Comparison of Combined Phacoemulsification, Intraocular Lens Implantation, and Goniosynechialysis With Phacotrabeculectomy in the Treatment of Primary Angle-Closure Glaucoma and Cataract

Comparison of Long-Term Effects Following Phacoemulsification Combined with Goniosynechialysis and Trabeculectomy in Patients with Primary Angle-Closure Glaucoma and Cataract

INTRODUCTION

Goniosynechialysis (Phaco-GSL) is a logical therapeutic approach for patients with primary angle-closure glaucoma (PACG) and cataract. The aim of this study was to compare the long-term effectiveness and safety of Phaco-GSL and trabeculectomy (TRB) in the management of PACG with coexisting cataract.

METHODS

A review was conducted on 96 Chinese patients (96 eyes) with PACG and cataract from Peking Union Medical College Hospital (PUMCH). Among them, 56 patients underwent Phaco-GSL, while 40 underwent TRB. Intraocular pressure (IOP), best corrected visual acuity (BCVA), use of supplemental antiglaucoma medical therapy, surgery success rates, and complications for both procedures were assessed.

RESULTS

The average follow-up period was 50.3 ± 18.7 months in the Phaco-GSL group and 61.2 ± 15.1 months in the TRB group. At the final follow-up, IOP decreased from 27.0 ± 11.1 mmHg to 13.5 ± 2.1 mmHg in the Phaco-GSL group and in the TRB group IOP decreased from 27.1 ± 7.7 mmHg to 16.5 ± 5.5 mmHg. The long-term postoperative IOP in the Phaco-GSL group was significantly lower than that in the TRB group. There was a statistically significant reduction in medication usage in both groups, with the TRB group having a higher number of postoperative medications at the final follow-up. The incidence of postoperative complications was significantly higher in the TRB group compared to the Phaco-GSL group.

CONCLUSIONS

Phaco-GSL is the recommended surgical approach for Chinese patients with primary angle-closure glaucoma (PACG) and cataract. Compared to traditional TRB, eyes undergoing Phaco-GSL show a reduced requirement for antiglaucomatous medications, improved management of IOP, decreased risk of complications, and higher long-term cumulative probability of treatment success for patients with PACG.

Meta-Analysis of the Comprehensive Efficacy of Intraocular Lens Implantation in Glaucoma Patients

This study is aimed at investigating the efficacy of intraocular lens (IOL) implantation in patients suffering from glaucoma through meta-analysis of the previously published research. For this purpose, different literature databases were searched for identification of clinical studies published between January 2000 and January 2022 on evaluating IOL's efficacy in treating glaucoma. RevMan 5.3 was used to conduct a meta-analysis of the pertinent data. The central anterior chamber depth (ACD), corneal endothelial cell counts, best-corrected visual acuity (BCVA), intraocular pressure (IOP), anti-glaucoma medications (AGM), and axial length (AL) changes were compared, and the incidence of postoperative complications was thoroughly evaluated. The Cochran chi-square test was used to examine the heterogeneity of the evaluation results. According to the inclusion and exclusion criteria, 20 studies included 948 glaucomatous eyes. IOP was significantly lower than before treatment (MD = 8.64, 95 CI: 5.75-11.53; Z = 5.86, P < 0.0001), while ACD increased significantly (MD = -1.38, 95 percent CI: -1.74-1.02; Z = 7.49, P < 0.0001). The corneal endothelial cell counts were homogeneous (MD = 225.08, 95% CI: -64.17 to -514.33; Z = 1.53, P = 0.20). AGM utilisation decreased (MD = 1.43, 95% CI: 0.752.12, Z = 4.09, P < 0.0001). AL decreased significantly (MD = 0.31; 95% CI: 0.09-0.54; Z = 2.71; P = 0.007). The incidence of complications remained insignificant after IOL treatment (OR = 1.05, 95% CI: 0.42 to 2.60; Z = 0.10, P = 0.92; P = 0.92). These findings indicate that IOL treatment can significantly reduce intraocular pressure, glaucoma drug use, and aqueous level (AL) in glaucoma patients while increasing the depth of the central anterior chamber. This study offers a theoretical foundation for selecting glaucoma treatment methods.

