Phacoemulsification Versus Combined Phacoemulsification and Viscogonioplasty in Primary Angle-Closure Glaucoma: A Randomized Clinical Trial

Predictors of intraocular pressure response and survival after phacoemulsification for glaucomatous eyes in the IRIS registry (Intelligent Research in Sight)

This retrospective cohort study describes the real-world incidence and maintenance of clinically meaningful intraocular pressure (IOP) reduction ("response") following stand-alone phacoemulsification for 667,987 eyes with suspected or confirmed glaucoma in the IRIS Registry (Intelligent Research in Sight) from 1/1/2013-9/30/2019. Intraocular pressure responders had ≥ 20% IOP reduction in daily mean IOP from baseline on two consecutive postoperative visits. We declared failure if a responder no longer maintained ≥ 20% IOP reduction. The estimated IOP responder rate was 41.3% by Kaplan-Meier analysis. Multivariate analysis demonstrated relationships between IOP response and baseline IOP (hazard ratio (HR) (95% confidence interval)) 1.48 (1.48-1.49), per 3 mmHg, P < 0.0001), age (HR 1.14 (1.13-1.14), per 10 years, P < 0.0001), male sex (HR 1.13 (1.12-1.15), P < 0.0001), prostaglandin analogue (HR 0.88 (0.87-0.90), P < 0.0001), and Rho-kinase inhibitor use (HR 1.50 (1.32-1.70), P = 0.01). Fifty percent of IOP responders failed at a median time of 14.3 months. Multivariate analysis demonstrated relationships between failure and baseline IOP (HR 0.75 (0.75-0.76), per 3 mmHg, P < 0.0001), nitric oxide donating prostaglandin (HR 1.78 (1.46-2.18), P < 0.0001) and Rho-kinase inhibitor use (HR 1.73 (1.43-2.09), P < 0.0001). Clinicians may counsel glaucoma patients with risk factors on whether to anticipate an IOP response and its expected duration after stand-alone phacoemulsification.

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.

Efficacy and Safety of Different Types of Intraocular Pressure-Lowering Surgeries in Patients with Primary Angle Closure (PAC) or PAC Glaucoma: Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

To compare the intraocular pressure (IOP)-lowering effect of different types of surgery available in the literature using a network meta-analysis (NMA) based on a systematic review.

METHODS

PubMed and the Cochrane database were searched. Randomized clinical trials involving surgical interventions for high IOP for PAC (primary angle closure) or PACG (primary angle closure glaucoma) were included. Descriptive statistics and outcomes were extracted. Bayesian NMA was performed to compare the IOP-lowering effect and the change in the number of antiglaucoma drugs required between baseline and endpoint, as well as success rates.

RESULTS

This NMA included 21 articles with 1237 eyes with PAC or PACG. Interventions were characterised as phacoemulsification (phaco), trabeculectomy, goniosynechialysis (GSL) with viscoelastic or blunt device, goniosurgery (GS) (trabeculotomy or goniotomy), micro-bypass stent (Istent®), endocyclophotocoagulation (ECPL) or various combinations of these procedures. Phaco+GSL [-1.73 (95%CrI: -3.53 to -0.13)] and phaco+GSL+GS [-3.92 (95%CrI: -6.91 to -1.31)] provided better IOP lowering effects than phaco alone. Phaco+trabeculectomy [-3.11 (95%CrI: -5.82 to -0.44)] was inferior to phaco+GSL+GS. Phaco+trabeculectomy [-0.45 (95%CrI: -0.81 to -0.13)] provided a better outcome in terms of reducing the need for antiglaucoma drug compared to phaco alone. There were no differences between the other surgeries in terms of reduction of antiglaucoma drug number and IOP lowering effect. Success rates were similar for all surgical procedures.

CONCLUSIONS

Phaco+GSL+GS showed the most promising results for lowering IOP. Phaco+trabeculectomy resulted in a significant reduction in the number of antiglaucoma drugs compared to phaco alone.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

[Phacoemulsification in prevention of acute angle-closure glaucoma attack]

Analysis of the effectiveness of preventative phacoemulsification (PE) in anatomically short eyes with an increased risk of an acute glaucoma attack in thickened lens can help in choosing the optimal management tactics for these patients.

PURPOSE

To study the changes in morphometric parameters of the anterior segment of anatomically short eyes with an increased risk of acute glaucoma attack before and after preventative PE.

