Surgical strategies in patients with cataract and glaucoma

Combined versus standalone XEN45 Gel Stent implantation in either phakic or pseudophakic patients: a case-matched study

PURPOSE

To determine differing outcomes among either phakic or pseudophakic patients who received standalone XEN45 Gel Stent (Allergan, an AbbVie Company, CA, USA) implantation and patients who underwent combined surgery with phacoemulsification.

METHODS

This retrospective single-center study involved 180 eyes of 180 participants who underwent XEN45 Gel Stent implantation, of which 60 eyes received combined surgery with phacoemulsification (combined group). Standalone stent implantation was performed on 60 phakic (phakic group) and on 60 pseudophakic eyes (pseudophakic group). The groups were matched in a ratio of 1:1:1 based on multiple criteria. Successful surgery was defined by three scores: IOP at the longest follow-up of < 21 mmHg (Score A) or < 18 mmHg (Score B) and an IOP reduction > 20% or IOP ≤ 15 mmHg and an IOP reduction ≥ 40% (Score C). In all scores, one open conjunctival revision was allowed, and additional repeat surgery was considered a failure.

RESULTS

After an average follow-up time interval of 20.6 ± 12.6 months, there was a mean IOP-reduction by 37% among the entire cohort. Comparative analysis between the three groups did not show significant differences regarding postoperative IOP, postoperative medication score, side effects, revision rate, repeat surgery rate or success rate. A dysfunctional stent was detected in eight eyes (4%) during open conjunctival revision in 76 eyes.

CONCLUSION

The clinical endpoints investigated did not differ significantly among either phakic or pseudophakic patients who received standalone stent implantation and patients who underwent combined surgery. However mean latency between primary stent implantation and first revision surgery after combined surgery was markedly shorter.

Comparison of bleb morphologies between phacoemulsification combined with Ex-PRESS mini shunt implantation, phacotrabeculectomy and trabeculectomy alone: a two-year retrospective in vivo confocal microscopy study

BACKGROUND

To compare the bleb morphologies of phacoemulsification combined with Ex-PRESS implantation (Phaco-ExPRESS), phaco trabeculectomy (Phaco-Trab), and trabeculectomy (Trab) in postoperative two years.

METHODS

Patients with primary open-angle glaucoma (POAG) with or without cataracts were included in this study. All patients underwent surgeries of either Phaco-ExPRESS, Phaco-Trab, or Trab. The morphologic structures of the filtering bleb, including microcysts area, hyperreflective dot density, and stromal connective tissue under in vivo confocal microscope (IVCM), were compared between the three groups. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, 12 months, 18 months, and 24 months.

RESULTS

Eighty-nine eyes from 89 patients were enrolled, including 32 in the Phaco-ExPRESS group, 25 in the Phaco-Trab group, and 32 in the Trab group. In a 24-month follow-up, bleb morphologies in Phaco-ExPRESS were similar to the Trab group. The area of epithelial microcysts was significantly increased in Phaco-ExPRESS and Trab groups while significantly decreased in Phaco-Trab. At postoperative 24 months, the complete success rate was 65.1% in Phaco-ExPRESS, 32.0% in Phaco-Trab, and 59.4% in the Trab group (P = 0.03). The phaco-Trab group had more postoperative anti-glaucoma medications than the other two groups (P < 0.05).

CONCLUSIONS

Phaco-ExPRESS group and Trab group had similar blebs morphologies in IVCM, with larger microcyst area, looser connective tissue, and less inflammation than Phaco-Trab, indicating that the function of blebs in the Phaco-ExPRESS and Trab group, was more potent than that of Phaco-Trab. All these surgical methods provided adequate IOP control, but Phaco-Trab required more anti-glaucoma medications.

Our Experience of Deep Sclerectomy at a Tertiary Center in the United Kingdom Over 14 Years

Background Deep sclerectomy (DS) is a non-penetrating surgical procedure for glaucoma, reducing the resistance to aqueous outflow and lowering intraocular pressure while maintaining a physiological barrier between the anterior chamber and the sub-scleral space. This offers a lower complication profile than penetrating procedures, though with less intraocular pressure (IOP) reduction. Methods We retrospectively reviewed the electronic record for all DS undertaken at our hospital (a tertiary care center) over 14 years, collecting data on demographics, diagnosis, IOP, visual acuity, complications, medications, and further procedures required. Results Eighty eyes of 69 patients underwent DS, with a mean follow-up period of 53.5 months. The mean pre-operative IOP was 23.55 mmHg (range 11-52, standard deviation 8.46); the mean final IOP was 13.61 mmHg (range 5-35, SD 4.73), with a mean reduction of 42.21%. The mean change in glaucoma medications was -1.64. 78.40% experienced a reduction in glaucoma treatment. Post-operatively, 43.80% had no complications; this improved to 85.0% when numerical hypotony and raised IOP without visual sequelae were excluded. Further procedures required included Nd:YAG goniopuncture (10%), bleb needling (13.75%) or revision (7.5%), iridectomy (3.75%), goniosynechiolysis (1.25%), and autologous blood injection (1.25%). Two eyes were converted to trabeculectomy peri-operatively, with seven overall (8.75%) requiring trabeculectomy over the course of follow-up. 3.75% underwent glaucoma drainage device implantation, and 3.75% underwent cyclodiode laser. Conclusion We have found DS to be a safe, effective procedure for selected patients where trabeculectomy has a high likelihood of failure or where a higher IOP can be tolerated.

Comparative anatomical outcomes of high-flow vs. low-flow phacoemulsification cataract surgery: A systematic review and meta-analysis

Background

Phacoemulsification is an effective and widely performed technique in cataract surgery, but the comparative anatomical outcomes, including endothelial cell loss (ECL), central corneal thickness (CCT), and central macular thickness (CMT), between high-flow and low-flow phacoemulsification cataract surgery remain unclear.

