently elevated IOP (12.0%), exudation (8.0%), and hyphema (4.0%).

CONCLUSIONS

Phacoemulsification combined with effective GSL under an endoscopic view may reopen residual angle-closure glaucoma and reduce the number of IOP-lowering medications for up to 6 months. It is an effective and safe method for patients with residual angle-closure glaucoma and lens opacity.

Comparison of the 1-year postoperative results of phacoemulsification-trabeculectomy and phacoemulsification-ExPRESS miniature shunt combined surgeries

BACKGROUND AND OBJECTIVE

This study aimed to compare the 1-year postoperative phacoemulsification-trabeculectomy (P-Trab) and phacoemulsification-ExPRESS^® (P-200 model) miniature shunt (P-ExPRESS) combined surgeries.

MATERIALS AND METHODS

This retrospective, comparative clinical study investigated 41 eyes of 41 patients diagnosed with open-angle glaucoma and cataract. Of these, 21 eyes underwent P-Trab surgery and 20 eyes underwent P-ExPRESS surgery. The 1-year follow-up results, including intraocular pressure (IOP), visual acuity (VA), medications, and complications, were reviewed and compared. A 5 ≤ IOP ≤ 18 mmHg or 30% reduction from baseline was defined as Qualified Success (QS-1), and target IOP without medication was defined as Complete Success (CS-1). A 5 ≤ IOP ≤ 15 mmHg or 40% reduction from baseline was defined as Qualified Success (QS-2), and target IOP without medication was defined as Complete Success (CS-2).

RESULTS

The mean follow-up time was 16 months (12-26 months). Results after the twelfth month for P-Trab versus P-ExPRESS are: CS-1: 42.8% versus 60.0% (P = 0.354); QS-1: 86.7% versus 95% (P = 0.606); CS-2:33.3% versus 40% (P = 0.751); QS-2: 66.6% versus 75% (P = 0.733). Kaplan-Meier survival analysis was not statistically significant between two groups for both QS-1, CS-1 and QS-2, CS-2 (P = 0.329 vs P = 0.365, P = 0.765 vs P = 0.789, respectively). Pre-op mean IOP was: 33.19 ± 8.7 versus 34.55 ± 11.3 mmHg; post-op mean IOP was: 15.19 ± 3.07 versus 15.30 ± 3.32 mmHg (P = 0.913); pre-op mean VA was: 1.17 ± 1.04 versus 1.15 ± 1.07 logMAR; and post-op mean VA was: 0.61 ± 0.80 versus 0.66 ± 0.99 logMAR (P = 0.869). The pre-op mean number of antiglaucomatous medications was 3.76 ± 0.53 versus 3.30 ± 1.45, and the post-op results were 1.52 ± 1.53 versus 0.85 ± 1.26 (P = 0.135). Comparing the pre-op and post-op values, both types of surgeries were equally effective (P = 0.00). Surgical failure was 14.2% (3/21) versus 5% (1/20), and the incidence ratios of significant complications were: 47% (10/21) versus 10% (2/20) and P-Trab versus P-ExPRESS, respectively (P = 0.015).

CONCLUSION

The 1-year postoperative results suggest that P-ExPRESS is as effective as P-Trab, with fewer complications.

Intraocular pressure change after phacoemulsification in angle-closure eyes without medical therapy

PURPOSE

To evaluate the intraocular pressure (IOP) change and associated factors 6 months after phacoemulsification in eyes with primary angle-closure suspect (PACS) and eyes with primary angle closure (PAC) that had no medical therapy.

SETTING

Singapore National Eye Center, Singapore, Singapore.

DESIGN

Retrospective case series.

METHODS

Patients with PACS or PAC (with corrected distance visual acuity <20/40) who had uneventful phacoemulsification were recruited. Patients were excluded if they were on IOP-lowering medications within 6 months preoperatively and postoperatively. Preoperative gonioscopy, A-scan biometry, anterior segment optical coherence tomography, and automated refraction were reviewed. Factors related to the percentage of and absolute IOP change were assessed using multiple linear regression analyses after adjusting for age, sex, and diagnosis.