MATERIAL AND METHODS

The study included 70 patients (70 eyes) with a high risk of acute glaucoma attack in short anatomical axial length and thickened lens, with posterior and middle positions of the ciliary body. They were divided into 2 groups: the main group consisted of 45 patients who agreed to undergo PE; the comparison group consisted of 25 patients who refused to undergo PE due to good visual functions and no complaints about vision. B-mode ultrasound examination of the anterior segment of the eye was used to evaluate the cross-sectional surface area of the lens (CSAL) and the cross-sectional surface area of the anterior chamber (CSAAC).

RESULTS

In the main group, on day 2-3 after PE the anterior chamber depth increased in all eyes, the CSAAC index increased, the anterior chamber angle (ACA) widened to Schaffer grade to II-III. After 1-3 years and 4-5 years, the anterior chamber depth, the CSAAC index and the width of the ACA remained stable. In the comparison group, after 1-3 years the anterior chamber depth and the CSAAC index significantly decreased, the ACA narrowed, and the intraocular pressure increased; after 4-5 years, there was a progressive increase in the CSAL index, the ACA was completely closed (0°).

CONCLUSION

In all cases of timely performed preventative PE, already on days 2-3 after surgery there was a statistically significant improvement in the main morphometric parameters of the eye, which remained stable for 4-5 years.

Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial

PRCIS

We used anterior segment optical coherence tomography to investigate anterior chamber angle in primary angle-closure glaucoma (PACG) eyes following phacoemulsification and phacotrabeculectomy. Angle widening was significantly greater after phacoemulsification up to 6 months after the surgery.

PURPOSE

To compare anterior chamber angle following 2 common surgeries for PACG.

METHODS

One hundred ten glaucoma patients were evaluated in this single center, prospective, randomized clinical trial. Those with concomitant PACG and senile cataract and without a history of ocular surgery, trauma, or chronic miotic use were recruited. Monocular patients were also excluded. Finally, 52 eligible subjects were randomly assigned to phacoemulsification ("Phaco" group, 25 eyes) or phacotrabeculectomy ("Combined" group, 27 eyes) surgeries. A swept-source, anterior segment optical coherence tomography device (CASIA SS-1000 OCT) was used to image the anterior segment. Mask graders used the images to measure the following parameters before and 1 week, 1 month, and 6 months after surgery: angle opening distance at 500 µm, trabecular iris surface area at 500 µm, and trabecular iris angle at 500 µm.

RESULTS

There was no significant difference between study groups regarding best-corrected visual acuity, intraocular pressure (IOP), and the number of glaucoma medications in preoperative or postoperative visits (P>0.076). Also, the measured angle parameters were not statistically significantly different between the 2 groups before surgery (P>0.123). After surgery, all measured parameters were significantly increased in both groups (P<0.0001). At the 6-month follow-up, nasal angle opening distance at 500 µm was 0.383±0.027 vs. 0.349±0.017, trabecular iris surface area at 500 µm was 0.141±0.007 vs. 0.125±0.005, and trabecular iris angle at 500 µm was 40.1±12.9 vs. 34.6±3.1 in Phaco and Combined groups, respectively (P<0.0001 for all).

CONCLUSIONS

Anterior chamber angle widening by anterior segment optical coherence tomography was observed in PACG patients following surgery and was significantly greater after phacoemulsification compared with combined phacotrabeculectomy at all time points. Similar IOP and medication burden were noted for up to 6 months as secondary outcomes. The contribution of angle changes to the IOP-lowering effect of phacoemulsification in PACG eyes needs further study.

Efficacy of bleb-independent penetrating canaloplasty in primary angle-closure glaucoma: one-year results

PURPOSE

To report the efficacy and safety of bleb-independent penetrating canaloplasty in the management of primary angle-closure glaucoma (PACG).

METHODS

This single-centre prospective interventional case series enrolled 57 eyes from 53 PACG patients with medically uncontrolled intraocular pressure (IOP) and peripheral anterior synechiae of over 270°. Penetrating canaloplasty, mainly consisted of tensioning suture-aided Schlemm's canal dilation and a trabeculectomy, was performed to create a direct communication between the anterior chamber and the Schlemm's canal. Postoperative IOP, number of glaucoma medications and procedure-related complications were evaluated. Rate of success was defined as IOP ≤ 21, ≤18 and ≤15 mmHg, and a ≥30% IOP reduction without (complete) or with/without (qualified) IOP-lowering medications.