Methods

This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Random-effects models were applied to measure pooled mean differences (MD) with 95% confidence intervals (CI) of anatomical outcomes between high-flow and low-flow phacoemulsification cataract surgery. We judged overall certainty of evidence (CoE) based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Results

We included six randomized controlled trials (RCTs) totaling 477 participants. The meta-analysis showed similar changes associated with these two surgery types in both ECL at postoperative days 2–14 (MD: −1.63%; 95% CI: −3.73 to 0.47%; CoE: very low), days 15–42 (MD: −0.65%; 95% CI −2.96 to 1.65%; CoE: very low) and day 43 to month 18 (MD: −0.35%; 95% CI: −1.48 to 0.78%; CoE: very low), and CCT at postoperative day 1 (MD: −16.37 μm; 95% CI: −56.91 to 24.17 μm; CoE: very low), days 2–14 (MD: −10.92 μm; 95% CI: −30.00 to 8.16 μm; CoE: very low) and days 15–42 (MD: −2.76 μm; 95% CI: −5.75 to 0.24 μm; CoE: low). By contrast, low-flow phacoemulsification showed less increase in CMT at postoperative days 15–42 (MD, −4.58 μm; 95% CI: −6.3 to −2.86 μm; CoE: low).

Conclusions

We found similar anatomical outcomes, except in CMT, for both high-flow and low-flow phacoemulsification cataract surgery. Future head-to-head RCTs on visual outcomes should confirm our findings.

Systematic review registration

PROSPERO, identifier: CRD42022297036.

Comparison of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification in primary open-angle glaucoma: a retrospective in vivo confocal microscopy study

BACKGROUND

To compare the efficacy of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification.

METHODS

A retrospective 12-month study on patients with coincident primary open-angle glaucoma (POAG) and cataract. The patients underwent combined phacoemulsification and Ex-PRESS implant (Phaco-ExPRESS, n = 35) or phacotrabeculectomy (Phaco-Trab, n = 35). The morphological structures of the filtering bleb were examined by slit-lamp, anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM). Complete success was defined as postoperative intraocular pressure (IOP) < 18 mmHg without the use of anti-glaucoma medication. Qualified success was defined as postoperative IOP < 18 mmHg with or without anti-glaucoma medications. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, and 12 months.

RESULTS

No significant difference in the variables such as age, IOP and perimetry was found between the groups of Phaco-ExPRESS and Phaco-Trab. At the one-year postoperative visit for filtering blebs, Phaco-ExPRESS increased the mean area of epithelial microcysts significantly from 0.10 ± 0.05 to 0.20 ± 0.09 μm² per μm², while Phaco-Trab decreased the mean area significantly from 0.08 ± 0.04 to 0.04 ± 0.06 μm² per μm². Notably, the hyperreflective dots detected by IVCM decreased by 84.9% in Phaco-ExPRESS but increased by 36.3% in Phaco-Trab. The hyperreflective dots were further identified as neutrophil- and monocyte-like cells. The number of these cells were negatively correlated with the microcysts area (r =  - 0.7, P < 0.01) but positively associated with the grade of connective tissue (r = 0.5, P < 0.01). By creating different microstructural changes in the filtering blebs, Phaco-ExPRESS produced a higher complete success rate (84.9% vs. 41.2%, P < 0.01) and significant decrease in the number of anti-glaucoma medications (P < 0.01) when compared with those in Phaco-Trab. However, the qualified success showed no significant difference between the two groups (100.0% vs. 91.2%, P = 0.24).

CONCLUSIONS

At the one-year follow-up, Phaco-ExPRESS generated better filtering bleb with larger area of microcysts, looser connective tissues, and less inflammation than that of Phaco-Trab, providing adequate IOP control and less IOP-lowering medications. These findings indicate that Phaco-ExPRESS could be more preferred than Phaco-Trab for the treatment of patients with coincident POAG and cataract.

Predictability of success and open conjunctival revision rates in the subsequent eye after XEN45 Gel Stent implantation according to lens status

PURPOSE

To determine the predictability of success and the risk of open conjunctival revision in the subsequent eye after XEN45 Gel Stent implantation according to lens status.

METHODS

This was a retrospective single-centre study involving 132 eyes of 66 participants who had undergone intraocular pressure (IOP)-lowering XEN45 Gel Stent implantation, either as a standalone procedure in phakic and pseudophakic eyes or in combination with phacoemulsification. Successful surgery was defined by three scores: IOP at follow-up < 21 mmHg (score A) or < 18 mmHg (score B) and an IOP reduction > 20% or IOP ≤ 15 mmHg and an IOP reduction ≥ 40% (score C). In all scores, one open conjunctival revision was allowed, and additional repeat surgery was considered a failure. The predictability of success and revision rate depending on the outcome of the first eye were calculated using Bayes' theorem.

RESULTS

IOP-lowering did not differ significantly between the first and second eyes. Success rates of standalone surgery in the second eye after successful surgery in the first eye significantly exceed rates after prior failure. For the combined procedure, the rates did not differ significantly. For score A, we determined a 76.6% chance of success following a prior success and a 57.9% chance, if prior surgery failed. The corresponding probabilities were 75% and 59.1% for score B, while 66.7% and 15.7% for score C, respectively. We calculated a 60% risk for revision surgery in the standalone phakic group. If the first eye was not revised, the risk of revision in the subsequent eye was 20%. The corresponding risks were 72.7% and 5% for the standalone procedure in pseudophakic patients and 38.4% and 41.7% for the combined procedure, respectively.

CONCLUSION

The results of our study offer a tool to predict the outcome of subsequent eye surgeries based on either the outcome in the initial eye and the type of surgery performed, owing to the high predictive potential.

Comparison of long-term results of trabeculectomy and phacotrabeculectomy in patients with pseudoexfoliation glaucoma and primary open-angle glaucoma: a single-center study

PURPOSE

To evaluate long-term surgical success and complications in pseudoexfoliation glaucoma (PEXG) and primary open-angle glaucoma (POAG) after trabeculectomy or phacotrabeculectomy.

METHODS

96 PEXG eyes and 114 POAG eyes who underwent primary trabeculectomy and phacotrabeculectomy were retrospectively evaluated considering intraocular pressure (IOP), the number of glaucoma medications, surgical success, and rate of complications. Two success criteria were used: Complete success comprised IOP of 5-18 mmHg and 20% reduction of baseline IOP without medication. Qualified success comprised IOP of 5-18 mmHg and 20% reduction of baseline IOP irrespective of medication. Success rates in PEXG and POAG groups, trabeculectomy and phacotrabeculectomy groups, and four groups divided according to surgery and etiology were analyzed via Kaplan-Meier survival analysis.