Efficacy and safety of phacoemulsification plus goniosynechialysis and trabectome in patients with primary angle-closure glaucoma

We evaluated the efficacy and safety of combined phacoemulsification, intraocular lens implantation, goniosynechialysis (GSL), and trabectome in patients with primary angle-closure glaucoma (PACG). Twenty patients (22 eyes) of PACG treated with combined phacoemulsification, intraocular lens implantation, GSL, and trabectome between September 2017 and September 2020 were included in this case series study. The intraocular pressure (IOP), number of glaucoma medications, and best-corrected visual acuity (BCVA) were recorded at baseline, 1, 3, 6, and 12 months after surgery. Successful surgery was defined as IOP < 21 mmHg with or without IOP-lowering medications. IOP was decreased significantly from 22.07 ± 6.62 mmHg at baseline to 15.06 ± 3.39 mmHg at 12 months' follow-up (p = 0.001). The number of glaucoma medications was significantly reduced from 2.68 ± 1.17 preoperatively to 0.78 ± 0.73 at 12 months' follow-up (p < 0.01). The rate of successful surgery was 88.9% at 12 months. The reduction in IOP showed a positive correlation with baseline IOP (p < 0.001), and the reduction in number of glaucoma medications was positively correlated with baseline number of glaucoma medications (p < 0.001). There were no vision-threatening complications intraoperatively or postoperatively. Combined phacoemulsification, IOL implantation, GSL, and trabectome were effective and safe in PACG patients in this study. These combined surgical techniques may be useful in PACG patients, especially those with long term and extensive peripheral anterior synechiae.

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.

Combined phacoemulsification and goniosynechialysis with or without endoscopic cyclophotocoagulation in the treatment of PACG with cataract

AIM

To investigate the efficacy and safety of combined phacoemulsification and goniosynechialysis with or without endoscopic cyclophotocoagulation (PGE group and PG group) for the treatment of patients with coexisting primary angle-closure glaucoma (PACG) and cataracts.

METHODS

The clinical data of patients with PACG and cataract were retrospectively reviewed. There was a total of 88 eyes in the study and were divided into two groups, 42 eyes in PGE group and 46 eyes in PG group. Surgery success cumulative survival, preoperative and postoperative intraocular pressure (IOP), number of IOP-lowering medications, best corrected visual acuity (BCVA) in the two groups were observed for more than 12mo and compared within each group and between two groups.

RESULTS

The mean IOP in PGE group declined from 24.9 mm Hg preoperatively to 14.1 mm Hg at the first month after operation (P<0.001) and at the last visit 16.2 mm Hg (P<0.001). Meanwhile PG group also showed significant decrease, from 24.1 mm Hg preoperatively to 13.0 mm Hg at 1mo after operation (P<0.001) and 15.3 mm Hg at the last visit (P=0.004). The mean medications reliance reduced in both groups, in PGE group was reduced from 1.62 preoperatively to 0.13 at the last visit (P<0.001), in PG group from 0.87 to 0.10 (P<0.001). At the last visit, BCVA increased from 0.21 to 0.60 in PGE group (P<0.001) and from 0.24 to 0.67 in PG group (P<0.001). The success rate of PGE group at 1mo was 95.2%, then decreased to 70.7% at the last visit, whereas in PG group, the success rate at 1mo was 100%, at the last visit was 73.4%.

CONCLUSION

PGE shows promise for PACG patients with cataracts to reduce IOP, lighten the medication burden and improve visual acuity, and PG still has its value in specific patients.

Modified phacoemulsification plus goniosynechialysis compared with conventional surgery for cataract and glaucoma