RESULTS

A total of 45 eyes had 360° catheterization successfully completed. The mean preoperative IOP was 33.9 ± 11.7 mmHg (range, 13-59.6 mmHg), on 3.2 ± 0.8 glaucoma medications (range 2-5), which was decreased to 15.4 ± 3.7 mmHg (range, 8.6-22.5) and 0.2 ± 0.6 (range, 0-3) medications at 6 months and 14.8 ± 3.5 mmHg (range, 9-24) and 0.1 ± 0.3 (range, 0-1) medications at 12 months postoperatively. Complete success at 12 months were achieved in 78.9% (95% CI: 0.65-0.93), 71.1% (0.56-0.86) and 50.0% (0.33-0.67) eyes at IOP ≤ 21, ≤18 and ≤15 mmHg, respectively. Transient IOP elevation (>30 mmHg, 26.7%) and hyphema (11.1%) were the most common early surgical complications.

CONCLUSION

Penetrating canaloplasty in PACG appeared to have good efficacy and safety profiles in this pilot study. Further studies are justified.

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.

Comparison of Surgical Outcomes Between Microhook Ab Interno Trabeculotomy and Goniotomy with the Kahook Dual Blade in Combination with Phacoemulsification: A Retrospective, Comparative Case Series

PURPOSE

To study surgical outcomes of patients with a minimum of 6 months of follow-up after undergoing combined phacoemulsification with either microhook ab interno trabeculotomy (μLOT-Phaco) or goniotomy using the Kahook Dual Blade (KDB-Phaco).

METHODS

This retrospective comparative case series examined 22 μLOT-Phaco eyes and 81 KDB-Phaco eyes that underwent surgery between December 2016 and October 2018. Data collected from medical records included pre- and postoperative intraocular pressure (IOP), number of IOP-lowering medications and complication occurrence. Potential risk factors for failure were determined by Cox proportional hazards regression analysis. Surgical failure was defined as an IOP of > 20 mmHg, < 20% reduction in preoperative IOP or additional glaucoma surgery. Kaplan-Meier survival analysis was used to assess success rates. Score matching used a genetic algorithm consisting of type of glaucoma.

RESULTS

Of 81 KDB-Phaco eyes, 22 eyes were matched to 22 μLOT-Phaco eyes. Mean IOP in the μLOT-Phaco group decreased from 24.7 ± 6.4 mmHg at baseline to 14.4 ± 3.0 mmHg (P < 0.01) and 13.0 ± 2.5 mmHg (P < 0.01) at 6 and 12 months, respectively. Mean IOP in the KDB-Phaco group decreased from 23.2 ± 5.4 mmHg to 15.8 ± 3.3 mmHg (P < 0.001) and 16.7 ± 2.1 mmHg (P < 0.001), respectively. Mean number of preoperative IOP-lowering medications in the μLOT-Phaco group at baseline was 3.7 ± 1.0, which decreased to 1.4 ± 1.5 (P < 0.01) at 12 months, while in the KDB-Phaco group it decreased from a baseline value of 3.3 ± 1.2 to 1.1 ± 1.4 (P < 0.01). Probability of qualified success at 12 months in the μLOT-Phaco and KDB-Phaco groups was 71.8% and 62.2%, respectively (P = 0.75). Similar postoperative complications were found between the groups.

CONCLUSIONS

Use of μLOT-Phaco and KDB-Phaco resulted in comparable IOPs and reductions in the number of medications.

MicroPulse Transscleral Laser Therapy with Kahook Dual Blade Excisional Goniotomy and Goniosynechialysis Combined with Phacoemulsification for Angle-Closure Glaucoma: A Case Report

Purpose

To report the efficacy and safety of MicroPulse transscleral laser therapy (TLT) and Kahook Dual Blade excisional goniotomy and goniosynechialysis combined with phacoemulsification for chronic angle-closure glaucoma (ACG).

Patients and Methods

A 39-year-old hyperopic female with a known history of ACG presented with a 2-week history of blurry vision, headache, and photophobia in the right eye (RE) following surgical peripheral iridectomy at another hospital. On examination, her uncorrected visual acuity was 20/50 in the RE, and 20/25 in the left eye (LE). Goldman applanation tonometry revealed an intraocular pressure (IOP) of 51 mmHg in the RE and 12 mmHg in the LE. Ocular examination of the RE revealed conjunctival hyperemia, corneal edema, shallow anterior chamber, posterior synechia, mid-dilated non-reactive pupil, and early cataractous changes. Anterior segment examination findings in the LE were normal except for a shallow anterior chamber. Gonioscopy revealed a closed angle (Schaffer grade 0) with 360° peripheral anterior synechia in the RE and a narrow angle (Schaffer grade 2) in the LE. The cup-to-disc ratios were 0.5 RE and 0.3 LE. The patient underwent MicroPulse TLT with phacoemulsification, Kahook Dual Blade-assisted goniosynechialysis, and excisional goniotomy in the RE.

Results

At the 1-year follow-up, her IOP remained stable without the need for antiglaucoma medications. No further optic nerve or visual field deterioration was noted.

