Combined cataract and glaucoma surgeries: traditional and new combinations

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.

Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma

PURPOSE

To provide efficacy and safety of surgery with Trabectome combined with phacoemulsification in primary open-angle glaucoma.

METHODS

In this interventional case series, 30 consecutive eyes that have had combined phacoemulsification with Trabectome were included. The main outcome measures were change in intraocular pressure (IOP), glaucoma medication use, and the rate of complications.

RESULTS

Mean IOP was 18.25 ± 3.28 mmHg preoperatively which decreased to 13.50 ± 2.53 mmHg at 1 year. (P < 0.05). There was a corresponding drop in glaucoma medications from 2.52 ± 0.60 at baseline to 1.40 ± 0.53 at 12 months (P < 0.01). The preoperative BCVA (Log Mar) was improved from 0.68 ± 0.26 pre-operatively to 0.26 ± 0.19, 0.18 ± 0.13, 0.17 ± 0.13, 0.11 ± 0.12, at 5 days and 2, 6, and 12 months, respectively (P < 0.01). The only frequent complication was transient blood reflux resolving spontaneously within a few days. No vision-threatening complication occurred.

CONCLUSION

Combined phacoemulsification and Trabectome significantly lowered IOP and medication use, with early visual rehabilitation in the majority of patients.

Phacoemulsification combined with deep sclerectomy augmented with mitomycin and amniotic membrane implantation in chronic primary open angle glaucoma with cataract

OBJECTIVE

The aim of this study was to determine the safety and efficacy of combined phacoemulsification plus Intraocular lens (IOL) implantation with deep sclerectomy augmented with mitomycin C (MMC) and sub-flap implantation of amniotic membrane for the management of uncontrolled, chronic, primary open-angle glaucoma patients.

METHODS

This prospective study included 41 patients with chronic, primary, open-angle glaucoma and cataract uncontrolled with medical treatment who underwent combined phacoemulsification augmented with mitomycin C (MMC) application and amniotic membrane implantation under the scleral flap. Intraocular pressure (IOP), visual acuity, glaucoma medications, stabilization of visual field, complications, and viability of the success rate were assessed a 36-month follow-up period.

RESULTS

The mean age of cases was 54.8 ± 5.3 years. Sixty-one percent of cases were males, and 39% were females. The mean IOP decreased from 23.8 ± 1.8 mmHg preoperatively to 16.8 ± 2.3 mmHg postoperatively. The overall success rate was 97.5, 95, and 92.7% in the first, second, and third year, respectively. The overall success rate was 90% in the first year, but that decreased to 85.3 and 78% in the second and third year, respectively. Qualified success was 7.5, 10, and 14.7% in the first, second, and third year, respectively. Failure was recorded as 2.5, 5, and 7.3% in the first, second, and third year, respectively. IOP reduction was sustained through the follow-up period. Visual acuity improved from 0.13 ± 0.06 to 0.9 ± 0.07 (p < 0.001). The visual field improved significantly in the first assessment, from 14.0 ± 2.7 preoperatively to 12.6 ± 2.6 at three months postoperatively (p < 0.001), after which it became stable for the remainder of the follow-up period. One hundred percent of cases were on three anti-glaucoma drugs preoperatively, while postoperatively, 12.2% were on three drugs, 4.2% were on two drugs, and 82.9% were controlled without anti-glaucoma treatment. There were minor postoperative complications all of which were minor, such as a spike in the post-operative IOP and the formation of fibrinous material in the anterior chamber, both of which were treated medically without any adverse effects on the final results.

CONCLUSION

Amniotic membrane implantation in conjunction with MMC application may be an effective alternative to expensive implants in deep sclerectomy combined with phacoemulsification, and this approach can be used safely in advanced cases.

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.

Fiber-optic microcatheter trabeculotomy combined with anterior segment surgery in children: report of three cases

Pediatric glaucoma may coexist with other anterior segment disorders, and when 2 surgeries are indicated in children, they are generally performed on separate days. We present 3 cases, documented with video, that illustrate the combination of anterior segment surgery (including cataract extraction and papillary membrane removal) with fiber-optic microcatheter trabeculotomy in infants. In one case, the microcatheter procedure could not be completed, and a trabeculotome was used to complete the trabeculotomy. One patient developed a mild hyphema after microcatheter trabeculotomy, which resolved. All cases were performed without other complications and with satisfactory results.