Optic nerve damage and visual impairment caused by glaucoma affect 66.8 million people worldwide, and causing bilateral blindness in 6.7 million people. Surgery is the main method for the treatment of cataract with glaucoma. In recent years, clinicians have increasingly paid attention to and applied phacoemulsification and intraocular lens implantation combined with goniosynechialysis for the treatment of cataract with angle-closure glaucoma. However, for patients with complicated cataract, the high ultrasonic energy of traditional phacoemulsification can largely damage the corneal endothelium. Modified phacoemulsification (lower ultrasonic energy) and intraocular lens implantation have now achieved certain efficacy. The efficacy and safety of modified phacoemulsification plus goniosynechialysis compared with conventional surgery for cataract and glaucoma was investigated. A total of 125 patients who underwent goniosynechialysis combined with phacoemulsification and intraocular lens implantation were enrolled in the control group, while 179 patients treated by modified phacoemulsification and intraocular lens implantation combined with goniosynechialysis were enrolled in the research group. The visual acuity and intraocular pressure were observed before and 6 months after surgery in both groups, and the incidence of complications was analyzed. After treatment, there were more patients with visual acuity of 0.2-0.4 and >0.4 in the research group than in the control group (P<0.05). The incidence of corneal edema and anterior chamber inflammation was lower in the research group than in the control group (both P<0.05), while the preoperative and postoperative intraocular pressure, central anterior chamber depth, angle-opening distance, and peripheral iridocorneal adhesions were not significantly different between the two groups (all P>0.05). Modified phacoemulsification and intraocular lens implantation plus goniosynechialysis for cataract with glaucoma can better improve the visual acuity, as well as effectively reduce corneal edema and anterior chamber inflammation.

Systematic Review and Meta-Analysis of Comparing Phacoemulsification Combined with goniosynechialysis to other mainstream procedures in treating patients with angle-closure glaucoma

BACKGROUND

The aim of this meta-analysis is to compare the efficacy and safety of combined phacoemulsification (Phaco) with goniosynechialysis (GSL) to either Phaco or to Phaco combined with trabeculectomy or trabeculectomy alone in patients with angle closure glaucoma (ACG).

METHODS

Five main electronic databases were searched for the eligible studies. Intraocular pressure (IOP) decrease was set as the primary outcome, while anti-glaucomatous medication decrease, changes of anterior chamber depth (ACD), range of peripheral anterior synechia (PAS), and complication occurrence were the secondary outcomes. Standard mean difference (SMD) and relative risk (RR) were the size effects for continuous and binomial data, respectively. Either fixed-effects model or random-effects model was chosen to pool the data based on the heterogeneities.

RESULTS

A total of 7 eligible studies were included. The combined data showed the IOP decreased more significantly after Phaco-GSL than that after Phaco alone (SMD = -0.42,95%CI: -0.70 - 0.14, I = 17.6%, Z = 2.90, P = .004). However, there were no distinct differences regarding medication decrease (SMD =  -0.25,95%CI: -0.70 - 0.21, I = 0%, Z = 1.06, P = 0.29), ACD, the range of PAS and complication occurrence rate when compared Phaco-GSL to Phaco. Moreover, Phaco-GSL was comparable to Phaco-trabeculectomy/trabeculectomy in decreasing IOP (SMD =  -0.08, 95%CI = -0.32 - 0.15, I = 0%, Z = 0.70, P = .49).

CONCLUSIONS

Phaco-GSL might be an optimal procedure to treat ACG with concomitant cataract due to its bleb-less nature, and its capacity for lowering IOP seems superior to Phaco alone and comparable to Phaco-trabeculectomy/trabeculectomy.

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

PURPOSE

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

DESIGN

Prospective, randomized, parallel group, active controlled trial.

PARTICIPANTS

Patients with PACG.

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Management of Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension caused by closure of the drainage angle. Angle closure is caused by appositional approximation or adhesion between the iris and the trabecular meshwork. The main treatment strategy for PACG lies in the reduction of intraocular pressure, reopening of the closed angle, and possible prevention of further angle closure. There is no universally agreed best surgical treatment for PACG. Trabeculectomy, goniosynechialysis (GSL), glaucoma implant, and cyclodestructive procedures are effective surgical options. Each of them plays an important role in the management of PACG with its own pros and cons. Accumulating evidence is available to show the effectiveness of visually significant and visually nonsignificant cataract extraction in the treatment of PACG. Trabeculectomy and GSL are often combined with cataract extraction, which may offer additional pressure control benefits to patients with PACG. This review article will discuss laser peripheral iridotomy, argon laser peripheral iridoplasty, and surgeries such as GSL, phacoemulsification, and phaco plus glaucoma surgeries that lower intraocular pressure and also alter the anterior segment and/or drainage angle anatomy. Currently, glaucoma implants and cyclodestruction are mainly reserved for PACG patients who have failed previous filtering operations. Their role as initial surgical treatment for PACG will not be discussed.