Conclusion

MicroPulse TLT combined with phacoemulsification and Kahook Dual Blade-assisted goniosynechialysis and excisional goniotomy safely reduced IOP and the need for antiglaucoma medications in chronic ACG, avoiding the complications associated with incisional glaucoma surgery.

Mitomycin C-augmented Phacotrabeculectomy Versus Phacoemulsification in Primary Angle-closure Glaucoma: A Randomized Controlled Study

PRECIS

Phacotrabeculectomy yielded similar results to phacoemulsification in primary angle-closure glaucoma (PACG) in terms of intraocular pressure (IOP) lowering, glaucoma medications and success rates. Although releasable sutures may have reduced the risk of hypotony; complications and interventions were more common with phacotrabeculectomy.

PURPOSE

To compare the efficacy and safety of phacotrabeculectomy using releasable sutures and adjunctive mitomycin C versus phacoemulsification alone in the management of PACG.

PATIENTS AND METHODS

In total, 63 eyes of 63 PACG patients were randomized to undergo either mitomycin C-augmented phacotrabeculectomy with tight scleral flap closure using releasable sutures aiming at no flow or phacoemulsification alone. The primary outcomes were success rates and complications. Secondary outcomes were IOP and glaucoma medications.

RESULTS

The IOP and glaucoma medications were significantly reduced at 1, 3, 6, and 12 months postoperatively in both groups (P<0.001). There was no statistically significant difference in IOP, IOP reduction, success rates, or survival times between both groups. Glaucoma medications were only significantly lower in the phacotrabeculectomy group at 1 and 3 months. The rates of postoperative interventions and complications were higher in the phacotrabeculectomy group. Complete success, defined as an IOP of 6 to 21 mm Hg on no medications and with no signs of glaucoma progression, was achieved in 58% in the phacotrabeculectomy group, compared with 62% in the phacoemulsification group (P=0.9). Only 2 eyes (6%) in the phacoemulsification group required a subsequent trabeculectomy.

CONCLUSIONS

Trabeculectomy did not seem to add an advantage when combined with phacoemulsification in PACG patients and was associated with more postoperative interventions. Despite the use of releasable sutures to allow titration of the IOP postoperatively, the rate of hypotony and other complications was higher in the phacotrabeculectomy group.

Effect of Phacoemulsification on Anterior Chamber Angle in Eyes with Medically Uncontrolled Filtered Primary Angle-Closure Glaucoma

Purpose

To evaluate the effect of phacoemulsification and intraocular lens (IOLs) implantation in eyes with medically uncontrolled primary angle-closure glaucoma (PACG) previously treated with trabeculectomy and to quantify the anatomical changes in the anterior chamber angle by ultrasound biomicroscopy (UBM).

Methods

Forty-four eyes of 37 consecutive patients with medically uncontrolled PACG coexisting cataracts with a surgical history of trabeculectomy were included in this study. Each patient underwent phacoemulsification and IOL implantation. Indentation gonioscopy and UBM were performed preoperatively and then again 3 months after surgery. The main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of antiglaucoma medications and anatomical changes in the anterior chamber angle.

Results

The mean logarithm of the minimum angle of resolution BCVA significantly improved from 0.52 ± 0.30 preoperatively to 0.26 ± 0.23 postoperatively (p < 0.001). The mean IOP significantly decreased from 24.33 ± 9.65 mmHg preoperatively to 18.04 ± 7.86 mmHg postoperatively (p < 0.05). 001). The median number of antiglaucoma medications decreased from 2 preoperatively to 1 postoperatively (p < 0.001). There was no significant difference in the extent of peripheral anterior synechia after the surgery (p > 0.05). Some parameters, including anterior central chamber depth, angle opening distance at 500 μm, trabecular-iris angle, and scleral ciliary process angle, were significantly higher after than before surgery (p < 0.001). However, the crystalline lens rise was significantly smaller following the surgery (p < 0.001).

Conclusions

Phacoemulsification and IOL implantation reduced the IOP and improved vision in eyes with medically uncontrolled filtered PACG. The mechanism underlying the outcomes observed following surgery might be related to the anterior chamber deepening, widened drainage angle, and improved aqueous fluid flow to the trabecular meshwork.

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.

Phacoemulsification, visco-goniosynechialysis, and goniotomy in patients with primary angle-closure glaucoma: A comparative study

OBJECTIVE

The aim of this study was to evaluate the effects of goniotomy on patients with primary angle-closure glaucoma who underwent "phacoemulsification and visco-goniosynechialysis."