RESULTS

The complete and qualified success were not different between PEXG and POAG groups. The qualified success curves show a similar pattern among the four groups throughout the follow-up of 1,2,3,5,7 and 9 years. Baseline IOP and the number of medications were similar in all four groups (p = 0.275 and p = 0.209, respectively). IOP levels and the number of medications were not statistically different between the four groups during the follow-up of 2,5 and 7 years. The total number of complications and interventions were similar between PEXG and POAG groups (p = 0.258).

CONCLUSIONS

Phacotrabeculectomy is an effective procedure as trabeculectomy with similar surgical success rates and few surgical complications when it comes to treating PAOG and PEXG patients. Both approaches resulted in similar postoperative IOP levels and medication numbers in both groups.

Clinical outcomes of viscocanalostomy and phacoviscocanalostomy in primary open angle glaucoma: Two years follow-up

PURPOSE

To compare the outcomes of phacoviscocanalostomy and viscocanalostomy in patients with primary open angle glaucoma.

METHODS

This non randomized, prospective comparative study included 168 eyes of 168 patients with primary open angle glaucoma (POAG). Phacoviscocanalostomy was performed in 94 eyes with POAG and cataract and viscocanalostomy was performed in 74 eyes with POAG. Preoperative and postoperative intraocular pressures (IOP), number of antiglaucoma medication, intraoperative and postoperative complications were recorded throughout the follow-up period.

RESULTS

The mean follow-up after surgery was 20.13 ± 7.9 months. Mean IOP decreased significantly 1 month after surgery in both groups (p < 0.001) and remained significantly lower from its preoperative value at all follow-up visits. The postoperative mean IOP at the last follow up in phacoviscocanalostomy and viscocanalostomy was 14.98 ± 4.8 mmHg and 16.84 ± 5.0 mmHg, respectively (p = 0.001). Complete success rate in phacoviscocanalostomy and viscocanalostomy groups was 83.1% and 56.8%, respectively (p = 0.008). Qualified success rate was achieved in 89.4% eyes in the phacoviscocanalostomy group and 83.8% of viscocanalostomy group (p = 0.534). The Best corrected visual acuity (BCVA) in phacoviscocanalostomy group improved significantly post-operatively (p = 0.001). Postoperative antiglaucoma medication in both groups were significantly less than the preoperative values (p = 0.001).

CONCLUSIONS

Both Phacoviscocanalostomy and viscocanalostmy are effective procedures in the control of IOP in patients with POAG with and without cataract. Higher complete success rates and BCVA were achieved in phacoviscocanalostomy. Therefore, phacoviscocanalostomy and viscocanalostomy are recommended in eyes with medically uncontrolled primary open-angle glaucoma with and without coexisting cataract.

A Retrospective Analysis of Safety and Efficacy of XEN 45 Microstent Combined Cataract Surgery in Open-Angle Glaucoma over 24 Months

Objectives:

To evaluate the effect on intraocular pressure (IOP) reduction and safety of ab interno gelatin microstent (XEN 45 Gel Stent; Aquesys, Inc, Aliso Viejo, CA, USA) microincisional glaucoma/cataract surgery in open-angle glaucoma (OAG).

Materials and Methods:

In this retrospective study, 30 eyes of 25 patients with OAG which underwent XEN 45 implantation combined with simultaneous phacoemulsification were clinically evaluated. Clinical outcomes analyzed included IOP, percent of IOP reduction, medication use, complications, best corrected visual acuity, and surgical outcomes at 24-month follow-up.

Results:

After the XEN 45 combined cataract surgery procedure, IOP dropped from 20.37±4.80 mmHg with a mean of 3.07±1.04 medication classes preoperatively to 14.83±1.91 mmHg with a mean of 0.94±1.11 medication classes at 24 months (p=0.001 for both). At 24 months, 55.6% of patients had IOP ≤18 mmHg without medication, 94.4% of patients had IOP ≤18 mmHg with or without medication, and 61.1% of patients reached ≥20% IOP reduction from baseline.

Conclusion:

XEN 45 is an effective minimally invasive surgical treatment for OAG with significant reduction in IOP and glaucoma medications and minimal complications in long-term follow-up.

Impact of fluidic parameters during phacoemulsification on the anterior vitreous face behavior: Experimental study

Purpose

To evaluate the eff ect of different aspiration flow rates (AFR) and bottle heights (BH) on vitreous face (AVF) during phacoemulsifi cation.

Methods

Experimental study in 20 porcine eyes. Transzonular viscodissection was performed between the posterior capsule(PC) and AVF to dissect out the Berger's space. Triamcinolone acetonide was injected into this space to aid visualization with ultrasound B-Scan(USG). Realtime USG was performed during phacoemulsifi cation. Eyes were divided randomly into-Group I: Low parameters(AFR = 20 cc/min, BH = 90 cm, vacuum = 400 mmHg),and Group II: High parameters (AFR = 40 cc/min, BH = 110 cm, vacuum=650 mm Hg).

Results

15 eyes were analysed (8 in Group I; 7 in Group II). In all eyes, forward and backward movement of the PC was seen when going from foot position 0 to 1, or on occlusion break. Amplitude of these movements was much greater in Group II compared to Group I. There was no PC rupture in either group. In 2 of the 7 eyes in Group II, USG showed a sudden, spontaneous dispersion appearance of sono-opaque echoes in the vitreous cavity alongwith disappearance of the well-defi ned, crescentic stained space despite an intact PC. This suggests rupture of the AVF, leading to dispersion of the triamcinolone into the entire vitreous cavity. No AVF rupture was seen in Group I.

Conclusion

We report a rarely described entity of AVF rupture with intact PC. The use of high AFR and BH may have clinically invisible detrimental consequences to the anterior vitreous face.

Use of a Collagen Matrix Implant as an Adjuvant in Combined Surgery Involving Phacoemulsification and Nonpenetrating Deep Sclerectomy

AIM

To assess the efficacy and safety of the Ologen collagen matrix as an adjuvant for combined phacoemulsification and nonpenetrating deep sclerectomy (Phaco-NPDS), in addition to mitomycin C (MMC).