RESULTS

The study evaluated 85 patients (85 eyes; 52 PACS, 33 PAC) after 7 eyes (1 PACS, 6 PAC) were excluded because of poor quality imaging. Overall, IOP decreased by 19.9% from the preoperative mean of 16.1 mm Hg ± 3.1 (SD) to 12.9 ± 2.7 mm Hg. The IOP change between the PACS group (-3.3 ± 2.8 mm Hg; -20.6%) and the PAC group (-3.2 ± 4.7 mm Hg; -19.6%) was similar (P > .05). In multiple linear regression analyses, a higher preoperative IOP (β = 0.68, P < .001) and fewer clock hours of peripheral anterior synechiae (PAS) (β = -0.30, P = .03) predicted a greater absolute change in and percentage of reduction in IOP, respectively.

CONCLUSIONS

The mean IOP reduction 6 months after phacoemulsification was 20%. Less IOP reduction was observed in the presence of lower preoperative IOP and more extensive PAS.

Goniotomy with a single-use dual blade: Short-term results

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of a single-use dual blade (Kahook) in patients with mild to end-stage glaucoma.

SETTING

International multicenter ophthalmic care centers.

DESIGN

Prospective interventional case series.

METHODS

Consecutive patients with glaucoma who had phacoemulsification plus goniotomy with the single-use dual blade were enrolled in this study. Each center collected deidentified clinical data, including preoperative and postoperative IOP, medication use, adverse events, and whether additional surgery was required during a 6-month follow-up.

RESULTS

Of the 71 eyes included in this study, 70% had primary open-angle glaucoma. Other diagnoses included angle-closure, pigmentary, pseudoexfoliative, and normal-tension glaucoma. Sixty-five percent of eyes were classified as having mild to moderate glaucoma and 35%, severe glaucoma. The mean baseline IOP decreased from 17.4 mm Hg ± 5.2 (SD) to 12.8 ± 2.6 mm Hg 6 months postoperatively and the hypotensive medication use decreased from 1.6 ± 1.3 to 0.9 ± 1.0, respectively (P < .001 and P = .005, respectively). The most common observation was blood reflux during surgery (39.4%).

CONCLUSION

Single-use dual blade goniotomy plus phacoemulsification resulted in a significant and sustained reduction in IOP and a decrease in glaucoma medications after 6 months of follow-up.

Assessment of Ganglion Cell Complex and Peripapillary Retinal Nerve Fiber Layer Changes following Cataract Surgery in Patients with Pseudoexfoliation Glaucoma

Purpose

To assess eye pressure, ganglion cell complex, and retinal nerve fiber layer changes following cataract surgery in patients with pseudoexfoliation glaucoma.

Methods

Eighty-five patients with pseudoexfoliation glaucoma (PEXG) were included in the study. They were divided into two groups; the first group included patients with PEXG and cataract who underwent phacoemulsification (pseudophakic group; n = 40 eyes). The second group included patients with PEXG without cataract (control group; n = 45 eyes). Both groups were on antiglaucoma treatment. IOP changes after surgery and the ganglion cell complex (GCC) and peripapillary retinal nerve fiber layer (pRNFL) thicknesses were evaluated in patients underwent cataract extraction surgery compared to controls that did not have cataract, nor underwent surgery. Both groups were followed up postoperatively for 18 months.

Results

There was no difference in the mean age and glaucoma stage in both groups (P=0.242 and 0.70, respectively). In the pseudophakic group, the mean IOP significantly dropped from 20.43 ± 0.90 to 17.00 ± 2.75 mmHg at the end of the follow-up period (P ≤ 0.001). Slight decrease (≈3 μm) was recorded in the mean GCC thickness of the pseudophakic patients from the baseline at the end of the follow-up period. This decrease was lower than that of the controls (≈5 μm). No significant pRNFL changes were recorded all over the postoperative visits (88.78 ± 22.55 μm at 3 months, 88.67 ± 23.14 μm at 6 months, 87.62 ± 23.04 μm at 12 months, and 87.32 ± 22.61 μm at 18 months) as compared to preoperative value (90.28 ± 22.31 μm) with P=0.335, 0.387, 0.158, and 0.110, respectively, or controls (89.69 ± 21.76 μm, 88.73 ± 21.08 μm, 87.33 ± 20.67 μm, and 87.23 ± 20.54 μm with P=0.850, 0.990, 0.951, and 0.984).

Conclusion

Phacoemulsification and IOL implantation may aid in managing pseudoexfoliation glaucoma by lowering IOP and slowing the rate of GCC and pRNFL losses over a short-term period.

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.