MATERIALS AND METHODS

This prospective randomized clinical trial was carried out on 63 eyes of 61 patients (48-85 years) with primary angle-closure glaucoma who were enrolled. The subjects were randomly assigned into two groups. In the first group (32 eyes) and the second group (31 eyes), the patients underwent "phacoemulsification + visco-goniosynechialysis + goniotomy" and "phacoemulsification + visco-goniosynechialysis," respectively. Intraocular pressure and antiglaucoma medication were evaluated (1 week, as well as 1, 3, and 6 months after the surgery). Anterior segment optical coherence tomography parameters (Casia, Tomey, USA) and goniotomy were evaluated preoperatively and 6 months after the surgery.

RESULTS

The mean intraocular pressure lowering the effects in the "phacoemulsification + visco-goniosynechialysis + goniotomy" group was higher than that in the "phacoemulsification + visco-goniosynechialysis" group (6.93 and 4.6, respectively). Furthermore, the difference in intraocular pressure between the two groups was significant at 3 months (P = 0.014) and 6 months (P = 0.021) after the surgery. There was no difference in anterior segment optical coherence tomography findings before the intervention; however, after the intervention, the anterior segment optical coherence tomography indices were significantly different between the two groups. Moreover, the difference in "phacoemulsification + visco-goniosynechialysis + goniotomy" indices was more than the changes in the "phacoemulsification + visco-goniosynechialysis" group.

CONCLUSION

The results of this study showed that phacoemulsification + visco-goniosynechialysis + goniotomy is a more effective surgery than phacoemulsification + visco-goniosynechialysis alone in undercounted primary angle-closure glaucoma.

Phacoemulsification with or without goniosynechialysis for angle-closure glaucoma: a global Meta-analysis based on randomized controlled trials

AIM

To compare the benefits and potential harms of routine phacoemulsification (phaco) alone and combined surgery with goniosynechialysis (GSL) for angle-closure glaucoma (ACG) and coexisting lens opacity, as shown in different randomized controlled trials (RCTs).

METHODS

A systematic review was conducted searching several databases including PubMed, Cochrane Library, EMBASE, ClinicalTrials.gov from the inception to September 2018 for RCTs with data published on the effects and safety of phaco and intraocular lens implantation combined with GSL or routine cataract surgery alone. Several studies were recruited which reported data at baselines and postoperative follow-up, including the mean values of postoperative intraocular pressure (IOP) and mean numbers of anti-glaucoma medications using postoperatively. The numbers of complications happening were also included. Fixed-effect and random-effect models were applied, and the quality of evidence was evaluated.

RESULTS

Analysis of the seven included RCTs, with a total number of 321 participants (358 eyes) diagnosed with ACG and cataract, received a solo procedure (phaco group) or a combined surgery (phaco-GSL group) randomly, and follow-up periods ranging from 2 to 12mo postoperatively. The involved studies showed that the mean value of IOP between the two groups at 3 (four studies, one study follow-up at 2mo postoperative was included), 6, 12mo postoperative were not significantly different. Only two studies reported the change in IOP value at 12mo compared with baseline but showed no significant differences between the two interventions. Although three studies did not have the significant difference in the number of medications using to reduce IOP at 3mo postoperatively, two studies reported that the participants using fewer anti-glaucoma medications at 12mo postoperative in the phaco group than in the phaco-GSL surgery group.

CONCLUSION

The analysis provides a low to moderate-quality evidence that phaco-GSL surgery lead to an equivalent IOP-lowering effect. The phaco-GSL surgery may not help patients to reduce the consumption of anti-glaucoma eyedrops in the long period. The results of this analysis suggested that additional GSL may not be necessary for primary angle closure glaucoma (PACG) patients. Further studies, especially RCTs with more participants and longer follow-up time were needed to provide more sufficient data.

Combined glaucoma and cataract surgery: Comparison of viscocanalostomy, endocyclophotocoagulation, and ab interno trabeculectomy

PURPOSE

To compare outcomes of phacoemulsification combined with viscocanalostomy, endocyclophotocoagulation (ECP), or ab interno trabulectomy for intraocular pressure (IOP) control and safety in eyes with open-angle glaucoma and visually significant cataract.

SETTING

Farabi Eye Hospital, Tehran, Iran.

DESIGN

Retrospective case series.

METHODS

Medical records of patients who had combined surgery and were followed for at least 1 year were reviewed. Complete success, postoperative IOP, number of medications at each visit, and complications were evaluated and compared before and after adjustments for confounders.