MATERIALS AND METHODS

This was a longitudinal retrospective comparative study of eyes treated with Phaco-NPDS, with (group 1) or without (group 2) an Ologen collagen matrix implant, in addition to MMC. The main outcome measures were operative success [absolute success: intraocular pressure (IOP) <18 mm Hg and an at least 20% reduction from baseline without medication; relative success: IOP<18 mm Hg and at least 20% reduction from baseline IOP with or without medication], mean reductions (%) in IOP and medication use; number of postoperative reinterventions (goniopuncture, needling, reoperation), and number of complications.

RESULTS

The mean age of the study population (N=100) was 72.0±9.7 years. Groups 1 (n=51) and 2 (n=49) achieved absolute success rates of 72.5% and 55.1%, respectively (P=0.054), and relative success rates of 90.2% and 83.7%, respectively (P=0.251). From a similar baseline IOP (19.8 and 20.7 mm Hg in groups 1 and 2, respectively, P=0.527), eyes in group 1 achieved a significant lower 12-month IOP (11.7 vs. 14.5 mm Hg, respectively, P=0.002) and a lower rate of medication use (0.2 vs. 0.9, respectively, P<0.001). Eyes in group 2 presented with a higher rate of bleb failure (12.2% vs. 2.0%, P=0.028), leading to a higher rate of needling procedures (38.8% vs. 2.0%, P<0.001) during the postoperative period.

CONCLUSIONS

The adjunctive use of Ologen collagen matrix in addition to MMC during Phaco-NPDS was associated with a higher rate of absolute success, a lower mean IOP at 12 months, a lower rate of bleb failure, and a lower rate of postoperative bleb needling.

The effect of canaloplasty with suprachoroidal drainage combined with cataract surgery - 1-year results

PURPOSE

The purpose of this study was to investigate the safety and efficacy of phacocanaloplasty with suprachoroidal drainage (PCscD) and to compare its intraocular pressure (IOP)-lowering and drug-sparing effect to canaloplasty with suprachoroidal drainage (CscD).

METHODS

The study retrospective interventional study included patients with open-angle glaucoma or secondary forms of glaucoma who underwent either CscD or PCscD between the year 2011 and 2014 in Knappschaft Eye Clinic Sulzbach. Primary end-points were IOP reduction and the number of IOP-lowering medication after 12 months. Secondary end-points were intraoperative and postoperative complications.

RESULTS

A total of 328 eyes were included, 193 were treated with CscD and 135 underwent PCscD. Canaloplasty with scD achieved an IOP reduction of 37.0% (from 20.9 ± 3.6 mmHg to 13.2 ± 2.6 mmHg) after 1 year, whereas PCscD showed a significant higher reduction of 47.4% (from 23.2 ± 5.1 mmHg to 12.2 ± 1.7 mmHg). Reduction in IOP-lowering medication was higher after PCscD (from 3.6 ± 0.6 to 0.2 ± 0.5) than after CscD (from 3.5 ± 0.8 to 0.7 ± 1.0). Twelve months after surgery 55.5% in the CscD group and 80.2% in the PCscD group were free of IOP-lowering medication. In both groups, no severe or sight-threatening complications occurred.

CONCLUSION

Combining cataract surgery and CscD achieves a higher IOP reduction, and patients postoperatively need less IOP-lowering medication than after CscD alone.

Two-site Phacotrabeculectomy versus Bimanual Microincision Cataract Surgery Combined with Trabeculectomy

Purpose

To compare the results of two-site phacotrabeculectomy with microincision cataract surgery (MICS) and trabeculectomy.

Methods

Fifty-eight eyes with coexisting cataract and glaucoma were randomly assigned to have a trabeculectomy in a superior quadrant combined with phacoemulsification and intraocular lens (IOL) implantation through temporal clear corneal incision (two-site phacotrabeculectomy group), or a trabeculectomy in a superior quadrant combined with MICS followed by IOL implantation from the trabeculectomy incision (MICS + trabeculectomy group). The main outcome measures were preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, best-corrected visual acuity (BCVA), and complications. Follow-up was period was 12 months.

Results

Twenty-eight two-site phacotrabeculectomies and 30 MICS + trabeculectomies were performed. Mean age of the subjects was 67.4 years. Mean preoperative IOP was 24.6±5.7 mmHg in the two-site phacotrabeculectomy group and 23.7±5.5 mmHg in the MICS + trabeculectomy group (p=0.52). At 12 months postoperatively mean IOP was 14.5±3.0 and 14.3±3.4 mmHg in two-site phacotrabeculectomy and MICS + trabeculectomy groups, respectively (p=0.8). Preoperative and postoperative glaucoma medication numbers were similar and mean number of glaucoma medications decreased in both groups after the surgery (p<0.05). BCVA improved in both groups. Twenty-six of 28 eyes (92%) in the two-site + trabeculectomy group and 27 of 30 (90%) in the MICS + trabeculectomy group had clinically apparent filtering blebs at 12 months (p=0.71). Postoperative complications were comparable.

Conclusions

MICS + trabeculectomy provided 1 year IOP control comparable to that with two-site phacotrabeculectomy with similar amount of complications and similar final BCVA.

Factors to be Considered when Performing Cataract Surgery in Patients Unable to Recline Flat

PURPOSE

Although phacoemulsification is routinely performed with the patient in a supine position, certain locomotor deformities and other severe ailments can lead to the inability of the patient to recline flat.

METHODS

The present article surveys publications and summarizes our own experience regarding positioning techniques during cataract surgery on patients unable to adopt a supine position.

RESULTS

The successful and effective performance of cataract surgery by phacoemulsification depend on the comfortable positioning of both the patient and the surgeon. In order to achieve the highest possible success rate in phacoemulsification surgery, optimal positioning of the patient and the operating microscope are essential. There are other features of pivotal importance, including the construction of the operating table, the anesthesia technique, and the surgical approach.

CONCLUSIONS

Surgeons often have to rely on their own imagination and experience in finding optimal positioning in order to perform effective and successful phacoemulsification surgery.

Effect of fluidics on corneal endothelial cell density, central corneal thickness, and central macular thickness after phacoemulsification with torsional ultrasound

Aim:

To study the relative effects of high and low fluidic parameters on endothelial cell density (ECD), central corneal thickness (CCT), and central macular thickness (CMT) after phacoemulsification with torsional ultrasound.