RESULTS

Forty-six eyes had combined phacoviscocanalostomy, 35 had phaco-ECP, and 28 eyes phaco-ab interno trabulectomy. The groups were matched for baseline IOP (P = .24). At the final follow-up (mean 17.2 months ± 5.5 [SD]), the phacoviscocanalostomy group had the lowest mean IOP (13.5 ± 4.7 mm Hg, 29% decrease) (P = .01). There was no significant difference in the final IOP between phaco-ECP and phaco-ab interno trabulectomy (16.4 ± 3.9 mm Hg, 20% decrease versus 15.8 ± 4.2 mm Hg, 15% decrease) (P = .88). The reduction in the number of medications was greater with phacoviscocanalostomy (77%) than with phaco-ECP (40%) and phaco-ab interno trabulectomy (44%) (P = .01). Phacoemulsification-ab interno trabulectomy had the fewest complications. Intraocular pressure spikes were more frequent in the phaco-ECP group (20%) than in the other groups (4%) (P = .05).

CONCLUSIONS

All procedures significantly lowered IOP. Phacoemulsification-ab interno trabulectomy resulted in fewest complications and phacoviscocanalostomy led to the largest IOP drop and largest reduction of medications.

Contemporary approach to the diagnosis and management of primary angle-closure disease

The primary angle-closure disease spectrum varies from a narrow angle to advanced glaucoma. A variety of imaging technologies may assist the clinician in determining the pathophysiology and diagnosis of primary angle closure, but gonioscopy remains a mainstay of clinical evaluation. Laser iridotomy effectively eliminates the pupillary block component of angle closure; however, studies show that, in many patients, the iridocorneal angle remains narrow from underlying anatomic issues, and increasing lens size often leads to further narrowing over time. Recent studies have further characterized the role of the lens in angle-closure disease, and cataract or clear lens extraction is increasingly used earlier in its management. As a first surgical step in angle-closure glaucoma, lens extraction alone often effectively controls the pressure with less risk of complications than concurrent or stand-alone glaucoma surgery, but may not be sufficient in more advanced or severe disease. We provide a comprehensive review on the primary angle-closure disease nomenclature, imaging, and current laser and surgical management.

Cataract, phacoemulsification and intraocular pressure: Is the anterior segment anatomy the missing piece of the puzzle?

Cataract extraction is a safe and effective surgery that has a lowering effect on the intraocular pressure. The specific mechanisms for this effect are still unclear. A direct inflammatory effect on the trabecular meshwork, alteration of the blood aqueous barrier, changes in the ciliary body and mechanical changes of the anterior segment anatomy are the key to understand cataract surgery and it's effects on aqueous humor dynamics. Additionally, with the advent of AS OCT, changes in the anterior segment of the eye have been studied and several parameters (such as lens vault, angle opening distance and anterior chamber depth) have been identified as predictors of intraocular pressure change. In eyes with narrow angles there is a greater drop in intraocular pressure after cataract surgery and it is correlated with parameters related to anterior chamber space. It is safe to affirm that cataract surgery is an important part of the modern glaucoma treatment and evidence should be analyzed as part of a bigger picture in order to more accurately understand its clinical relevance.

Lens Position Parameters as Predictors of Intraocular Pressure Reduction After Cataract Surgery in Glaucomatous Versus Nonglaucomatous Eyes

Purpose

To evaluate the relationship between lens position parameters and intraocular pressure (IOP) reduction after cataract surgery in patients with primary open-angle glaucoma (POAG) and in nonglaucomatous patients.

Methods

The main outcomes of this prospective study were percent and absolute IOP change, which were calculated using the preoperative IOP and the IOP 4 months after cataract surgery in POAG and nonglaucomatous eyes. Lens position (LP), defined as anterior chamber depth (ACD) + one-half lens thickness (LT), was assessed preoperatively using parameters from optical biometry. Preoperative IOP, axial length (AL), ACD, LT, relative lens position (RLP), and the ratio of preoperative IOP to ACD (PD ratio) were also evaluated as potential predictors of IOP change.

Results

Four months postoperatively, the average IOP reduction was 2.80 ± 3.83 mm Hg (15.79%) from the preoperative mean of 14.73 ± 2.89 mm Hg for nonglaucomatous eyes. The average IOP reduction was 2.66 ± 2.07 mm Hg (16.98%) from the preoperative mean of 14.86 ± 2.97 mm Hg for POAG eyes. Preoperative IOP, sex, AL, ACD, PD ratio, and LP predicted IOP change in nonglaucomatous eyes. Preoperative IOP and PD ratio predicted IOP change in POAG eyes.