Settings and Design:

Prospective, randomized clinical trial based on a tertiary eye hospital.

Subjects and Methods:

The study included 65 patients in each group. Patients were randomized to either the high or the low flow group using a computerized random number table. The study was patient and examiner masked. All patients underwent phacoemulsification with torsional ultrasound. Visual acuity, ECD, CCT, and CMT were measured for all patients preoperatively at 2 weeks and 6 weeks postoperatively.

Statistical Analysis Used:

The Shapiro–Wilks test was used to assess the normality of the data. Mann–Whitney U-test with the P value set at 0.05 was used to compare the two groups.

Results:

Cumulative dissipated energy was significantly higher in the low flow group (16.44 ± 9.07 vs. 11.74 ± 6.68; P = 0.002). No statistically significant difference was noted between the two groups in the ECD, CCT, CMT, or corrected distance visual acuity at the end of 6 weeks.

Conclusions:

No significant difference was noted in the postoperative outcome between high and low flow groups. Parameters can be modified to suit the surgeon's preference, as both high and low flow parameters were found to have comparable postoperative outcomes.

The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia

Purpose: To evaluate and compare the safety and efficacy of combined two-site phacoemulsification and trabeculectomy surgery with mitomycin C (MMC) in glaucoma-cataract patients with retrobulbar or topical anesthesia.

Patients and methods: A retrospective, nonrandomized review of consecutive phacotrabeculectomy patients with a minimum follow-up time of 6 months, no previous glaucoma surgeries, and a preoperative visual acuity (VA) greater than light perception. The main outcome measures were preoperative and postoperative VA, intraocular pressure (IOP), use of glaucoma medications, and complications. A complete surgical success required an IOP from 6 to 18 mm Hg, no visually devastating complications, no return to surgery, and no use of glaucoma medications. Qualified success allowed the use of up to two glaucoma medications. Anesthesia groups were compared by student t-tests and log rank comparison of Kaplan-Meier survival rates.

Results: Eighty-seven eyes (83 patients) met inclusion criteria, with a mean follow-up of 19 ± 12 months (6-57 months). The average eye gained 3.1 ± 4.9 lines of VA, lost 4.0 ± 7.1 mm Hg of IOP, and decreased 1.0 ± 1.3 glaucoma medications. Retrobulbar and topical anesthesia groups had statistically equivalent mean changes in VA (p = 0.910), IOP (p = 0.268), and use of glaucoma medications (p = 0.964). Postoperative complication rates were also statistically similar (p = 0.580). Complete success was greater in the retrobulbar group (p = 0.006), however, qualified success was equivalent in both groups (p = 0.769).

Conclusion: Two-site phacotrabeculectomy with MMC in West Indian patients is as safe and effective for glaucoma-cataract patients with topical anesthesia as it is under retrobulbar anesthesia, and without short-term losses in VA and the chance of serious complications from injection.

How to cite this article: Rodriguez R, Alburquerque R, Sauer T, Batlle JF. The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia. J Curr Glaucoma Pract 2016;10(1):7-12.

Comparison of 1-Site and 2-Site Phacotrabeculectomy in the Small Adult Eyes With Concomitant Cataract and Glaucoma

The aim of this study was to compare the outcomes after phacotrabeculectomy at 1 or 2 sites in the small adult eyes with concomitant cataract and glaucoma.Patients who had 1-site (n = 26) or 2-site (n = 14) phacotrabeculectomy over a 4-year period at an eye surgery center were included. Eighteen eyes of 18 patients with glaucoma using any 1 prostaglandin analogue (latanoprost, travoprost, or bimatoprost) were compared with 8 normal control patients. The records of patients were reviewed, and intraocular pressure, best-corrected visual acuity, axial length, anterior chamber depth, corneal endothelial cell (CEC) density, Diopter were measured. The outcome was compared with postoperative and preoperative measurements for 3-month follow-ups.The follow-up time was 3 months. There was no difference between the operations in improving best-corrected visual acuity, lowering intraocular pressure, shortening axial length, and deepening anterior chamber depth. However, 2-site surgery was associated with significantly more CEC loss and refractive error. Postoperative complications were not different between the 2 groups.The CEC loss and the refractive error in 2-site group were higher than that of 1-site group. One-site surgery seems to cause less CEC damage and refractive error than the 2-site operation during the follow-up time of 3 months.

Phacoemulsification combined with a new ab interno gel stent to treat open-angle glaucoma: Pilot study

PURPOSE

To study the effect on intraocular pressure (IOP) of implanting a new gelatin stent at the time of cataract surgery in the treatment of open-angle glaucoma (OAG).

SETTING

Multicenter university and private-practice settings.

DESIGN

Nonrandomized prospective clinical trial.

METHODS

The implantation of 2 models of a gelatin stent (Xen140 and Xen63) was performed at the time of cataract surgery without mitomycin-C. Complete success was defined as a postoperative IOP of less than 18 mm Hg and more than a 20% reduction in IOP at 12 months without glaucoma medication. Failure was defined as loss of light perception vision or worse, a need for additional glaucoma surgery, or less than a 20% reduction in the IOP from baseline.

RESULTS

The study included 37 eyes of 37 patients. The mean preoperative IOP was 22.4 mm Hg ± 4.2 (SD) on 2.5 ± 1.4 medication classes. Twelve months postoperatively, the mean IOP was reduced to 15.4 ± 3.0 mm Hg on 0.9 ± 1.0 medication classes (P < .0001). This resulted in a qualified success of 85.3% and a complete success rate off medications of 47.1%. There were no failures.

CONCLUSION

Cataract surgery combined with implantation of the gelatin stent resulted in a significant reduction in IOP in eyes with OAG.

FINANCIAL DISCLOSURE

Dr. Sheybani has received travel reimbursement from Aquesys, Inc. Dr. Ahmed is a paid consultant to Aquesys, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Comparison of surgical outcomes after phacotrabeculectomy in primary angle-closure glaucoma versus primary open-angle glaucoma

PURPOSE

To compare postoperative outcomes and assess factors associated with intraocular pressure (IOP) reduction after phacotrabeculectomy in patients with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

METHODS

This is a retrospective study of patients who underwent phacotrabeculectomy between 2010 and 2013. Factors including age, gender, visual field (VF), the number of glaucoma medications used, biometric changes, IOP, and surgical success rates were compared between groups.

RESULTS

There were 27 PACG and 34 POAG patients. The PACG group had a greater mean IOP reduction after phacotrabeculectomy compared to the POAG group (5.5 ± 7.9 mmHg versus 2.0 ± 4.2 mmHg; p = 0.03). However, the final mean IOP was similar between the two groups (PACG: 12.2 ± 4.8 mmHg, POAG: 12.3 ± 3.1 mmHg; p = 0.92). Phacotrabeculectomy resulted in a mean decrease in axial length (AL) of 0.16 ± 0.15 mm in PACG and 0.16 ± 0.11 mm in POAG (p = 0.96), and an increase in anterior chamber depth (ACD) of 1.41 ± 0.91 mm in PACG, and 0.87 ± 0.86 mm in POAG (p = 0.04). At 2 years follow-up, the cumulative success rate of phacotrabeculectomy was 74% in PACG and 62% in POAG. Multivariate analysis found that early glaucoma stage, greater postoperative increase in ACD, and high preoperative IOP were factors associated with greater IOP reduction.

CONCLUSION

Postoperative success rates and mean IOP on the final visit after phacotrabeculectomy were similar between the PACG and POAG groups. Factors associated with IOP reduction were greater postoperative increase in ACD, and high preoperative IOP.

Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma

BACKGROUND

Cataract and glaucoma are both common comorbidities among older patients. Combining glaucoma surgery with minimal invasive phacoemulsification (phaco) is a considerable option to treat both conditions at the same time, although the combination with filtration surgery can produce a strong inflammatory response. Combined non-penetrating procedures like canaloplasty have shown to reduce intraocular pressure (IOP) comparable to trabeculectomy without the risk of serious bleb-related complications. The purpose of this retrospective study was to compare the outcomes of phacotrabeculectomy and phacocanaloplasty.

METHODS

Thirty-nine eyes with concomitant cataract and glaucoma who underwent phacotrabeculectomy (n=20; 51.3%) or phacocanaloplasty (n=19; 48.7%) were included into this trial on reduction of IOP, use of medication, success rate, incidence of complications and postsurgical interventions. Complete success was defined as IOP reduction by 30% or more and to 21 mmHg or less (definition 1a) or IOP to less than 18 mmHg (definition 2a) without glaucoma medication.

RESULTS

Over a 12-month follow-up, baseline IOP significantly decreased from 30.0 ± 5.3 mmHg with a mean of 2.5 ± 1.2 glaucoma medications to 11.7 ± 3.5 mmHg with a mean of 0.2 ± 0.4 medications in eyes with phacotrabeculectomy (P< .0001). Eyes with phacocanaloplasty had a preoperative IOP of 28.3 ± 4.1 mmHg and were on 2.8 ± 1.1 IOP-lowering drugs. At 12 months, IOP significantly decreased to 12.6 ± 2.1 mmHg and less glaucoma medications were necessary (mean 1.0 ± 1.5 topical medications; P< .05). 15 patients (78.9%) with phacotrabeculectomy and 9 patients (60.0%) in the phacocanaloplasty group showed complete success according to definition 1 and 2 after 1 year (P= .276). Postsurgical complications were seen in 7 patients (36.8%) of the phacocanaloplasty group which included intraoperative macroperforation of the trabeculo-Descemet membrane (5.3%), hyphema (21.1%) and bleb formation (10.5%). Although more complications were observed in the phacotrabeculectomy group, no statistically significant difference was found.

CONCLUSIONS

Phacocanaloplasty offers a new alternative to phacotrabeculectomy for treatment of concomitant glaucoma and cataract, although phacotrabeculectomy yielded in better results in terms of IOP maintained without glaucoma medications.

Does phacoemulsification affect the long-term success of non-penetrating deep sclerectomy?

BACKGROUND AND OBJECTIVE

Phaco non-penetrating deep sclerectomy (PhacoNPDS) is an option to simultaneously treat cataract and glaucoma. The authors assessed tensional success of PhacoNPDS and NPDS up to 3 years of follow-up.

PATIENTS AND METHODS

A longitudinal consecutive retrospective study was conducted comparing 376 eyes undergoing NPDS (group 1) and 87 eyes undergoing PhacoNPDS (group 2). Success was defined as complete 1 (intraocular pressure [IOP] < 21 mm Hg without medication); complete 2 (at least a 20% reduction of preoperative IOP without medication), and qualified (IOP < 21 mm Hg with or without medication).

RESULTS

Preoperative IOP and number of medications were 23.7 and 2.7 in group 1 and 23.1 and 2.6 in group 2, respectively. Postoperative IOP (3 years) was 13.1 mm Hg in group 1 and 13.4 mm Hg in group 2 (P = .000). Complete 1, complete 2, and qualified success in 3 years were 57.5%, 53.7%, and 94.5% in group 1 and 56.1%, 56.1%, and 100% in group 2, respectively (P = .861, .772, and .159). Final number of medications was 0.5 in group 1 and 0.3 in group 2.

CONCLUSION

PhacoNPDS seems to achieve similar tensional results as NPDS alone up to 3 years of follow-up.

Factors that influence intraocular pressure after cataract surgery in primary glaucoma

OBJECTIVE

We sought to find predictive factors for favourable postoperative intraocular pressure (IOP) after cataract surgery in patients with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

STUDY DESIGN

Retrospective evaluation of patients who had undergone cataract surgery.

PARTICIPANTS

Forty-eight patients with POAG and 48 patients with PACG.

METHODS

Various clinical factors were evaluated retrospectively in 96 patients. All patients had undergone standard 2.75-3.5 mm limbal incision cataract surgery. Clinical parameters in patients with successful postoperative IOP courses were compared with those in unsuccessful patients. Success was defined as an IOP between 6 and 21 mm Hg, with fewer antiglaucoma medications needed compared with before surgery, and no need of additional glaucoma surgery.