Conclusions

Intraocular pressure reduction after phacoemulsification cataract surgery in nonglaucomatous eyes is significantly greater in more anteriorly positioned lenses. Though it did not reach statistical significance in patients with glaucoma, the association of LP with IOP reduction is in the same direction as in nonglaucomatous patients where smaller LP appears to predict greater IOP reduction. Lens position is a simple, easily calculable, accurate, and widely available parameter, which clinicians can potentially utilize in managing glaucoma.

Aqueous outflow facility after phacoemulsification with or without goniosynechialysis in primary angle closure: a randomised controlled study

BACKGROUND

Goniosynechialysis (GSL) to remove peripheral anterior synechiae (PAS) alongside standard cataract surgery has potential theoretical advantages, Published randomised trials, however, have not shown conclusive functional benefits and aqueous outflow changes following GSL are unknown. This study aimed to compare electronic Shiøtz tonographic aqueous outflow facility (TOF) following phacoemulsification with or without GSL in patients with primary angle closure (PAC) and PAC glaucoma. Secondary outcomes were changes in intraocular pressure (IOP) and use of glaucoma medications.

METHODS

Prospective randomised pilot study of 26 patients on glaucoma medication, with ≥90° PAS and significant lens opacity. Patients were randomised 1:1 to receive phacoemulsification with intraocular lens (IOL) implantation only (phaco) or phacoemulsification with IOL plus GSL (phaco-GSL).

RESULTS

Fourteen patients were randomised to phaco-GSL and 12 to phaco alone. TOF increased with phaco-GSL from 0.099±0.07 μL/min/mm Hg to 0.194±0.07, μL/min/mm Hg, p=0.0006, while the phaco group showed no significant change. IOP reduced in both groups, but reduced significantly more following phaco-GSL (46.0%) compared with phaco alone (27.6%, p=0.04). Medication use and extent of PAS only reduced with phaco-GSL, from 0.923±0.86 to 0.384±0.18 medications, p=0.0279, and from 249.2±83.4 to 110.8±53.9° PAS, 6 months postoperatively. No serious adverse events occurred in either group.

CONCLUSIONS

Eyes randomised to both surgical groups had similar and good outcomes at 6 months in this pilot study. However, only eyes undergoing GSL combined with standard phacoemulsification had significantly increased TOF, reduced glaucoma medication dependence and PAS postoperatively. GSL should therefore be considered in such patients.

TRIAL REGISTRATION NUMBER

NCT00719290, Results.

Comparison of phacotrabeculectomy and sequential surgery in the treatment of chronic angle-closure glaucoma coexisted with cataract

AIM

To compare the safety and effectiveness of phacotrabeculectomy versus sequential surgery in chronic angle-closure glaucoma (CACG) with coexisting cataract.

METHODS

One hundred and sixty-two CACG patients (162 eyes) were retrospectively analyzed. Of them, 87 patients (87 eyes) in group A had underwent phacotrabeculectomy with intraocular lens (IOL) implantation, and 75 patients (75 eyes) in group B had underwent sequential surgery with IOL implanted. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), complications and anterior chamber angle (ACA) were measured.

RESULTS

Demographic characteristics of the two groups were similar. A mean follow-up period was 15±6mo (range 13 to 24mo), a mean IOP of 16.61±6.43 mm Hg in group A and 15.80±5.35 mm Hg in group B (P=0.84) at the last follow up. The Kaplan-Meier analysis revealed that the cumulative probability of success in both groups was similar (P=0.61). Anterior uveitis and hypotony were the most common complications in group A, whereas group B experienced shallow anterior chamber with trabeculectomy. With the exception of anterior uveitis, no complications occurred to 11 trabeculectomized eyes. All postoperative measurements of anterior chamber showed statistically significant differences in each group according to the preoperative data (P<0.05). However, fewer changes occurred in group B than in group A.

CONCLUSION

Phacotrabeculectomy and sequential surgery exhibit similar IOP reduction, visual recovery, and complications when treating CACG patients with cataract. However, for a wider ACA, phacotrabeculectomy has demonstrated higher effectiveness than sequential surgery.

Predictors of intraocular pressure change after phacoemulsification in patients with pseudoexfoliation syndrome

AIM

To evaluate anterior chamber biometric factors and intraoperative metrics associated with the intraocular pressure (IOP) reduction after phacoemulsification in non-glaucomatous pseudoexfoliative syndrome (PXS) eyes.

METHOD

Thirty-three patients were enrolled in this prospective interventional study. Images were excluded if they had poor quality, poor perpendicularity or inability to locate sclera spurs. Anterior chamber depth (ACD), anterior chamber area (ACA), iris thickness, iris area, iris curvature, lens vault, angle opening distance (AOD500, AOD750) and trabecular iris space area (TISA500, TISA750) were measured in qualified images using the Zhongshan Angle Assessment Program and compared preoperatively and 3 months postoperatively. Cumulative dissipated energy (CDE), aspiration time and infusion fluid usage during cataract surgery were obtained from the phacoemulsification machine's metrics record. Postoperative IOP change was compared with these anatomical and intraoperative metric parameters.