RESULTS

In POAG, eyes with a highest preoperative IOP of <31 mm Hg or those being treated with <3 antiglaucoma medications before surgery had a significantly higher probability of success. In PACG, the probability of success was significantly higher if the highest preoperative IOP was <42 mm Hg, the number of antiglaucoma medications before surgery was <3, or the areas of peripheral anterior synechiae were <4 clock hours.

CONCLUSIONS

Primary small-incision cataract surgery using phacoemulsification and foldable intraocular lens implantation may be the procedure of choice in patients with medically controlled glaucoma and coexisting visually significant cataracts, considering the highest preoperative IOP and number of antiglaucoma medications in POAG and PACG, and the area of peripheral anterior synechiae in PACG.

Effect of hydrodynamic parameters on corneal endothelial cell loss after phacoemulsification

PURPOSE

To evaluate the effect of power, vacuum, and flow rate on endothelial cell loss after phacoemulsification.

SETTING

Labbafinejad Medical Center Medical Center, Tehran, Iran.

METHODS

In a prospective randomized clinical trial, phacoemulsification was performed in 2 groups (high vacuum and low vacuum) with 3+ nuclear sclerosis. The stop-and-chop technique was used with the Sovereign machine. Machine parameters during the chop stage were vacuum 400 mm Hg in the high-vacuum group and 200 mm Hg in the low-vacuum group and flow rate, 40 cc/min and 20 cc/min, respectively. Endothelial cell density preoperatively before and 1, 6, and 12 weeks postoperatively were compared.

RESULTS

Each group comprised 30 eyes. The mean US power was 9.2% +/- 4.3% (SD) in the low-vacuum group and 13.1% +/- 4.6% in the high-vacuum group (P = .001) and the mean phaco time, 1.28 +/- 1.0 minutes and 0.88 +/- 0.6 minutes, respectively (P = .04). Total US energy and total fluid consumed were similar between groups. After 12 weeks, the mean endothelial cell loss was 9.0% +/- 4.0% in the low-vacuum group and 9.6% +/- 4.6% in the high-vacuum group (P = .6). There was a relationship between total US energy and endothelial loss (P<.001); however, total fluid volume was not a significant predictor (P = .19).

CONCLUSIONS

Vacuum level did not have a significant effect on total US energy or total fluid consumed during phacoemulsification. There was a strong relationship between total US energy and endothelial cell loss but not between total infused fluid and endothelial cell loss.

Canaloplasty: Circumferential viscodilation and tensioning of Schlemm's canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults

PURPOSE

To evaluate the safety and efficacy of circumferential viscodilation and tensioning of the inner wall of Schlemm's canal in a new surgical procedure for the treatment of open-angle glaucoma (OAG).

SETTING

Fourteen clinical sites in the United States and Germany.

METHODS

In this international multicenter prospective study of adult patients with OAG having glaucoma surgery, patients with qualifying preoperative intraocular pressure (IOP) of at least 16 mm Hg or higher and open angles were eligible. Evaluation was performed at baseline and 1 day, 1 week, and 1, 3, 6, and 12 months preoperatively. After a nonpenetrating dissection technique to expose Schlemm's canal was performed, a flexible microcatheter (iTrack 250A, iScience Interventional) was used to dilate the full circumference of the canal by injecting sodium hyaluronate 1.4% (Healon GV) during catheterization. A suture loop was placed in the canal to apply tension to the trabecular meshwork. High-resolution ultrasound imaging was used to assess Schlemm's canal and anterior segment angle morphology, including distension of the trabecular meshwork caused by the tensioning suture. Data analysis was performed in 2 groups: Group 1, in which patients met all inclusion criteria, and Group 2, made up of Group 1 patients who had successful suture placement.

RESULTS

Group 1 comprised 94 patients and Group 2, 74 patients. The mean baseline IOP in Group 1 was 24.7 mm Hg+/-4.8 (SD) on a mean of 1.9+/-1.0 medications per patient. In Group 2 (patients with sutures), the mean IOP was 16.1+/-4.7 mm Hg 3 months postoperatively, 15.6+/-4.0 mm Hg at 6 months, and 15.3+/-3.8 mm Hg at 1 year. Medication use dropped to a mean of 0.6+/-0.9 per patient at 12 months. Suture tensioning was an apparent contributing factor in achieving surgical success. Patients with measurable trabecular meshwork distension from suture tension had a mean IOP of 15.9+/-5.2 mm Hg at 6 months and 14.5+/-3.0 mm Hg at 12 months. Surgical and postsurgical adverse events were reported in 15 of 94 patients (16%) and included hyphema (3), elevated IOP greater than 30 mm Hg (3), Descemet's tear (1), hypotony (1), choroidal effusion (1), and exposed closure suture with eyelid edema and erythema epiphora (1); 4 patients were subsequently converted to trabeculectomy.

CONCLUSION

Circumferential viscodilation and tensioning of Schlemm's canal was a safe and effective surgical procedure to reduce IOP in adult patients with OAG.

Phacotrabeculectomy with mitomycin C in patients with uveitis

PURPOSE

To evaluate the safety and efficacy of combined phacoemulsification, intraocular lens implantation, and trabeculectomy with mitomycin C for the management of uveitic complications.

DESIGN

Retrospective case-control study.

METHODS

We conducted a retrospective review of the records of 23 consecutive eyes with chronic noninfectious uveitis (uveitic group) and 43 nonuveitic eyes (control group) that had received primary phacotrabeculectomy. Mitomycin C was used in all the uveitic eyes. Considering the high preoperative intraocular pressure (IOP) of the uveitic group, nonuveitic eyes that had a preoperative IOP of >or=20 mm Hg or that had been given two or more medications were included in the control group. All patients were followed for at least one year. The main outcome measures were postoperative vision, IOP control, complications, and acute uveitis relapse rates.

RESULTS

Visual outcome of the uveitic group was similar to the control group. In the uveitic group, the success rate of IOP control (91.3% at one year, 84.8% at two years) was favorable but was significantly lower than in the control group (P = .0423). Complications were comparable between the groups. Primary surgical failure in the uveitic group was associated with the postoperative acute uveitis attack. In the uveitic group, the acute uveitis attack rate showed no change after surgery (P = .283).