RESULTS

Mean IOP was 18.1±3.4 mm Hg preoperatively and decreased by 3.3 mm Hg (18%) to 14.8±3.6 mm Hg at 3 months postoperatively (p<0.001). All angle parameters, ACD and ACA increased significantly postoperatively (p<0.001 for all) and iris curvature decreased (p<0.001). In univariate analysis, preoperative IOP (B=-0.668, p=0.002), infusion fluid usage (B=-0.040, p=0.04) and aspiration time (B=-0.045, p=0.003) were negatively associated with IOP decrease after phacoemulsification. Changes in IOP did not demonstrate significant associations with CDE measurements or anterior segment optical coherence tomography measurements, including preoperative angle, iris or anterior segment parameters. In the final multivariate regression model, preoperative IOP (B=-0.668, p=0.002) and infusion fluid usage (B=-0.041, p=0.04) were significantly associated with IOP drop and together can predict 45.1% (p=0.002) of the variability in IOP change.

CONCLUSIONS

Non-glaucomatous patients with PXS experience moderate IOP reduction following phacoemulsification, and this effect is correlated with preoperative IOP, aspiration time and infusion fluid used intraoperatively.

Management of Different Subtypes of Primary Angle Closure with Phacoemulsification and Viscogoniosynechialysis

PURPOSE

To retrospectively assess the effectiveness of combined phacoemulsification with viscogoniosynechialysis for patients with different subtypes of primary angle closure (PAC).

METHODS

Forty-three eyes of 37 patients diagnosed with PAC (12 eyes), PAC with glaucoma (PACG, 20 eyes), and acute PAC (11 eyes) were treated with phacoemulsification and viscogoniosynechialysis between November 2010 and October 2012. Main outcome measures were anterior chamber depth (ACD), intraocular pressure (IOP), the number of IOP-lowering medication, extent of peripheral anterior synechia (PAS), and visual acuity preoperatively and one month postoperatively.

RESULTS

All operations were successfully accomplished and no intra-operative complications were observed. The ACD, IOP, PAS, and visual acuity were all significantly improved postoperatively, especially in the acute PAC group, which resulted in few glaucoma drugs being needed. The IOP was decreased into equal or less than 21 mmHg in most patients postoperatively, except four patients had IOP slightly higher than 21 mmHg. However, they were restored to normal spontaneously or by medication at last follow-up. The extent of PAS was all reduced to less than 90 or 180°, with the visual acuity restored to more than 0.1.

CONCLUSIONS

Combined phacoemulsification with viscogoniosynechialysis seems to be an effective surgical procedure in the treatment of various subtypes of PAC.

Early phacoemulsification in patients with acute primary angle closure

PURPOSE

To compare long term efficacy of phacoemulsification in the early management of acute primary angle closure (APAC) after aborting an acute attack and performing laser peripheral iridotomy (LPI).

METHODS

In this nonrandomized comparative prospective study, we included 35 subjects presenting with APAC who had responded to medical treatment and LPI with intraocular pressure (IOP) less than 25 mmHg. Twenty patients with visually significant cataract with visual acuity of <20/30 were assigned to the "Phaco/LPI" group and underwent phacoemulsification within 6 weeks of the attack. Fifteen subjects with clear lens were assigned to the "LPI Only" group and were followed clinically. The primary measured outcome was the prevalence of IOP rise after 1 month (treatment failure), defined as 1) if a patient developed IOP rise resulting in IOP >21 mmHg with or without medication, or 2) if a patient required any medication to have IOP ≤21 mmHg after 1 month. Patients were followed for at least one year.

RESULT

IOP, number of medications, gonioscopy grading, and amount of synechiae were not significantly different at baseline between the two groups. Acute attack did not recur in any patient. There was more significant failure in the LPI Only group compared with the Phaco/LPI group (40% vs. 5%; p = 0.02). There was a significant difference in final IOP between the two study groups (13.90 ± 2.17 vs. 17.8 ± 4.16 in the Phaco/LPI and LPI Only groups, respectively; p = 0.001). Patients in the Phaco-LPI group needed less medication than the other group at final follow-up. No serious complications have arisen from the immediate LPI or phacoemulsification.

CONCLUSION

Phacoemulsification is a safe procedure for preventing IOP rise after aborting acute primary angle closure if performed within a few weeks of the attack.