CONCLUSION

With adequate inflammation suppression, phacotrabeculectomy with mitomycin C is an effective and safe therapeutic option for the management of secondary cataract and glaucoma in uveitic eyes. A lower surgical success rate of the uveitic group might be attributable to the postoperative inflammation recurrence.

Microincision bimanual phacotrabeculectomy in eyes with coexisting glaucoma and cataract

PURPOSE

To report the technique and surgical outcomes of microincision bimanual phacotrabeculectomy in eyes with glaucoma and coexisting cataract.

SETTING

Glaucoma Service, Hong Kong Eye Hospital, Hong Kong SAR, China

METHODS

Microincision bimanual phacoemulsification with a sleeveless phaco needle and irrigating chopper was performed in combination with trabeculectomy. Phacoemulsification was performed through 2 small clear corneal wounds, sparing the trabeculectomy site from trauma. The intraocular lens (IOL) was then implanted through the trabeculectomy site, so no corneal wound larger than 1.5 mm was required for IOL implantation.

RESULTS

The first 10 consecutive eyes of 10 patients who had combined phacotrabeculectomy by a microincision bimanual technique had significantly reduced intraocular pressure. There was a 10.5% reduction in the mean corneal endothelial cell count. There were no other complications up to 6 months after surgery.

CONCLUSION

Microincision bimanual phacotrabeculectomy appeared to be an effective and safe option in patients with glaucoma and coexisting cataract.

Phacoemulsification in patients with Baerveldt tube shunts

PURPOSE

To investigate the effects of phacoemulsification in glaucomatous eyes with functioning Baerveldt tube shunts.

SETTING

Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

METHODS

This retrospective analysis followed 9 eyes of 8 patients with functioning Baerveldt tube shunts who had clear corneal phacoemulsification. Intraocular pressure (IOP), number of glaucoma medications, corneal thickness, visual acuity, and additional glaucoma surgery were measured.

RESULTS

The mean follow-up was 21 months +/- 3 (SD) (range 17 to 25 months). The mean change in IOP and the number of glaucoma medications used did not significantly change at 1 month (P>.19), 1 year (P>.17), or the last follow-up (P>.17). At the last examination, 2 eyes had IOP increases of 2 to 4 mm Hg, 3 eyes had no change, and 4 eyes had decreases of 4 to 7 mm Hg. Intraocular pressure increased in 1 eye at 8 months and required a tube shunt revision. No eye developed corneal decompensation. Visual acuity improved in 8 eyes; the mean improvement was 4 +/- 3 Snellen lines.

CONCLUSION

In most cases, phacoemulsification in glaucomatous eyes with a functioning Baerveldt tube shunt improved vision and maintained control of IOP.

Insertion of a foldable hydrophobic IOL through the trabeculectomy fistula in cases with microincision cataract surgery combined with trabeculectomy

Background

The use of conventional foldable hydrophobic intraocular lenses (IOLs) in microincision cataract surgery (MICS) currently requires wound enlargement. We describe a combined surgical technique of MICS and trabeculectomy with insertion of a foldable IOL through the trabeculectomy fistula.

Methods

After completion of MICS through two side port incisions, a 3.2 mm keratome is used to enter the anterior chamber under the previously outlined scleral flap. An Acrysof multi piece IOL (Alcon labs, Fort Worth, Tx) is inserted into the capsular bag through this incision. The scleral flap is then elevated and a 2 × 2 mm fistula made with a Kelly's punch. The scleral flap and conjunctival closure is performed as usual.

Results

Five patients with primary open angle glaucoma with a visually significant cataract underwent the above mentioned procedure. An IOL was implated in the capsular bag in all cases with no intraperative complications. After surgery, all patients obtained a best corrected visual acuity of 20/20, IOL was well centered at 4 weeks follow up. The mean IOP (without any antiglaucoma medication) was 13.2 + 2.4 mm Hg at 12 weeks with a well formed diffuse filtering bleb in all the cases.

Conclusion

The technique of combining MICS with trabeculectomy and insertion of a foldable IOL through the trabeculectomy fistula is a feasible and valuable technique for cases which require combined cataract and glaucoma surgery.

Pharmacologic and pharmacokinetic assessment of anti-TGFbeta2 aptamers in rabbit plasma and aqueous humor

PURPOSE

The aim of the study is to determine the bioactivity and effects of PEGylation on the pharmacokinetics in rabbit aqueous humor and plasma of an aptamer directed against TGFbeta2.

METHODS

Pharmacological activity of anti-TGFbeta2 aptamer in rabbit ocular fluid was demonstrated using a mink lung epithelial cell proliferation assay. For pharmacokinetic analyses, concentrations of aptamers in plasma and aqueous humor were determined over time following bilateral subconjunctival administration to Dutch-belted rabbits using a hybridization-based pseudo-enzyme-linked immunosorbent assay (ELISA) assay.

RESULTS

Anti-TGFbeta2 aptamer (ARC81) binds to human TGFbeta2 with a K(D) of approximately 5 nM and inhibits the activity of human TGFbeta2 in vitro in a cell-based assay with an IC(50) of approximately 100 nM. ARC81 blocks endogenously derived TGFbeta2 in rabbit aqueous humor in vitro with an IC(50) of approximately 200 nM and an IC(90) of approximately 1 microM. In vivo in rabbit, ARC81 [no polyethylene glycol (PEG)] entered systemic circulation rapidly (t(max) = 1 h in plasma) relative to aptamer conjugates ARC117 (20 kDa PEG) and ARC119 (40 kDa PEG), which showed prolonged residence in the subconjunctival space and aqueous compartment (t(max) = 6 and 12 h, respectively, in plasma). Both 20- and 40-kDa aptamer conjugates reached maximal concentrations (C(max)) in aqueous humor of 23-30 nM and remained at or above 1 nM for as long as 12 h.

CONCLUSIONS

Pharmacologically active levels of anti-TGFbeta2 aptamers can be sustained in the ocular fluid and local tissue environment over a 12-h period after single administration. Daily subconjunctival administration of PEGylated anti-TGFbeta2 aptamers should allow further pharmacological evaluation of these agents in a rabbit conjunctival scarring model. Perioperative administration, via subconjunctival injection, may prove to be an effective means to deliver therapeutic quantities of TGFbeta2 aptamer conjugates in trabeculectomy procedures.